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A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?
- A. Discard soiled wound care supplies in a trash receptacle outside the client's room.
- B. Administer antibiotic therapy before culturing the client's wound.
- C. Place the client in a private room with a private bathroom.
- D. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client's room.
Correct Answer: C
Rationale: A private room with a private bathroom helps control infection spread from a foul-smelling, infectious wound. Supplies should be discarded in biohazard containers, cultures taken before antibiotics, and hand hygiene should be thorough, not just 5 seconds.
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A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?
- A. Ask the provider for a prescription for a pureed diet.
- B. Have an assistive personnel feed the client.
- C. Obtain a referral for physical therapy.
- D. Apply foam handles to the client's eating utensils.
Correct Answer: D
Rationale: Chronic arthritis often impairs hand dexterity and grip strength, making self-feeding challenging. Option A, a pureed diet, addresses swallowing issues, not arthritis-related difficulties with utensils, so it's irrelevant here. Option B, having assistive personnel feed the client, undermines independence and dignity without addressing the root issue of utensil handling. Option C, physical therapy, may improve joint function long-term but doesn't provide immediate help for eating. Option D is correct applying foam handles increases utensil girth, improving grip for arthritic hands, promoting self-feeding and autonomy. This intervention directly tackles the physical limitation caused by arthritis, aligning with nursing goals of enhancing quality of life and independence. It's practical, cost-effective, and can be implemented quickly, offering immediate relief while other therapies (like PT) work in the background. Evidence supports adaptive equipment as a first-line strategy for arthritis patients struggling with daily activities, making this the most appropriate and empowering choice.
A nurse in a health clinic is collecting data from an older adult client. Which of the following information in the client's history increases her risk for osteoporosis?
- A. The client is a gardener.
- B. The client is lactose intolerant.
- C. The client has a glass of red wine every evening
- D. The client walks 3.2 km (2 mi) daily.
- E. The client smokes daily.
- F. The client has a family history of osteoporosis.
- G. The client takes corticosteroids long-term.
Correct Answer: B
Rationale: Lactose intolerance limits calcium intake, a key risk factor for osteoporosis; gardening and walking are protective, and moderate wine has minimal impact.
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
- A. Experiences nocturia
- B. History of generalized anxiety disorder
- C. Recent exposure to tuberculosis
- D. Reports periodic migraine headaches
Correct Answer: C
Rationale: Recent TB exposure is the priority due to infection risk to others in a semi-private room, requiring immediate isolation precautions.
A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
- A. Nerve damage
- B. Infection
- C. Infiltration
- D. Phlebitis
Correct Answer: C
Rationale: Edema, coolness, and tenderness suggest infiltration, where IV fluid leaks into surrounding tissue. Infection involves warmth/redness, phlebitis includes inflammation, and nerve damage affects sensation/movement.
A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps?
- A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
- B. Check the medication administration record to verify the client's allergies.
- C. Slowly inject the medication into the site without aspirating.
- D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle.
- E. Ensure an air bubble is present in the prefilled enoxaparin syringe.
Correct Answer: B,E,A,D,C
Rationale: The sequence is: Verify allergies (B), check the air bubble (E), locate the site (A), pinch and inject at 90° (D), and inject slowly without aspirating (C) per enoxaparin protocol.