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An elderly man is admitted to a medical unit with shortness of breath and is diagnosed with an upper respiratory infection (URI). He is placed on droplet precautions. The nurse has just finished giving him his PO medications. As the nurse leaves his room, the nurse should
- A. wash hands, remove the gown and mask, and throw the trash in a container outside of the room.
- B. remove the mask, wash hands, and throw the trash in a container inside the room.
- C. wash hands, remove the mask, and throw the trash in a container inside the room.
- D. remove the gown and gloves, wash hands, remove the mask, and throw the trash in a container inside the room.
Correct Answer: C
Rationale: hands should be washed before removing mask to prevent transfer of microbes to face
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A patient is returned from surgery with a Jackson-Pratt drain in place. The nurse observes a student nurse perform a dressing change for the patient.
Which of the following activities if performed by the student nurse would require an intervention by the nurse?
- A. Documents the amount and character of the drainage in the patient's chart.
- B. Attaches the drain to the top sheet on the bed.
- C. Empties the reservoir of the drain.
- D. Records the amount of drainage on the output sheet.
Correct Answer: B
Rationale: Strategy: 'Require an intervention' indicates an incorrect response. (1) drains used to prevent wound infections and abscess formation (2) correct-drain should be attached to patient's gown or pajamas, never to the sheet or mattress (3) Jackson-Pratt drain is a self-contained suction device that is emptied as needed (4) important to monitor output
The nurse is caring for a client with a nasogastric (NG) tube. Which of the following actions should the nurse take to ensure proper functioning of the NG tube?
- A. Irrigate the tube with 50 mL of sterile water every 4 hours.
- B. Check for residual volume every 8 hours.
- C. Secure the tube to the client's gown only.
- D. Keep the head of the bed flat at all times.
Correct Answer: B
Rationale: checking residual volume ensures the tube is functioning and prevents overfeeding or aspiration
An elderly man is admitted to an inpatient psychiatric unit with an initial diagnosis of psychotic depression. The INITIAL nursing priority is to
- A. clarify perceptual distortions.
- B. establish reality orientation.
- C. ensure client and milieu safety.
- D. increase self-esteem.
Correct Answer: C
Rationale: initial nursing priority for all psychiatric patients is to ensure their safety and the safety of all members of the milieu
After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain
A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occur with aging?
- A. Decreased frequency.
- B. Incontinence.
- C. Sphincter reflexes decrease.
- D. Formation of bladder stones.
Correct Answer: B
Rationale: ureters, bladder, and urethra lose muscle tone results in stress and urge incontinence