Nokea
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Stethoscope.
- B. Bed linens.
- C. Sputum specimen.
- D. Paper mask and gown.
Correct Answer: D
Rationale: Disposable PPE prevents contamination.
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The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
- A. Dizziness can occur during cleansing.
- B. The pubic area should be kept shaved.
- C. The foreskin should not be retracted.
- D. An erection may occur while providing care.
Correct Answer: D
Rationale: Reflex erection is normal and should be explained.
A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?
- A. Uses normal saline to irrigate the wound.
- B. Cleans from less soiled to more soiled areas.
- C. Opens a sterile package towards the body.
- D. Places soiled dressing in a plastic bag.
Correct Answer: C
Rationale: Opening towards body risks contamination.
The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?
- A. Analogies.
- B. Role-playing.
- C. Return demonstration.
- D. Journaling.
Correct Answer: B
Rationale: Role-playing builds communication skills.
The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?
- A. Increase the liter flow of oxygen.
- B. Encourage the client to take deep breaths.
- C. Remove the mask to deflate the bag.
- D. Document the assessment data.
Correct Answer: A
Rationale: Increasing flow ensures oxygen delivery.
While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?
- A. Obtain the specimen from the client's current bowel movement.
- B. Contact the healthcare provider before obtaining the specimen.
- C. Wait to obtain the specimen until observable blood is present.
- D. Withhold specimen collection until tarry black stool is observed.
Correct Answer: A
Rationale: Normal stool is suitable for occult blood testing.