Nokea
The nurse is reinforcing teaching with a client who is starting to use a cervical cap for contraception. Which client statement would require follow-up?
- A. I should apply spermicide to the cervical cap before inserting it.
- B. I can insert the cervical cap several hours before I have sexual intercourse.
- C. I should leave the cervical cap in place for at least 24 hours after intercourse.
Correct Answer: C
Rationale: Leaving the cervical cap in for at least 24 hours increases infection risk; it should remain for 6-8 hours post-intercourse. Applying spermicide and inserting hours before intercourse are correct practices for effective use.
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Someone who has received a recent tattoo should be screened for:
- A. tuberculosis.
- B. herpes.
- C. hepatitis.
- D. syphilis.
Correct Answer: C
Rationale: Tattooing with non-sterile equipment risks transmission of hepatitis B or C, blood-borne pathogens. The other infections are not primarily associated with tattooing. Safety and Infection Control
The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the most concerning?
- A. Pain and pallor in one foot
- B. Pain in both knees
- C. Splinter hemorrhages in the nail beds
- D. Temperature of 38.2°C (100.8°F)
Correct Answer: A
Rationale: Pain and pallor in one foot suggest an embolic event, a serious complication of infective endocarditis that could lead to tissue ischemia or infarction, requiring urgent intervention. Knee pain, splinter hemorrhages, and mild fever are less immediately threatening.
The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?
- A. Ask the UAP to go back and ask the client what the current needs are
- B. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room
- C. Tell the UAP to inform the client in the next room that the nurse will be there shortly
- D. Tell the UAP to tell the charge nurse about the needs of the client in the next room
Correct Answer: D
Rationale: During moderate sedation, the nurse must remain with the client to monitor vital signs and response. Directing the UAP to inform the charge nurse ensures the other client's needs are addressed without compromising the sedated client's safety. UAP cannot monitor sedation or take over.
The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?
- A. Crackles in the lungs
- B. Confusion and restlessness
- C. Distended neck veins
- D. Use of accessory muscles
Correct Answer: B
Rationale: Confusion and restlessness. Neurological changes, including impaired mental status, are early signs of inadequate oxygenation.
The nurse is caring for a woman who has diabetic neuropathy. The nurse knows that the client needs more instruction when the client makes which statement?
- A. I'll use a hot water bottle if my feet hurt.'
- B. I should dry my feet and toes carefully.'
- C. I go to the podiatrist to have my toenails cut.'
- D. The Tegretol seems to help my leg pain.'
Correct Answer: A
Rationale: Hot water bottles can burn insensitive neuropathic feet, risking injury. Drying feet, podiatrist care, and using Tegretol for neuropathic pain are appropriate.