Nokea
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Reflexology
- D. Acupuncture
Correct Answer: D
Rationale: The correct answer is D: Acupuncture. Herpes zoster, also known as shingles, is a viral infection that affects the nerves and causes a painful rash. Acupuncture involves inserting thin needles into specific points on the body to alleviate pain and promote healing. However, in the case of herpes zoster, the skin lesions and nerve involvement increase the risk of spreading the virus through acupuncture needles, leading to potential complications. Therefore, acupuncture is contraindicated in clients with herpes zoster to prevent the spread of the virus.
A: Biofeedback, B: Aloe, and C: Reflexology are not contraindicated for clients with herpes zoster. Biofeedback is a non-invasive technique that helps individuals control physiological processes such as reducing stress and managing pain. Aloe is a natural plant extract commonly used for its anti-inflammatory and soothing properties, which can be beneficial for skin irritations caused by herpes zoster. Reflexology is a therapeutic technique that involves applying pressure to
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A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
- A. Make sure the client's room has at least six air exchanges per hour.
- B. Make sure the client wears a mask when outside her room if there is construction in the area.
- C. Place the client in a private room with negative-pressure airflow.
- D. Wear an N95 respirator when giving the client direct care.
Correct Answer: A
Rationale: The correct answer is A: Make sure the client's room has at least six air exchanges per hour. This is essential for a protective environment post-allogeneic stem cell transplant to reduce the risk of infection. Increasing air exchanges helps remove airborne pathogens and maintain a clean environment. Option B is incorrect as wearing a mask outside the room is not a part of a protective environment. Option C is incorrect as negative-pressure airflow is typically used for clients with airborne infections, not for stem cell transplant clients. Option D is incorrect as N95 respirators are not routinely required for providing direct care in a protective environment setting.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This action ensures proper fit and compression without causing restriction or compromising circulation. A: Assisting the client into a prone position is not necessary for applying the sleeves. B: Placing the sleeve with the opening at the knee is incorrect as it should be at the top of the leg. D: Setting the ankle pressure at 65 mm Hg is not specified for thigh-length sleeves and may not be appropriate.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider's statement in the medical record.
- B. Consult the facility's risk manager.
- C. Complete an incident report.
- D. Notify the nursing manager.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should document the provider's statement in the medical record. This is important for legal and communication purposes. By documenting the surgeon's instructions, the nurse ensures that the care provided is well-documented and can be tracked for continuity of care. It also serves as evidence that the nurse followed the provider's orders appropriately.
Summary:
B: Consulting the facility's risk manager is not necessary at this point as the situation does not involve a risk management issue.
C: Completing an incident report is not warranted as there is no indication of an incident or error that has occurred.
D: Notifying the nursing manager is not the immediate action required in this situation. The nurse should prioritize following the provider's instructions and documenting the communication.
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
- A. Increase in hematocrit.
- B. Increase in respiratory rate.
- C. Decrease in heart rate.
- D. Decrease in capillary refill time.
Correct Answer: C
Rationale: The correct answer is C: Decrease in heart rate. Administering 0.9% sodium chloride would help rehydrate the client, leading to an increase in blood volume and improved cardiac output. As a result, the heart doesn't have to work as hard, leading to a decrease in heart rate, indicating successful treatment.
Incorrect choices:
A: Increase in hematocrit - This would indicate dehydration, not successful treatment.
B: Increase in respiratory rate - This could be a sign of respiratory distress, not related to fluid volume correction.
D: Decrease in capillary refill time - This could indicate improved peripheral circulation, but not a direct indicator of successful fluid resuscitation.
A nurse +2:43 is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is transmitted through respiratory droplets from infected individuals. Droplet precautions involve wearing a mask when within 3 feet of the client to prevent the transmission of droplets. Contact precautions (Choice A) are for diseases spread through direct contact with the client or contaminated surfaces. Airborne precautions (Choice C) are for diseases that are transmitted through tiny particles that remain suspended in the air. Protective precautions (Choice D) are not a standard precaution type but rather a set of measures to protect immunocompromised clients from infections.