Nokea
A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the partner indicates an understanding of the teaching?
- A. I can take my partner outside of the room as long as they wear a mask.
- B. I will wash my hands as soon as I leave the room.
- C. I will wear a gown when I help my partner take a bath.
- D. I will reuse unsoiled gloves when I re-enter the room.
Correct Answer: B
Rationale: Hand washing upon leaving prevents MRSA spread, a key contact precaution. Masks don't suffice, gowns are needed for bathing, and gloves must be fresh each entry.
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A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
- A. Isopropyl alcohol
- B. Hydrogen peroxide
- C. Bleach
- D. Chlorhexidine
Correct Answer: C
Rationale: AIDS, caused by HIV, requires strict infection control due to bloodborne transmission risk. Option C, bleach (typically a 1:10 dilution with water), is correct CDC guidelines recommend it for disinfecting HIV-contaminated surfaces, as it effectively inactivates the virus by denaturing proteins. Option A, isopropyl alcohol, disinfects but isn't the standard for blood spills; it evaporates quickly, potentially leaving viable pathogens. Option B, hydrogen peroxide, oxidizes but lacks evidence as a primary bloodborne pathogen disinfectant compared to bleach. Option D, chlorhexidine, excels for skin antisepsis, not environmental surfaces or blood cleanup. Bleach's broad-spectrum efficacy, affordability, and alignment with universal precautions make it the gold standard. Teaching this ensures the new nurse protects themselves and others, adhering to OSHA and hospital protocols, while reinforcing the importance of proper dilution (e.g., 1 part bleach to 9 parts water) for safety and effectiveness.
Medication Administration Record
Ceftriaxone 2 gm IV BID
Acetaminophen 325 mg PO every 4 hr PRN fever over 39° C (102.2° F)
Guaifenesin 200 mg PO every 4 hr PRN cough
Diagnostic Results
Complete Blood Count:
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 45% (37% to 47%)
WBC count 15,000/mm* (5000 to 10,000/mm*)
Basic Metabolic Profile:
Creatinine 2.8 mg/dL (0.5 to 1.1 mg/di)
BUN 19 mg/dL (10 to 20 mg/dL)
Sputum Culture and Sensitivity:
Klebsiella pneumonia
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
- E. Oxygen saturation
- F. Blood pressure
- G. Respiratory rate
Correct Answer: B
Rationale: Elevated creatinine (2.8 mg/dL) indicates potential kidney injury, a priority over sputum (expected Klebsiella), WBC (infection), or temperature.
A nurse is assisting in the care of the client who is postoperative following a fasciotomy. The nurse is reviewing the client's electronic medical record (EMR). Which of the following statements in the EMR indicate the client's condition is improving since implementing interventions?
- A. Client reports pain as a 4 on a scale of 0 to 10.
- B. Bilateral breath sounds clear and present throughout.
- C. Right leg warm to touch, incision dressing dry and intact.
- D. Wound drain negative-pressure system, draining small amount of serosanguinous fluid.
Correct Answer: C
Rationale: Fasciotomy relieves compartment syndrome pressure, so improvement hinges on limb perfusion and wound stability. Right leg warm to touch with a dry, intact dressing indicates good circulation and no excessive bleeding or infection key recovery signs post-fasciotomy. Pain at 4/10 may suggest improvement if previously higher, but it's subjective and less specific without baseline comparison. Clear breath sounds are reassuring but unrelated to the surgical site unless pulmonary complications were a concern, not implied here. Small serosanguinous drainage is normal initially, but small' alone doesn't confirm progress without prior volume context. Warmth and a stable dressing directly reflect surgical success restored blood flow and wound healing making it the strongest EMR indicator of improvement, per postoperative assessment priorities.
A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
- A. Use a hair dryer to blow hot air into the cast to relieve itching.
- B. Perform neurovascular checks of the affected extremity every 2 hr.
- C. Position the fractured arm below the level of the client's heart.
- D. Immobilize the client's fingers using a hand splint.
Correct Answer: B
Rationale: Neurovascular checks every 2 hours assess circulation and nerve function, critical after cast application. Hot air can burn, elevation reduces swelling, and finger immobilization isn't standard unless specified.
A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?
- A. Discard soiled wound care supplies in a trash receptacle outside the client's room.
- B. Administer antibiotic therapy before culturing the client's wound.
- C. Place the client in a private room with a private bathroom.
- D. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client's room.
Correct Answer: C
Rationale: A private room with a private bathroom helps control infection spread from a foul-smelling, infectious wound. Supplies should be discarded in biohazard containers, cultures taken before antibiotics, and hand hygiene should be thorough, not just 5 seconds.