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A home health nurse manager is caring for a client who has methicillin-resistant Staphylococcus aureus. Which of the following actions should the nurse take?
- A. Remove fresh flowers from the client's home
- B. Wear a mask when within 3 feet of the client
- C. Encourage the client to use a HEPA filter in the house
- D. Double bag soiled dressing in polyethylene bags
Correct Answer: D
Rationale: The correct answer is D: Double bag soiled dressing in polyethylene bags. This is important to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) to others. Double bagging the soiled dressing in polyethylene bags helps contain the bacteria and reduces the risk of transmission.
Choice A: Removing fresh flowers is not directly related to preventing the spread of MRSA.
Choice B: Wearing a mask within 3 feet of the client may not be effective in preventing MRSA transmission.
Choice C: Using a HEPA filter is not specifically targeted at preventing MRSA transmission.
In summary, choice D is correct because it directly addresses the prevention of MRSA transmission, while the other choices are not as directly related to this specific concern.
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A nurse is counseling a client who is to undergo enzyme-linked immunosorbent assay (ELISA) testing for HIV. Which of the following information should the nurse include?
- A. The test monitors progression of the disease
- B. The test measures antibodies to the virus
- C. The test results are accurate 24 hr after exposure to the virus
- D. A positive result requires initiating immunoglobulin administration
Correct Answer: B
Rationale: The correct answer is B because ELISA testing for HIV measures antibodies to the virus, indicating exposure to the virus. This is crucial for diagnosing HIV infection. Choice A is incorrect because ELISA does not monitor disease progression. Choice C is incorrect as it takes weeks, not hours, for accurate results post-exposure. Choice D is incorrect as immunoglobulin administration is not the treatment for a positive HIV result.
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep-vein thrombosis.
- B. A client who is 1 day postoperative following a vertebroplasty.
- C. A client who has cancer and a sealed implant for radiation therapy.
- D. A client who has COPD and a respiratory rate of 44/min.
Correct Answer: B
Rationale: The correct choice is B: A client who is 1 day postoperative following a vertebroplasty. This client is the most stable among the options provided. Early discharge is appropriate because the client is 1 day postoperative, likely past the critical immediate postoperative period. Discharging this client will create space for incoming emergency admissions. Choice A should not be discharged early as managing deep-vein thrombosis with heparin requires close monitoring to prevent complications. Choice C should not be discharged early due to the need for ongoing cancer treatment. Choice D should not be discharged early as the client with COPD and a high respiratory rate of 44/min requires close monitoring and intervention to prevent respiratory distress.
A nurse is providing education to a group of adolescents who are pregnant and attending high school. Which of the following information should the nurse include in their teaching?
- A. The need for supplemental folic acid is greatest during the third trimester
- B. The incidence of high birth weight infants is higher in adolescent pregnancy
- C. Pregnant adolescents need to gain less weight than adult mothers
- D. Caffeinated beverages should be replaced with caffeine-free beverages
Correct Answer: D
Rationale: The correct answer is D: Caffeinated beverages should be replaced with caffeine-free beverages. Pregnant adolescents should limit their caffeine intake as excessive caffeine can lead to complications during pregnancy. Caffeine can cross the placenta and affect the baby's heart rate and sleep patterns. It is important for pregnant adolescents to switch to caffeine-free beverages to ensure the health and well-being of both the mother and baby.
A: The need for supplemental folic acid is not specific to the third trimester, it is important throughout pregnancy.
B: The incidence of high birth weight infants is not necessarily higher in adolescent pregnancy compared to adult mothers.
C: Pregnant adolescents actually need to gain weight within the recommended range, similar to adult mothers, to support fetal growth and development.
A faith community nurse is preparing to meet with the family of an adolescent who has leukemia. Which of the following actions should the nurse plan to take?
- A. Focus the discussion on the adolescent's future career plans.
- B. Determine how the adolescent's health has affected family roles.
- C. Ask another family from the same faith congregation to attend the meeting for support.
- D. Direct conversation to the parents to avoid embarrassing the adolescent.
Correct Answer: B
Rationale: The correct answer is B: Determine how the adolescent's health has affected family roles. This is important because the nurse needs to understand the impact of the adolescent's illness on the family dynamics and roles. By assessing this, the nurse can provide appropriate support and resources to help the family cope effectively.
Choice A is incorrect because focusing on the adolescent's future career plans may not address the immediate concerns and emotional needs of the family facing a health crisis.
Choice C is incorrect as involving another family may not be appropriate without the consent of the adolescent and their family.
Choice D is incorrect because directing the conversation solely to the parents may exclude the adolescent from being an active participant in their own care and may not address their unique needs.
A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
- A. Encourage the family to join a support group
- B. Provide the family with information about respite care
- C. Educate the family regarding the progression of dementia
- D. Engage the family in informal conversation
Correct Answer: D
Rationale: The correct answer is D: Engage the family in informal conversation. This is the first action the nurse should take during the initial visit because building rapport and establishing trust with the family is crucial in the care of a client with dementia. By engaging in informal conversation, the nurse can observe family dynamics, assess the family's understanding of the client's condition, and gather valuable information about the client's daily routine and needs. This lays the foundation for effective communication and collaboration moving forward.
A: Encouraging the family to join a support group can be beneficial but should come after establishing rapport and assessing the family's needs.
B: Providing information about respite care is important, but it is not the priority during the initial visit.
C: Educating the family about the progression of dementia is important, but it should be done after building rapport and assessing their current understanding.