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The client has methicillin-resistant Staphylococcus aureus (MRSA).
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
- A. Don gloves prior to assisting the client with brushing their teeth.
- B. Have the client wear a mask when they are out of their room.
- C. Ensure that the negative air pressure is active for the client's room.
- D. Place the client in a room with a high-efficiency particulate air (HEPA) filter.
Correct Answer: A
Rationale: Gloves prevent MRSA transmission during close contact like brushing teeth.
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A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
- A. Educate the infant's guardians about exchange transfusion.
- B. Administer granulocyte colony-stimulating factor.
- C. Initiate droplet precautions.
- D. Monitor the infant's lymphocyte count.
Correct Answer: D
Rationale: Monitoring lymphocyte count tracks HIV progression in infants.
The client delivered a newborn by cesarean birth 1 day ago.
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?
- A. You can apply counterpressure to your back with each position change.
- B. You should change positions as little as possible.
- C. You can splint the incision with a pillow when changing positions.
- D. You should use patterned-paced breathing when changing positions.
Correct Answer: C
Rationale: Splinting the incision with a pillow reduces pain during movement.
A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?
- A. Evaluate the need for the client to remain in mitten restraints.
- B. Determine the circulation status of the affected extremities every 2 hr.
- C. Instruct the client's family about the purpose of mitten restraints.
- D. Assist the client with range-of-motion exercises of the hands.
Correct Answer: D
Rationale: Assisting with range-of-motion is within the AP's scope, unlike evaluation or teaching.
The child has pertussis.
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?
- A. Facial erythema
- B. Peeling of the hands and feet
- C. Fever
- D. Beefy, red tongue
Correct Answer: C
Rationale: Fever is a common symptom of pertussis.
The client has quadriplegia.
A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?
- A. Place the client's glasses on the bedside table.
- B. Place the call light within the client's reach.
- C. Check on the client every 4 hr.
- D. Place the client in a room near the nurses' station.
Correct Answer: B
Rationale: Placing the call light within reach ensures the client can summon help.