Nokea
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
- A. Carry a client's soiled linens out of the room in a mesh linen bag
- B. Place a client who has tuberculosis in a room with negative-pressure airflow
- C. Provide disposable plates and utensils for a client who is HIV-positive
- D. Dispose of a client's blood-saturated dressing in a biohazard bag
Correct Answer: B
Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.
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A healthcare professional is reviewing a client's medication prescription, which reads, 'digoxin 0.25 by mouth every day.' Which of the following components of the prescription should the healthcare professional question?
- A. the medication
- B. the route
- C. the dose
- D. the frequency
Correct Answer: C
Rationale: The healthcare professional should question the dose indicated in the prescription. In this case, '0.25' is incomplete without a unit of measurement, such as mg (milligrams). Without a specified unit, the dose lacks the necessary information for accurate administration. Choices A, B, and D are not incorrect components to question in medication prescriptions; however, in this scenario, the incompleteness of the dose is the most critical concern that needs clarification to ensure safe and effective medication administration.
During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse's priority?
- A. A client who received crush injuries to the chest and abdomen and is expected to die.
- B. A client who has a 4-inch laceration to the head.
- C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest.
- D. A client who has a fractured fibula and tibia.
Correct Answer: C
Rationale: During a mass casualty event, the priority client for the nurse is the one with partial-thickness and full-thickness burns to the face, neck, and chest. Clients with severe burns in critical areas require immediate attention due to the potential for life-threatening complications such as airway compromise, fluid loss, and infection. Crush injuries and fractures, although serious, are generally less urgent in comparison and can be managed after addressing the burns. Therefore, the client with burns to the face, neck, and chest should be the nurse's priority over the other clients described.
A nurse is counseling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?
- A. "I spent my whole life dreaming about retirement, and now I wish I had my job back."
- B. "It's been so stressful for me to have to depend on my child to help around the house."
- C. "I just heard my friend Al die. That's the third one in 3 months."
- D. "I keep forgetting which medications I have taken during the day."
Correct Answer: C
Rationale: The correct answer is C. The statement expressing the loss of friends is the priority issue as it indicates potential grief and emotional distress. Losing multiple friends within a short period can have a profound impact on an older adult's emotional well-being. Option A expresses regret but does not indicate an immediate emotional crisis. Option B focuses on stress related to dependence, which is important but not as urgent as coping with loss. Option D highlights a memory concern, which is significant but does not address the emotional impact of loss.
A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
- B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
- C. A client who has a UTI and low-grade fever
- D. A client who has pneumonia and an oxygen saturation of 96%
Correct Answer: A
Rationale: The nurse should see the client who has new onset of dyspnea 24 hours after a total hip arthroplasty first. New onset of dyspnea, especially after surgery, can indicate a serious complication such as a pulmonary embolism or deep vein thrombosis. It is essential to assess this client promptly to rule out potentially life-threatening conditions. Acute abdominal pain, a UTI with low-grade fever, and pneumonia with an oxygen saturation of 96% are important issues but do not indicate the urgency and potential severity of a post-operative complication like pulmonary embolism or deep vein thrombosis.
A client is being discharged with a prescription for digoxin (Lanoxin). Which of the following instructions should the nurse include in the discharge teaching?
- A. Take your pulse daily before taking this medication.
- B. Take an extra dose if you miss a dose of this medication.
- C. Take this medication with food.
- D. Avoid eating foods high in potassium while taking this medication.
Correct Answer: A
Rationale: The correct answer is A: 'Take your pulse daily before taking this medication.' It is essential for clients taking digoxin to monitor their pulse daily to detect bradycardia, a potential side effect. Choice B is incorrect because clients should never take an extra dose if a dose is missed; they should take the missed dose as soon as remembered unless it is close to the time for the next dose. Choice C is incorrect because digoxin is preferably taken with food to minimize gastrointestinal side effects. Choice D is incorrect because digoxin itself can cause low potassium levels, so avoiding potassium-rich foods is not necessary.