Nokea
A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?
- A. Wear a mask when entering the client's room.
- B. Remove potted plants from the room.
- C. Allow the client to leave the room every 2 hr.
- D. Dedicate equipment and supplies for use with the client.
Correct Answer: D
Rationale: The correct answer is D: Dedicate equipment and supplies for use with the client. This is essential for preventing the spread of infection. By dedicating equipment to the client, the nurse reduces the risk of contaminating other clients. Choice A is incorrect because wearing a mask is not necessary for contact precautions unless respiratory droplets are a concern. Choice B is irrelevant to contact precautions. Choice C is incorrect as allowing the client to leave the room frequently can increase the risk of spreading infection.
You may also like to solve these questions
A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene.
- A. Adjust the suction to 120 to 150 mm Hg.
- B. Apply intermittent suction while rotating the catheter.
- C. Don sterile gloves.
- D. Check the function of the suction catheter.
- E. Insert the catheter without suction.
- F. Hyperoxygenate the client.
- G. Check for secretion clearance.
Correct Answer: A,F,D,C,E,B
Rationale: Check for secretion clearance.
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
- A. Keep a night light on in the client's room and bathroom.
- B. Keep the bed at a comfortable working height.
- C. Lock the wheels on beds and wheelchairs during transfers.
- D. Place the bedside table within the client's reach.
- E. Administer a sedative at bedtime.
Correct Answer: A,C,D
Rationale: The correct actions to contribute to the fall prevention plan are A, C, and D. A night light can help the client see clearly at night, reducing the risk of tripping. Locking the wheels on beds and wheelchairs ensures stability during transfers. Placing the bedside table within reach promotes independence and prevents falls from reaching for items. Choice B is incorrect as bed height doesn't directly impact fall risk. Choice E, administering a sedative, can increase fall risk due to drowsiness.
A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?
- A. Assist the guest to the floor and begin mouth-to-mouth resuscitation.
- B. Observe the guest before taking further action.
- C. Perform the Heimlich maneuver on the guest.
- D. Slap the guest on the back several times.
Correct Answer: C
Rationale: The correct answer is C: Perform the Heimlich maneuver on the guest. This is the appropriate action for a choking individual who is unable to speak or breathe. The Heimlich maneuver helps dislodge the obstruction from the airway by applying abdominal thrusts. It is crucial to act quickly in such situations to prevent further complications like loss of consciousness or asphyxiation.
Choice A is incorrect as mouth-to-mouth resuscitation is not appropriate for a choking victim. Choice B is incorrect as observing without taking immediate action can be dangerous if the individual's airway is completely blocked. Choice D is incorrect as slapping the back may not effectively dislodge the obstruction. It is essential to prioritize the Heimlich maneuver to clear the airway and restore breathing.
A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?
- A. Non-palpable spleen
- B. Slightly moist skin
- C. Presence of surface papillae on tongue
- D. Depigmented hair
Correct Answer: D
Rationale: The correct answer is D: Depigmented hair. Malnutrition can lead to changes in hair color and texture, resulting in depigmented or thinning hair. This is due to the body lacking essential nutrients needed for healthy hair growth. Non-palpable spleen (A) is not typically associated with malnutrition. Slightly moist skin (B) is more likely to be seen in a well-nourished individual. Presence of surface papillae on the tongue (C) is not a common manifestation of malnutrition. Therefore, depigmented hair (D) is the most likely manifestation of malnutrition in this scenario.
A nurse is reinforcing teaching with a client on how to use meditation and progressive relaxation techniques to manage stress. Which of the following physiologic outcomes should the nurse instruct the client to expect?
- A. Arousal reduction
- B. Decreased blood pressure
- C. Decreased heart rate
- D. Increased oxygen consumption
- E. Increased respiratory rate
Correct Answer: A,B,C
Rationale: Meditation and relaxation techniques reduce physiological stress responses, leading to lower blood pressure, heart rate, and arousal.