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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.
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A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause brings hormonal shifts, but urinary frequency stands out it may signal a UTI, bladder issue, or pelvic pathology, requiring urgent evaluation over typical symptoms. Difficulty sleeping and hot flashes stem from estrogen fluctuations, common and manageable with lifestyle changes. Vaginal dryness, also hormonal, responds to lubricants or estrogen therapy, not immediate concern. Frequency, however, risks infection or renal complications older women often present atypically (e.g., confusion), per geriatric guidelines. Using ABCs, elimination issues outrank comfort, driving prompt reporting for diagnostics (e.g., urinalysis), preventing progression, making it the priority finding.
A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
- A. Confusion
- B. Hypothermia
- C. Referred pain in the right shoulder
- D. Orange colored urine
- E. Fever
- F. Dysuria
- G. Urgency
Correct Answer: A
Rationale: Confusion is common in older adults with cystitis due to altered mental status from infection.
A nurse is reinforcing teaching with a female client who has a history of urinary tract infections. Which of the following instructions should the nurse include?
- A. Increase milk consumption to make the urine more alkaline.
- B. Urinate before and after sexual intercourse.
- C. Use a vaginal douche once a week.
- D. Empty the bladder at least every 6 hr.
Correct Answer: B
Rationale: Urinating before and after sexual intercourse flushes bacteria from the urethra, a primary UTI prevention strategy, especially in women due to their shorter urethra. Milk consumption may alkalinize urine, but this doesn't prevent infection cranberry juice is more evidence-based, reducing bacterial adhesion. Vaginal douching disrupts normal flora, increasing UTI risk by promoting pathogen growth, contrary to hygiene goals. Emptying the bladder every 6 hours helps, but more frequent voiding (e.g., every 2-3 hours) is ideal; post-coital urination targets the key risk moment. This instruction empowers the client to reduce recurrence, aligns with urologic recommendations, and addresses a common trigger, making it the most effective teaching point.
A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?
- A. You will need to record daily activities in a diary.
- B. You should remove the electrodes when you go to bed.
- C. You can bathe while wearing the electrodes.
- D. You should not have sexual intercourse while the monitor is in place.
- E. Avoid exercise entirely.
- F. Keep the monitor in water.
- G. Remove it if it beeps.
Correct Answer: A
Rationale: Recording activities helps correlate symptoms with heart activity; electrodes stay on, and bathing is avoided.
A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Chill the dialysate prior to infusion.
- B. Monitor the client for diarrhea.
- C. Weigh the client before and after the treatment.
- D. Use clean gloves when handling dialysate bags.
Correct Answer: C
Rationale: Weighing before and after tracks fluid removal in peritoneal dialysis, assessing treatment effectiveness. Dialysate is warmed, diarrhea isn't a primary concern, and sterile gloves are preferred.