Nokea
A client is admitted with suspected Legionnaires' disease. Which factor increases the risk of developing Legionnaires' disease?
- A. Treatment of arthritis with steroids
- B. Foreign travel
- C. Eating fresh shellfish twice a week
- D. Doing volunteer work at the local hospital
Correct Answer: A
Rationale: Steroid use increases the risk of Legionnaires' disease by suppressing the immune system, making individuals more susceptible to Legionella infection.
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The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?
- A. a client who is post-op day 2 from a spinal fusion at L34 with a pain level of 4 on a scale of 1-10
- B. a client with a peripheral IV on a 6-hour infusion with 42 cc remaining
- C. a client who is 6 hours post-atrial fibrillation ablation, is agitated, has a HR of 130 with B/P at 90/50, and has a urine output of 30 cc in the last 2 hours
- D. a client with a nasogastric tube in place who is complaining of gastric distress
Correct Answer: C
Rationale: The client post-atrial fibrillation ablation with agitation, tachycardia (HR 130), hypotension (BP 90/50), and low urine output (30 cc in 2 hours) indicates potential instability, requiring immediate assessment. This takes priority over stable post-op pain, an IV with remaining fluid, or gastric distress.
All of the following are parts of the middle ear EXCEPT the
- A. pinna.
- B. incus.
- C. stapes.
- D. malleus.
Correct Answer: A
Rationale: The middle ear includes the incus, stapes, and malleus (ossicles). The pinna is part of the outer ear.
The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
- A. Optimal restoration of the client's elimination pattern
- B. Restoration of the client's neurosensory function
- C. Prevention of complications from impaired elimination
- D. Promotion of a positive body image
Correct Answer: C
Rationale: The primary goal is to prevent complications like infections or skin breakdown by establishing effective bowel and bladder management.
The nurse is preparing to transfer a client from the ED to the orthopedic unit. She knows that adhering to the hospital policy for client handoffs best ensures which of the following?
- A. privacy
- B. Patient's Bill of Rights
- C. continuity of care
- D. case management
Correct Answer: C
Rationale: Proper handoffs ensure continuity of care by transferring critical information accurately between care teams.
Based on clinical findings, the physician suspects that a 65-year-old client has kidney disease and has ordered a blood-urea-nitrogen (BUN) test. Which of the following results is within normal limits?
- A. 5 mg/dL
- B. 15 mg/dL
- C. 40 mg/dL
- D. 100 mg/dL
Correct Answer: B
Rationale: Normal BUN is 7-20 mg/dL, so 15 mg/dL (B) is within range. Other values (A, C, D) are too low or high.