Nokea
A student nurse performs morning rounds and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus who is in contact precautions. The nurse preceptor intervenes when the student performs which action?
- A. Cleans the stethoscope with 2% chlorhexidine solution before removing it from the room
- B. Removes the urine specimen cup from the room in a sealed, leak-proof bag
- C. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen
- D. Uses an alcohol-based hand antiseptic after removing gloves
Correct Answer: A
Rationale: Chlorhexidine (A) is not standard for stethoscope cleaning in contact precautions; alcohol or approved disinfectants are used to prevent MRSA transmission. Sealed bags for specimens (B), scrubbing the port (C), and hand hygiene (D) are correct actions to maintain infection control.
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A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with over dosage?
- A. Memory loss and lack of appetite
- B. Confusion and fatigue
- C. Heightened reflexes
- D. Tinnitus and spasticity
Correct Answer: B
Rationale: Lidocaine Hydrochloride can cause fatigue and confusion if an over dosage occurs.
A client with emphysema comes for a routine follow-up visit. The nurse assisting with the initial assessment knows that which manifestations are characteristic of emphysema? Select all that apply.
- A. Barrel chest
- B. Bilateral coarse crackles
- C. Decreased activity tolerance
- D. Diminished breath sounds
- E. Increased sputum production
Correct Answer: A,C,D
Rationale: Emphysema causes air trapping, leading to barrel chest (A), reduced exercise capacity (C), and diminished breath sounds (D). Crackles (B) suggest fluid, and sputum (E) is more typical of chronic bronchitis.
The client complains of frequent insomnia affecting her ability to rest well. Which of the following factors or lifestyle choices in her assessment history most likely contributes to her inability to sleep?
- A. Having a slight snack at bedtime
- B. Heart disease prevention of one baby aspirin each day
- C. Reading in bed prior to going to sleep
- D. Smoking 1½ packs of filtered cigarettes each day
Correct Answer: D
Rationale: Nicotine in cigarettes is a stimulant, disrupting sleep and likely contributing to insomnia, unlike snacks, aspirin, or reading.
A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next?
- A. Discard potassium and document administration of a partial dose
- B. Exchange the IV pump with a different one
- C. Insert a new IV catheter in a different location
- D. Remove the pump and administer medication by gravity drip
Correct Answer: B
Rationale: An occlusion alarm with patent tubing suggests a pump malfunction. Exchanging the pump (B) ensures safe delivery. Discarding (A) is unnecessary, a new catheter (C) is not indicated, and gravity drip (D) risks rapid infusion.
A child with a high level of school absenteeism is diagnosed with separation anxiety disorder. The school nurse should remind the child’s parent to take what action?
- A. Allow the child to stay home when the child seems anxious
- B. Call the teacher to get the child’s schoolwork to do at home
- C. Have the child attend school, starting with a few hours a day
- D. Sit with the child in the classroom whenever possible
Correct Answer: C
Rationale: Gradual exposure to school, starting with partial attendance (C), helps desensitize the child to separation anxiety. Staying home (A) reinforces avoidance, schoolwork at home (B) delays reintegration, and parental presence (D) hinders independence.