Nokea
A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first?
- A. Institute droplet precautions.
- B. Obtain the child's vital signs.
- C. Ask the parent about medication allergies.
- D. Inquire about the health of siblings at home.
Correct Answer: A
Rationale: Meningococcal meningitis is transmitted via droplets, so instituting precautions is the priority to prevent spread.
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Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation?
- A. Practice meticulous hand hygiene.
- B. Maintain the head of the bed elevation at 10 degrees.
- C. Perform suctioning of oral cavity secretions every 4 hours.
- D. Have the respiratory therapist change the ventilator circuit tubing every 4 hours.
Correct Answer: A
Rationale: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:
- A. If I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: D
Rationale: Clients with preterm labor should get out of the car every 1-2 hours to promote circulation and prevent complications, not every 4 hours, indicating a need for further instruction.
The nurse is teaching a client with hypertension about dietary modifications. Which statement by the client indicates understanding of the teaching?
- A. I should increase my intake of processed foods.'
- B. I will limit my sodium intake to 2,300 mg per day.'
- C. I can drink coffee as much as I want.'
- D. I should avoid fruits like bananas.'
Correct Answer: B
Rationale: Limiting sodium to 2,300 mg per day or less helps manage hypertension by reducing fluid retention and blood pressure.
A client has been given a prescription to begin using nitroglycerin transdermal patches. The nurse instructs the client about this medication administration system and tells the client to expect which side effect?
- A. Sweating
- B. Headache
- C. Dry mouth
- D. Constipation
Correct Answer: B
Rationale: Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. A common side effect of this medication is an intense headache. Clients should be instructed about this side effect and that acetaminophen can be helpful in alleviating discomfort. The remaining options are not associated with the use of this medication.
The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first?
- A. Apply oxygen.
- B. Administer morphine sulfate.
- C. Start an intravenous (IV) line.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.