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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A healthcare provider is providing teaching to a client who has a new medication prescription. Which of the following manifestations of a mild allergic reaction should the healthcare provider include?
- A. Ptosis
- B. Hematuria
- C. Urticaria
- D. Nausea
Correct Answer: C
Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. Ptosis refers to drooping of the eyelid and is not typically associated with allergic reactions. Hematuria indicates blood in the urine and is not a typical allergic reaction symptom. Nausea can occur with various conditions, but it is not a specific manifestation of a mild allergic reaction.
A nurse on a medical-surgical unit is dividing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?
- A. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she 'doesn't like him.'
- B. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions.
- C. The family of a client who has a terminal illness asks the provider not to tell the client the diagnosis.
- D. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications.
Correct Answer: C
Rationale: The correct answer is C because an ethical dilemma involves conflicting moral principles. In this scenario, the family's request not to disclose the terminal diagnosis to the client raises the moral question of truth-telling and patient autonomy. Choice A does not present an ethical dilemma but rather a challenge in client compliance. Choice B involves professional responsibility and accountability, not an ethical dilemma. Choice D relates to financial concerns and insurance coverage, which do not constitute an ethical dilemma but rather a financial issue.
A nurse is planning care for a client who had a stroke. What task should be assigned to the assistive personnel?
- A. Assist the client with a partial bed bath
- B. Measure the client's blood pressure after the nurse administers antihypertensive medications
- C. Use a communication board to ask what the client wants for lunch
- D. Feed the client
Correct Answer: A
Rationale: The correct answer is to assign the assistive personnel to assist the client with a partial bed bath. This task falls within the scope of practice for assistive personnel and is a common activity in caring for clients who have had a stroke. Choice B involves measuring blood pressure, which should be done by a licensed nurse. Choice C requires the use of a communication board, which can be done by any healthcare team member, not just assistive personnel. Choice D involves feeding the client, which may require assessment and intervention by a licensed nurse to ensure proper nutrition and safety.
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
- A. When do you usually bathe, in the morning or evening?
- B. Do you prefer a bath or a shower?
- C. At what temperature do you prefer your bath water?
- D. Are you able to help with your hygiene care?
Correct Answer: D
Rationale: The priority assessment question before beginning hygiene care for a new resident is determining if the resident is able to help with their hygiene care. This is essential to ensure the resident's safety during the procedure and prevent any potential injuries. Options A, B, and C, while relevant to providing personalized care, are not as critical as assessing the resident's ability to participate in their own hygiene care. Asking about the resident's ability to assist also promotes their independence and autonomy in self-care activities.
A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?
- A. Members of the same religion may have varying feelings about their religion.
- B. A shared religion background does not guarantee identical beliefs.
- C. The same religious beliefs can influence individuals differently.
- D. Discussing differences and commonalities in beliefs may not always be relevant.
Correct Answer: C
Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.