Nokea
A client diagnosed with tuberculosis asks the nurse when he can return to work. The nurse should tell the client that:
- A. He can return to work when he has three negative sputum cultures.
- B. He can return to work as soon as he feels well enough.
- C. He can return to work after a week of being on the medication.
- D. He should think about applying for disability because he will no longer be able to work.
Correct Answer: A
Rationale: Three negative sputum cultures indicate the client is no longer contagious, allowing safe return to work after tuberculosis treatment.
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The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
- A. Offering high-calorie snacks
- B. Watching for signs of infection
- C. Observing for signs of oversedation
- D. Using a sunscreen with an SPF of 30
Correct Answer: C
Rationale: Ritalin, a stimulant, can cause side effects like insomnia or agitation, not oversedation. The mother's mention of oversedation indicates a misunderstanding, but the question implies correct teaching, so observing for side effects like overstimulation is key.
A client is admitted with a blood alcohol level of 180 mg/dL. The nurse recognizes that the alcohol in the client's system should be fully metabolized within:
- A. 3 hours
- B. 5 hours
- C. 7 hours
- D. 9 hours
Correct Answer: D
Rationale: A blood alcohol level of 180 mg/dL (0.18%) typically takes about 9 hours to metabolize, assuming a metabolism rate of 0.02% per hour.
Lochia serosa usually is evident on days 4 to 10 postpartum. When teaching the client about postpartum care, how should the nurse describe lochia serosa?
- A. Dark red discharge with small clots
- B. Yellowish discharge
- C. Pinkish to brownish discharge
- D. Clear watery discharge
Correct Answer: C
Rationale: Lochia serosa, days 4-10 postpartum, is pinkish to brownish (C) due to decreased blood and increased serous fluid. Dark red (A) is lochia rubra, yellowish (B) or clear (D) are not typical.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with methcillin resistant-staphylococcus aureas (MRSA)
- B. The client with diabetes
- C. The client with pancreatitis
- D. The client with Addison's disease
Correct Answer: A
Rationale: Clients with MRSA require contact precautions due to the highly contagious nature of the infection, necessitating a private room to prevent transmission to others.
A nurse needs to draw a blood sample from a patient's central line. The line is currently infusing Ringer's lactate. In which order should the nurse take the following steps to draw the blood sample? Number the steps below.
- A. attach the flush syringe and flush catheter with normal saline
- B. stop the infusion and disconnect Ringer's lactate
- C. withdraw a blood sample and discard
- D. scrub the catheter hub
- E. withdraw the blood sample for the lab
Correct Answer: B,D,C,A,E
Rationale: Order: Stop infusion (B), scrub hub (D), withdraw/discard blood (C), flush with saline (A), withdraw lab sample (E). This ensures a clean, accurate sample.