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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The nurse is caring for a client with hepatic encephalopathy who is receiving lactulose. Which of the following findings would indicate that the medication has been effective?
- A. Improved mental status
- B. Looser consistency of stool
- C. Reduced abdominal distension
- D. Increased serum potassium level
Correct Answer: A
Rationale: Lactulose is used in hepatic encephalopathy to reduce ammonia levels by promoting its excretion through the stool. Improved mental status (A) indicates reduced ammonia toxicity, directly reflecting the medication's therapeutic effect. Looser stools (B) and reduced abdominal distension (C) are expected effects of lactulose but are secondary to the primary goal of ammonia reduction. Increased serum potassium (D) is incorrect, as lactulose does not directly affect potassium levels.
Which meal should the nurse recommend for a client at 13 weeks gestation?
- A. Baked chicken, turnip greens, peanut butter cookie, and grape juice
- B. Baked swordfish, fries, baked apples, and fat-free milk
- C. Chilled ham and cheese sandwich, broccoli, orange slices, and water
- D. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water
Correct Answer: A
Rationale: Baked chicken, greens, cookie, and juice (A) provide balanced nutrients without high-mercury fish (B), deli meats (C), or undercooked liver (D), which pose risks in pregnancy.
The nurse observes a client using a walker. Which observation indicates that the client needs more instruction?
- A. The client uses the walker to pull herself out of a chair.
- B. The client moves the walker forward and then takes a step.
- C. The client complains that the walker is not waist high.
- D. The client sometimes does not use the walker.
Correct Answer: A
Rationale: Using the walker to pull up risks tipping, indicating improper use and a need for further instruction on safe walker technique.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
The doctor has ordered two medications to be given intramuscularly. The nurse should:
- A. Ask the doctor to clarify the order.
- B. Give one injection, wait 30 minutes, and give the other.
- C. Determine whether the medications can be combined.
- D. Administer the injections, one in each hip.
Correct Answer: C
Rationale: The nurse must check if the medications are compatible for combination in one syringe to minimize injections. Administering separately without checking or in specific sites is premature.