Nokea
A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications?
- A. Air embolus
- B. Fat embolus
- C. Stress fractures
- D. Thrombophlebitis
Correct Answer: D
Rationale: Complete bed rest increases the risk of thrombophlebitis due to venous stasis from immobility, promoting clot formation. Air embolus is rare, fat embolus is associated with fractures, and stress fractures result from repetitive trauma, not bed rest.
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Several clients come to the emergency department with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply.
- A. Call in extra staff to assist with the possibility of more clients with the same condition.
- B. Isolate all the suspected clients in the emergency department in one area.
- C. Call housekeeping for diluted household bleach.
- D. Restrict visitors from the emergency department.
- E. Quarantine all contacts.
Correct Answer: A,B,C,D,E
Rationale: Ebola requires comprehensive measures: extra staff for surge capacity, isolation to prevent spread, bleach for disinfection, visitor restrictions, and contact quarantine to control the outbreak.
When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply.
- A. Checking the hemoglobin levels before administering subsequent doses.
- B. Shaking the vial thoroughly to mix the concentrated white, milky solution.
- C. Keeping the multidose vial refrigerated between scheduled twice-a-day doses.
- D. Administering the medication through the I.V. line without other medications.
- E. Adjusting the initial doses according to the client's changes in blood pressure.
- F. Educating the client to avoid driving and performing hazardous activity during the initial treatment.
Correct Answer: A,C,D,F
Rationale: For IV erythropoietin therapy, the nurse should check hemoglobin levels to monitor response and prevent overcorrection, keep multidose vials refrigerated to maintain stability, administer without mixing with other medications to avoid interactions, and educate about avoiding hazardous activities due to potential side effects like dizziness. Shaking the vial can denature the protein, and dose adjustments are typically based on hematologic response, not blood pressure.
The nurse is preparing to administer a medication to a client with a history of Clostridium difficile infection. Which precaution is most important?
- A. Wear a face mask during administration.
- B. Use a dedicated stethoscope for the client.
- C. Administer the medication in a private room.
- D. Clean the medication cart with alcohol wipes.
Correct Answer: B
Rationale: Using a dedicated stethoscope for a client with C. difficile prevents cross-contamination, as the infection spreads via contact with contaminated surfaces. A face mask is unnecessary, a private room is ideal but not always required, and alcohol wipes are ineffective against C. difficile spores. CN: Safety and infection control; CL: Synthesize
A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim:
- A. Starts to become cyanotic.
- B. Cannot speak due to airway obstruction.
- C. Can make only minimal vocal noises.
- D. Is coughing vigorously.
Correct Answer: B
Rationale: Inability to speak indicates a complete airway obstruction, necessitating the Heimlich maneuver to dislodge the blockage.
The client with a laryngectomy communicates to the nurse that he does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. Which of the following nursing diagnoses would be most appropriate?
- A. Deficient knowledge about the care of a stoma.
- B. Disturbed personal identity related to change in appearance.
- C. Disturbed body image related to neck surgery.
- D. Hopelessness related to irreversible changes in body functioning.
Correct Answer: C
Rationale: Disturbed body image related to neck surgery addresses the client's negative feelings about the stoma's appearance. Deficient knowledge is less relevant here. Disturbed personal identity is broader. Hopelessness implies a deeper psychological state not fully supported by the description.