Nokea
A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply.
- A. Keep dedicated equipment for client
- B. Perform hand hygiene before exiting the room
- C. Place a 'No Visitors' sign on the client's door
- D. Wear a face mask when in the room
- E. Wear an isolation gown when providing direct care
Correct Answer: A,B,E
Rationale: Dedicated equipment, hand hygiene, and an isolation gown prevent the spread of vancomycin-resistant enterococcus. A 'No Visitors' sign is unnecessary, and a face mask is not required unless droplet precautions are indicated.
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Which of the following instructions would not be included in the discharge teaching for a client receiving Thorazine (chlorpromazine)?
- A. Wear protective clothing when working outside.
- B. Avoid eating aged cheese.
- C. Carry hard candy to decrease dryness of the mouth.
- D. Report a sore throat immediately.
Correct Answer: B
Rationale: Avoiding aged cheese is relevant for MAOIs, not chlorpromazine. Protective clothing prevents photosensitivity, hard candy relieves dry mouth, and reporting a sore throat is critical for agranulocytosis.
The nurse is talking with a client with obsessive-compulsive disorder. When the client performs ritualistic behaviors, the nurse should recognize that the client
- A. is hearing voices
- B. is trying to control feelings of anger
- C. has an intense desire to control the environment
Correct Answer: C
Rationale: Ritualistic behaviors in OCD are driven by an intense need to control the environment or reduce anxiety through repetitive actions. They are not related to hearing voices or controlling anger, which are more associated with other disorders.
The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is
- A. The top layer of the skin is destroyed.'
- B. The skin layers are swollen and reddened.'
- C. All layers of the skin were destroyed in the burn.'
- D. Muscle, tissue and bone have been injured.'
Correct Answer: C
Rationale: All layers of the skin were destroyed in the burn.' A third degree burn is a full thickness injury to dermis, epidermis and subcutaneous tissue.
The nurse is contributing to the plan of care for a client with diabetes who reports breast tenderness, vaginal discharge, and urinary frequency. Which action is most important to include in the plan of care?
- A. Ask if the client performs breast self-exams
- B. Ask the client about characteristics of vaginal discharge
- C. Determine the date of the client's last menstrual period
- D. Review the client's home blood sugar logs
Correct Answer: C
Rationale: Determining the date of the client's last menstrual period is critical to assess for pregnancy or menopausal changes, which could explain the symptoms and impact diabetes management. Breast self-exams and vaginal discharge characteristics are less urgent, and blood sugar logs, while important, are not directly related to the reported symptoms.
A young couple asks the nurse what method of contraception they should use. What information is most important for the nurse to have before giving an answer?
- A. The exact age of the couple
- B. The sexual history of both partners
- C. The method they find most acceptable
- D. How soon they want to start a family
Correct Answer: C
Rationale: The couple's preferred contraceptive method ensures adherence and satisfaction, guiding the nurse's recommendations. Age, sexual history, or family planning timeline are secondary.