Nokea
The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement?
- A. Standard Precautions.
- B. Contact Precautions.
- C. Droplet Precautions.
- D. Airborne Precautions.
Correct Answer: D
Rationale: TB is transmitted via airborne droplets, requiring airborne precautions (D) with negative-pressure rooms. Standard (A), contact (B), and droplet (C) are insufficient.
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The nursing staff on an oncology unit is interviewing applicants for the unit manager position. Which type of organizational structure does this represent?
- A. Centralized decision making.
- B. Decentralized decision making.
- C. Shared governance.
- D. Pyramid with filtered-down decisions.
Correct Answer: C
Rationale: Staff interviewing for a manager (C) reflects shared governance, empowering nurses in decisions. Centralized (A), decentralized (B), and pyramid (D) involve top-down structures.
Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital?
- A. Avoid smoking and exposure to smoke.
- B. Do not receive flu or pneumonia vaccines.
- C. Avoid any type of alcohol intake.
- D. It will take about one (1) month to recuperate.
Correct Answer: A
Rationale: Avoiding smoke (A) prevents further lung damage, a priority post-ARDS. Vaccines (B) are recommended, alcohol (C) is not restricted, and recovery time (D) varies.
During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
- A. Release the suction by opening the vent
- B. Continue suctioning to remove the obstruction
- C. Increase the pressure
- D. Suction deeper
Correct Answer: A
Rationale: Releasing suction by opening the vent prevents trauma to the tracheal mucosa when the catheter adheres to the wall.
The client diagnosed with community-acquired pneumonia is admitted to the medical unit. Which health-care provider order should the nurse implement first?
- A. Start IV with 1,000 mL 0.9% saline.
- B. Ceftriaxone 1 gm IVPB every 12 hours.
- C. Obtain sputum and blood cultures.
- D. CBC and basic metabolic panel.
Correct Answer: C
Rationale: Sputum/blood cultures (C) must be obtained before antibiotics to identify pathogens, a priority. IV fluids (A), antibiotics (B), and labs (D) follow.
Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy?
- A. I must avoid hair spray and powders.
- B. I should take a shower instead of a tub bath.
- C. I will need to cleanse around the stoma daily.
- D. I can use an electric larynx to speak.
Correct Answer: D
Rationale: Using an electric larynx (D) is related to speech, not tracheostomy care, indicating a misunderstanding of tracheostomy management. Avoiding hair spray/powders (A), showering (B), and daily stoma cleaning (C) are correct tracheostomy care practices.