Nokea
A client who has had an allogeneic stem cell transplant needs protective measures. What precaution should the nurse plan for this client?
- A. Ensure the client wears a mask when outside the room if there is construction nearby.
- B. Place the client in a private room with positive pressure airflow.
- C. Restrict all visitors from seeing the client.
- D. Provide a HEPA filter in the client's room.
Correct Answer: A
Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to minimize exposure to potential sources of infection. Wearing a mask when outside the room, especially in areas with construction or other potential risks, helps protect the client's compromised immune system. Positive pressure airflow rooms are typically used for clients with airborne infections, not for those post-stem cell transplant. Restricting all visitors may contribute to the client's well-being, but it is not a direct protective measure against infection. While HEPA filters can be beneficial in maintaining air quality, wearing a mask when exposed to external risks is a more targeted and immediate protective measure in this scenario.
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A client has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Abdominal cramping
- B. Increased thirst
- C. Elevated blood pressure
- D. Elevated heart rate
Correct Answer: A
Rationale: Abdominal cramping is a common manifestation of hyponatremia (low sodium levels). When sodium levels drop, it can lead to changes in the body's water balance, affecting cell function and causing symptoms like abdominal cramping. Increased thirst (choice B) is more commonly associated with hypernatremia (high sodium levels) due to the body's attempt to dilute the excess sodium. Elevated blood pressure (choice C) and elevated heart rate (choice D) are not typically direct manifestations of low sodium levels and are more commonly seen in conditions like dehydration or shock.
A nurse manager is preparing to review practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
- A. Insert an implanted port
- B. Close a laceration with sutures
- C. Place an endotracheal tube
- D. Initiate an enteral feeding through a gastrostomy tube
Correct Answer: D
Rationale: The correct answer is D: Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. Options A, B, and C involve procedures that typically fall within the scope of other healthcare professionals. Inserting an implanted port is often performed by specialized nurses or physicians, closing a laceration with sutures is usually done by healthcare providers with specific training in wound care, and placing an endotracheal tube is a procedure commonly carried out by anesthesiologists or respiratory therapists.
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client fell out of bed. Which of the following statements should the nurse document?
- A. "Client found lying on the floor."
- B. "Client fell out of bed and was found on the floor."
- C. "Client experienced a fall from the bed."
- D. "Client was discovered on the floor following a fall from the bed."
Correct Answer: B
Rationale: The correct answer is B. The documentation should be clear and precise, providing details about the context of the fall. Choice A is vague and does not specify the cause of the client being on the floor. Choice C is less specific and does not directly state that the client fell from the bed. Choice D is wordy and less direct compared to option B, which clearly states that the client fell out of bed and was found on the floor.
The healthcare provider is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD). Which assessment finding would be most concerning?
- A. Barrel chest
- B. Clubbing of the fingers
- C. Cough with sputum production
- D. Use of accessory muscles
Correct Answer: D
Rationale: The use of accessory muscles is the most concerning finding in a client with COPD. It indicates increased work of breathing and may signal respiratory distress, requiring immediate attention. Barrel chest is a common physical characteristic in individuals with COPD due to chronic air trapping and hyperinflation of the lungs but is not as acutely concerning as the use of accessory muscles. Clubbing of the fingers is a late sign of chronic hypoxia and is often seen in conditions with prolonged hypoxemia but is not as acute as the use of accessory muscles. Cough with sputum production is a common symptom in COPD due to excess mucus production but does not indicate immediate respiratory distress as the use of accessory muscles does.
A healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?
- A. Collect at least 2 inches of formed stool.
- B. Wear sterile gloves while obtaining the specimen.
- C. Use a culturette for specimen collection.
- D. Record the date and time the stool was collected.
Correct Answer: A
Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.