Nokea
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions must still be implemented.
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A client with dementia.
The nurse knows that which of these plans would be MOST successful in caring for a client with dementia?
- A. Teach new skills for adjusting to the aging process.
- B. Adjust the environment to meet the client's individual needs.
- C. Encourage competitive activities to keep the client physically strong.
- D. Provide unstructured activities with frequent changes to increase stimulation.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unable to learn new skills (2) correct-client with dementia does not have cognitive abilities to learn new skills or to adapt, environment must be adapted for client with attention to safety and predictability (3) requires skills the client with dementia does not have (4) requires skills the client with dementia does not have
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. An elderly woman, 8-hours postoperative, following an open-reduction and internal fixation of the right hip.
- B. An elderly man admitted 4 hours ago with status asthmaticus.
- C. A middle-aged man admitted 2 days ago with pneumonia who has a temperature of 101.2°F (38.4°C).
- D. A middle-aged woman who suffered a myocardial infarction (MI) 3 days ago.
Correct Answer: B
Rationale: Strategy: Determine the least stable client. (1) leg needs to be abducted at all times, ice to operative site, turn patient as ordered (2) correct-life-threatening condition which can last longer than 24 hours, constantly monitor client (3) requires follow-up, assess breath sounds (4) monitor vital signs, I and O, teach to modify lifestyle (stop smoking, reduce stress, modify intake of calories, fat, and salt)
Which comment is the client who has Parkinson's disease most likely to make?
- A. My hands shake when I reach to pick up my coffee cup.'
- B. I get very stiff when I sit for long periods of time.'
- C. I have to drink a lot because my mouth is so dry.'
- D. It is easier for me to pick up my feet than to slide them.'
Correct Answer: B
Rationale: Rigidity and stiffness, especially after immobility, are hallmark Parkinson's symptoms, unlike tremors (more action-specific), dry mouth, or gait preferences.
The nurse is teaching a client with a new diagnosis of hyperthyroidism about propylthiouracil (PTU). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a fever to my doctor.
- B. I should take this medication with food.
- C. I should avoid eating shellfish.
- D. I should stop this medication if my thyroid levels are normal.
Correct Answer: D
Rationale: Stopping propylthiouracil when thyroid levels are normal is incorrect, as hyperthyroidism requires prolonged treatment to maintain euthyroid status. Options A, B, and C are correct: fever may indicate agranulocytosis, food reduces GI upset, and shellfish (iodine-rich) should be avoided.
A client experiencing alcohol withdrawal.
Which finding would indicate to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms?
- A. Increasing lethargy.
- B. Uncoordinated motor movements.
- C. Elevated pulse rate.
- D. Improved orientation to time and place.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to alcohol withdrawal. (1) would indicate a need for less sedation and a thorough physical assessment (2) suggests neurological trauma or damage (3) correct-pulse rate is a good indicator of client's progress through withdrawal, increasingly elevated pulse signals impending alcohol withdrawal delirium, requiring more sedation (4) suggests that the client is improving and will subsequently require less sedation