Nokea
An older adult client in stage 2 of Parkinson's disease is being discharged with cellulitis of the right lower extremity. Which of the following nursing diagnoses will guide the discharge teaching? Select all that apply.
- A. Ineffective tissue perfusion related to decreased cardiac output.
- B. Impaired skin integrity related to barrier changes of the skin.
- C. Risk for injury related to environmental hazards.
- D. Impaired verbal communication related to dysarthria.
- E. Security intolerance related to painful lower extremity.
Correct Answer: B,C
Rationale: Cellulitis causes impaired skin integrity due to infection and inflammation. Parkinson's increases fall risk, supporting risk for injury. Other options are less directly related.
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The nurse should caution sexually active female clients taking isoniazid (INH) that the drug has which of the following effects?
- A. Increases the risk of vaginal infection.
- B. Has mutagenic effects on ova.
- C. Decreases the effectiveness of hormonal contraceptives.
- D. Inhibits ovulation.
Correct Answer: C
Rationale: Isoniazid induces liver enzymes, potentially reducing the effectiveness of hormonal contraceptives. It does not increase vaginal infection risk, affect ova, or inhibit ovulation.
A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply.
- A. Monitor serum creatinine and blood urea nitrogen levels.
- B. Administer a sedative.
- C. A. Administer humidified oxygen.
- D. Auscultate the lungs.
Correct Answer: C,D
Rationale: Administering humidified oxygen (C) improves oxygenation in ARDS. Auscultating lungs (D) monitors crackles and ventilation. Creatinine/BUN monitoring is unrelated to acute respiratory status. Sedatives may depress respiration.
When teaching about prevention of infection to a client with a long-term venous catheter, the nurse can document that the client has understood discharge instructions when the client states which of the following?
- A. I will not remove the dressing until I return to the clinic next week.
- B. My husband or I will do the dressing changes three times per week, exactly the way you showed us.
- C. I will monitor my temperature once each weekday.
- D. I know it is very important to wash my hands after irrigating the catheter.
Correct Answer: B
Rationale: Regular dressing changes (three times per week) performed correctly indicate understanding of infection prevention for a long-term venous catheter.
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.
The nurse is teaching a caregiver how to administer an injection of a prefilled syringe of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should expel the air bubble before administering."
- C. "Green leafy vegetables are allowed while taking this medication."
- D. "This medication may increase the risk for bleeding."
Correct Answer: B
Rationale: The air bubble in a prefilled enoxaparin syringe should not be expelled, as it ensures the full dose is administered.