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A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?
- A. Provide negative room ventilation
- B. Wear a face mask with shield
- C. Wear a particulate respirator mask
- D. Institute airborne precautions
Correct Answer: C
Rationale: Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.
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The nurse has reinforced teaching with a client who has anxiety and a new prescription for alprazolam. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can continue to take my prescribed muscle relaxant as needed.
- B. I can omit the medication on days when I do not feel anxious.
- C. I should eliminate aged cheese and processed meats from my diet.
- D. I will discontinue the medication and notify my health care provider if I become pregnant.
Correct Answer: D
Rationale: Alprazolam is a benzodiazepine, and its use during pregnancy can pose risks to the fetus. Discontinuing and notifying the provider is critical. Muscle relaxants may enhance sedation, skipping doses disrupts therapeutic levels, and dietary restrictions like avoiding tyramine are not required for alprazolam.
The nurse is preparing teaching for a client with Parkinson disease. Which of the following techniques are appropriate when communicating with a client with Parkinson disease? Select all that apply.
- A. Encourage the client to speak slowly and pause to take deep breaths periodically
- B. Identify and promote the client's capabilities and strengths throughout the sessions
- C. Provide client teaching during times of day when the client has the most energy
- D. Reserve discussion of important or complex teaching for the client's caregiver
- E. Schedule teaching sessions at times with low risk of rushing or interruptions
Correct Answer: A,B,C,E
Rationale: Speaking slowly aids clarity, promoting strengths builds confidence, teaching during high-energy times optimizes learning, and uninterrupted sessions enhance focus. Complex teaching should include the client, not just the caregiver, to respect autonomy.
A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?
- A. Administer 10 units oxytocin IM
- B. Apply oxygen via nonrebreather facemask at 10 L/min
- C. Assist the client to void on a bedpan
- D. Obtain blood for a hemoglobin and hematocrit level
Correct Answer: C
Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.
A nursing assistant comes to the LPN/LVN and complains that she has more residents to care for than another nursing assistant (NA). She has one more resident assigned to her than the other NA. However, the other NA has more total care residents than the complaining NA. How should the LPN/LVN handle this situation?
- A. Tell the complaining NA that this is the assignment
- B. Promise to give her an easier assignment tomorrow
- C. Discuss with her the needs of her assignment and help her organize her care
- D. Tell her that the other NA will help her as needed
Correct Answer: C
Rationale: Discussing needs and organizing care addresses the NA's concerns constructively, promoting teamwork and efficiency without dismissing or deferring.
A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
- A. Ask the client if he has noticed any bleeding or dark stools
- B. Tell the client to call 911 and go to the emergency department immediately
- C. Schedule a repeat Hemoglobin and Hematocrit in 1 month
- D. Tell the client to schedule an appointment with a hematologist
Correct Answer: A
Rationale: Ask the client if he has noticed any bleeding or dark stools. These values indicate mild anemia, and the first step is to assess for potential sources of blood loss.