Nokea
A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?
- A. Airborne
- B. Contact
- C. Protective
- D. Droplet
Correct Answer: D
Rationale: The correct answer is D: Droplet precautions. Pertussis is primarily spread through respiratory droplets from coughing or sneezing. Droplet precautions involve wearing a mask and eye protection to prevent transmission through these droplets. Airborne precautions are for diseases spread through small particles, contact precautions are for direct physical contact, and protective precautions are not a standard type of transmission-based precaution. Droplet precautions are the most appropriate choice for pertussis to prevent the spread of the infection to others.
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A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which of the following statements by the client indicates a need for clarification?
- A. The health care proxy does not go into effect until I am incapable of making decisions.
- B. I have to choose a family member as my health proxy.
- C. I can change who I designate as my health care proxy at any time.
- D. If I become incapacitated, end-of-life choices will be made by my proxy.
Correct Answer: B
Rationale: The correct answer is B: "I have to choose a family member as my health proxy." This statement indicates a need for clarification because it is incorrect. The client can choose any competent adult to be their health care proxy, not just a family member. This misconception may limit the client's options and understanding of their rights.
Incorrect choices:
A: This statement is correct as the health care proxy only goes into effect when the client is incapable of making decisions.
C: This statement is correct as the client can change their designated health care proxy at any time.
D: This statement is correct as the health care proxy will make end-of-life choices if the client becomes incapacitated.
A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
- A. Akathisia
- B. Tardive dyskinesia
- C. Dystonia
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Tardive dyskinesia is a common adverse effect of long-term antipsychotic medication use, such as chlorpromazine. It is characterized by involuntary movements of the tongue and face. This condition is often irreversible and can be distressing for the client. Akathisia (choice A) is a different extrapyramidal side effect characterized by restlessness and the urge to move constantly. Dystonia (choice C) is another extrapyramidal side effect that presents as sustained muscle contractions causing abnormal postures. In this case, the symptoms described in the question are more indicative of tardive dyskinesia due to the specific type of involuntary movements observed in the client.
A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will wipe from the back to front with the cleaning cloth.
- B. I need to urinate a small amount in the toilet before collecting the sample.
- C. I should let the urine cool to room temperature before sending it to the lab.
- D. I should not collect a urine sample when I am menstruating.
Correct Answer: B
Rationale: Correct Answer: B - "I need to urinate a small amount in the toilet before collecting the sample."
Rationale:
1. This statement indicates the client understands the importance of collecting a midstream urine sample.
2. By urinating a small amount first, the initial stream clears any bacteria present in the urethra, ensuring a more accurate sample.
3. Collecting a midstream sample helps to avoid contamination from the surrounding genital area.
4. This method is essential for accurate urinalysis results and diagnosis of potential urinary tract infections.
Incorrect Choices:
A: Incorrect - Wiping from back to front can introduce bacteria from the anal region into the urethra, leading to contamination.
C: Incorrect - Cooling the urine to room temperature is not necessary for a midstream urine sample collection.
D: Incorrect - Menstruation does not interfere with the accuracy of a midstream urine sample collection.
A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?
- A. Assist the client to sit upright in a chair for 4 hours at a time.
- B. Expect clear drainage on the spinal dressing.
- C. Log roll the client every 2 hours.
- D. Perform neurological checks every 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Log roll the client every 2 hours. This action is crucial for preventing complications such as pressure ulcers and maintaining spinal alignment post spinal fusion surgery. Log rolling helps to keep the spine in proper alignment and reduces the risk of injury to the surgical site. Assisting the client to sit upright for 4 hours at a time (choice A) can put excessive pressure on the surgical site and hinder the healing process. Expecting clear drainage on the spinal dressing (choice B) is not appropriate as drainage may vary and is not necessarily an indicator of infection. Performing neurological checks every 8 hours (choice D) is important but should be done more frequently in the immediate postoperative period.
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Obtain a 12-lead ECG.
- B. Suggest that the client use a salt substitute.
- C. Advise the client to add citrus juices and bananas to her diet.
- D. Obtain a blood sample for a serum sodium level.
Correct Answer: A
Rationale: The correct answer is A: Obtain a 12-lead ECG. A potassium level of 6.8 mEq/L indicates hyperkalemia, which can lead to serious cardiac arrhythmias. Therefore, obtaining an ECG is crucial to assess for any potential cardiac abnormalities. Choice B is incorrect as salt substitutes often contain potassium, exacerbating the issue. Choice C is incorrect as citrus juices and bananas are high in potassium, which should be avoided in hyperkalemia. Choice D is incorrect as it focuses on sodium levels, not addressing the immediate concern of hyperkalemia.