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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 assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
- A. Close the pinch clamp on the CVC.
- B. Administer oxygen via non-rebreather mask.
- C. Place the client in Trendelenburg position.
- D. Obtain emergency IV access.
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (D) is not the first priority in this situation; preventing air embolism is critical.
A nurse notes that a clients eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?
- A. Decreased TSH levels
- B. Increased T4 levels
- C. Elevated calcium levels
- D. Low hemoglobin levels
Correct Answer: B
Rationale: The nurse should expect increased T4 levels in a client with slightly protruding eyes, known as exophthalmos, as it is a classic sign of hyperthyroidism, where the thyroid gland is overactive. Thyroid hormones, such as T4, are responsible for regulating metabolism, and elevated levels can lead to symptoms like exophthalmos. Decreased TSH levels (choice A) would actually be seen in primary hyperthyroidism due to negative feedback. Elevated calcium levels (choice C) are more indicative of hyperparathyroidism. Low hemoglobin levels (choice D) are not typically associated with exophthalmos or hyperthyroidism.
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?
- A. Surgical drain output 300 mL during an 8-hr shift
- B. Bounding peripheral pulses
- C. Neck vein distention
- D. Weight gain of 2 kg (4.4 lb) in 24 hours
Correct Answer: A
Rationale: The correct answer is A: Surgical drain output 300 mL during an 8-hr shift. This finding indicates potential fluid loss, which can lead to fluid volume deficit. Surgical drain output is a direct measure of fluid loss from the body and can help assess the client's fluid status. Bounding peripheral pulses (B) and neck vein distention (C) are signs of fluid volume excess, not deficit. Weight gain of 2 kg (4.4 lb) in 24 hours (D) suggests fluid retention, not deficit.
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching?
- A. Avoid dairy products.
- B. Use disposable utensils for meals.
- C. Sleep next to family members.
- D. Increase iodine-rich foods in your diet.
Correct Answer: B
Rationale: The correct answer is B: Use disposable utensils for meals. This is important to prevent contamination of utensils by the radioactive iodine, which can be harmful to others. A - Avoiding dairy products is irrelevant for radioactive iodine therapy. C - Sleeping next to family members can expose them to radiation. D - Increasing iodine-rich foods can interfere with the therapy. Thus, B is the most appropriate instruction to include in the teaching.
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?
- A. Elevated toilet seat
- B. Compression stockings
- C. Heating pad
- D. Nebulizer
Correct Answer: A
Rationale: The correct answer is A: Elevated toilet seat. The nurse should ensure the client has this equipment to facilitate safe and easy toileting post-hip arthroplasty. An elevated toilet seat helps prevent excessive bending at the hip joint, reducing strain and risk of injury. Option B, compression stockings, are used for venous circulation and are not specifically required for hip arthroplasty. Option C, a heating pad, may provide comfort but is not essential for postoperative care. Option D, a nebulizer, is used for respiratory conditions and is not relevant to hip arthroplasty.