Nokea
A nurse manager is discussing the responsibility of nurses caring for clients who have Clostridium difficile. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system
- B. Use alcohol-based hand sanitizer when leaving the client's room
- C. Clean contaminated surfaces in the client's room with a phenol solution
- D. Have family members wear a gown and gloves when visiting
Correct Answer: D
Rationale: The correct answer is D because having family members wear a gown and gloves when visiting a client with Clostridium difficile is essential to prevent the spread of infection. Options A, B, and C are incorrect. Negative air-flow systems are not necessary for preventing the spread of C. difficile. While alcohol-based hand sanitizers are effective for routine hand hygiene, they may not be sufficient for C. difficile. Cleaning contaminated surfaces with a phenol solution is not the most effective method for preventing the spread of C. difficile, as spores can be resistant to many disinfectants.
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A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Monitor daily fluid intake
- B. Monitor blood glucose levels
- C. Measure intake and output
- D. Administer insulin as prescribed
Correct Answer: B
Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?
- A. Sit up for at least 30 minutes after eating
- B. Avoid fluids between meals
- C. Increase the intake of high-carbohydrate foods
- D. Avoid eating large meals that are high in simple sugars and liquids
Correct Answer: D
Rationale: The correct answer is D: 'Avoid eating large meals that are high in simple sugars and liquids.' Clients who have undergone partial gastrectomy are at risk of dumping syndrome, which can occur due to the rapid emptying of stomach contents into the small intestine. Consuming large meals high in simple sugars and liquids can exacerbate this syndrome, leading to symptoms like abdominal cramping and diarrhea. Choices A, B, and C are not directly related to preventing dumping syndrome and are not the priority concerns for a client post-partial gastrectomy.
When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?
- A. Cancer of any kind
- B. Impaired hearing
- C. Prescription drug intoxication
- D. Heart failure
Correct Answer: C
Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.
How should a healthcare provider assess a patient for fluid overload?
- A. Monitor weight and assess for shortness of breath
- B. Auscultate lung sounds and monitor blood pressure
- C. Assess for edema in the extremities
- D. Assess for jugular venous distension
Correct Answer: A
Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.
A client with a tracheostomy is exhibiting signs of respiratory distress. What is the nurse's immediate priority?
- A. Increase the oxygen flow rate
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Administer a bronchodilator
Correct Answer: B
Rationale: When a client with a tracheostomy is experiencing respiratory distress, the immediate priority for the nurse is to suction the tracheostomy. This action helps clear the airway of secretions and ensures that the client can breathe effectively. Increasing the oxygen flow rate may be necessary but addressing the airway obstruction is more critical. Notifying the physician immediately is important but may cause a delay in addressing the immediate need for airway clearance. Administering a bronchodilator may help with bronchospasm but should not take precedence over ensuring a clear airway in a client with respiratory distress.