Nokea
An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
- A. Stay with client and observe for airway obstruction
- B. Collect pillows and pad the side rails of the bed
- C. Place an oral airway and use the body
- D. Announce a cardiac arrest, and assist with intubation
Correct Answer: A
Rationale: Stay with client and observe for airway obstruction. For the client's safety, remain at the bedside and observe respirations and level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure.
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The nurse is instructing the client who is to have surgery. According to Medicare's Surgical Care Improvement Project, what instruction is important for the client to receive prior to arrival at the hospital to prevent postoperative infection?
- A. Arrive in time to receive an antibiotic before surgery.
- B. Notify the nurse of any antibiotic and food allergies.
- C. Be sure to wash your hands before coming to the hospital.
- D. Do not shave hair from the surgical incision site.
Correct Answer: D
Rationale: D: Avoiding shaving prevents skin lacerations that increase infection risk. A, B: While important, they are managed in-hospital. C: Hand washing by the client is less critical.
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
- A. every four to six hours
- B. continuously
- C. in a bolus
- D. every hour
Correct Answer: B
Rationale: continuously. Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula.
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
The charge nurse is planning a room assignment for the client with meningococcal meningitis. Which room and precautions should the nurse plan for this client?
- A. A private room with droplet precautions
- B. A private room with airborne precautions
- C. A semiprivate room with a roommate who has a similar diagnosis and standard precautions
- D. A semiprivate room with a roommate who has a similar diagnosis and contact precautions
Correct Answer: B
Rationale: B: Meningococcal meningitis requires airborne precautions and a private room due to possible airborne transmission. A, C, D: These are insufficient or inappropriate.
Which information should the nurse reinforce to the parents of a child recently diagnosed with Kawasaki disease?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes.'
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.'
- C. Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent.'
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.'
Correct Answer: C
Rationale: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent, particularly Japanese. Other findings in the initial phase are extremely red eyes (conjunctivitis), a rash on the main part of the body (trunk) and in the genital area, red, dry, cracked lips; a red, swollen tongue resembling a strawberry; swollen, red skin on the palms of the hands and the soles of the feet; swollen lymph nodes in the neck.