Nokea
In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Universal precautions
Correct Answer: A
Rationale: Rubella is an illness transmitted by large-particle droplets, so the nurse should implement droplet precautions in addition to standard precautions. Airborne precautions are used for diseases spread through small particles in the air, such as tuberculosis, varicella, and rubeola. Contact precautions are utilized for diseases transmitted by direct contact with the patient or their environment. Universal precautions and body substance isolations are part of the CDC's standard precautions recommendations, but do not specifically address the transmission route of rubella.
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Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?
- A. Keep all of the side rails up
- B. Review prescribed medications
- C. Complete the "get up and go"? test
- D. Place the bed in the lowest position
Correct Answer: D
Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.
When caring for a patient with latex allergy, the healthcare provider creates a latex-safe environment by doing which of the following?
- A. Carefully cleaning the wall-mounted blood pressure device before using it.
- B. Donning latex gloves outside the room to limit powder dispersal.
- C. Using a latex-free pharmacy protocol.
- D. Placing the patient in a semi-private room.
Correct Answer: C
Rationale: Creating a latex-safe environment for a patient with latex allergy is crucial to prevent allergic reactions. Using a latex-free pharmacy protocol is essential as it ensures that medications and supplies provided to the patient are free of latex components. Cleaning a wall-mounted blood pressure device may not be sufficient as the device itself may contain latex parts that can trigger an allergic reaction. Donning latex gloves, even outside the room, is not recommended as powder dispersal can cause issues; only non-latex gloves should be used in a latex-safe environment. Placing the patient in a semi-private room does not directly address the need to eliminate latex exposure from medical supplies and equipment, which is better achieved through a latex-free pharmacy protocol.
Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?
- A. Vest restraints should be used because they are the least restrictive type.
- B. Restraints should be used for 48 hours in non-psychiatric patients.
- C. Restraints should be applied to prevent wandering behavior.
- D. Alternative measures must be attempted first.
Correct Answer: D
Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.
For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?
- A. Assessing the patient for jaundice
- B. Providing oral hygiene after a meal
- C. Palpating the abdomen for distention
- D. Assisting the patient to choose the diet
Correct Answer: B
Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.
Which of the following tests would MOST LIKELY be performed on a patient who is being monitored for coagulation therapy?
- A. PT/INR
- B. CBC
- C. PTT
- D. WBC
Correct Answer: A
Rationale: The correct answer is A: PT/INR. Prothrombin times (PT/INR) are commonly used to monitor patients on Coumadin (warfarin) therapy, an anticoagulant that slows the blood's ability to clot. Monitoring PT/INR levels helps ensure the patient is receiving the appropriate dosage of Coumadin. Choice B, CBC (Complete Blood Count), is a general test that provides information on red blood cells, white blood cells, and platelets but is not specific to monitoring coagulation therapy. Choice C, PTT (Partial Thromboplastin Time), is another coagulation test but is not as commonly used for monitoring Coumadin therapy. Choice D, WBC (White Blood Cell count), is unrelated to monitoring coagulation therapy and is used to assess immune system function.