Nokea
A client with pneumonia is receiving antibiotic therapy. Which finding indicates that the treatment is effective?
- A. Decreased white blood cell count
- B. Decreased respiratory rate
- C. Increased breath sounds
- D. Increased heart rate
Correct Answer: C
Rationale: The correct answer is C: Increased breath sounds. When a client with pneumonia is receiving antibiotic therapy, increased breath sounds indicate that the lungs are clearing and the pneumonia is resolving. This improvement in breath sounds suggests that the antibiotics are effectively treating the infection. Choices A, B, and D are incorrect because a decreased white blood cell count, decreased respiratory rate, and increased heart rate are not specific indicators of the effectiveness of antibiotic therapy in treating pneumonia. While these parameters may change in response to treatment, they do not directly reflect the resolution of the pneumonia infection.
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A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
- A. Why don¢â‚¬â„¢t we now have the client turn back to the left side.
- B. That was done correctly. Did you have any problems with the insertion?
- C. Let¢â‚¬â„¢s check to see if the suppository is in far enough.
- D. Did you feel any stool in the intestinal tract?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client asks about the purpose of advance directives. Which of the following statements should the nurse make?
- A. They allow the court to overrule an adult client's refusal of medical treatment.
- B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.
- C. They permit a client to withhold medical information from health care personnel.
- D. They allow health care personnel in the emergency department to stabilize a client's condition.
Correct Answer: B
Rationale: The correct answer is B. Advance directives specify the type of medical treatment a client wishes to receive or avoid in the event of a serious illness. Choice A is incorrect because advance directives do not allow the court to overrule a client's refusal of medical treatment; they empower the client to make their own healthcare decisions. Choice C is incorrect because advance directives do not permit a client to withhold medical information; they provide guidance on the client's treatment preferences. Choice D is incorrect because advance directives do not specifically address the actions of health care personnel in the emergency department; they focus on the client's treatment preferences in general.
A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?
- A. Charge nurse
- B. Registered nurse (RN)
- C. Practical nurse (PN)
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: In this scenario, a client who has undergone thoracic surgery and is being admitted from the PACU requires a high level of nursing care. Registered nurses (RNs) have the education and training necessary to provide the complex care and monitoring needed for a post-thoracic surgery client. Charge nurses may oversee units but may not always be directly involved in providing bedside care. Practical nurses (PNs) have a different scope of practice compared to RNs and may not have the advanced skills needed for post-thoracic surgery care. Assistive personnel (AP) provide valuable support but do not have the qualifications to manage the care of a client following thoracic surgery.
A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?
- A. Empty the drainage bag at least every 8 hours
- B. Keep the drainage bag below the level of the bladder
- C. Use sterile technique to collect a specimen from the drainage system
- D. Secure the catheter to the lower abdomen with a securement device
Correct Answer: B
Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).
A client with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: Contact precautions are necessary when performing postmortem care on a client with MRSA to prevent the spread of infection. Contact precautions involve using barriers like gloves and gowns to limit direct contact with the deceased individual's body fluids and tissues. Airborne precautions are used for pathogens that are transmitted through the air, like tuberculosis. Droplet precautions are for pathogens that are transmitted through respiratory droplets, such as influenza. Compromised host precautions are not a recognized standard precaution type and are not applicable in this scenario.