Nokea
A client diagnosed with hepatitis B asks the nurse how the virus is transmitted. Which of the following is the correct response?
- A. by infectious blood or needles
- B. by infectious blood, sexual contact, and needles, and from mother to newborn
- C. by contaminated food and water
- D. by contaminated water only
Correct Answer: B
Rationale: Hepatitis B is transmitted via blood, sexual contact, needles, and perinatally from mother to newborn.
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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 nurse asks an unlicensed assistive personnel (UAP) to help admit a 22-year-old female client with ulcerative colitis. Which activity is appropriate for the nurse to assign the UAP?
- A. obtain a stool sample
- B. obtain abbreviated history of symptoms for the past 30 days
- C. instruct the client on the reason for undergoing a lower gastric X-ray exam
- D. obtain a sample of gastric contents from nasogastric tube
Correct Answer: A
Rationale: Obtaining a stool sample is within the UAP’s scope, as it is a non-invasive task. Other activities involve assessment or teaching, which require RN expertise.
A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring efficacy while minimizing toxicity; a level of 20 mcg/mL is within this range.
The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?
- A. Use the left hand to cleanse the client's rectal area.
- B. Ask a female family member to assist the client.
- C. Wear gloves when cleansing the client's rectal area.
- D. Ask the client's husband to assist the client.
Correct Answer: B
Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (B) to maintain modesty. The left hand (A) is traditionally used by the client, not the nurse. Gloves (C) are standard but not cultural. The husband (D) may not be appropriate due to modesty.
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
- A. Diminished femoral pulses
- B. Harlequin's sign
- C. Circumoral pallor
- D. Acrocyanosis
Correct Answer: A
Rationale: Diminished femoral pulses suggest coarctation of the aorta, a cardiac anomaly, requiring further evaluation.