Nokea
The charge nurse is making assignments for the day shift. One of the nurses is 5 months pregnant. Which of the following clients is the most appropriate assignment for this expectant nurse?
- A. a client with shingles
- B. a client with measles
- C. a client with pneumonia
- D. a client with Clostridium difficile
Correct Answer: C
Rationale: Pneumonia is less likely to pose a risk to a pregnant nurse compared to shingles, measles (both vaccine-preventable and highly contagious), or C. difficile (requiring strict contact precautions).
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The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peaches
- C. Cucumber salad
- D. Yeast rolls
Correct Answer: C
Rationale: Cucumber salad contains seeds and roughage, which can irritate the colon in diverticulosis and should be avoided.
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.
A 20-year-old male has recently been diagnosed with schizophrenia. The nurse knows which of the following are classic signs and symptoms of this disorder? Select all that apply.
- A. social withdrawal
- B. agitation
- C. auditory hallucinations
- D. disorganized speech
- E. obsession with personal hygiene
Correct Answer: A,C,D
Rationale: Schizophrenia symptoms include social withdrawal, auditory hallucinations, and disorganized speech. Agitation may occur but is less specific, and obsession with hygiene is not typical.
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
- A. Apply a clean dressing to protect the wound
- B. Cover the exposed viscera with a sterile saline gauze
- C. Gently replace the abdominal contents
- D. Cover the area with a petroleum gauze
Correct Answer: B
Rationale: Covering exposed viscera with sterile saline gauze keeps the tissue moist and prevents infection until surgical intervention, as replacing contents or using non-sterile dressings risks contamination.
The physician has ordered 2 units of whole blood for a client following surgery. To provide for client safety, the nurse should:
- A. Obtain a signed permit for each unit of blood
- B. Use a new administration set for each unit transfused
- C. Administer the blood using a $Y$ connector
- D. Check the blood type and Rh factor three times before initiating the transfusion
Correct Answer: B
Rationale: Using a new administration set for each unit prevents contamination and ensures accurate delivery, enhancing transfusion safety.