Nokea
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid foods prepared with tap water.
- B. Vaccination against hepatitis B and C is recommended.
- C. Wash hands thoroughly after using the restroom.
- D. Food should be prepared with purified water.
Correct Answer: D
Rationale: The correct answer is D: Food should be prepared with purified water. Hepatitis A virus can be spread through contaminated water or food. Using purified water for food preparation can help prevent the transmission of the virus. Choice A is incorrect because avoiding foods prepared with tap water alone may not be sufficient to prevent hepatitis. Choice B is incorrect as there is no vaccination available for hepatitis C. Choice C is important for general hygiene but may not specifically prevent hepatitis transmission.
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A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
- A. Pantoprazole 80 mg IV bolus twice daily
- B. Furosemide 40 mg IV
- C. Lactulose 20 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: A
Rationale: The correct answer is A: Pantoprazole 80 mg IV bolus twice daily. In acute pancreatitis, gastric acid hypersecretion can occur, leading to exacerbation of pancreatic inflammation. Pantoprazole is a proton pump inhibitor that helps reduce gastric acid secretion, which can alleviate pancreatic irritation. IV administration ensures rapid onset of action.
B: Furosemide is a diuretic used for conditions like heart failure or edema, not indicated for acute pancreatitis.
C: Lactulose is a laxative used for hepatic encephalopathy to reduce ammonia levels, not indicated for acute pancreatitis.
D: Acetaminophen is a pain reliever, but it does not address the underlying cause of acute pancreatitis.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Use of public transportation
- C. Group activities
- D. Unrestricted visitors
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and plants can harbor bacteria and fungi that can potentially cause infections. Therefore, restricting fresh flowers and plants helps minimize the risk of infection. Choices B, C, and D are incorrect because they do not directly relate to the risk of infection in neutropenic clients. Using public transportation, engaging in group activities, or having visitors are generally safe as long as proper infection control measures are followed.
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
- A. Changing the client's linens
- B. Administering oral medications
- C. Taking vital signs
- D. Completing a dressing change
Correct Answer: D
Rationale: The correct answer is D: Completing a dressing change. When completing a dressing change for a client who is HIV positive and postoperative, the nurse should wear a gown as personal protective equipment to prevent potential exposure to blood or body fluids. This is crucial for infection control and to protect both the nurse and the client.
Choice A: Changing the client's linens does not necessarily require wearing a gown unless there is a risk of exposure to blood or body fluids.
Choice B: Administering oral medications does not require wearing a gown as there is no risk of exposure to blood or body fluids.
Choice C: Taking vital signs also does not require wearing a gown unless there is a possibility of exposure to blood or body fluids during the procedure.
In summary, completing a dressing change involves the risk of exposure to blood or body fluids, hence the need for wearing a gown. Other actions listed do not carry the same level of risk, therefore do not require the use of a gown as personal protective
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
- A. Atropine
- B. Epinephrine
- C. Magnesium
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Rationale: Atropine is the correct answer because it is the first-line medication for symptomatic bradycardia. It works by blocking the parasympathetic nervous system, increasing heart rate. Epinephrine is used for cardiac arrest, not bradycardia. Magnesium is for torsades de pointes, not bradycardia. Sodium bicarbonate is for metabolic acidosis, not bradycardia.
A nurse explains to a client why two chest tubes are in place after a lobectomy. What is the lower chest tube for?
- A. Draining air from the pleural space
- B. Draining blood and fluid from the pleural space
- C. Providing oxygen directly to the lungs
- D. Preventing lung collapse
Correct Answer: B
Rationale: The lower chest tube after a lobectomy is to drain blood and fluid from the pleural space. This is crucial to prevent complications such as fluid accumulation, which can lead to infection or impaired lung expansion. The other choices are incorrect because: A) Draining air is usually done by the upper chest tube, C) Providing oxygen does not require a chest tube, and D) Preventing lung collapse is more related to the function of the upper chest tube in maintaining negative pressure in the pleural space.