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A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is primarily spread through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve wearing a mask and eye protection within 3 feet of the patient to prevent the transmission of respiratory secretions. Contact precautions (Choice A) are for diseases transmitted through direct contact with the patient or contaminated surfaces. Airborne precautions (Choice C) are for diseases spread through tiny particles that can remain suspended in the air for long periods. Protective precautions (Choice D) are not a standard precaution type.
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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often, since it is not controlling my pain.
- B. Breathing faster will help me keep my mind off of the pain.
- C. It might help me to listen to music while trying to sleep.
- D. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C: "It might help me to listen to music while trying to sleep." This answer indicates that the client understands the preoperative teaching about pain management, as distraction techniques such as listening to music can help manage pain perception. Listening to music can be a non-pharmacological method to alleviate pain and promote relaxation. Choices A and D indicate a lack of understanding as they suggest inappropriate responses to pain. Choice B suggests a distraction technique but not the most effective one. Choices E, F, and G are not provided, but based on the context, they would likely be irrelevant or incorrect in the context of pain management.
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?
- A. Using an electronic messaging system to remind clients when to take medications.
- B. Educating clients about contraindications to specific immunizations.
- C. Helping clients understand health screenings covered by their insurance plans.
- D. Providing clients with information about the benefits of exercise.
Correct Answer: A
Rationale: The correct answer is A because using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. Tertiary prevention focuses on managing and minimizing the impact of a disease or condition to prevent complications or further deterioration. By reminding clients to take their medications, the nurse is helping to prevent disease progression and improve health outcomes.
Choice B, educating clients about contraindications to specific immunizations, is an example of secondary prevention as it aims to detect and treat a disease early to prevent complications.
Choice C, helping clients understand health screenings covered by their insurance plans, is an example of primary prevention as it aims to prevent the onset of a disease or condition.
Choice D, providing clients with information about the benefits of exercise, is also an example of primary prevention as it focuses on promoting overall health and preventing the development of diseases.
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A non-coring needle
Correct Answer: D
Rationale: The correct answer is D: A non-coring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes the risk of coring (removal of a piece of the septum) which can lead to complications. Using an angiocatheter (choice A) or a butterfly needle (choice C) can increase the risk of coring, causing damage to the port. A 25-gauge needle (choice B) is too small for accessing the port effectively. In summary, the non-coring needle is the optimal choice for accessing the port safely and effectively, while the other options pose risks of coring or inefficiency.
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
- A. Provide frequent rest periods for the client
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions.
- D. Place the client on a low-carbohydrate diet
- E. Instruct the client to avoid blowing their nose forcefully
- F. Assess the client's level of orientation.
Correct Answer: A,B,C,E,F
Rationale: The correct actions for the nurse to take are A, B, C, E, and F. Providing rest periods (A) promotes healing and recovery. Restricting sodium intake (B) is important for certain conditions like hypertension. Advising the client to avoid soap and alcohol-based lotions (C) can prevent skin irritation. Instructing the client to avoid blowing their nose forcefully (E) prevents potential harm to nasal passages. Assessing the client's level of orientation (F) is crucial for monitoring mental status and detecting any changes. These actions prioritize the client's well-being, safety, and overall health.
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing.
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings.
- D. Discourage the client from coughing during feedings.
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This position helps promote proper swallowing mechanics and reduces the risk of aspiration in clients with dysphagia. Sitting at or below eye level encourages proper head positioning and coordination during swallowing. Choices A and B are incorrect as they do not directly address the physical positioning needed for safe feeding. Choice D is incorrect as coughing during feedings can help prevent aspiration.