Nokea
A healthcare professional is admitting a client who has influenza. Which of the following types of transmission precautions should the healthcare professional initiate?
- A. Airborne
- B. Droplet
- C. Contact
- D. Protective environment
Correct Answer: B
Rationale: Droplet precautions should be initiated for clients with infections that spread via droplet nuclei larger than 5 microns in diameter, such as influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. In the case of influenza, the virus is primarily spread through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne precautions are used for pathogens that remain infectious over long distances, typically smaller than 5 microns, like tuberculosis. Contact precautions are for diseases transmitted by direct or indirect contact, and protective environment precautions are for immunocompromised individuals to protect them from environmental pathogens.
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When assessing the skin of an immobilized patient, what should the nurse do?
- A. Assess the skin every 4 hours.
- B. Limit the amount of fluid intake.
- C. Use a standardized tool such as the Braden Scale.
- D. Have special times for inspection to not interrupt routine care.
Correct Answer: C
Rationale: When assessing the skin of an immobilized patient, it is essential to use a standardized tool like the Braden Scale. This tool helps in systematically evaluating the patient's risk of developing pressure ulcers. Assessing the skin every 4 hours (Choice A) may be too frequent or unnecessary unless there are specific concerns or orders. Limiting fluid intake (Choice B) is not directly related to skin assessment in an immobilized patient. Having special times for inspection to avoid interrupting routine care (Choice D) is not as crucial as using a standardized tool for consistent and comprehensive skin assessment.
When assessing a client's neurologic system, what should the nurse ask the client to close their eyes and identify?
- A. A word whispered by the nurse 30cm from the ear
- B. A number traced on the palm of the hand
- C. The vibration of a tuning fork placed on the foot
- D. A familiar object placed in the hand
Correct Answer: B
Rationale: When a nurse asks a client to identify a number traced on the palm of the hand with their eyes closed, it assesses the client's ability to perceive touch sensations. This test specifically evaluates the tactile discrimination of the client. The other options do not test the client's ability to identify sensations accurately with eyes closed. Option A tests auditory perception, option C tests vibratory sense, and option D tests object recognition but not tactile discrimination, making them incorrect choices.
A client has a new prescription for a metered-dose inhaler. Which of the following instructions should the nurse include?
- A. Inhale quickly and deeply while pressing down on the inhaler.
- B. Hold your breath for 10 seconds after inhaling the medication.
- C. Exhale immediately after inhaling the medication.
- D. Shake the inhaler before each use.
Correct Answer: B
Rationale: The correct instruction for using a metered-dose inhaler is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to be absorbed more effectively in the lungs. Inhaling quickly and deeply while pressing down on the inhaler (Choice A) may cause the medication to deposit in the mouth and throat rather than reaching the lungs. Exhaling immediately after inhaling the medication (Choice C) may also lead to medication wastage. Shaking the inhaler before each use (Choice D) is not necessary for all types of inhalers and can sometimes cause improper drug delivery.
A client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the LPN monitor closely while the client is taking this medication?
- A. Sodium
- B. Potassium
- C. Calcium
- D. Magnesium
Correct Answer: B
Rationale: The LPN should monitor potassium levels closely while the client is taking furosemide (Lasix) due to the medication's potential to cause hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Hypokalemia can result in serious complications such as cardiac dysrhythmias. Monitoring sodium levels (choice A) is important but not as critical as monitoring potassium in this context. Calcium (choice C) and magnesium (choice D) levels are not typically affected by furosemide and are not the priority for monitoring in this scenario.
A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention?
- A. Providing cholesterol screening
- B. Teaching about a healthy diet
- C. Providing information about antihypertensive medications
- D. Developing a list of cardiac rehabilitation programs
Correct Answer: B
Rationale: Teaching about a healthy diet is considered a primary prevention activity. Primary prevention aims to prevent the onset of a disease or health problem. Educating individuals on healthy lifestyle choices, such as diet modification, falls under primary prevention. Providing cholesterol screening (choice A) is a secondary prevention measure aimed at early detection. Offering information about antihypertensive medications (choice C) falls under secondary prevention, focusing on controlling risk factors. Developing a list of cardiac rehabilitation programs (choice D) is part of tertiary prevention, focusing on rehabilitation and improving outcomes post-disease onset.