Nokea
The census on the unit is 90 percent, and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client?
- A. A double room with a client admitted for impetigo.
- B. A double room with another client with the same diagnosis.
- C. A four-bed room with three clients who have had orthopedic surgery.
- D. A double room with an elderly client with a diagnosis of chickenpox.
Correct Answer: B
Rationale: When a private room is not an option, the best choice is to assign the elderly client with influenza to a double room with another client diagnosed with the same condition. This is ideal as droplet precautions would likely already be in place for the other client, reducing the risk of spreading the infection to other clients in the unit. Choice A is not appropriate as impetigo does not require the same precautions as influenza. Choice C is not ideal as orthopedic surgery does not involve respiratory precautions. Choice D is incorrect because chickenpox requires airborne precautions, which could pose a risk to the elderly client with influenza.
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After abdominal surgery, an adult is now alert and oriented. What position is most appropriate for the client?
- A. Semi-Fowler's
- B. Prone
- C. Supine
- D. Sim's
Correct Answer: A
Rationale: The most appropriate position for a client following abdominal surgery is Semi-Fowler's. This position promotes greater thoracic expansion and reduces pressure on the suture line, aiding in respiratory function and preventing strain on the incision site. Choices B, C, and D are incorrect. Prone position (Choice B) would not be suitable after abdominal surgery as it can put pressure on the abdomen. Supine position (Choice C) may cause discomfort and strain on the incision area. Sim's position (Choice D) is primarily used for rectal exams and enemas, which are unrelated to the needs post-abdominal surgery.
A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?
- A. Administer sublingual nitroglycerin
- B. Obtain a 12-lead electrocardiogram (ECG)
- C. Apply oxygen via nasal cannula
- D. Initiate continuous cardiac monitoring
Correct Answer: C
Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.
When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?
- A. Use a mechanical lift to transfer the client from the bed to a chair.
- B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
- C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
- D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.
Correct Answer: D
Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.
What instruction should be provided for a UAP caring for a client with MRSA who has an order for contact precautions?
- A. Do not allow visitors until precautions are discontinued
- B. Wear sterile gloves when handling the client's body fluids
- C. Have the client wear a mask whenever someone enters the room
- D. Don a gown and gloves when entering the room
Correct Answer: D
Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the client's room. This precaution is essential to prevent the spread of MRSA and protect both the client and the healthcare worker from potential infection. Choice A is incorrect because visitors should not be restricted solely based on contact precautions. Choice B is incorrect as wearing sterile gloves is not necessary, standard precautions with regular gloves are sufficient. Choice C is incorrect because the client wearing a mask is not a standard practice for contact precautions; it is the healthcare worker who should take preventive measures.
Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client's plan of care?
- A. Recent serum hemoglobin level of 16 g/dL
- B. Opioid analgesic received one hour ago
- C. Stooped posture with an unsteady gait
- D. Expressed feelings of depression
Correct Answer: B
Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client's care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.