Nokea
A client is diagnosed with methicillin-resistant Staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: The correct answer is 'D: Contact.' Contact precautions are necessary for clients with MRSA pneumonia to prevent the spread of the resistant bacteria. MRSA is primarily spread by direct contact, so using contact precautions, such as wearing gloves and gowns, is essential. Choice A, 'Reverse,' is not a type of isolation precaution. Choice B, 'Airborne,' is not the appropriate isolation for MRSA pneumonia, as MRSA is not transmitted through the airborne route. Choice C, 'Standard precautions,' are important for all clients, but for MRSA pneumonia specifically, contact precautions are more targeted and necessary.
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A client who is pregnant and has hyperemesis gravidarum is being taught about nutrition at home by a nurse. Which of the following statements indicate that the client understands the teachings?
- A. I will drink water with my meals.
- B. I will eat every 6 hours throughout the day.
- C. I will eat crackers before I get out of bed in the morning.
- D. I will limit my protein intake.
Correct Answer: C
Rationale: The correct answer is C. Eating crackers before getting out of bed can help manage nausea associated with hyperemesis gravidarum. Choice A is incorrect because drinking water with meals may exacerbate nausea. Choice B is incorrect as eating every 6 hours may not be frequent enough to combat nausea and vomiting. Choice D is incorrect because protein intake should not be limited during pregnancy, especially in cases of hyperemesis gravidarum.
After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to suck on ice chips
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.
A client with a history of deep vein thrombosis (DVT) is being treated with anticoagulants. Which of these findings is most concerning to the nurse?
- A. Presence of bruising on the arms and legs
- B. The client reports new onset of severe headache
- C. The client reports pain and swelling in the calf
- D. The client reports increased urination
Correct Answer: C
Rationale: The correct answer is C because pain and swelling in the calf can indicate a new or worsening DVT, requiring immediate attention. Bruising on the arms and legs may be a common side effect of anticoagulants but is not as concerning as a potential DVT. Severe headache may indicate other conditions like a migraine or hypertension and is not directly related to DVT. Increased urination is not typically associated with DVT and may point towards other health issues like diabetes or urinary tract infections.
A nurse is reinforcing teaching with a client about dietary choices for celiac disease. Which of the following menu choices selected by the client indicates an understanding of the teaching?
- A. Hamburger on a wheat bun
- B. Baked chicken and potato chips
- C. Bacon, lettuce, and tomato sandwich on rye toast
- D. Beef and barley soup with crackers
Correct Answer: B
Rationale: The correct answer is B because baked chicken and potato chips are gluten-free options suitable for a client with celiac disease. Choice A, a hamburger on a wheat bun, contains gluten, which is harmful to individuals with celiac disease. Choice C, a bacon, lettuce, and tomato sandwich on rye toast, also contains gluten. Choice D, beef and barley soup with crackers, includes gluten from the barley and crackers, making it unsuitable for someone with celiac disease.
A healthcare provider is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficiency?
- A. Dry, red conjunctiva
- B. Swollen, bleeding gums
- C. Inflammation of the tongue
- D. Pale, brittle nails
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.