Nokea
A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will increase the amount of fresh fruits and vegetables I consume.'
- B. I will need to take my clothes to the dry cleaners to sterilize them.'
- C. I will be sure to wear gloves and wash my hands when I change my cat's litter box.'
- D. I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash.'
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Using alcohol to wipe up areas soiled with body fluids helps to disinfect the surfaces, reducing the risk of infection spread.
2. Immediately disposing of the trash containing body fluids prevents further exposure to infectious materials.
3. This statement demonstrates understanding of infection control measures crucial for someone with AIDS.
Incorrect Choices:
A: Increasing fresh fruits and vegetables is a healthy choice but not directly related to preventing infection spread in the context of AIDS.
B: Taking clothes to the dry cleaners for sterilization is unnecessary and does not address infection control.
C: Wearing gloves and washing hands when changing a cat's litter box is a good hygiene practice but not specific to preventing transmission of HIV.
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A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Surgical site
- C. Pain level
- D. Respiratory status
Correct Answer: D
Rationale: The correct answer is D: Respiratory status. In the PACU, ensuring adequate oxygenation and ventilation is crucial for the client's immediate postoperative recovery. Monitoring respiratory status helps prevent complications like hypoxia or respiratory distress. Assessing the airway, breathing rate, depth, and oxygen saturation takes precedence over other assessments. Level of consciousness (A) is important but can be affected by respiratory issues. Surgical site (B) assessment is important but not an immediate priority. Pain level (C) is important but can be managed once respiratory status is stable. Summary: Respiratory status is the priority as it directly impacts the client's immediate well-being and recovery.
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.
For each potential provider's prescription, click to specify if the potential prescription is anticipated, Non-essential or contraindicated for the client.
- A. Metoprolol 15 mg IV bolus
- B. Oxygen at 2 L/min via nasal cannula
- C. Draw electrolytes along with Hgb and Hct
- D. Morphine 6 mg IV bolus every 3 hrs as needed for pain
- E. Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 doses
- F. Obtain daily weight
Correct Answer: A,B,C,D E, F
Rationale: [1,1,1,1,1,1]
- Metoprolol 15 mg IV bolus: Anticipated for managing hypertension or tachycardia.
- Oxygen at 2 L/min via nasal cannula: Anticipated for hypoxemia.
- Draw electrolytes along with Hgb and Hct: Anticipated for baseline assessment.
- Morphine 6 mg IV bolus every 3 hrs: Anticipated for pain management.
- Nitroglycerin 0.5 mg SL: Not included in the options.
- Obtain daily weight: Important for monitoring fluid status.
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration?
- A. A client who has a history of asthma
- B. A client who has hypertension
- C. A client who has a history of migraines
- D. A client who has stable angina
Correct Answer: A
Rationale: The correct answer is A. Propranolol is a non-selective beta-blocker that can potentially worsen asthma symptoms by causing bronchoconstriction. Therefore, for a client with a history of asthma, the nurse should clarify the prescription with the provider to avoid exacerbating respiratory issues. The other choices (B, C, D) do not typically contraindicate propranolol administration, as it is commonly used to manage hypertension, migraines, and stable angina. It is important to consider individual client factors when administering medications to ensure safety and effectiveness.
A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
- A. Take the sample from the outer edge of formed stool.
- B. Wear sterile gloves when collecting the sample.
- C. Collect three samples from a single bowel movement.
- D. Discard samples that contain urine.
Correct Answer: D
Rationale: The correct answer is D: Discard samples that contain urine. This is crucial because urine can interfere with the accuracy of the fecal occult blood test results, leading to false positives. By discarding samples that contain urine, the nurse ensures the reliability of the test.
A: Taking the sample from the outer edge of formed stool is not necessary for a guaiac smear sample.
B: Wearing sterile gloves is important for infection control but not specifically for collecting a guaiac smear sample.
C: Collecting three samples from a single bowel movement is not standard practice for fecal occult blood testing and may not be necessary.
E, F, G: No further options provided.