Nokea
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions due to the risk of varicella-zoster virus transmission through respiratory droplets and contact.
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The nurse is reviewing a client's PRN pain medications. There is an order for acetaminophen 1,000 mg PO q4 hours as needed for pain. How should the nurse proceed?
- A. call the health care provider to clarify the order
- B. administer the medication as ordered if needed for pain
- C. give other PRN medications for pain and ignore the order
- D. avoid giving pain medication every 4 hours and give it every 6 hours
Correct Answer: B
Rationale: Acetaminophen 1,000 mg q4 hours PRN is within safe dosing (max 4,000 mg/day), so it can be administered as ordered.
Which of the following are common neurological changes associated with aging? Select all that apply.
- A. Dementia occurs.
- B. Threshold for sensory input increases.
- C. Perspiration is reduced.
- D. Short-term memory is impaired.
- E. Muscles atrophy.
Correct Answer: B,D
Rationale: Aging commonly increases sensory input threshold (B), making stimuli harder to perceive, and impairs short-term memory (D). Dementia (A) is not universal, perspiration reduction (C) is not neurological, and muscle atrophy (E) is musculoskeletal.
A client who just delivered is concerned about her neonate's Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?
- A. Your infant is fine. Don't worry.
- B. Apgar scores indicate a need for extra medical care at birth. Your baby's score of 7 is fine.
- C. There are many good special education programs available I can recommend.
- D. I'll ask the physician to speak with you.
Correct Answer: B
Rationale: Apgar scores of 7 and 8 are within normal limits, indicating no immediate need for extra care, and this response addresses the mother's concern accurately without dismissing it.
A nurse is at a local swimming pool, and a man collapses with a cardiac arrest after exiting the pool. The man is still wet when the nurse begins cardiopulmonary resuscitation (CPR), and another person brings the automated external defibrillator (AED). Which of the following should the nurse do next?
- A. Apply the AED pads and deliver a shock.
- B. Wipe the chest dry with an available cloth or towel.
- C. Continue CPR because a client who is wet cannot receive a shock.
- D. Wipe the chest with an alcohol hand wipe to speed the evaporation of the water.
Correct Answer: B
Rationale: Wiping the chest dry (B) ensures AED pads adhere properly and deliver an effective shock. Applying pads on a wet chest (A) risks ineffective defibrillation, continuing CPR (C) delays defibrillation, and alcohol wipes (D) are inappropriate.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- A. Will cause dark staining of the surrounding skin
- B. Produces a cooling sensation when applied
- C. Can alter the function of the thyroid
- D. Produces a burning sensation when applied
Correct Answer: D
Rationale: Sulfamylon (mafenide acetate) causes a burning sensation upon application, which should be explained to the client.