Nokea
A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective
Correct Answer: A
Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.
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When planning interventions for a group of clients who are obese, what can the nurse do to improve their commitment to a long-term goal of weight loss?
- A. Developing a strict diet plan
- B. Attempting to develop the clients' self-motivation
- C. Providing frequent rewards
- D. Encouraging group exercise
Correct Answer: B
Rationale: To improve clients' commitment to a long-term goal of weight loss, attempting to develop their self-motivation is crucial. Self-motivation is essential for sustaining behavior changes over time. Providing a strict diet plan (choice A) may not address the root motivation needed for long-term success. While rewards (choice C) can be motivating, relying solely on external rewards may not foster the intrinsic motivation required for sustained weight loss. Encouraging group exercise (choice D) is beneficial, but without addressing individual motivation, it may not lead to long-term commitment to weight loss goals.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?
- A. Obtain the pre-transfusion hemoglobin level.
- B. Prime the tubing and set up the blood pump.
- C. Monitor vital signs every 15 minutes for the first hour.
- D. Ensure the accuracy of the blood type match.
Correct Answer: D
Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.
When changing a client's colostomy pouch and noticing peristomal skin irritation, which of the following actions should the nurse take?
- A. Change the pouch as needed based on individual requirements.
- B. Apply the pouch only when the skin barrier is completely dry.
- C. Pat the peristomal skin dry after cleaning.
- D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.
Correct Answer: D
Rationale: When a nurse observes peristomal skin irritation while changing a client's colostomy pouch, it is crucial to ensure that the pouch is slightly larger (0.32 cm or 1/8 inch) than the stoma. This extra space helps prevent the pouch from rubbing against the stoma and causing further irritation. Option A is correct because colostomy pouches should be changed based on individual needs, not necessarily every 24 hours. Option B is incorrect because applying the pouch only when the skin barrier is completely dry ensures better adhesion. Option C is incorrect as patting the peristomal skin dry after cleaning is more gentle and less likely to cause irritation compared to rubbing.
A client with diabetes mellitus and a new prescription for insulin is being discharged. Which of the following actions should the nurse plan to complete first?
- A. Provide the client with printed information on insulin self-administration.
- B. Obtain printed information on insulin self-administration.
- C. Make a copy of the medication reconciliation form for the client.
- D. Determine whether the client can afford the insulin administration supplies.
Correct Answer: B
Rationale: Obtaining printed information on insulin self-administration should be the nurse's first priority. This action ensures that the client has the necessary knowledge to safely self-administer insulin at home. Providing the client with printed information (Choice A) is essential to empower the client with the required knowledge before considering additional resources. Making a copy of the medication reconciliation form for the client (Choice C) is important for documentation purposes but not as urgent as ensuring the client's understanding of insulin administration. Determining the client's ability to afford insulin administration supplies (Choice D) is crucial but should follow after ensuring the client is equipped with the necessary information for safe self-administration.
During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse's priority?
- A. A client who received crush injuries to the chest and abdomen and is expected to die.
- B. A client who has a 4-inch laceration to the head.
- C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest.
- D. A client who has a fractured fibula and tibia.
Correct Answer: C
Rationale: During a mass casualty event, the priority client for the nurse is the one with partial-thickness and full-thickness burns to the face, neck, and chest. Clients with severe burns in critical areas require immediate attention due to the potential for life-threatening complications such as airway compromise, fluid loss, and infection. Crush injuries and fractures, although serious, are generally less urgent in comparison and can be managed after addressing the burns. Therefore, the client with burns to the face, neck, and chest should be the nurse's priority over the other clients described.