Nokea
Regardless of their practice area, nurses should be concerned with:
- A. All drug-resistant bacteria
- B. Microorganisms that are critical
- C. Transmission of microorganisms
- D. Overprescription of bacteriostatic drugs
Correct Answer: C
Rationale: Preventing microorganism transmission is a universal nursing concern to protect clients, families, and staff, achieved through asepsis and infection control practices.
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A nurse is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines which of the following percents most accurately describes the severity of the injury?
- A. 36%
- B. 27%
- C. 18%
- D. 9%
Correct Answer: C
Rationale: Each lower extremity is scored as 18% according to the Rule of Nines, which estimates burn severity.
When a client has a chest drainage system in place, where should the system be placed?
- A. above the client's head
- B. at the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct Answer: D
Rationale: A chest drainage system should be placed below the level of the client's chest so that the drainage flows out of the chest into the system. The remaining choices are too high and do not allow fluid to drain out of the chest.
Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs?
- A. epilepsy
- B. Parkinson's
- C. muscular sclerosis
- D. Huntington's chorea
Correct Answer: D
Rationale: Huntington's chorea is characterized by writhing, twisting movements of the face and limbs. The remaining options are neurological disorders that do not have such movements as part of their disease process.
A client begins bleeding from the site of a previous arterial blood gas draw on the right wrist. What should the nurse do first?
- A. Check the blood count.
- B. Apply pressure to the site.
- C. Document the bleeding.
- D. Monitor the bleeding.
Correct Answer: B
Rationale: If a client begins bleeding from the site of a previous arterial blood gas draw on the right wrist, the nurse should first apply pressure to the site. This prevents further bleeding. The remaining choices can be performed later.
Which of the following clients require airborne precautions?
- A. a client with fever, chills, vomiting, and diarrhea
- B. a client suspected of varicella (chickenpox)
- C. a client with abdominal pain and purpura
- D. a client diagnosed with AIDS
Correct Answer: B
Rationale: Chickenpox (varicella) is an acute, infectious, airborne illness that requires others in direct contact to wear a respirator mask.