Nokea
In addition to standard precautions, a nurse should implement contact precautions for which client?
- A. 60 year-old with herpes simplex
- B. 6 year-old with mononucleosis
- C. 45 year-old with pneumonia
- D. 3 year-old with scarlet fever
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
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A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
- A. Magnesium sulfate 4 gm (25%) IV
- B. Brethine 10 mcg IV
- C. Stadol 1 mg IV push every 4 hours PRN for pain
- D. Ancef 2 gm IVPB every 6 hours
Correct Answer: B
Rationale: Brethine (terbutaline) is a tocolytic used to stop preterm labor, which is inappropriate at 34 weeks with diabetes, as delivery may be indicated. Magnesium sulfate is used for preeclampsia, Stadol is for pain, and Ancef is an antibiotic, all of which may be appropriate.
A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.
Laboratory results
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L) 126 mg/dL
(7.0 mmol/L)
The nurse in the outpatient clinic is caring for a 40-year-old client with acromegaly. Which of the following findings would be most important to report to the health care provider?
- A. Dark, leathery skin
- B. Fasting blood glucose level
- C. Presence of S3 and S4 heart sounds
- D. Reports of knee pain when walking
Correct Answer: C
Rationale: S3 and S4 heart sounds indicate heart failure, a serious complication of acromegaly due to cardiac hypertrophy, requiring urgent reporting. Skin changes, glucose levels, and knee pain are expected but less critical.
While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:
- A. Check the doctor's orders for an antipyretic.
- B. Ask the client whether he has received any medication for his fever.
- C. Call the nurse at home to validate whether the medication was given.
- D. Retake the client's temperature.
Correct Answer: D
Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.
A 6-month old is brought to the ER by her mother. During the assessment, the nurse finds multiple bruises in different stages of healing and decreased range of motion of the right leg. X-ray confirms a fracture of the right femur. Which statement made by the mother would contribute to a diagnosis of child abuse?
- A. She got her leg caught in the crib and twisted it.
- B. She hurt her leg while she was crawling.
- C. I can't remember her falling or getting hurt.
- D. She fell out of her car seat before I could get the belt fastened.
Correct Answer: C
Rationale: The mother's inability to recall any injury event, combined with multiple bruises and a femur fracture, raises suspicion of child abuse due to inconsistent history.