Nokea
A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?
- A. Instruct the parents to avoid bringing fresh flowers into the room.
- B. Use an N95 respirator.
- C. Initiate contact precautions.
- D. Place the child in a room that has a HEPA filtration system.
Correct Answer: C
Rationale: Initiating contact precautions is correct. Clostridium difficile is highly contagious and spreads through spores that can survive on surfaces. Contact precautions, including the use of gloves and gowns and proper hand hygiene with soap and water, help prevent transmission.
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A nurse is collecting data from a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following findings should the nurse expect?
- A. The client reports a tightening of her abdomen.
- B. The client reports increased urinary output.
- C. The client reports a temperature of 38.9°C (102°F).
- D. The client reports seeing bright red blood.
Correct Answer: A
Rationale: A tightening of the abdomen indicates uterine contractions, a hallmark of preterm labor, which the nurse should expect at 32 weeks of gestation.
A nurse is caring for a client who has a new prescription for montelukast. Which of the following adverse effects should the nurse monitor for?
- A. Mood changes
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Montelukast, a leukotriene inhibitor, can cause mood changes, including anxiety or depression, which require monitoring.
A nurse is caring for a client who has a new prescription for venlafaxine. Which of the following adverse effects should the nurse monitor for?
- A. Hypertension
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Venlafaxine, an SNRI, can cause hypertension by increasing norepinephrine levels, requiring monitoring.
A nurse is caring for a client who has a new diagnosis of sarcoidosis. Which of the following findings should the nurse expect?
- A. Lung nodules
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Lung nodules are a common finding in sarcoidosis due to granuloma formation in the lungs.
A nurse is reinforcing teaching with a client who is scheduled for a barium swallow. Which of the following instructions should the nurse include?
- A. Fast for 8 hours before the procedure.
- B. Avoid dairy products after the procedure.
- C. Expect to receive sedation during the procedure.
- D. Take a laxative before the procedure.
Correct Answer: A
Rationale: Fasting for 8 hours before a barium swallow ensures a clear view of the esophagus and stomach.