Nokea
A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory tract infection following delivery. The nurse determines the client understands principles of infection control to follow when the client says:
- A. I must use barrier isolation.
- B. I must wear a gown and gloves.
- C. I must use individual client care equipment.
- D. I must practice frequent hand washing.
Correct Answer: D
Rationale: Frequent hand washing is the most effective infection control measure for a respiratory tract infection.
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When assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?
- A. Painless vaginal bleeding.
- B. Uterine tetany.
- C. Intermittent pain with spotting.
- D. Dull lower back pain.
Correct Answer: A
Rationale: Painless vaginal bleeding is characteristic of placenta previa.
A client asks about the risks of the contraceptive injection. Which of the following would the nurse include?
- A. Increased risk of blood clots.
- B. Decreased bone density with long-term use.
- C. Permanent weight loss.
- D. Guaranteed regular periods.
Correct Answer: B
Rationale: The contraceptive injection may decrease bone density with long-term use, which is a significant risk. It does not significantly increase blood clot risk, cause permanent weight loss, or guarantee regular periods.
A primiparous client who delivered a viable term neonate vaginally 48 hours ago has a midline episiotomy and a third-degree laceration. When preparing the client for discharge, which of the following assessments would be most important?
- A. Constipation.
- B. Diarrhea.
- C. Excessive bleeding.
- D. Rectal fistulas.
Correct Answer: C
Rationale: Excessive bleeding is critical to assess due to the risk of hemorrhage with a third-degree laceration.
A 16-year-old client at 34 weeks' gestation, who is being monitored at home with home nursing visits, is diagnosed with mild preeclampsia and has gained 2 lb in the past week. Her current blood pressure is 144/92 mm Hg. Which assessment finding would require further action by the home health nurse?
- A. Occasional headache.
- B. Frequent voiding in large amounts.
- C. 1+ pedal edema.
- D. 3+ protein on urine dipstick.
Correct Answer: D
Rationale: Significant proteinuria suggests worsening preeclampsia.
A nurse is teaching a client about the lactational amenorrhea method. Which of the following client statements indicates a need for further teaching?
- A. I need to exclusively breastfeed for this method to work.
- B. This method is effective for up to 6 months postpartum.
- C. I can use this method even if my periods have returned.
- D. I must breastfeed on demand, including at night.
Correct Answer: C
Rationale: The lactational amenorrhea method is not effective if periods have returned, as this indicates ovulation may have resumed, requiring further teaching. The other statements are correct.