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A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching?
- A. Place on airborne precautions.
- B. Avoid direct contact.
- C. Isolate for 24 hr. after lesions appear.
- D. Administer a broad-spectrum antibiotic.
Correct Answer: B
Rationale: Avoiding direct contact prevents the spread of tinea corporis, a fungal infection. Airborne precautions and antibiotics are inappropriate, and isolation isn't required beyond contact precautions.
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A nurse is preparing to administer filgrastim 6 mcg/kg subcutaneously to a client who weighs 110 lb. Available is filgrastim solution for injection 480 mcg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 0.3 mL
- B. 0.4 mL
- C. 0.5 mL
- D. 0.6 mL
Correct Answer: C
Rationale: To calculate the correct dose, convert the client's weight from pounds to kilograms (110 lb ÷ 2.2 = 50 kg). Filgrastim is dosed at 6 mcg/kg, so 6 mcg/kg × 50 kg = 300 mcg needed. The available concentration is 480 mcg in 0.8 mL. Set up the proportion: (300 mcg ÷ 480 mcg) × 0.8 mL = 0.5 mL. Option A (0.3 mL) underdoses at 180 mcg, Option B (0.4 mL) gives 240 mcg, and Option D (0.6 mL) overdoses at 360 mcg. Option C (0.5 mL) delivers exactly 300 mcg, matching the prescribed dose. Rounding to the nearest tenth, 0.5 mL is correct with no trailing zero, adhering to medication safety standards. This calculation ensures therapeutic efficacy (e.g., boosting white blood cells) while minimizing risks like overdose-related bone pain or underdose-related infection susceptibility, making C the precise and safe choice.
A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?
- A. We should remove gloves before leaving the hospital room.
- B. There is no cure for MRSA.
- C. MRSA only occurs in health care facilities.
- D. We will need to wear masks when we are in the hospital room.
- E. We can touch the client without precautions.
- F. MRSA will resolve without treatment.
- G. We should wash hands after glove removal.
Correct Answer: A
Rationale: Gloves should be removed before leaving to prevent contamination spread; MRSA is treatable, can occur outside facilities, and masks aren't required for contact precautions.
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
- A. Distended neck veins
- B. Polyuria
- C. Vomiting
- D. Hypertension
- E. Fever and chills
- F. Tachycardia
- G. Hypotension
Correct Answer: C
Rationale: Vomiting is a sign of a septic reaction due to contaminated blood; distended veins suggest fluid overload, polyuria isn't typical, and hypertension isn't specific.
A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
- A. Pull the fire alarm panel.
- B. Obtain a fire extinguisher.
- C. Remove the client from the room.
- D. Close the door to the client's room.
Correct Answer: C
Rationale: In a fire emergency, the RACE protocol (Rescue, Alarm, Contain, Extinguish) guides nursing actions, prioritizing safety. Option C is correct removing the client from the room first ensures their immediate safety from smoke inhalation or burns, the primary risk in this scenario. Option A, pulling the alarm, is crucial but secondary; the client's life takes precedence over alerting others. Option B, obtaining an extinguisher, delays rescue and assumes the nurse can safely fight the fire, which may not be feasible with smoke present. Option D, closing the door, helps contain the fire but traps the client in danger if done first. Rescuing the client aligns with the ethical duty to protect life, addresses the imminent threat of smoke (a leading cause of fire-related death), and allows subsequent steps (alarm, containment) to follow safely. This sequence reflects standard fire safety training and hospital policy, making it the nurse's first action.
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?
- A. Ask the provider for a prescription for a pureed diet.
- B. Have an assistive personnel feed the client.
- C. Obtain a referral for physical therapy.
- D. Apply foam handles to the client's eating utensils.
Correct Answer: D
Rationale: Chronic arthritis often impairs hand dexterity and grip strength, making self-feeding challenging. Option A, a pureed diet, addresses swallowing issues, not arthritis-related difficulties with utensils, so it's irrelevant here. Option B, having assistive personnel feed the client, undermines independence and dignity without addressing the root issue of utensil handling. Option C, physical therapy, may improve joint function long-term but doesn't provide immediate help for eating. Option D is correct applying foam handles increases utensil girth, improving grip for arthritic hands, promoting self-feeding and autonomy. This intervention directly tackles the physical limitation caused by arthritis, aligning with nursing goals of enhancing quality of life and independence. It's practical, cost-effective, and can be implemented quickly, offering immediate relief while other therapies (like PT) work in the background. Evidence supports adaptive equipment as a first-line strategy for arthritis patients struggling with daily activities, making this the most appropriate and empowering choice.