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A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will place my used tissues in a plastic bag.
- B. I will share my utensils with my family.
- C. I will not need to wear a mask at home.
- D. I will stop taking my medications when I feel better.
Correct Answer: A
Rationale: The correct answer is A: "I will place my used tissues in a plastic bag." This statement indicates understanding of infection control for tuberculosis by properly disposing of contaminated materials to prevent the spread of the disease. Placing used tissues in a plastic bag helps contain the bacteria.
Choices B, C, and D are incorrect:
B: Sharing utensils can spread the infection to family members.
C: Not wearing a mask at home can expose others to the bacteria.
D: Stopping medications prematurely can lead to treatment failure and drug resistance.
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A nurse is providing preoperative teaching to a client who is scheduled for a radical prostatectomy. Which of the following information should the nurse include in the teaching?
- A. You will have a urinary catheter for several days.
- B. A PCA pump will be used for postoperative pain control.
- C. You will be discharged the same day as surgery.
- D. You should avoid all fluid intake after surgery.
Correct Answer: B
Rationale: The correct answer is B: A PCA pump will be used for postoperative pain control. This is crucial information for the client undergoing a radical prostatectomy as it ensures effective pain management post-surgery. The use of a PCA pump allows the client to self-administer pain medication within safe limits, promoting better pain control and comfort during the recovery period. It also empowers the client to actively participate in their pain management.
Choice A is incorrect because while the client may have a urinary catheter after surgery, it is not the most crucial information to include in preoperative teaching.
Choice C is incorrect as radical prostatectomy typically requires a hospital stay, not same-day discharge.
Choice D is incorrect as avoiding all fluid intake after surgery is not recommended; adequate hydration is important for recovery.
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
A nurse is assessing a client who has Cushings syndrome. Which of the following findings should the nurse expect?
- A. Osteoporosis
- B. Hypertension
- C. Weight loss
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Osteoporosis. In Cushing's syndrome, excess cortisol weakens bones, leading to osteoporosis. B: Hypertension is common in Cushing's due to cortisol's effects on blood vessels. C: Weight gain, not loss, is typically seen in Cushing's due to cortisol-induced fat redistribution. D: Hyperglycemia, not hypoglycemia, is common due to cortisol's role in glucose metabolism. E, F, G are irrelevant. In summary, osteoporosis is expected due to cortisol's impact on bone health, while the other options are not typical findings in Cushing's syndrome.
A home health nurse is inspecting a clients residence for electrical hazards as part of the agencys quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?
- A. An IV pump is plugged into an outlet near a sink.
- B. A lamp with a short cord is used in the bedroom.
- C. A television is plugged into a surge protector.
- D. The client uses a nightlight in the hallway.
Correct Answer: A
Rationale: Correct Answer: A. An IV pump is plugged into an outlet near a sink.
Rationale: Plugging an IV pump near a sink poses a significant risk of electrical shock due to water exposure. Water conducts electricity and can lead to electrocution. This situation directly violates electrical safety guidelines.
Summary of other choices:
B. A lamp with a short cord in the bedroom: While a short cord may not be ideal, it does not pose an immediate safety hazard unless it is frayed or damaged.
C. A television plugged into a surge protector: This is a safe practice as surge protectors help prevent damage from power surges and do not pose a direct safety hazard.
D. The client uses a nightlight in the hallway: Nightlights are commonly used for safety and do not typically pose an electrical hazard if used correctly.
A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?
- A. 0.4 mL
- B. 0.5 mL
- C. 0.6 mL
- D. 0.7 mL
Correct Answer: B
Rationale: To calculate the dose of enoxaparin, first convert the client's weight from pounds to kilograms: 154 lb/2.2 = 70 kg. Then, calculate the dose: 0.75 mg/kg x 70 kg = 52.5 mg. Since the concentration is 60 mg/0.6 mL, divide the dose needed by the concentration: 52.5 mg/60 mg x 0.6 mL = 0.5 mL. Therefore, the correct answer is B (0.5 mL). Choice A is incorrect as it is less than the calculated dose. Choice C is incorrect as it is based on the concentration but does not match the calculated dose. Choice D is incorrect as it is higher than the calculated dose.