Nokea
A nurse 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 primarily spread through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve wearing a mask and eye protection within 3 feet of the patient to prevent the transmission of respiratory secretions. Contact precautions (Choice A) are for diseases transmitted through direct contact with the patient or contaminated surfaces. Airborne precautions (Choice C) are for diseases spread through tiny particles that can remain suspended in the air for long periods. Protective precautions (Choice D) are not a standard precaution type.
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The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.
- A. Limit alcohol intake to 0 oz per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an anti-obesity medication.
- D. Administer an antihypertensive medication.
- E. Limit foods high in potassium.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A: Limiting alcohol intake helps manage conditions like hypertension. B: Keeping fat intake below 35% helps prevent heart disease. D: Administering antihypertensive medication is essential for managing high blood pressure. C: Administering anti-obesity medication may not be necessary if the client's weight is not the primary concern. E: Limiting foods high in potassium is not necessary unless the client has specific medical conditions requiring it. Therefore, choices C and E are incorrect as they are not the priorities for the client's care in this scenario.
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
- A. Choose a vein that is palpable and straight.
- B. Elevate the client's arm prior to insertion.
- C. Apply a tourniquet below the venipuncture site.
- D. Select a site on the client's dominant arm.
Correct Answer: A
Rationale: Correct Answer: A. Choose a vein that is palpable and straight.
Rationale: Selecting a palpable and straight vein ensures successful insertion and reduces the risk of complications like infiltration or phlebitis. A straight vein allows for easier catheter insertion and reduces the chance of vein damage. Palpability helps in accurately locating the vein for successful cannulation.
Summary of Other Choices:
B: Elevating the client's arm may help distend the veins, but it is not a necessary step for IV catheter insertion.
C: Applying a tourniquet below the venipuncture site can help visualize veins better but is not crucial for successful IV catheter insertion.
D: Selecting the site on the client's dominant arm is not necessary. The nurse should choose the best vein regardless of the arm dominance to ensure successful cannulation.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys, leading to blood in the urine. This is due to damage to the glomerular capillaries allowing red blood cells to leak into the urine. Oliguria (A) is not a common finding as there is usually normal to increased urine output. Hypotension (B) is not typically seen as glomerulonephritis can lead to fluid overload and hypertension. Weight loss (C) is unlikely as fluid retention is common. Hematuria (D) is the hallmark finding due to the damage to glomeruli.
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming.
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is essential for proper foot care in diabetes mellitus as it helps prevent fungal infections and keeps feet dry. Soaking feet twice daily (choice A) can lead to skin breakdown. Rounding the edges of toenails (choice B) can increase the risk of ingrown toenails. Using moisturizing lotion between the toes (choice C) can create a moist environment, fostering fungal growth. Therefore, wearing clean cotton socks daily is the most appropriate instruction to promote foot health in a client with diabetes mellitus.
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine.
- B. How to secure the tracheostomy tube with ties at the back of the neck.
- C. How to change the nondisposable tracheostomy tube daily.
- D. How to change the tracheostomy dressing using clean technique.
Correct Answer: D
Rationale: The correct answer is D: How to change the tracheostomy dressing using clean technique. This is important to prevent infection and promote healing. First, wash hands thoroughly to maintain cleanliness. Second, gather necessary supplies such as clean gloves, sterile gauze, and saline solution. Third, remove the old dressing carefully and inspect the stoma for any signs of infection or irritation. Fourth, clean around the stoma with saline solution and gently pat dry. Finally, apply a new, sterile dressing using clean technique to maintain a clean and dry environment. Choice A is incorrect because operating a suction machine is typically done by healthcare professionals. Choice B is incorrect as securing the tracheostomy tube is usually done by healthcare providers to ensure proper placement. Choice C is incorrect as changing the tracheostomy tube daily is not a standard practice unless specifically indicated by a healthcare provider.