Nokea
A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Turn the client every 2 hr to prevent pressure ulcers.
- B. Place a mirror in the client's room for reality orientation.
- C. Offer the client written instructions for performing oral hygiene.
- D. Ask the client open-ended questions to encourage conversation.
Correct Answer: A
Rationale: Late-stage Alzheimer's reduces mobility, heightening pressure ulcer risk. Turning every 2 hours redistributes weight, preserving skin integrity, a preventive standard (e.g., NPUAP guidelines). Mirrors confuse patients unable to recognize themselves, increasing agitation. Written instructions are futile severe cognitive loss prevents comprehension; physical cues work better. Open-ended questions overwhelm, as verbal ability is minimal; simple prompts suit better. Repositioning addresses a physical priority, reduces complications like infection, and upholds care quality, making it the essential action.
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An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result?
- A. A client whose injection site is scabbed
- B. A client whose injection site is firm and measures 3 mm (0.1 in)
- C. A client whose injection site has an elevated area measuring 15 mm (0.6 in)
- D. A client whose injection site is ecchymotic
Correct Answer: C
Rationale: An induration of 15 mm after 48 hours indicates a positive TB skin test, suggesting exposure or infection. Smaller indurations, scabbing, or bruising do not meet the criteria for a positive result.
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
- A. History of generalized anxiety disorder
- B. Recent exposure to tuberculosis
- C. Reports periodic migraine headaches
- D. Experiences nocturia
Correct Answer: B
Rationale: Recent tuberculosis exposure is a public health priority it's contagious via airborne droplets, risking spread in a semi-private room. Immediate isolation and testing (e.g., PPD, chest X-ray) protect the client, roommate, and staff, per CDC guidelines. Anxiety disorder affects mental health but isn't acutely transmissible or life-threatening here. Migraines cause discomfort, not immediate danger, manageable with later intervention. Nocturia disrupts sleep and may signal underlying issues, but it's less urgent than infection control. TB exposure triggers rapid response respiratory isolation, contact tracing due to its morbidity (e.g., pulmonary damage) and outbreak potential, making it the top priority to address on admission.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?
- A. Abdominal wound dry, without redness
- B. Client received an adequate amount of fluid
- C. Client status unchanged throughout shift
- D. Incision healing well
- E. Pain level stable
- F. No fever noted
- G. Ambulated without difficulty
Correct Answer: A
Rationale: Specific, objective data like 'dry, without redness' is required; vague terms like 'adequate' or 'unchanged' are insufficient.
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A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Clamp the catheter tubing distal to the sampling port for 15 min.
- B. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Empty the urine into a sterile container labeled with the client identifiers.
- E. Document in the client's electronic medical record that the specimen was sent to the laboratory
- F. Wash hands before starting.
- G. Check the client's ID band.
Correct Answer:
Rationale: Clamping allows urine to collect, wiping ensures sterility, aspirating collects the sample, transferring maintains sterility, and documenting completes the process.
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed for 1 hr after the feeding
- B. Administer the feeding solution at a cold temperature.
- C. Rotate the jejunostomy tube once per day.
- D. Flush the tube with 90 mL of sterile water before and after the feeding
Correct Answer: A
Rationale: Elevating the head for 1 hour prevents aspiration, essential for jejunostomy feeding safety. Cold solutions, rotation, and large flushes are not recommended.