Nokea
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. There is no cure for MRSA.
- B. We will need to wear masks when we are in the hospital room.
- C. MRSA only occurs in health care facilities.
- D. We should remove gloves before leaving the hospital room.
Correct Answer: D
Rationale: Removing gloves before leaving prevents the spread of MRSA, consistent with contact precautions.
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A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Current medication prescriptions
- B. Primary health problem
- C. Number of family members who have visited
- D. Admission vital signs from 1 week ago
- E. Scheduled times for dressing changes
Correct Answer: A,B,E
Rationale: Medications, primary problem, and dressing schedules are critical for continuity of care in the ICU; family visits and old vital signs are less relevant.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?
- A. Administer a glycerin suppository.
- B. Ambulate the client in the hallway.
- C. Request the client to be NPO.
- D. Offer an analgesic medication.
Correct Answer: B
Rationale: Ambulating the client first promotes bowel motility, addressing hypoactive bowel sounds and cramping, a common postoperative issue.
A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?
- A. Do you have any pain this morning?
- B. Is your pain the same as it has been?
- C. Could you rate your pain on a scale from 0 to 10?
- D. What does your pain feel like?
Correct Answer: D
Rationale: Asking 'What does your pain feel like?' assesses the quality (e.g., sharp, dull), a key component of pain assessment.
Medical History
Vital Signs
Nurses’ notes
Provider’s prescription
Type 2 diabetes mellitus
Hypertension
Hyperlipidemia
Peptic ulcer disease
A nurse is preparing to administer medications to a client. The nurse has reviewed the information above. Based on the findings, complete the following sentence by using the list of options. The nurse should clarify the prescription for due to the client's.
- A. Peptic ulcer disease
- B. Metformin
- C. Type 2 diabetes mellitus
- D. Ibuprofen
Correct Answer: D
Rationale: Ibuprofen can exacerbate peptic ulcer disease by irritating the stomach lining, so the nurse should clarify this prescription due to the client's condition.
A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter.
- A. Apply pressure to the venipuncture site with sterile gauze.
- B. Perform hand hygiene.
- C. Clamp the IV tubing.
- D. Withdraw the catheter from the client's vein.
- E. Remove the dressing and tape from the venipuncture site.
Correct Answer: B,E,C,A,D
Rationale: The sequence is: hand hygiene, remove dressing/tape, clamp tubing, apply pressure, withdraw catheter-ensuring safety and preventing bleeding.