Nokea
A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse?
- A. When I take in a deep breath, it stabs like a knife.'
- B. The pain came on after dinner. That soup seemed very spicy.'
- C. When I turn to the left, it feels like my heart is being squeezed.'
- D. The pain radiates to my jaw and left arm.'
Correct Answer: D
Rationale: Chest pain radiating to the jaw and left arm is a classic symptom of myocardial infarction, requiring immediate action to assess for a life-threatening cardiac event.
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The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.
An adult comes to the physician's office with a history of headache yesterday and today and pain in the back. The nurse observes a horizontal band of pustular rash on the back extending from the spine to midline in the front. The client describes it as very painful. What would the nurse expect to be prescribed for this client?
- A. Antiviral
- B. Antibiotics
- C. Topical hydrocortisone
- D. Benadryl
Correct Answer: A
Rationale: The painful, unilateral, dermatomal pustular rash suggests herpes zoster (shingles), treated with antivirals like acyclovir.
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
- A. Offer the baby sterile water between feedings of formula
- B. Apply an emollient to the baby's skin to prevent drying
- C. Wear a gown, gloves, and a mask while caring for the infant
- D. Place the baby on enteric isolation
Correct Answer: B
Rationale: Applying an emollient prevents skin drying, a common issue during phototherapy due to exposure to light.
A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?
- A. Blood urea nitrogen
- B. Acid phosphatase
- C. Bilirubin
- D. Sedimentation rate
Correct Answer: C
Rationale: Bilirubin. Hepatitis B causes liver dysfunction, leading to elevated bilirubin levels.
The nurse is caring for a client who had a portable water seal chest drainage system inserted today. Which observation indicates that the client's drainage system is working properly?
- A. There are no bubbles in the water seal bottle.
- B. The suction control chamber has continuous bubbles.
- C. There are bubbles in the drainage chamber.
- D. There is no fluctuation in the fluid in the water seal chamber.
Correct Answer: A
Rationale: No bubbles in the water seal bottle indicates a stable system without air leaks, confirming proper function post-insertion.