Nokea
A healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective environment
Correct Answer: C
Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.
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A healthcare professional is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the healthcare professional implement to prevent infection?
- A. Thread the catheter up to the hub
- B. Use a sterile technique throughout the procedure
- C. Clean the insertion site with alcohol only
- D. Use gloves but not a mask during the procedure
Correct Answer: B
Rationale: Using a sterile technique throughout the procedure is essential to prevent infection when inserting an IV catheter. This includes maintaining aseptic conditions, using sterile equipment, and following proper hand hygiene practices. Choice A is incorrect because threading the catheter up to the hub does not specifically address infection prevention. Choice C is incorrect as cleaning the insertion site with alcohol only may not provide adequate disinfection, as it is essential to use an antiseptic solution to reduce microbial load. Choice D is incorrect as wearing gloves alone is not sufficient protection against infection; a mask should also be worn to prevent the spread of microorganisms through respiratory secretions.
When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?
- A. Place the client in a side-lying position
- B. Instill 15 mL of irrigation fluid into the catheter with each flush
- C. Subtract the amount of irrigant used from the client's urine output
- D. Perform the irrigation using a 20 mL syringe
Correct Answer: C
Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.
A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?
- A. Ask the teenager to wait until a parent or legal guardian can be contacted
- B. Withhold treatment until telephone consent can be obtained from the partner
- C. Refer the teenager to a community pediatric hospital emergency department
- D. Proceed with the triage process in the same manner as any adult client
Correct Answer: D
Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.
A client with a terminal illness is being cared for by a nurse. Which of the following findings indicates that the client's death is imminent?
- A. Cold extremities
- B. Increased appetite
- C. Elevated blood pressure
- D. Increased level of consciousness
Correct Answer: A
Rationale: Cold extremities are a common sign observed in clients nearing death. This occurs due to decreased blood circulation as the body's systems begin to shut down. Cold extremities indicate poor perfusion and reduced function of vital organs. Increased appetite (Choice B) is not typically seen in clients approaching death; instead, a decreased appetite is more common. Elevated blood pressure (Choice C) is not a typical finding in clients nearing the end of life, as blood pressure tends to decrease. An increased level of consciousness (Choice D) is also not indicative of imminent death, as clients near death often experience decreased level of consciousness or become unresponsive.
The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?
- A. Treatment involves using regular shampoo.
- B. Products containing lindane are not recommended.
- C. Head lice may spread to furniture and other people.
- D. Manual removal is essential in treatment.
Correct Answer: C
Rationale: The correct answer is C. Head lice are highly contagious and can spread to furniture and other people if not treated promptly. Informing the parents about the potential spread of head lice emphasizes the importance of thorough treatment and prevention measures. Choice A is incorrect as regular shampoo is not typically effective in treating head lice. Choice B is incorrect as products containing lindane are not recommended due to safety concerns. Choice D is incorrect as manual removal, though labor-intensive, is a crucial step in effectively treating head lice infestations, but it is not the most pertinent information to include in the teaching session.