Nokea
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Administer aspirin to the child for fever.
- C. Use droplet precautions when caring for the child
- D. Assess the child for Koplik spots
Correct Answer: A
Rationale: Correct Answer: A - Assign the child to a negative air pressure room.
Rationale:
1. Varicella is highly contagious through airborne transmission.
2. Negative air pressure rooms help prevent the spread of infectious particles.
3. Isolation precautions are essential to protect other patients and healthcare workers.
4. Placing the child in a negative air pressure room minimizes the risk of transmission.
Summary of other choices:
B: Administering aspirin can lead to Reye's syndrome in children with varicella.
C: Droplet precautions are used for diseases like influenza, not varicella.
D: Koplik spots are associated with measles, not varicella.
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Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
A nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: A
Rationale: The correct answer is A because a client who uses a wheelchair and is confused is at the highest risk during a fire evacuation due to mobility limitations and decreased ability to follow instructions. Evacuating this client first ensures their safety and prevents potential delays in the evacuation process.
Choice B is incorrect because a bedridden client wearing a hearing aid can still be safely evacuated with assistance. Choice C is incorrect as an ambulatory client receiving oxygen can usually move independently and should be evacuated after the client in a wheelchair. Choice D is incorrect because a client with a fracture in traction can be safely moved with proper equipment and should not be the first priority for evacuation.
A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?
- A. An induration measuring 10 mm
- B. An induration measuring 5 mm
- C. A reddened area measuring 10 mm
- D. A reddened area measuring 5 mm
Correct Answer: A
Rationale: The correct answer is A: An induration measuring 10 mm. An induration of 10 mm or greater is considered a positive result for a tuberculin skin test in individuals who are at higher risk for tuberculosis. This indicates exposure to the tuberculosis bacteria and an immune response. Choices B, C, and D are incorrect because the presence of redness or a smaller induration size does not meet the criteria for a positive test result. Redness alone does not signify a positive result, and a smaller induration size is not indicative of a positive test. It is important to interpret tuberculin skin tests accurately to guide further testing and treatment decisions.
A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, 'Providing constant care is very stressful and is affecting all areas of my life.' Which of the following actions should the nurse take?
- A. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
- B. Recommend allowing the client to have time alone in their room throughout the day
- C. Discuss methods of how to communicate with the client about resolving problem behaviors
- D. Assist the caregiver to arrange for a daycare program for the client
Correct Answer: D
Rationale: The correct answer is D: Assist the caregiver to arrange for a daycare program for the client. This option addresses the caregiver's concern of stress and the impact on their life by providing respite care. This allows the caregiver to have a break and attend to their own needs while ensuring the client's safety and well-being. It promotes caregiver self-care and prevents burnout.
Option A is incorrect as prescribing antipsychotic medication is not appropriate for caregiver stress. Option B may not address the caregiver's need for a break or support. Option C, while important, focuses on communication strategies rather than providing immediate relief for the caregiver.
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Calcium
- B. Folate
- C. Iron
- D. Zinc
Correct Answer: B
Rationale: The correct answer is B: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the formation of the neural tube during early pregnancy. Calcium (A) is important for bone health but not specifically for preventing neural tube defects. Iron (C) is crucial for preventing anemia but not directly related to neural tube defects. Zinc (D) is important for immune function and wound healing but not specifically for neural tube defects.