Nokea
A client is diagnosed with methicillin-resistant Staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: The correct answer is 'D: Contact.' Contact precautions are necessary for clients with MRSA pneumonia to prevent the spread of the resistant bacteria. MRSA is primarily spread by direct contact, so using contact precautions, such as wearing gloves and gowns, is essential. Choice A, 'Reverse,' is not a type of isolation precaution. Choice B, 'Airborne,' is not the appropriate isolation for MRSA pneumonia, as MRSA is not transmitted through the airborne route. Choice C, 'Standard precautions,' are important for all clients, but for MRSA pneumonia specifically, contact precautions are more targeted and necessary.
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During an assessment on a client in congestive heart failure, what is most likely to be revealed upon auscultation of the heart?
- A. S3 ventricular gallop
- B. Apical click
- C. Systolic murmur
- D. Split S2
Correct Answer: A
Rationale: The correct answer is A: S3 ventricular gallop. An S3 sound is a common finding in congestive heart failure due to fluid overload in the heart. It is associated with decreased ventricular compliance. Choices B, C, and D are incorrect. An apical click is not typically associated with congestive heart failure. A systolic murmur may be heard in conditions like mitral regurgitation but is not specific to congestive heart failure. A split S2 is associated with conditions like pulmonary hypertension, not congestive heart failure.
A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?
- A. Figs
- B. Broccoli
- C. Stewed tomatoes
- D. Skim milk
Correct Answer: D
Rationale: Skim milk is a reliable source of Vitamin B12, which is essential for the health of both the mother and the developing fetus. While figs, broccoli, and stewed tomatoes are nutritious foods, they are not significant sources of Vitamin B12. Figs are a good source of fiber and other vitamins, broccoli is rich in Vitamin C and K, and stewed tomatoes are high in Vitamin C and antioxidants, but they do not contain Vitamin B12 as much as skim milk does.
A client with a history of deep vein thrombosis (DVT) is being treated with anticoagulants. Which of these findings is most concerning to the nurse?
- A. Presence of bruising on the arms and legs
- B. The client reports new onset of severe headache
- C. The client reports pain and swelling in the calf
- D. The client reports increased urination
Correct Answer: C
Rationale: The correct answer is C because pain and swelling in the calf can indicate a new or worsening DVT, requiring immediate attention. Bruising on the arms and legs may be a common side effect of anticoagulants but is not as concerning as a potential DVT. Severe headache may indicate other conditions like a migraine or hypertension and is not directly related to DVT. Increased urination is not typically associated with DVT and may point towards other health issues like diabetes or urinary tract infections.
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg is the most concerning finding as it indicates poor blood flow, potentially suggesting a serious circulatory problem that requires immediate attention. Diminished bowel sounds, loss of appetite, and tachypnea may be relevant but are not as indicative of a critical circulatory issue as a cold, pale lower leg.
A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?
- A. Bleeding time
- B. Platelet count
- C. Activated PTT
- D. Clotting time
Correct Answer: C
Rationale: Activated PTT is the correct lab value to monitor for clients on heparin therapy. Activated PTT (partial thromboplastin time) helps assess the effectiveness of heparin therapy by measuring the time it takes for blood to clot. Monitoring activated PTT ensures that the client is within the therapeutic range of heparin to prevent both clotting and bleeding complications. Bleeding time (Choice A) and platelet count (Choice B) are not specific indicators of heparin therapy effectiveness. Clotting time (Choice D) is not as sensitive as activated PTT in monitoring heparin therapy.