A nurse is contributing to the plan of care for a client who...

A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all.

A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr
B. Wear a mask when providing care within 3 ft of the client
C. Place a surgical mask on the client if transportation to another dept is unavoidable
D. Use sterile gloves when handling soiled linens
E. Wear a gown when performing care that may result in contamination from secretions

Correct Answer: B, C, E

Rationale: The correct answers are B, C, and E.
B: Wearing a mask within 3 ft of the client helps prevent the transmission of pertussis through respiratory droplets.
C: Placing a surgical mask on the client during transportation reduces the spread of the infection to others.
E: Wearing a gown when handling secretions helps prevent contamination and spread of the infection.
Incorrect choices:
A: Negative air pressure is not necessary for the care of a pertussis patient.
D: Sterile gloves are not required for handling soiled linens in pertussis cases.

A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all.

A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level
E. Measuring vital signs

Correct Answer: A, B, C, E

Rationale: The correct answer includes choices A, B, and C because Certified Nursing Assistants (CNAs) are typically responsible for assisting with activities of daily living such as bathing, ambulating, and toileting. These tasks are within the scope of practice for CNAs and are essential for maintaining the comfort and well-being of patients. Choice E, measuring vital signs, is also a common task performed by CNAs as it helps monitor the patient's health status and provides valuable information to the healthcare team. Choices D and F are incorrect as CNAs are not typically responsible for determining pain levels, which is typically done by nurses or physicians, and choice G is not provided. Overall, the correct choices align with the typical responsibilities of CNAs in providing direct patient care and support.

A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.

A. Instruct the client not to use the Valsalva maneuver
B. Apply elastic stockings
C. Review lab values for total protein level
D. Place pillows under the client's knees & lower extremities
E. Assist the client to change position often

Correct Answer: B, E

Rationale: The correct answers are B and E. Applying elastic stockings helps promote circulation and prevent stasis, reducing the risk of thrombus formation. Assisting the client to change position often prevents prolonged immobility, which can lead to blood pooling and clot formation. Choice A is incorrect because the Valsalva maneuver can increase intra-abdominal pressure, potentially leading to venous stasis and thrombus formation. Choice C is irrelevant to thrombus prevention. Placing pillows under the client's knees and lower extremities (choice D) may promote comfort but does not directly reduce thrombus risk.

A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items?

A. A word she whispers 30cm from his ear
B. A number she traces on the palm of his hand
C. The vibration of a tuning fork she places on his foot
D. A familiar object she places in his hand

Correct Answer: D

Rationale: The correct answer is D: A familiar object she places in his hand. Stereognosis is the ability to recognize objects by touch without visual cues. By asking the client to identify a familiar object placed in his hand with his eyes closed, the nurse is testing his ability to perceive and interpret tactile sensations. This assessment helps evaluate the client's sensory perception and integration in the neurosensory system. The other choices are incorrect because they do not specifically assess stereognosis. Choice A involves auditory perception, choice B involves tactile perception but not recognition of objects, and choice C involves vibratory perception rather than object recognition through touch.

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.

A. Keep the head of the bed elevated 30 degrees
B. Massage the client's bony prominences often
C. Apply cornstarch liberally to the skin after bathing
D. Have the client sit on a gel cushion when in a chair
E. Reposition the client at least Q 3 hr while in bed

Correct Answer: A, D

Rationale: The correct interventions (A and D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.

Incorrect Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.

A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives?

A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
B. I know they won't go ahead w/the surgery unless I prepare these forms.
C. I plan to write that I don't want them to keep me on a breathing machine.
D. I will get my regular doctor to approve my plan before I hand it in at the hospital.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates understanding of advance directives by stating a specific treatment preference, which is not wanting to be kept on a breathing machine. This indicates the client's awareness of the purpose of advance directives in specifying their healthcare wishes.

Choice A is incorrect because it shows a lack of understanding that the client is the one who should make decisions about their care. Choice B is incorrect as it focuses on the surgery proceeding rather than the purpose of advance directives. Choice D is incorrect as it does not show an understanding of the purpose of advance directives but rather a general approval process.