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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 client to cough sputum into container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
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The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?
- A. "Persons entering the room with colds should stay at least 3 feet from me."
- B. "My family plans to bring flowers from my garden to help me feel better."
- C. "The precautions will protect me and help my blood count recover faster."
- D. "Persons entering my room should perform hand hygiene before entering."
Correct Answer: D
Rationale: D: Hand hygiene is critical to prevent pathogen introduction. A: Visitors with colds should avoid entry. B: Flowers can harbor microbes. C: Precautions don't improve neutrophil counts.
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
- A. Presence of blood in stools
- B. Oozing liquid stool
- C. Continuous climbing flatulence
- D. Absence of bowel movements
Correct Answer: B
Rationale: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
- A. A 79 year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. An incontinent client who has had 3 diarrhea stools
- D. An 80 year-old ambulatory diabetic client
Correct Answer: A
Rationale: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct Answer: C
Rationale: Participate with the compressions or breathing. Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse to leave the room for equipment. The client's advanced directives should have been filed on admission and his choices known prior to the initiation of CPR.
The nurse is caring for the client with DM who has an open wound on the left heel. Which assessment findings should the nurse associate with a wound infection? Select all that apply.
- A. Oral temperature 100.6°F (38°C)
- B. Heel feels warm when touched
- C. Yellow and purulent drainage
- D. Reduced sensation in the left foot
- E. Elevated white blood cell count
Correct Answer: A,B,C,E
Rationale: A: Fever indicates possible infection. B: Warmth suggests inflammation or infection. C: Purulent drainage is a sign of infection. E: Elevated WBC count indicates an immune response to infection. D: Reduced sensation is related to neuropathy, not infection.