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The charge nurse is making room assignments for assigned clients. The charge nurse has one private room remaining, the nurse should assign the private room to the client admitted with
- A. Epilepsy, who had a tonic-clonic seizure two hours ago.
- B. An indwelling urinary catheter and has proteus mirabilis in the urine.
- C. Viral meningitis and has a fever.
- D. Clostridium difficile who is incontinent of stool.
Correct Answer: D
Rationale: C. difficile with incontinence requires contact precautions, necessitating a private room to prevent spread. Other conditions do not require isolation.
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The nurse performs a home safety survey for an older adult. Click to specify the findings that require intervention by the nurse.
- A. Scatter rugs at the end of the stairs
- B. Smoke detector present without a battery
- C. Stairs present with sturdy hand rails
- D. New light fixtures installed and connected in a grounded electrical outlet
- E. Extension cord covered with an anti-skid area rug
- F. Unlabeled household chemicals under the sink
- G. Fire extinguisher present 30 feet from the stove
Correct Answer: A,B,E
Rationale: Scatter rugs and extension cords pose trip hazards, and a non-functional smoke detector is a fire risk. Unlabeled chemicals risk poisoning, requiring intervention.
The nurse is performing community health screenings. A client tells the nurse that they smoke two packs a day of cigarettes and they have smoked for the past six years. How should the nurse document the Pack-years this client has smoked?
- A. 3.5 pack years
- B. 3 pack years
- C. 12 pack years
- D. 6 pack years
Correct Answer: C
Rationale: Pack-years = packs per day × years smoked = 2 × 6 = 12 pack-years. Other calculations are incorrect.
The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client
- A. Trendelenburg
- B. Side-lying
- C. high-Fowler's
- D. Reverse Trendelenburg
Correct Answer: C
Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.
The nurse is teaching a client how to ambulate using a cane. Which action should the nurse take?
- A. Stand on the client's unaffected (stronger) side during ambulation
- B. Instruct the client to look down at their feet as they ambulate
- C. Instruct the client to move the weaker leg to the cane after placing the cane forward.
- D. Advance the cane 6-10 inches with each step
Correct Answer: A
Rationale: Standing on the stronger side provides support. Looking down risks falls, the stronger leg moves first, and advancement is 12-16 inches.
Following scheduled radioactive iodine therapy in a nuclear medicine department, a nurse is speaking with a client following the client's ingestion of radioactive iodine regarding strategies to avoid radiating the client's family members. The nurse recognizes the need for additional client teaching when the client states:
- A. I understand the need to avoid sharing food or utensils with others.
- B. My children will miss my hugs and kisses for the next week.
- C. I'll travel for a couple of weeks to prevent my family from receiving radiation from me.
- D. I understand the need to flush the toilet with the lid closed two to three times after each use.
Correct Answer: C
Rationale: Traveling for weeks is excessive and unnecessary. Avoiding shared items, limiting close contact, and double flushing are appropriate to reduce radiation exposure.