Nokea
Several clients who work in the same building are brought to the emergency department. They all common to the patient's condition. Including fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate?
- A. Contact isolation with double-gloving and shoe covers.
- B. Respiratory isolation with positive pressure rooms.
- C. Enteric precautions.
- D. Reverse isolation.
Correct Answer: A
Rationale: Symptoms suggest a hemorrhagic fever (e.g., Ebola), requiring contact isolation with enhanced precautions like double-gloving and shoe covers to prevent transmission.
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What is a goal of care for a client with acute renal failure?
- A. Maintain urine output of 30 mL/hour.
- B. Keep potassium above 5.5 mEq/L.
- C. Increase protein intake.
- D. Limit ambulation.
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate?
- A. A gelatin dessert.
- B. Yogurt.
- C. An orange.
- D. Peanuts.
Correct Answer: A
Rationale: Gelatin dessert is low in potassium, suitable for a client with hyperkalemia, unlike yogurt, oranges, or peanuts.
A client expresses concern about how a hypophysectomy will affect his sexual function. Which of the following statements provides the most accurate information about the physiologic effects of hypophysectomy?
- A. Removing the source of excess hormone should restore the client's libido, erectile function, and fertility.'
- B. Potency will be restored, but the client will remain infertile.'
- C. Fertility will be restored, but impotence and decreased libido will persist.'
- D. Exogenous hormones will be needed to restore erectile function after the adenoma is removed.'
Correct Answer: D
Rationale: Hypophysectomy may disrupt pituitary hormone production, including those affecting sexual function. Exogenous hormones (e.g., testosterone) are often needed to restore erectile function.
The nurse is caring for an older adult in the emergency department with moderate hypothermia. Which of the following actions should the nurse take? Select all that apply.
- A. Apply external heat with a heating blanket to the client's trunk.
- B. Actively rewarm the extremities first, followed by the client's trunk.
- C. Use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis.
- D. Monitor for fluid, electrolyte, and metabolic abnormalities.
- E. Administer ordered medications at spaced longer intervals.
- F. Administer room temperature intravenous (IV) fluids for core rewarming.
Correct Answer: A,D,F
Rationale: Applying heat to the trunk (A), monitoring electrolytes (D), and using room-temperature IV fluids (F) are appropriate for moderate hypothermia. Rewarming extremities first (B) risks core afterdrop, extracorporeal methods (C) are for severe cases, and altering medication intervals (E) lacks evidence.
A client who is recovering from gastric surgery is receiving I.V. fluids to be infused at 100 mL/hour. The I.V. tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour?
Correct Answer: 25 gtt/minute
Rationale: To calculate: (100 mL/hour × 15 gtt/mL) ÷ 60 minutes/hour = 25 gtt/minute. The nurse should set the flow rate to 25 drops per minute.