Nokea
Client room environments should include:
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
- E. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
Correct Answer: B
Rationale: Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.
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A patient that has TB can be taken off restrictions after which of the following parameters have been met?
- A. Negative culture results.
- B. After 30 days of isolation.
- C. Normal body temperature for 48 hours.
- D. Non-productive cough for 72 hours.
Correct Answer: A
Rationale: Negative culture results indicate absence of active infection, allowing the patient to be taken off restrictions.
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Measuring intake and output assesses fluid balance, critical in enteral feeding to prevent dehydration or fluid overload due to hyperosmotic feedings.
The nurse is observing the UAP providing oral hygiene to the client Which action by the UAP requires follow-up?
- A. Replacing the upper denture before the lower denture.
- B. Placing the unconscious client in a supine position.
- C. Brushing the tongue with a soft-bristled toothbrush.
- D. Donning clean gloves prior to performing oral hygiene.
Correct Answer: B
Rationale: B: The unconscious client should be placed in a side-lying position with the head turned to the side to prevent aspiration. A: Replacing the upper denture first is correct for ease of insertion. C: Brushing the tongue removes debris, reducing infection risk. D: Gloves adhere to standard precautions for oral care.
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO0. How many milliliters of fluid did the patient ingest?
- A. $440 \mathrm{ml}$
- B. $480 \mathrm{ml}$
- C. $22 \mathrm{ml}$
- D. $660 \mathrm{ml$
Correct Answer: B
Rationale: 1 ounce = 30 ml, so Juice, 6 ounces (half of 12 oz) × 30 = 180 ml (Remember that oz is an abbreviation for ounces.) Soup, 4 ounces × 30 = 120 ml JELL-OB, 6 ounces × 30 = 180 ml 180 + 120 + 180 = 480 ml Note that gelatin, ice cream, and other things that are liquid at room temperature are counted as fluids.
The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply.
- A. Perform hand hygiene and don gloves.
- B. Pinch the lens over the pupil and remove.
- C. Place the lens in a sterile container with normal saline.
- D. Irrigate the eye with normal saline to loosen the lens.
- E. Instruct the client to look up when removing the lens.
Correct Answer: A,C,E
Rationale: A: Hand hygiene and gloves prevent infection. C: Normal saline keeps lenses moist if no lens solution is available. E: Looking up aids safe lens removal. B: Pinching over the pupil risks corneal abrasion. D: Irrigation could damage or lose the lens.