Nokea
A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
- A. Measure the client's intake and output every 8 hr.
- B. Dim the lighting in the client's room.
- C. Monitor the client's temperature every 6 hr.
- D. Initiate contact precautions for the client.
Correct Answer: B
Rationale: Dimming the lighting reduces photophobia, a common symptom of viral meningitis, improving client comfort. Intake/output and temperature monitoring are useful but less specific, and contact precautions are not typically required for viral meningitis.
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A nurse in a provider's office is assisting in the care of a client. For each potential provider's prescription, which is anticipated for the client?
- A. Administer an iron supplement.
- B. Collaborate with a nutritional consultant.
- C. Place the client on a low sodium diet.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Given the client's vegan diet, fatigue, weakness, pale mucous membranes, and rapid pulse (Exhibit 1), iron deficiency anemia is likely. Administering an iron supplement is anticipated it corrects low hemoglobin, a common vegan shortfall without meat or fortified sources, directly addressing the suspected etiology. Nutritional consultation helps long-term, but immediate supplementation is urgent for symptom relief and oxygen delivery. A low-sodium diet suits heart failure or hypertension, not anemia blood pressure (132/60 to 102/50 mm Hg) reflects orthostasis, not sodium issues. Fluid restriction applies to fluid overload, not here, where hydration supports circulation. Iron supplementation aligns with anemia management guidelines (e.g., ferrous sulfate), offering rapid hematologic improvement, making it the expected prescription for this presentation.
A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
- A. Have the client wear a surgical mask during transport.
- B. Wear an N95 mask while providing care to the client.
- C. Administer an influenza immunization to the client.
- D. Place the client in a negative airflow room.
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.
A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
- A. Isopropyl alcohol
- B. Bleach
- C. Hydrogen peroxide
- D. Chlorhexidine
Correct Answer: B
Rationale: A 1:10 bleach solution is the standard for decontaminating blood spills in AIDS care, effectively killing HIV. Other agents are less effective against bloodborne pathogens.
A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply heat to my affected ankle to decrease swelling.
- B. I can bear full weight on my affected ankle.
- C. I can dangle my affected ankle from the edge of the bed.
- D. I will wrap my affected ankle with an elastic bandage.
Correct Answer: D
Rationale: Wrapping with an elastic bandage provides compression to reduce swelling in a grade 2 sprain. Heat increases swelling, full weight-bearing is premature, and dangling worsens edema.
A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should instruct the client that which of the following foods has the highest iron content?
- A. 3 oz chicken breast
- B. 3 oz canned tuna
- C. 3 oz pork roast
- D. 3 oz ground beef
Correct Answer: D
Rationale: Ground beef has the highest iron content (about 2.7 mg/3 oz) among these options, making it best for iron-deficiency anemia.