Nokea
A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keep conversations short. Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, it may increase demands on the client's energy. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.
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A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
- A. A 79 year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. An incontinent client who has had 3 diarrhea stools
- D. An 80 year-old ambulatory diabetic client
Correct Answer: A
Rationale: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?
- A. "Persons entering the room with colds should stay at least 3 feet from me."
- B. "My family plans to bring flowers from my garden to help me feel better."
- C. "The precautions will protect me and help my blood count recover faster."
- D. "Persons entering my room should perform hand hygiene before entering."
Correct Answer: D
Rationale: D: Hand hygiene is critical to prevent pathogen introduction. A: Visitors with colds should avoid entry. B: Flowers can harbor microbes. C: Precautions don't improve neutrophil counts.
The nurse is wearing PPE. Place the steps to removing the PPE in the correct sequence.
- A. Remove gown
- B. Remove gloves and perform hand hygiene
- C. Remove mask
- D. Remove eye protection
- E. Perform hand hygiene
Correct Answer: B,D,A,C,E
Rationale: B: Gloves are removed first due to high contamination risk, followed by hand hygiene. D: Eye protection is removed next. A: Gown is removed before leaving. C: Mask is removed at the doorway. E: Final hand hygiene ensures cleanliness.
The HCP is about to examine the client on contact precautions for MRSA without donning PPE. Which is the best action by the nurse?
- A. Hand the provider a gown and gloves
- B. Not say anything; it is the HCP's decision
- C. Notify the charge nurse and unit manager
- D. Monitor for increased infections on the unit
Correct Answer: A
Rationale: A: Providing PPE ensures immediate compliance with contact precautions. B: Ignoring the breach risks transmission. C, D: These actions delay intervention.
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
- A. Presence of blood in stools
- B. Oozing liquid stool
- C. Continuous climbing flatulence
- D. Absence of bowel movements
Correct Answer: B
Rationale: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.