Nokea
A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. Implementing airborne precautions involves placing the client in a negative pressure room, using an N95 respirator, and ensuring proper ventilation. Standard precautions (A) are used for all clients. Contact precautions (C) are used for clients with infections that can be spread by direct or indirect contact. Droplet precautions (D) are used for infections spread through larger respiratory droplets. In this case, airborne precautions are specifically needed due to the mode of transmission of tuberculosis.
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A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?
- A. Atrial fibrillation
- B. Jugular vein distention
- C. Bradycardia
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Jugular vein distention. In cardiac tamponade, fluid accumulates in the pericardial sac, compressing the heart. This leads to increased pressure in the heart chambers, causing jugular vein distention due to impaired venous return. A: Atrial fibrillation is a common arrhythmia but not specific to cardiac tamponade. C: Bradycardia is not a typical finding in cardiac tamponade as the body tries to compensate for decreased cardiac output. D: Hypotension can be present but is a late sign and not specific to cardiac tamponade.
A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client?
- A. Surgical mask
- B. N95 respirator
- C. Sterile gloves
- D. Gown and face shield
Correct Answer: A
Rationale: The correct answer is A: Surgical mask. The nurse should use a surgical mask when caring for a client with bacterial meningitis to prevent the spread of infectious droplets. A surgical mask is sufficient for this infection, as it primarily spreads through respiratory droplets. Using an N95 respirator, sterile gloves, or a gown and face shield would be unnecessary and excessive for this particular situation, as they are typically reserved for airborne precautions or when there is a high risk of contact with bodily fluids. Thus, the use of a surgical mask is the most appropriate and effective choice in this scenario.
A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The clients vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurses priority?
- A. Administer an antipyretic for the fever.
- B. Encourage the client to ambulate.
- C. Assess the surgical incision for signs of infection.
- D. Increase IV fluid administration.
Correct Answer: C
Rationale: The correct answer is C: Assess the surgical incision for signs of infection. This is the priority because the client has a fever (indicating possible infection) post-surgery, putting them at risk for complications. Assessing the surgical incision allows for early detection of infection, prompt treatment, and prevention of further complications. Administering an antipyretic (choice A) only addresses the symptom but not the underlying cause. Encouraging ambulation (choice B) and increasing IV fluids (choice D) are important but assessing for infection takes precedence due to the potential severity of an infected surgical site.
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the clients coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?
- A. Notify risk management.
- B. Inform the transferring agency of the clients condition.
- C. Contact the family regarding the clients condition.
- D. Privately interview the client about the injuries.
Correct Answer: D
Rationale: Correct Answer: D - Privately interview the client about the injuries.
Rationale:
1. As a healthcare provider, the nurse must prioritize the well-being and safety of the client.
2. Privately interviewing the client allows for a confidential conversation to gather information directly from the client.
3. This approach respects the client's autonomy and confidentiality.
4. It enables the nurse to assess the situation, gather more details, and determine if further actions are needed to address the suspected elder abuse.
5. Notifying risk management (A) is important but should come after gathering information from the client.
6. Informing the transferring agency (B) may not address the immediate concern of potential abuse.
7. Contacting the family (C) may not be appropriate if they are involved in the abuse.
8. Failing to interview the client may result in a missed opportunity to address the issue effectively.
Summary:
Option D is correct as it prioritizes the client's well-being, respects autonomy, and
A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect?
- A. Low urine specific gravity
- B. High urine specific gravity
- C. Elevated potassium levels
- D. Decreased potassium levels
Correct Answer: A
Rationale: The correct answer is A: Low urine specific gravity. Excessive diuretic use can lead to volume depletion and low sodium levels. Low sodium levels cause the kidneys to excrete more water, resulting in dilute urine with low specific gravity. High urine specific gravity would indicate concentrated urine, which is not expected in this situation. Elevated potassium levels (choice C) are not typically associated with overuse of diuretics, as diuretics can actually lead to potassium loss. Similarly, decreased potassium levels (choice D) are commonly seen with diuretic use due to increased excretion of potassium by the kidneys.