Nokea
The nurse recognizes that it is acceptable for which pair of clients to be assigned to share a semi-private room?
- A. 35-year-old with blood loss anemia and a 28-year-old diagnosed with severe anorexia nervosa
- B. 50-year-old who had a bowel resection 2 days ago and a 40-year-old diagnosed with pneumonia
- C. 60-year-old who had a total hip arthroplasty yesterday and a 58-year-old with fever of unknown origin
- D. 60-year-old with gastroenteritis and a 70-year-old with diarrhea and vomiting related to chemotherapy
Correct Answer: D
Rationale: Clients with gastroenteritis and chemotherapy-induced diarrhea (D) have similar non-airborne conditions, making them suitable roommates. Pneumonia (B) and fever of unknown origin (C) pose infection risks. Anemia and anorexia (A) are unrelated but not optimal.
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A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the cancers mentioned in answers A, C, and D, so those are incorrect.
During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take?
- A. Do not continue the handoff report with the oncoming nurse
- B. Document the incident according to facility policy
- C. Notify the charge nurse
- D. Say nothing but watch for impaired behavior
- E. Tell the oncoming nurse that he/she is not fit for duty
Correct Answer: B,C
Rationale: Notifying the charge nurse (C) and documenting (B) ensure patient safety and follow protocol. Stopping handoff (A) disrupts care continuity. Watching silently (D) delays action, and confronting directly (E) may escalate the situation.
The nurse is observing a staff member collecting a sputum specimen from a client with active tuberculosis. The nurse should intervene if the staff member is observed
- A. leaving unused supplies in the client's room after the procedure
- B. putting on clean gloves before putting on a protective gown
- C. leaving a dedicated, disposable stethoscope in the client's room
- D. putting on an N95 respirator mask and face shield before entering the client's room
Correct Answer: A
Rationale: Leaving supplies (A) in a TB room risks contamination. Gloves before gown (B), dedicated stethoscope (C), and N95 with face shield (D) are appropriate.
An alert adult is being admitted for elective surgery. Which comment made by the client indicates a need for more instruction regarding advance directives?
- A. I brought a copy of the completed form with me.
- B. I am glad I don't have to make decisions about my care anymore.
- C. My husband is the one who gets to make decisions for me.
- D. My children all have copies of the living will.
Correct Answer: B
Rationale: Advance directives allow clients to specify care preferences, not relinquish decision-making entirely. This comment suggests a misunderstanding that requires further education.
The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?
- A. BUN of 60 mg/dL (21.4 mmol/L)
- B. serum sodium level of 155 mEq/L (155 mmol/L)
- C. serum potassium level of 7.0 mEq/L (7.0 mmol/L)
- D. serum creatinine level of 4.0 mg/dL (353.6 μmol/L)
Correct Answer: C
Rationale: A potassium level of 7.0 mEq/L (C) is life-threatening and would likely cause arrhythmias, inconsistent with normal sinus rhythm and asymptomatic status, suggesting an error. Elevated BUN (A), sodium (B), and creatinine (D) are concerning but plausible in renal or dehydration issues without immediate cardiac effects.