Nokea
A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will place my used tissues in a plastic bag.
- B. I will share my utensils with my family.
- C. I will not need to wear a mask at home.
- D. I will stop taking my medications when I feel better.
Correct Answer: A
Rationale: The correct answer is A: "I will place my used tissues in a plastic bag." This statement indicates understanding of infection control for tuberculosis by properly disposing of contaminated materials to prevent the spread of the disease. Placing used tissues in a plastic bag helps contain the bacteria.
Choices B, C, and D are incorrect:
B: Sharing utensils can spread the infection to family members.
C: Not wearing a mask at home can expose others to the bacteria.
D: Stopping medications prematurely can lead to treatment failure and drug resistance.
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A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurses priority?
- A. Monitor urine output.
- B. Assess level of consciousness.
- C. Check ABGs.
- D. Monitor for signs of withdrawal.
Correct Answer: C
Rationale: The correct answer is C: Check ABGs. In this scenario, monitoring the client's arterial blood gases (ABGs) is the priority assessment because heroin toxicity can lead to respiratory depression and impaired gas exchange. ABGs provide crucial information about the client's oxygenation and ventilation status, which is essential for managing mechanical ventilation and preventing respiratory complications. Monitoring urine output (A) is important but not the priority in a client with potential respiratory compromise. Assessing level of consciousness (B) is significant, but ensuring adequate oxygenation takes precedence. Monitoring for signs of withdrawal (D) is important but not as urgent as assessing respiratory status.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
- A. Maintain low intermittent suction.
- B. Clamp the NG tube every 2 hours.
- C. Remove the NG tube immediately.
- D. Encourage high-fiber foods.
Correct Answer: A
Rationale: Correct Answer: A: Maintain low intermittent suction.
Rationale: Maintaining low intermittent suction helps to decompress the bowel, reducing the risk of further obstruction. Suction also helps to remove excess fluid and gas from the digestive system, providing relief to the client. It is essential to prevent excessive suction, as it can cause damage to the bowel and worsen the obstruction.
Summary of other choices:
B: Clamping the NG tube every 2 hours is not recommended as it can lead to a buildup of fluid and gas in the bowel, potentially worsening the obstruction.
C: Removing the NG tube immediately is contraindicated as it is necessary for decompression and monitoring of bowel function.
D: Encouraging high-fiber foods is inappropriate in the case of a small bowel obstruction as it can further obstruct the bowel.
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first?
- A. Administer a vasopressor.
- B. Verify that the client has adequate IV access.
- C. Place the client in the Trendelenburg position.
- D. Prepare for endoscopic intervention.
Correct Answer: B
Rationale: The correct answer is B: Verify that the client has adequate IV access. This is the priority action because the client is hypotensive from hemorrhaging, indicating a need for immediate fluid resuscitation to stabilize their condition. Without adequate IV access, the nurse cannot administer life-saving fluids and medications. Administering a vasopressor (A) or preparing for endoscopic intervention (D) may be necessary later but addressing the hypotension is the priority. Placing the client in Trendelenburg position (C) is not recommended as it can increase intracranial pressure.
A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit. Which of the following findings indicate the client is most likely experiencing deep vein thrombosis (DVT)?
- A. Unilateral right lower extremity swelling and warmth below the knee
- B. Pain level as 2 on a scale of 0 to 10
- C. Ambulating in hallway with assistance
- D. Not wearing sequential compression devices
Correct Answer: A
Rationale: The correct answer is A. Unilateral right lower extremity swelling and warmth below the knee are classic signs of deep vein thrombosis (DVT). The swelling occurs due to blood clot formation, leading to impaired venous return and warmth due to inflammation. Choice B is incorrect because pain level alone is not a specific indicator of DVT. Choice C is incorrect as ambulating with assistance does not directly relate to DVT. Choice D is incorrect as not wearing sequential compression devices does not definitively indicate DVT.