Nokea
A new client is admitted with a major abscess on her thigh caused by scratching mosquito bites with dirty hands after digging in her garden. She is on isolation precautions in a private room after surgical debridement. The physician changes her dressings daily. What should the nurse wear when providing care for this client?
- A. An N95 respirator and gloves
- B. Eye protection and a face mask
- C. Gloves and gown
- D. A gown only
Correct Answer: C
Rationale: Gloves and gown are required for contact precautions due to the abscess, preventing transmission of infection.
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The nurse working on a pediatric oncology unit recognizes which as a personal coping strategy for remaining effective when caring for dying children?
- A. Attending a child's memorial service
- B. Avoiding expressing personal feelings of grief or loss directly with the family
- C. Ending personal contact with the deceased's family members after they leave the hospital
- D. Increasing length of daily exercise routines
Correct Answer: D
Rationale: Increasing exercise (D) is a healthy coping strategy to manage stress. Attending memorials (A), avoiding grief expression (B), or ending contact (C) may not promote long-term emotional resilience.
A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which of the following additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.
- A. Blood pressure 82/64 mm Hg
- B. Crackles on auscultation
- C. Distended jugular veins
- D. Pulse 120/min
- E. Shoulder pain
Correct Answer: A, D, E
Rationale: Low blood pressure (A), tachycardia (D), and shoulder pain (E) indicate hemorrhage from a ruptured ectopic pregnancy. Crackles (B) and jugular vein distension (C) are unrelated.
The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately?
- A. slight pink-tinged drainage
- B. abdominal discomfort
- C. muscle weakness
- D. cloudy drainage
Correct Answer: D
Rationale: Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). The other options are expected side effects of peritoneal dialysis.
The nurse is giving home care to a 69-year-old client who has severe arthritis. Which comment made by the client would indicate to the nurse that the client is experiencing normal changes associated with the aging process?
- A. I have such a hard time with the pain in my feet and knees.
- B. I have had loose stools for the last few months.
- C. My children say I keep my apartment too warm.
- D. I have a hard time at night because the lights are all big and fuzzy.
Correct Answer: C
Rationale: Feeling cold and preferring a warmer environment is a normal age-related change due to decreased thermoregulation. Pain, loose stools, and visual changes may indicate pathology requiring further investigation.
A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?
- A. Inject into the upper arm where the sleeve can be pulled up
- B. Inject into the most accessible vein
- C. Inject through the clothing into thigh and hold in place for 10 seconds
- D. Take the child inside, remove excess clothing, and inject into the thigh
Correct Answer: C
Rationale: Injecting through clothing into the thigh (C) ensures rapid administration during anaphylaxis. Arm injection (A) is incorrect, IV injection (B) is not for EpiPens, and delaying to remove clothing (D) is dangerous.