Nokea
A 3-year-old child had a PPD skin test 2 days ago. When the mother brings the child back to the clinic to have the nurse check the results, the nurse notes a 10 mm area of induration. This is considered
- A. an inconclusive skin test.
- B. a positive skin test.
- C. a negative skin test.
- D. too early to determine the results.
Correct Answer: B
Rationale: A 10 mm induration 48-72 hours post-PPD is positive in children, indicating TB exposure, especially in high-risk groups.
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Which of the following roommates would be most suitable for the client with myasthenia gravis?
- A. A client with hypothyroidism
- B. A client with Crohn's disease
- C. A client with pylonephritis
- D. A client with bronchitis
Correct Answer: A
Rationale: Hypothyroidism poses no infection risk, unlike pyelonephritis or bronchitis.
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
- A. An alternate method should be tried prior to applying a restraint.
- B. Confused clients are almost always safer in restraints.
- C. Restraints must be removed and the client reassessed at least every 2 hours.
- D. A written policy for application of restraints must be in place.
- E. The most restrictive restraint should be applied.
- F. The nurse does not need an order for a restraint if the client is in danger.
Correct Answer: A,C,D
Rationale: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
The charge nurse considers both patient-related and staff-related factors when making daily assignments. All of the following are patient-related factors EXCEPT
- A. mechanical ventilation use.
- B. complex medication regimen.
- C. isolation precaution requirements.
- D. nurse-to-client ratio.
Correct Answer: D
Rationale: Nurse-to-client ratio is a staff-related factor, affecting workload distribution. Ventilation, medications, and isolation are patient-specific needs.
A client with emphysema has been receiving oxygen at 3 L per minute by nasal cannula. The nurse knows that the goal of the client's oxygen therapy is achieved when the client's PaO2 reading is:
- A. 50-60 mm Hg
- B. 70-80 mm Hg
- C. 80-90 mm Hg
- D. 90-98 mm Hg
Correct Answer: B
Rationale: For clients with emphysema, a PaO2 of 70-80 mm Hg indicates adequate oxygenation without suppressing the respiratory drive.
The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
- A. The security guard
- B. The registered nurse
- C. The licensed practical nurse
- D. The nursing assistant
Correct Answer: B
Rationale: An RN has the authority to initiate seclusion based on clinical judgment.