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A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
- A. Ask the client to cough sputum into a container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct Answer: D
Rationale: Assisting with oral hygiene is the essential initial step before collecting a sputum specimen for acid-fast bacillus (AFB) to prevent contamination of the sample. Ensuring the client's mouth is clean reduces the risk of introducing unwanted bacteria into the specimen. Asking the client to cough sputum into a container, having the client take deep breaths, and providing a specimen container are important steps in the specimen collection process, but they should follow ensuring proper oral hygiene.
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The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. Exercise by doing weight-bearing activities
- B. Exercise to reduce weight
- C. Avoid exercise activities that increase the risk of fracture
- D. Exercise to strengthen muscles and thereby protect bones
Correct Answer: A
Rationale: The correct answer is A: Exercise by doing weight-bearing activities. Weight-bearing activities help strengthen bones and prevent further bone loss in clients with osteoporosis. This type of exercise includes activities like walking, dancing, and weightlifting, which help improve bone density. Choice B is incorrect because the primary focus should be on bone health, not weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture can lead to muscle weakness and a decline in bone health. Choice D is also incorrect because while strengthening muscles is beneficial, the emphasis for osteoporosis management should be on weight-bearing exercises specifically.
A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?
- A. Side-lying on the left with the head elevated 10 degrees
- B. Side-lying on the left with the head elevated 35 degrees
- C. Side-lying on the right with the head elevated 10 degrees
- D. Side-lying on the right with the head elevated 35 degrees
Correct Answer: A
Rationale: The correct position for a client with viral pneumonia affecting 2/3 of the right lung is side-lying on the left with the head elevated 10 degrees. This position helps maximize lung expansion and oxygenation in cases of pneumonia affecting the right lung. Choice B is incorrect as excessive elevation can put pressure on the lung, and choices C and D are incorrect as side-lying on the right would not be beneficial for a client with pneumonia in the right lung.
The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?
- A. The treatment requires reapplication in 8 to 10 days.
- B. Bedding and clothing can be boiled or steamed.
- C. Children are not to share hats, scarves, and combs.
- D. Nit combs are necessary to comb out nits.
Correct Answer: C
Rationale: The most crucial information to prevent the spread of lice in schools is to avoid sharing hats, scarves, and combs. This is important as lice can easily spread through shared personal items. Choices A, B, and D are not as critical as choice C in preventing the spread of lice. Reapplication of treatment, boiling or steaming bedding and clothing, and using nit combs are important but not as crucial as avoiding the sharing of personal items.
A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first?
- A. Determine the client's usual pattern of activity.
- B. Assist the client in developing a healthy eating plan.
- C. Encourage the client to join a support group.
- D. Provide the client with a list of signs and symptoms to report to the provider.
Correct Answer: A
Rationale: Assessing the client's usual pattern of activity is crucial as it helps the nurse understand the client's current level of physical activity, any limitations, and areas needing improvement. This information is essential to create a safe and effective exercise plan tailored to the client's specific needs. Choice B, assisting the client in developing a healthy eating plan, is important but not the first step when the client's immediate goal is to start an exercise program. Encouraging the client to join a support group may be beneficial for motivation and emotional support but is not the priority at this stage. Providing a list of signs and symptoms to report to the provider is important for client education but is not the initial step when the client expresses a desire to begin an exercise program.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?
- A. Nausea and vomiting
- B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. Diffuse macular rash
- D. Muscle tenderness
Correct Answer: B
Rationale: A high fever, such as 103 degrees Fahrenheit (39.5 degrees Celsius), in a client with infective endocarditis indicates that the infection may not be responding to the antibiotics and requires immediate medical evaluation. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically associated with the ineffectiveness of antibiotic therapy in infective endocarditis.