Nokea
The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?
- A. Non-steroidal anti-inflammatory drugs (NSAIDs)
- B. Cough medicines with guaifenesin
- C. Histamine blockers
- D. Laxatives containing magnesium salts
Correct Answer: A
Rationale: Non-steroidal anti-inflammatory drugs (NSAIDs). Medications with NSAIDs may increase the response to Coumadin (warfarin) and increase the risk of bleeding.
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The client is admitted with a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which precaution should be implemented to prevent spreading the infection to health care workers and other clients?
- A. Wearing a mask within 3 feet of the client
- B. Placing the client in a private room
- C. Wearing an N95 respirator mask
- D. Ensuring a negative-air-pressure room
Correct Answer: B
Rationale: B: A private room prevents MRSA transmission via contact. A, C: Masks are unnecessary for MRSA. D: Negative air pressure is for airborne precautions.
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
- A. Presence of blood in stools
- B. Oozing liquid stool
- C. Continuous climbing flatulence
- D. Absence of bowel movements
Correct Answer: B
Rationale: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
- A. Ask client to cough sputum into container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
The nurse is wearing PPE. Place the steps to removing the PPE in the correct sequence.
- A. Remove gown
- B. Remove gloves and perform hand hygiene
- C. Remove mask
- D. Remove eye protection
- E. Perform hand hygiene
Correct Answer: B,D,A,C,E
Rationale: B: Gloves are removed first due to high contamination risk, followed by hand hygiene. D: Eye protection is removed next. A: Gown is removed before leaving. C: Mask is removed at the doorway. E: Final hand hygiene ensures cleanliness.
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
- A. A 79 year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. An incontinent client who has had 3 diarrhea stools
- D. An 80 year-old ambulatory diabetic client
Correct Answer: A
Rationale: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.