Nokea
The hospitalized client tells the nurse about feeling a strong shock when turning on an electric hair dryer. What should the nurse do first?
- A. Assess the client's heart rhythm and apical pulse
- B. Disconnect the hair dryer from the electrical outlet
- C. Assess the client's skin for signs of electrical burn
- D. Tag and send the hair dryer for inspection
Correct Answer: A
Rationale: Assessing the client's heart rhythm is the priority, as an electrical shock can cause dysrhythmias due to the body's conductivity.
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The nurse is caring for a client who has just returned from the operating room after a cholecystectomy. Which of these findings requires immediate follow-up by the nurse?
- A. A temperature of 100.4°F (38°C)
- B. Pulse rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Oxygen saturation of 88%
Correct Answer: D
Rationale: An oxygen saturation of 88% indicates hypoxia, requiring immediate intervention to prevent respiratory compromise.
A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:
- A. Linens from the client's bed should be double-bagged.
- B. Meals should be served on washable dishes.
- C. Extensive isolation rarely causes psychological problems.
- D. Paper trays and plastic utensils prevent disease transmission.
Correct Answer: A
Rationale: Linens should be double-bagged. Isolation refers to techniques used to prevent or to limit the spread of infection. Some form of isolation has been used for centuries, whether to protect a high-risk person from exposure to pathogens or to prevent the transmission of pathogens from an infected person to others. Special handling of articles and linen soiled by any body fluid is indicated. These articles should be placed in impervious bags before they are removed from the client's bedside. Bagging in watertight containers is indicated to prevent exposure of personnel and contamination of the environment. The outside of the bag should not be contaminated when placing articles inside it. Each hospital and community agency has procedures for labeling and decontaminating exposed articles. Items that are visibly soiled with body substances should be rinsed and placed in plastic bags or clearly marked containers, often labeled 'Contaminated.' If the outside of the bag becomes contaminated, placing that bag in another bag (double-bagging) is required.
A 6-year-old is admitted to the ED after ingesting oxycodone tablets that had been prescribed for the parent. The parent provides the prescription bottle that originally contained 15 tablets of oxycodone 5 mg. The parent stated taking 3 tablets. There are 9 tablets remaining in the bottle. If the child ingested the missing tablets, how many mg of oxycodone did the child ingest?
Correct Answer: 15
Rationale: 15 - 3 = 12; 12 - 9 = 3; 3 tablets x 5 mg = 15 mg. The child ingested 15 mg of oxycodone.
The client with DM is receiving care in the home for a foot ulcer. The home health nurse documents the narrative note illustrated. Which problem should be the nurse's priority on the return visit?
- A. Impaired skin integrity related to left foot ulcer
- B. Potential for injury related to improper footwear
- C. Potential altered nutrition: less than body requirements related to nausea
- D. Ineffective therapeutic regimen management related to not taking medications as prescribed
Correct Answer: B
Rationale: Improper footwear increases the risk of injury or falls, which is critical for a diabetic client with reduced foot sensation and a healing ulcer.
Which of these actions is the primary nursing intervention designed to limit transmission of a client's Salmonella infection?
- A. Wash hands thoroughly before and after client contact
- B. Wear gloves when in contact with body secretions
- C. Double glove when in contact with feces or vomitus
- D. Wear gloves when disposing of contaminated linens
Correct Answer: A
Rationale: Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary means of contamination. Thorough handwashing can prevent the spread of salmonella.