Nokea
A 20-year-old client has an infected leg wound from a motorcycle accident and has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:
- A. Visitors must wear a mask and a gown
- B. There are no special requirements for visitors of clients on contact precautions
- C. Visitors should wash their hands before and after touching the client
- D. Visitors -
Correct Answer: C
Rationale: The correct answer is C: 'Visitors should wash their hands before and after touching the client.' When a client is on contact precautions, it is essential for visitors to practice good hand hygiene to prevent the spread of infection. While wearing a mask and a gown might be necessary for healthcare providers, it is not typically required for visitors. Option B is incorrect because there are indeed special requirements for visitors on contact precautions, including practicing good hand hygiene. Option D is incomplete and does not provide any guidance on infection prevention measures.
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A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?
- A. Administer insulin as ordered
- B. Encourage the client to drink fluids
- C. Notify the healthcare provider
- D. Recheck the blood glucose level in 30 minutes
Correct Answer: A
Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.
A client is scheduled for a colonoscopy. Which of these instructions should the nurse provide?
- A. You should avoid eating or drinking anything after midnight the day before the test.
- B. You may have a light breakfast the morning of the test.
- C. You will need to drink a bowel preparation solution the day before the test.
- D. You will need to avoid taking any medications the day before the test.
Correct Answer: C
Rationale: The correct answer is C: 'You will need to drink a bowel preparation solution the day before the test.' Before a colonoscopy, it is essential to cleanse the colon thoroughly by drinking a bowel preparation solution. This helps to ensure that the colon is clear for the procedure, allowing for better visualization and examination of the colon. Choices A, B, and D are incorrect because avoiding eating or drinking after midnight, having a light breakfast, and avoiding medications are not specific instructions related to the colonoscopy preparation process.
The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?
- A. We will call the healthcare provider if the child develops acne.
- B. Our child should brush and floss carefully after every meal.
- C. We will skip the next dose if vomiting or fever occurs.
- D. When our child is seizure-free for 6 months, we can stop the medication.
Correct Answer: B
Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.
When assessing constipation in elders, which action should be the nurse's priority?
- A. Obtain a complete blood count
- B. Obtain a health and dietary history
- C. Refer to a provider for a physical examination
- D. Measure height and weight
Correct Answer: B
Rationale: The correct answer is to obtain a health and dietary history when assessing constipation in elders. This action is crucial as it helps the nurse identify potential causes and contributing factors to constipation in elderly clients. Obtaining a complete blood count (choice A) may be necessary at some point, but it is not the priority in this situation. Referring to a provider for a physical examination (choice C) and measuring height and weight (choice D) are important but are not the priority actions when assessing constipation.
A nurse is reinforcing teaching with a group of older adults about oil-rich foods. The nurse should include which of the following foods as the equivalent of 4 tsp of oil?
- A. 1 tbsp of soft margarine
- B. ½ oz of nuts
- C. 2 tbsp of peanut butter
- D. 1 oz of sunflower seeds
Correct Answer: C
Rationale: The correct answer is C: 2 tbsp of peanut butter. Two tablespoons of peanut butter is approximately equivalent to 4 teaspoons of oil, providing healthy fats in the diet. Choice A, 1 tbsp of soft margarine, is not equivalent to 4 tsp of oil as margarine contains additional ingredients. Choice B, ½ oz of nuts, and choice D, 1 oz of sunflower seeds, do not provide an equivalent amount of oil as requested in the question.