Nokea
A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute?
- A. Historic precautions.
- B. Hand-washing precautions.
- C. Reverse isolation.
- D. Standard precautions.
Correct Answer: D
Rationale: SARS requires standard precautions plus airborne and contact precautions, but standard precautions are the baseline for all patients to prevent transmission.
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The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This drug acts to:
- A. Increase potassium excretion from the colon.
- B. Release hydrogen ions for sodium ions.
- C. Increase calcium absorption in the colon.
- D. Exchange sodium for potassium ions in the colon.
Correct Answer: D
Rationale: Kayexalate exchanges sodium for potassium in the colon, reducing serum potassium levels in acute renal failure.
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first:
- A. Assess for changes in vital signs.
- B. Draw an arterial blood gas.
- C. Evaluate heart sounds with the client leaning forward.
- D. Obtain a 12 Lead electrocardiogram.
Correct Answer: A
Rationale: A new systolic murmur post-myocardial infarction may indicate complications like ventricular septal rupture or mitral regurgitation. Assessing vital signs first helps determine the client's stability and guides further actions.
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels, key in managing hepatic encephalopathy. Coordination (C) and pupil reaction (D) are unrelated. High carbohydrates (E) and physical activity (F) are not primary goals.
A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:
- A. Irrigate the catheter with 30 mL of normal saline every 8 hours.
- B. Ensure that the catheter is draining freely.
- C. Clamp the catheter every 2 hours for 30 minutes.
- D. Ensure that the catheter drains at least 30 mL/hour.
Correct Answer: B
Rationale: Ensuring free drainage prevents obstruction or pressure buildup, which could harm the surgical site or kidney function.
The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations?
- A. It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies.
- B. It is believed that the liver identifies the platelets as foreign bodies.
- C. It is now believed that the syndrome is related to an underactive immune system.
- D. The cause is unknown.
Correct Answer: A
Rationale: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune condition where antibodies coat platelets, marking them for destruction by the spleen. This leads to a low platelet count. The liver is not primarily involved, ITP is not due to an underactive immune system, and while 'idiopathic' means the exact trigger is unknown, the autoimmune mechanism is well-established.