By rolling contaminated gloves inside-out, the healthcare professional is affecting which step in the chain of infection?
- A. Mode of transmission
- B. Portal of entry
- C. Reservoir
- D. Portal of exit
Correct Answer: A
Rationale: When contaminated gloves are rolled inside-out, they are serving as a mode of transmission by carrying pathogens from the reservoir's portal of exit to a new portal of entry. This action increases the risk of transmitting infections from one person to another, emphasizing the importance of proper glove removal techniques to prevent the spread of pathogens. Choices B, C, and D are incorrect in this context. Portal of entry refers to the route through which a pathogen enters a susceptible host, reservoir is the habitat where the pathogen lives, grows, and multiplies, and portal of exit is the path through which a pathogen leaves its host.
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In a client with moderate, persistent, chronic neuropathic pain due to diabetic neuropathy who takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily, if Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
- A. Continue gabapentin.
- B. Discontinue ibuprofen.
- C. Add aspirin to the protocol.
- D. Add oral methadone to the protocol.
Correct Answer: A
Rationale: In the presence of moderate, persistent, chronic neuropathic pain, the WHO pain relief ladder recommends continuing gabapentin, as it is effective for managing both anxiety and pain. Ibuprofen, a nonsteroidal anti-inflammatory drug, is not the mainstay for neuropathic pain relief according to the ladder and can be discontinued if needed. Aspirin is not typically added to the protocol for neuropathic pain management at this step. Methadone is reserved for severe pain and is not the standard choice at Step 2 of the WHO pain relief ladder for neuropathic pain.
An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?
- A. Apply flannel pajamas to provide warmth.
- B. Administer a PRN dose of ibuprofen.
- C. Perform range of motion exercises in a warm tub.
- D. Drape the sheets over the footboard of the bed.
Correct Answer: D
Rationale: The correct answer is D. The nurse should first address the immediate comfort concern of the client, which is the weight of the linen on her legs causing severe joint pain. By draping the sheets over the footboard of the bed rather than tucking them under the mattress, the nurse can alleviate the pressure that the client perceives as the source of her pain. This action is a simple and effective way to provide relief and should be the initial step taken by the nurse. Choices A, B, and C do not directly address the client's immediate discomfort caused by the weight of the linen on her legs, making them less appropriate initial actions.
The healthcare professional is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the healthcare professional to implement?
- A. Stay with the client while the client is standing.
- B. Record the findings on the graphic sheet in the chart.
- C. Keep the blood pressure cuff on the same arm.
- D. Record changes in the client's pulse rate.
Correct Answer: A
Rationale: In obtaining a lie-sit-stand blood pressure reading, it is crucial for the healthcare professional to stay with the client while the client is standing. This action is the most important as it ensures client safety during the procedure. Recording findings, keeping the blood pressure cuff on the same arm, and monitoring pulse rate are all important tasks, but staying with the client while standing takes priority to prevent any potential falls or adverse events. By staying with the client, the healthcare professional can promptly address any signs of dizziness or instability, ensuring a safe environment for the client throughout the procedure.
Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?
- A. White blood cell count
- B. Albumin
- C. Calcium
- D. Sodium
Correct Answer: D
Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
- A. Encourage the client to increase ambulation in the room.
- B. Offer the client a high-carbohydrate snack for energy.
- C. Force fluids to thin the client's pulmonary secretions.
- D. Determine if pain is causing the client's tachypnea.
Correct Answer: D
Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.
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