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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, texture, and quality due to lack of essential nutrients. Depigmented hair is a common manifestation.
A: Non-palpable spleen is not directly related to malnutrition.
B: Slightly moist skin is not a typical manifestation of malnutrition.
C: Presence of surface papillae on the tongue may indicate other conditions, not specifically malnutrition.
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A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?
- A. Chlorhexidine washes
- B. Urinary catheterization
- C. Malnutrition
- D. Multiple caregivers
Correct Answer: B
Rationale: The correct answer is B: Urinary catheterization. This is a common cause of HAIs due to the introduction of bacteria into the urinary tract. Catheters provide a direct pathway for bacteria to enter the body, leading to infections such as urinary tract infections. The other choices are incorrect because:
A: Chlorhexidine washes are actually used to prevent infections by killing bacteria on the skin.
C: Malnutrition can weaken the immune system and make individuals more susceptible to infections, but it is not a direct cause of HAIs.
D: Multiple caregivers can increase the risk of infections if proper hygiene practices are not followed, but it is not a specific cause of HAIs like urinary catheterization.
A nurse is reviewing the medical record of a client who has a fluid volume deficit. The nurse should expect which of the following findings?
- A. BUN 12 mg/dL
- B. Urine output 15 mL/hr
- C. Hct 43%
- D. Urine specific gravity 1.020
Correct Answer: B
Rationale: The correct answer is B: Urine output 15 mL/hr. In a client with fluid volume deficit, the body tries to conserve fluids by decreasing urine output. A urine output of 15 mL/hr indicates decreased renal perfusion and fluid conservation, which are common in fluid volume deficit. Choices A, C, and D are within normal ranges and do not specifically indicate fluid volume deficit. Choice A (BUN 12 mg/dL) is within the normal range and is not significantly altered in fluid volume deficit. Choice C (Hct 43%) is also within normal range and may be elevated in dehydration, but not specific to fluid volume deficit. Choice D (Urine specific gravity 1.020) is concentrated, but not definitive for fluid volume deficit.
A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?
- A. Ensure that a family member is present who can interpret health care information.
- B. Use pictures to reinforce instructions given to the client.
- C. Speak in a loud voice when talking to the client.
- D. Encourage the client to nod to indicate understanding.
Correct Answer: B
Rationale: Using pictures as reinforcement supports effective communication and understanding.
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.
A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching?
- A. You'll have to remove metal objects such as watches and body jewelry.
- B. Your exposure to radiation will be minimal.
- C. You will not be able to talk to the technician during the procedure.
- D. Unlike an x-ray, the MRI allows you to move around a bit.
Correct Answer: A
Rationale: The correct answer is A: You'll have to remove metal objects such as watches and body jewelry. This is important for MRI safety as the magnetic field can interact with metal objects, causing harm or image distortion. Removing metal ensures the client's safety during the procedure. Choice B is incorrect as MRI does not involve radiation exposure but magnetic fields. Choice C is incorrect as communication with the technician is usually possible through an intercom system. Choice D is incorrect as clients must remain still during an MRI to prevent image blurring.