Nokea
A client has Clostridium difficile infection. Which of the following actions should the nurse take?
- A. Wash hands with an alcohol-based hand rub.
- B. Place the client on contact precautions.
- C. Wear a mask when entering the client's room.
- D. Double-bag all linens before removing them from the room.
Correct Answer: B
Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.
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A nurse is teaching a prenatal class about infections. Which statement by a participant indicates a need for further teaching?
- A. I can clean the cat's litter box during pregnancy.
- B. I can visit someone with the flu after receiving the vaccine.
- C. I should take antibiotics for viral infections.
- D. I should wash my hands after gardening.
Correct Answer: C
Rationale: The correct answer is C. This statement indicates a need for further teaching because antibiotics are ineffective against viral infections. It is important to educate the participant that antibiotics are only effective against bacterial infections, not viral ones. Choices A, B, and D are correct statements that promote good hygiene practices and infection prevention during pregnancy.
A nurse is teaching a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?
- A. "You should expect to feel an improvement in your symptoms within 1 week."
- B. "You may experience weight gain while taking this medication."
- C. "You should take this medication in the morning to prevent insomnia."
- D. "You should stop taking this medication if you experience dry mouth."
Correct Answer: B
Rationale: The correct statement the nurse should include is that the client may experience weight gain while taking fluoxetine. Weight gain is a common side effect of fluoxetine, and patients should be informed about this potential issue. Stating that the client should expect improvement in symptoms within 1 week (Choice A) is incorrect as fluoxetine may take a few weeks to have a noticeable effect. Taking the medication in the morning to prevent insomnia (Choice C) is not necessary since fluoxetine can be taken at any time of the day. Instructing the client to stop taking the medication if experiencing dry mouth (Choice D) is misleading, as dry mouth is a common but usually not serious side effect of fluoxetine.
A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which manifestation should the nurse expect?
- A. Loose stools.
- B. Jitteriness.
- C. Hypertonia.
- D. Abdominal distention.
Correct Answer: B
Rationale: Jitteriness is a common symptom of neonatal hypoglycemia. When a newborn has a low blood glucose level, they may exhibit signs of central nervous system dysfunction, such as jitteriness. Loose stools (Choice A) are not typically associated with neonatal hypoglycemia. Hypertonia (Choice C) refers to increased muscle tone, which is not a common manifestation of hypoglycemia in newborns. Abdominal distention (Choice D) is more often associated with gastrointestinal issues rather than hypoglycemia.
A client has had vomiting and diarrhea for the past 3 days. Which of the following findings indicates the client is experiencing fluid volume deficit?
- A. Jugular vein distention
- B. Bradycardia
- C. Increased respiratory rate
- D. Bounding pulses
Correct Answer: C
Rationale: An increased respiratory rate is a sign of fluid volume deficit as the body attempts to compensate for decreased blood volume. Jugular vein distention, bradycardia, and bounding pulses are not typical findings of fluid volume deficit. Jugular vein distention is more commonly associated with fluid volume overload, bradycardia can be a sign of fluid volume excess or other issues, and bounding pulses are not typically seen in fluid volume deficit.
A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?
- A. Potassium 4.2 mEq/L
- B. Glucose 250 mg/dL
- C. Bicarbonate 20 mEq/L
- D. Sodium 135 mEq/L
Correct Answer: B
Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.