Nokea
The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply.
- A. 38-year-old with methicillin-resistant Staphylococcus aureus
- B. 42-year-old with Clostridium difficile diarrhea
- C. 69-year-old with pertussis infection
- D. 72-year-old with vancomycin-resistant Enterococcus
- E. 80-year-old with influenza
Correct Answer: A,B,D
Rationale: MRSA, C. difficile, and VRE require contact precautions due to direct contact transmission. Pertussis and influenza require droplet precautions.
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A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.
Following a stroke, an elderly client develops ptosis. When assessing the client, the nurse will note:
- A. Drooping of the eyelid on the affected side
- B. Inverted eyelid margins
- C. Eversion of eyelid margins
- D. Granulomatous inflammation of the eyelids
Correct Answer: A
Rationale: Ptosis or drooping of the eyelid can occur as the result of a stroke or Bell's palsy. Answer B refers to entropion, and answer C refers to ectropion, so they are incorrect. Answer D refers to chalazion, so it's incorrect. Answers B, C, and D are incorrect because they do not relate to ptosis.
Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.
- A. Exercise programs
- B. Good room lighting
- C. Handrails in stairwell
- D. Smooth-soled shoes
- E. Staff hourly rounds
Correct Answer: A,B,C,E
Rationale: Exercise, lighting, handrails, and rounds reduce fall risk. Smooth-soled shoes increase slipping risk.
Following a cholecystectomy, drainage from the client's T tube for the first 24 hours after the operation was 350 cc. What is the appropriate nursing action?
- A. Notify the physician.
- B. Raise the level of the drainage bag to decrease the rate of flow.
- C. Increase the IV flow rate to compensate for the loss.
- D. Continue to observe and measure drainage.
Correct Answer: D
Rationale: T-tube drainage of 300–500 mL in the first 24 hours post-cholecystectomy is expected as bile drains externally. Continuing to observe and measure is appropriate unless other signs of complications arise.
The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply.
- A. Avoid annual influenza vaccination
- B. Avoid situations that cause physical and emotional stress
- C. Avoid sun exposure and ultraviolet light when possible
- D. Notify the health care provider if you have fever
- E. Use antibiotic soap to cleanse skin rashes
Correct Answer: B,C,D
Rationale: Stress, sun exposure, and infections can exacerbate lupus. Influenza vaccination is recommended, and antibiotic soap is unnecessary.