Nokea
A client has been admitted with draining foot lesions. The nurse should do which of the following? Select all that apply.
- A. Place the client in a room with negative air pressure.
- B. Admit the client to a semi-private room.
- C. Admit the client to a private room.
- D. Post a "contact isolation" sign on the door.
- E. Wear a protective gown when in the client's room.
- F. Wear latex-free gloves when providing direct care.
Correct Answer: C,D,E,F
Rationale: Draining lesions require contact precautions, including a private room, isolation signage, gowns, and gloves (latex-free to avoid allergies). Negative pressure is for airborne pathogens.
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A client with renal calculi reports sudden cessation of pain. The nurse should:
- A. Strain all urine.
- B. Administer analgesics.
- C. Check vital signs.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Sudden pain cessation may indicate stone passage; straining urine confirms this.
A client is receiving dopamine hydrochloride for treatment of shock. The nurse should:
- A. Administer pain medication concurrently.
- B. Monitor blood pressure continuously.
- C. Evaluate arterial blood gases at least every 2 hours.
- D. Monitor for signs of infection.
Correct Answer: B
Rationale: Dopamine can cause significant changes in blood pressure due to its inotropic and vasopressor effects. Continuous blood pressure monitoring is essential to titrate the dose and prevent complications. Pain medication, arterial blood gases, and infection monitoring are not primary.
Peripheral blood flow is dependent on which of the following variables?
- A. Blood viscosity and diameter of vessels
- B. Diameter and resistance of vessels
- C. Force of contraction of the heart and resistance of vessels
- D. Pressure differences in the arterial and venous systems and resistance
Correct Answer: D
Rationale: Peripheral blood flow depends on pressure differences between the arterial and venous systems (driving force) and vascular resistance (opposing force). This relationship is governed by Poiseuille's law and Ohm's law for fluid flow, where flow is proportional to the pressure gradient and inversely proportional to resistance. The other options are incomplete or incorrect combinations of factors.
Postoperative nursing management of the client following a radical neck dissection for laryngeal cancer requires:
- A. Complete bed rest minimizing head movement.
- B. Vital signs once a shift.
- C. A. All the nurse should be made to be removed at 48 hours.
- D. Frequent suctioning of the laryngectomy tube.
Correct Answer: D
Rationale: Frequent suctioning of the laryngectomy tube prevents mucus buildup and maintains airway patency. Complete bed rest is unnecessary; early mobility is encouraged. Vital signs should be monitored more frequently than once per shift. The third option is unclear but likely incorrect.
A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior is probably caused by:
- A. Uncertainty and an underlying fear of recurrence.
- B. The usual trajectory of a short-term illness.
- C. A history of a behavioral illness.
- D. The one-time crisis from learning of the diagnosis.
Correct Answer: A
Rationale: Disruptive behavior in a cancer client is often driven by uncertainty and fear of recurrence, reflecting ongoing emotional distress.