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A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor?
- A. The nurse wears a gown when bathing the client.
- B. The nurse admits another client who has shingles to the client's double room.
- C. The nurse wears gloves when providing direct care to the client.
- D. The nurse wears an N95 respirator mask.
Correct Answer: B
Rationale: Shingles is highly contagious, especially to those without chickenpox immunity. Cohorting clients with shingles in a shared room risks viral transmission. Other actions are appropriate precautions.
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A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
- A. The first 2 min
- B. The final 2 min
- C. The final 15 min
- D. The first 15 min
Correct Answer: D
Rationale: Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for signs of a reaction, such as fever, chills, rash, or difficulty breathing.
A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage?
- A. Hypotension
- B. Diaphoresis
- C. Bradycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypotension and tachypnea are signs of hemorrhage due to decreased blood volume and compensatory increased respiratory rate. Diaphoresis may occur but is less specific, while bradycardia and diarrhea are not typical.
A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?
- A. Check the client's vital signs.
- B. Cover the wound with a moist, sterile gauze dressing.
- C. Assess the client's pain level.
- D. Obtain a culture and sensitivity of the wound drainage
Correct Answer: B
Rationale: Covering the wound with a moist, sterile dressing is the priority to protect it from infection and manage drainage, preventing further contamination and supporting healing.
A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?
- A. Avoid crowds
- B. Eat plenty of fresh fruits and vegetables
- C. Take temperature weekly.
- D. Perform mild exercise, such as gardening
Correct Answer: A
Rationale: Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens. Fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early. Gardening can expose individuals to soil-borne organisms that could lead to infections.
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?
- A. Notifying the provider
- B. Stopping the transfusion
- C. Covering the client with a blanket
- D. Assessing the client's skin for a rash
Correct Answer: B
Rationale: Chills and back pain suggest a serious transfusion reaction, like hemolytic reaction. Stopping the transfusion immediately is the priority to prevent further complications.