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Nurse contributing to a care plan for a client being admitted to a facility with suspected pertussis. Which should the nurse include in the care plan? (Select all that apply.)
- A. Place client in a room with negative air pressure of at least 6 exchanges per hour
- B. Wear mask when providing care within 3 ft of client
- C. Place mask on client if transportation to another department is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear gown when performing care that may result in contamination from secretions
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Wearing a mask within 3 ft of the client helps prevent the spread of pertussis, which is transmitted through respiratory secretions.
C: Placing a mask on the client during transportation reduces the risk of spreading the infection to others.
E: Wearing a gown during care that may result in contamination from secretions further prevents transmission.
A: Negative air pressure is not necessary for pertussis transmission control.
D: Sterile gloves are not required for handling soiled linens in pertussis cases.
In summary, the correct answers focus on preventing the spread of pertussis through respiratory secretions, while the incorrect choices are not directly related to infection control measures for this condition.
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Client who will undergo neurosurgery in 1 week tells the nurse in office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands them?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead with the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C: "I plan to write that I don't want them to keep me on a breathing machine." This statement indicates understanding of advance directives as it demonstrates the client's specific wishes regarding life-sustaining treatment. By stating his preference clearly, the client shows he understands the purpose of advance directives in communicating his healthcare decisions.
Choice A: This indicates a lack of understanding as the client is unsure about who should make decisions for him, showing confusion about the purpose of advance directives.
Choice B: While this choice shows awareness of the importance of advance directives, it does not demonstrate understanding of the content or purpose of the document.
Choice D: Involving the regular doctor is not necessary for advance directives and does not indicate comprehension of the document's purpose.
In summary, choice C is correct as it directly addresses a specific healthcare decision, while the other choices do not demonstrate a clear understanding of advance directives.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face, neck, chest
- D. Client with fractured fibula & tibia
Correct Answer: C
Rationale: The correct answer is C because clients with partial & full-thickness burns to face, neck, chest are the highest priority during a mass casualty event. This is due to the potential for airway compromise and risk of respiratory distress. Burns to these areas can cause swelling and compromise the airway, leading to respiratory distress and possible respiratory failure. Immediate intervention is crucial to ensure adequate oxygenation and ventilation. Clients with crush injuries (A) or fractures (D) may have serious injuries but are not at immediate risk of airway compromise. A laceration to the head (B) may require urgent attention but is not as life-threatening as airway compromise.
Nurse admitting a client with acute cholecystitis to the med-surg unit. Which of the following actions are essential to the admission procedure? (Select all that apply.)
- A. Explain roles of other care delivery staff
- B. Begin discharge planning
- C. Provide info about advance directives
- D. Document the client's wishes about organ donation
- E. Introduce client to his roommate
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Explaining roles of other care delivery staff helps manage client expectations and ensures effective communication among healthcare team members.
B: Beginning discharge planning early improves continuity of care and helps prevent delays in the discharge process.
C: Providing information about advance directives ensures the client's wishes are documented and respected in case of incapacitation.
E: Introducing the client to his roommate promotes social interaction and helps create a comfortable environment for the client.
Summary:
Choice D is incorrect as documenting organ donation wishes is not directly related to the admission process for acute cholecystitis.
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. Because doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B: "For now, I should continue to have a mammogram each year." This response shows understanding of the need for annual mammograms for breast cancer screening, which is recommended for women aged 45 and older. The other choices are incorrect because: A suggests delaying colon cancer screening, which is typically recommended starting at age 50; C implies annual pap smears, which are usually done every 3-5 years depending on age and risk factors; D indicates a lack of understanding about the frequency of blood glucose testing for diabetes screening.
Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. confidence
- B. perseverance
- C. integrity
- D. discipline
Correct Answer: D
Rationale: The correct answer is D: discipline. The nurse demonstrated discipline by following a systematic head-to-toe approach in conducting the physical assessment. This method ensures that no area is missed and all aspects of the client's health are thoroughly evaluated. Confidence (A) is important but not specific to the approach used. Perseverance (B) and integrity (C) are important traits but do not directly relate to the method of assessment. By demonstrating discipline, the nurse shows a commitment to thoroughness and professionalism in preparing the client for surgery.