Nokea
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?
- A. Giving antibiotics prior to treatments
- B. Monitoring the client's vital signs
- C. Performing appropriate hand hygiene
- D. Placing the client in protective isolation
Correct Answer: C
Rationale: Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.
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A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care?
- A. I can scratch with a coat hanger
- B. I should feel my fingers for warmth
- C. I will keep the cast clean and dry
- D. I will return to have the cast removed
Correct Answer: A
Rationale: Nothing should be placed under the cast to use for scratching, as this can cause skin damage or infection. The other statements show a good understanding of cast care instructions.
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth. What action by the nurse is best?
- A. Ask the client to explain his feelings related to this disorder
- B. Ask how dental hygiene is related to overall health
- C. Tell the client that he will become malnourished in time
- D. Inform the client about dental care options
Correct Answer: A
Rationale: Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
- A. Avoid having teeth pulled for 1 year
- B. Avoid heavy lifting for 6 months
- C. Do not use harsh chemicals on your face
- D. Inform your dentist of this procedure
Correct Answer: C
Rationale: The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the affected side to prevent injury. The other instructions are not necessary.
A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment is most important?
- A. Ability to chew and swallow without aspiration
- B. Eating 75% of meals and between-meal snacks
- C. Intake greater than output for 3 days
- D. Weight gain of 3 pounds in 1 month
Correct Answer: D
Rationale: Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty is necessary for an intact airway. Since the question does not include what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.
An older client is hospitalized with Guillain-Barr?© syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?
- A. Assess the client's oxygen saturation
- B. Check the medication list for interactions
- C. Place the client on a bed alarm
- D. Put the client on safety precautions
Correct Answer: A
Rationale: In an older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate but only after this assessment occurs.