Nokea
A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system.
- B. Use alcohol-based hand sanitizer when leaving the client's room.
- C. Clean contaminated surfaces in the client's room with a phenol solution.
- D. Have family members wear a gown and gloves when visiting.
Correct Answer: D
Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.
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A client is scheduled for a bronchoscopy. After the nurse explains the procedure, which statement by the client indicates a need for further teaching?
- A. I'm glad I don't have to lie still for this procedure.
- B. I will have a local anesthetic to help with discomfort.
- C. I hope I get some medicine to relax me.
- D. I can't eat or drink for 6 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A because the client's statement indicates a misunderstanding about the need to lie still during the bronchoscopy procedure. The client actually needs to remain still for the procedure to ensure its accuracy and safety. Choices B, C, and D demonstrate an understanding of the procedure by acknowledging the local anesthetic for discomfort, the possibility of receiving medicine for relaxation, and the requirement to fast before the procedure, respectively.
A client with diabetes mellitus is being taught by a nurse how to perform a capillary blood glucose test. Which of the following instructions should the nurse include in the teaching?
- A. Don sterile gloves after cleansing the site
- B. Puncture the site after cleansing and before the antiseptic dries
- C. Gently wipe the puncture site until a large droplet of blood forms
- D. Hold the finger below the heart level to puncture
Correct Answer: B
Rationale: The correct instruction is to puncture the site after cleansing and before the antiseptic dries. This sequence helps ensure proper blood collection without introducing contaminants. Choice A is incorrect because wearing sterile gloves is not necessary for capillary blood glucose testing. Choice C is incorrect as wiping the puncture site can introduce contaminants and alter the blood sample. Choice D is incorrect as holding the finger below the heart level is not required for a capillary blood glucose test.
The LPN/LVN is assisting with the care of a client who has just had a liver biopsy. What position should the nurse place the client in immediately following the procedure?
- A. Supine with the right arm raised above the head
- B. Supine with the head of the bed elevated
- C. Right side-lying with a pillow under the costal margin
- D. Left side-lying with the head of the bed flat
Correct Answer: C
Rationale: The correct position for a client immediately following a liver biopsy is right side-lying with a pillow under the costal margin. This position helps prevent bleeding by applying pressure to the biopsy site. Placing the client supine with the right arm raised above the head (Choice A) or supine with the head of the bed elevated (Choice B) are not ideal positions for post-liver biopsy care as they do not provide the necessary pressure to the biopsy site. Left side-lying with the head of the bed flat (Choice D) is also not recommended as it does not assist in preventing bleeding after a liver biopsy.
Which goal is most appropriate for a patient who has had a total hip replacement?
- A. The patient will ambulate briskly on the treadmill by the time of discharge.
- B. The patient will walk 100 feet using a walker by the time of discharge.
- C. The nurse will assist the patient to ambulate in the hall 2 times a day.
- D. The patient will ambulate by the time of discharge.
Correct Answer: B
Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer?
- A. 0.5 ml
- B. 1 ml
- C. 1.5 ml
- D. 2 ml
Correct Answer: A
Rationale: To administer 4 mg of morphine, as prescribed, the LPN/LVN needs to calculate the correct volume based on the concentration provided (8 mg per ml). Since the desired dose is 4 mg, half of 8 mg (0.5 ml) is required to administer the correct amount. Therefore, the correct answer is 0.5 ml. Choices B, C, and D are incorrect as they would either underdose or overdose the patient.