Nokea
A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?
- A. Hydrogen peroxide
- B. Chlorhexidine
- C. Isopropyl alcohol
- D. Chlorine bleach
Correct Answer: D
Rationale: Chlorine bleach is the recommended agent for cleaning blood spills due to its effectiveness in killing bloodborne pathogens like HIV and hepatitis B. Hydrogen peroxide, Chlorhexidine, and Isopropyl alcohol are not as effective as chlorine bleach in disinfecting surfaces contaminated with blood and eliminating bloodborne pathogens, making them incorrect choices.
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A client who is having suicidal thoughts tells the nurse, "It just doesn't seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?
- A. Why do you think your life is not worth it anymore?
- B. Do you have a plan to end your life?
- C. I need to know what you mean by misery
- D. You can trust me and tell me what you're thinking
Correct Answer: B
Rationale: The appropriate response by the nurse is to ask about the client's plan to end their life. This question helps to assess the severity of the client's suicidal ideation and the immediacy of the risk, allowing the nurse to determine the appropriate level of intervention. Choices A, C, and D do not directly address the immediate risk assessment needed in this situation.
A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?
- A. Blood glucose of 150 mg/dL
- B. Urine output of 20 mL per hour
- C. Systolic blood pressure of 140 mm Hg
- D. BUN 20 mg/dL
Correct Answer: B
Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.
A client who is at 32 weeks gestation and has a history of cardiac disease is being cared for by a nurse. Which of the following positions should the nurse place the client in to best promote optimal cardiac output?
- A. The chest
- B. Standing
- C. Supine
- D. Left lateral
Correct Answer: D
Rationale: The correct answer is the left lateral position. Placing the client in the left lateral position promotes optimal cardiac output during pregnancy by reducing pressure on the inferior vena cava, improving blood flow to the heart and fetus. Choice A, 'The chest,' is incorrect as it does not describe a position that benefits cardiac output. Choice B, 'Standing,' is incorrect as it does not alleviate pressure on the vena cava. Choice C, 'Supine,' is contraindicated in pregnancy, especially in clients with cardiac disease, as it can compress the vena cava and decrease cardiac output.
A nurse is assessing a client who has a blood glucose level of 250 mg/dL. Which of the following clinical manifestations is associated with this finding?
- A. Confusion
- B. Thirst
- C. Diaphoresis
- D. Shakiness
Correct Answer: B
Rationale: Corrected Detailed Rationale: A blood glucose level of 250 mg/dL indicates hyperglycemia. Thirst (polydipsia) is a common clinical manifestation associated with hyperglycemia. The body tries to compensate for the high blood sugar by increasing fluid intake. Confusion (choice A) is more commonly associated with hypoglycemia, not hyperglycemia. Diaphoresis (choice C) and shakiness (choice D) are typical manifestations of hypoglycemia, not hyperglycemia. Therefore, the correct answer is increased thirst (polydipsia) in response to the elevated blood glucose level.
A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following actions should the nurse take?
- A. Administer the TPN solution separately from 0.9% sodium chloride
- B. Check for an allergy to eggs
- C. Discuss the TPN solution with the client
- D. Monitor for hypoglycemia
Correct Answer: B
Rationale: The correct action for the nurse to take when preparing to administer TPN with fat supplements is to check for an allergy to eggs. The lipid emulsion in TPN often contains egg phospholipids, so screening for egg allergies is crucial to prevent any adverse reactions. Option A is incorrect because TPN should not be piggybacked with 0.9% sodium chloride to avoid any interactions or dilution of the TPN solution. Option C is incorrect as discussing the TPN solution with the client is not the priority when preparing to administer it. Option D is incorrect as monitoring for hypoglycemia, although important in TPN administration, is not specifically related to the addition of fat supplements.