Nokea
A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?
- A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
- B. ''I need to avoid drinking fluids if I develop symptoms.''
- C. ''I need a flu shot every 2 years because of the different flu strains.''
- D. ''I should cover my mouth with my hand when I sneeze.''
Correct Answer: A
Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.
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A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?
- A. Oxygen equipment
- B. Incentive spirometer
- C. Pulse oximeter
- D. Sterile dressing
Correct Answer: B
Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.
During discharge teaching, a client informs the nurse about a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching?
- A. I will decrease my fluid intake while taking this medication.
- B. I will expect to have black, tarry stools.
- C. I will take my medication with meals.
- D. I will monitor for weight loss while on this medication.
Correct Answer: C
Rationale: Taking prednisone with meals can help reduce the risk of gastrointestinal upset and irritation. It is important for the client to understand how to take the medication correctly to maximize its effectiveness and minimize potential side effects. Monitoring for weight loss or changes in stools may be important but does not directly relate to the administration of the medication with meals.
When preparing an in-service on malpractice issues in nursing, which of the following examples should the nurse include in the teaching?
- A. Leaving a nasogastric tube clamped after administering oral medication
- B. Documenting communication with a provider in the progress notes of the client's medical record
- C. Administering potassium via IV bolus
- D. Placing a yellow bracelet on a client who is at risk for falls
Correct Answer: C
Rationale: Administering potassium via IV bolus is a high-risk procedure that requires careful attention and adherence to established protocols to prevent serious complications like cardiac arrest. Errors in administering IV medications, especially potent ones like potassium, can lead to severe harm to the patient and potential legal consequences for the healthcare provider. Therefore, including this example in the in-service on malpractice issues helps emphasize the importance of safe medication administration practices and the potential implications of errors.
A healthcare provider is preparing to care for a client following chest tube placement. Which of the following items should NOT be available in the client's room?
- A. Oxygen
- B. Sterile water
- C. Enclosed hemostat clamps
- D. Indwelling urinary catheter
Correct Answer: D
Rationale: Following chest tube placement, an indwelling urinary catheter is not typically needed or relevant to the care provided. Chest tube placement is primarily concerned with managing pleural effusion or pneumothorax, and urinary catheterization is not directly related to this procedure. Oxygen, sterile water, and enclosed hemostat clamps are commonly used items in the care of a client with a chest tube in place, to ensure proper oxygenation, maintain drainage system integrity, and manage any bleeding that may occur. Therefore, the indwelling urinary catheter should not be available in the client's room following chest tube placement.
When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?
- A. Percussion of the frontal sinuses
- B. Auscultation of the trachea
- C. Inspection of the nasal mucosa
- D. Palpation of the orbital areas
Correct Answer: D
Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.