Nokea
A client asks the nurse how to become an organ donor. Which information should the nurse include in the discussion?
- A. The client can donate by written consent.
- B. A family member must witness the consent.
- C. The donor must be older than 21 years of age.
- D. A family member must be present when a client consents to organ donation.
Correct Answer: A
Rationale: The client has the right to donate her or his own organs for transplantation, and any person who is 18 years of age or older may become an organ donor by written consent without the permission or presence of the family. In the absence of suitable documentation, a family member or legal guardian can authorize donation of the decedent's organs.
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The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?
- A. Isolate the child until the skin vesicles have dried and crusted.
- B. Ensure that the child uses a separate bathroom for elimination.
- C. Bring all household members to the clinic for a varicella vaccine.
- D. Request a prescription for antibiotics for all household members.
Correct Answer: A
Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.
The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety?
- A. Holding the oxygen tank on your lap when traveling
- B. Checking the oxygen level of the tank on a regular basis
- C. Lighting candles at least a few feet away from the oxygen tank
- D. Reporting low oxygen levels in the tank to the primary health care provider (HCP)
Correct Answer: B
Rationale: The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.
A home care nurse is visiting an older client recovering from a mild stroke affecting the left side. The client lives alone but receives regular assistance from the daughter and son, who both live within 10 miles. To assess for risk factors related to safety, which actions should the nurse take? Select all that apply.
- A. Assess the client's visual acuity.
- B. Observe the client's gait and posture.
- C. Evaluate the client's muscle strength.
- D. Look for any hazards in the home care environment.
- E. Ask a family member to move in with the client until recovery is complete.
- F. Request that the client transfer to an assisted living environment for at least 1 month.
Correct Answer: A,B,C,D
Rationale: To conduct a thorough client assessment, the nurse assesses for possible risk factors related to safety. The assessment should include assessing visual acuity, gait and posture, and muscle strength because alterations in these areas place the client at risk for falls and injury. The nurse should also assess the home environment, looking for any hazards or obstacles that would affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable.
The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with a diagnosis of chronic kidney disease. The nurse manager should note that the new nurse needs further teaching and intervene if which action is carried out by the new nurse?
- A. Uses sterile technique for needle insertion
- B. Wears full protective clothing such as goggles, mask, gown, and gloves
- C. Covers the connection site with a bath blanket to enhance extremity warmth
- D. Puts on a mask and gives one to the client to wear during connection to the machine
Correct Answer: C
Rationale: While the client is receiving hemodialysis, the connection site should not be covered, and it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the procedure. Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both the nurse and client are extremely important. It is also imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and a gown.
A client with a diagnosis of an acute respiratory infection and sinus tachycardia is admitted to the hospital. The nurse should develop a plan of care for the client and include which intervention?
- A. Limiting oral and intravenous fluids
- B. Measuring the client's pulse once each shift
- C. Providing the client with short, frequent walks
- D. Eliminating sources of caffeine from meal trays
Correct Answer: D
Rationale: Sinus tachycardia is an elevated heart rate that can be exacerbated by stimulants such as caffeine. Eliminating sources of caffeine from meal trays helps manage the client's heart rate, which is critical in the context of an acute respiratory infection where cardiac demand may already be increased. Limiting fluids is not indicated unless specific fluid overload conditions are present, which is not mentioned. Measuring the pulse once per shift is insufficient for monitoring tachycardia, as more frequent assessments are needed. Short, frequent walks may be beneficial for respiratory function but do not directly address tachycardia management.