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A nurse +2:43 is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is transmitted through respiratory droplets from infected individuals. Droplet precautions involve wearing a mask when within 3 feet of the client to prevent the transmission of droplets. Contact precautions (Choice A) are for diseases spread through direct contact with the client or contaminated surfaces. Airborne precautions (Choice C) are for diseases that are transmitted through tiny particles that remain suspended in the air. Protective precautions (Choice D) are not a standard precaution type but rather a set of measures to protect immunocompromised clients from infections.
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A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
- A. Insert the catheter at a 45-degree angle.
- B. Place the client's arm in a dependent position.
- C. Shave excess hair from the insertion site.
- D. Initiate IV therapy in the veins of the hand.
Correct Answer: A
Rationale: The correct answer is A: Insert the catheter at a 45-degree angle. When inserting a peripheral IV catheter for an older adult client, the nurse should aim to insert the catheter at a 45-degree angle to reduce the risk of complications such as infiltration. Inserting at this angle helps to ensure proper placement in the vein and reduces the likelihood of the catheter slipping out or causing discomfort to the client. Placing the client's arm in a dependent position (B) is not necessary and could potentially cause unnecessary discomfort. Shaving excess hair from the insertion site (C) is not recommended as it can irritate the skin and increase the risk of infection. Initiating IV therapy in the veins of the hand (D) may not be the best choice for an older adult client due to potential fragility of hand veins and difficulty with vein accessibility.
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
- A. Verify the client's name on their identification bracelet with the medication administration record.
- B. Call the pharmacy to determine whether the client's medications are available.
- C. Compare the client's home medications with the provider's prescriptions.
- D. Place the client's home medication bottles in a secure location.
Correct Answer: C
Rationale: The correct answer is C: Compare the client's home medications with the provider's prescriptions. This is essential for medication reconciliation to ensure accuracy and prevent medication errors. By comparing the client's home medications with the provider's prescriptions, the nurse can identify discrepancies, address any missing medications or duplications, and ensure the client receives the correct treatment. Verifying the client's name (A) is important for patient safety but not directly related to medication reconciliation. Calling the pharmacy (B) may provide some information but does not involve comparing home medications with provider prescriptions. Placing home medication bottles in a secure location (D) is not part of the medication reconciliation process.
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Place a name tag on the body.
- B. Obtain the pronouncement of death from the provider.
- C. Remove tubes and indwelling lines.
- D. Wash the client's body.
- E. Ask the client's family members if they would like to view the body.
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at flow rate of no more than 6 L/min.
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares face and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the appropriate action for administering oxygen therapy to prevent oxygen toxicity. Oxygen should be delivered at the lowest effective flow rate to minimize the risk of complications. Choices A, C, and D are incorrect. A is incorrect because the flow rate should be aligned with the bottom of the ball in the flow meter, not the top. C is incorrect because the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen delivery. D is incorrect because petroleum jelly should not be used in oxygen therapy due to the risk of fire hazard.
A nurse is caring for a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia, Pulses to lower extremities weak with +2 dependent edema present, Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this am. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from.
- A. Document the client's vital signs.
- B. Measure the client's intake and output.
- C. Transfer the client from wheelchair to bed.
- D. Insert an NG tube for the client.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Documenting vital signs is within the scope of practice for an assistive personnel (AP) as it involves measuring and recording objective data.
B: Measuring intake and output is a task that can be safely delegated to the AP as it requires basic monitoring skills and doesn't involve complex decision-making.
C: Transferring the client from a wheelchair to bed is a physical task that can be delegated to the AP, as long as proper body mechanics are used to prevent injury.
Summary:
D: Inserting an NG tube is a skilled nursing task that requires specialized training and should not be delegated to an AP.
E: No task provided for this option.
F: No task provided for this option.
G: No task provided for this option.