Nokea
The nurse evaluates a certified nursing assistant. Which of the following actions by the CAN demonstrates understanding of standard precautions?
- A. Wears gloves during all client contact
- B. Cleans blood spills with soap and water
- C. Pours bulk blood and other secretions down a drain connected to a sanitary sewer
- D. Carries blood sample to the lab in an open basket
Correct Answer: A
Rationale: The correct action that demonstrates understanding of standard precautions is wearing gloves during all client contact. Standard precautions are designed to prevent the transmission of infectious agents from both recognized and unrecognized sources of infection. Wearing gloves during client contact helps protect both the patient and the healthcare worker from potential infection transmission through contact with bodily fluids, skin, mucous membranes, and non-intact skin. Cleaning blood spills with soap and water is also part of standard precautions to prevent the spread of infection. However, pouring bulk blood and other secretions down a drain connected to a sanitary sewer and carrying a blood sample to the lab in an open basket do not align with standard precautions and could pose infection control risks.
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A 16-year-old mother complaining of breast engorgement feels unhappy living with her husband. The MOST appropriate action is
- A. refer her to an obstetrician
- B. advise her to apply stimulant medications for milk expression
- C. explain that this is a normal phenomenon
- D. stop feeding the baby
Correct Answer: A
Rationale: Referral to an obstetrician is necessary for proper evaluation and management.
Obstruction of the airway in the patient with asthma is caused by all of the following except:
- A. thick mucus.
- B. swelling of bronchial membranes.
- C. destruction of the alveolar wall.
- D. contraction of muscles surrounding the bronchi
Correct Answer: C
Rationale: Obstruction of the airway in a patient with asthma is primarily caused by inflammation and narrowing of the airways due to a combination of factors such as thick mucus, swelling of bronchial membranes, and contraction of muscles surrounding the bronchi. Destruction of the alveolar wall is not a direct cause of airway obstruction in asthma patients; alveolar wall destruction is typically associated with conditions like emphysema. In asthma, the primary mechanisms contributing to airway obstruction are related to inflammation, mucus production, and bronchoconstriction.
A patient is being given Digoxin to treat heart failure. Which of the ff. is a usual adult daily dosage of digoxin (Lanoxin)?
- A. 0.005 mg
- B. 0.025 mg
- C. 0.25 mg
- D. 2.5 mg
Correct Answer: C
Rationale: The usual adult daily dosage of digoxin (Lanoxin) for the treatment of heart failure typically ranges from 0.125 mg to 0.25 mg. The maintenance dose is specific to each individual patient's needs and is adjusted based on factors such as age, weight, renal function, and the presence of other medical conditions. The dosage prescribed should be carefully determined by a healthcare provider to ensure optimal therapeutic effects and minimize the risk of side effects associated with digoxin. Dosages higher than 0.25 mg are usually not recommended due to the narrow therapeutic index of digoxin. It is essential for patients taking digoxin to have their drug levels monitored regularly to prevent toxicity.
A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery-this will go away on its own". In considering her response to the client, the nurse must depend on the ethical principle of:
- A. Beneficence
- B. Advocacy
- C. Autonomy
- D. Justice
Correct Answer: C
Rationale: The ethical principle most relevant in this situation is autonomy. Autonomy refers to a person's right to make decisions about their own care and treatment. In this case, the client is expressing her wish to avoid surgery and believes her condition will improve on its own. It is important for the nurse to respect the client's autonomy and involve her in the decision-making process regarding her treatment. The nurse should provide information, support, and guidance to help the client make an informed decision that aligns with her values and preferences. While the nurse can provide education and encourage the client to consider the physician's recommendation, ultimately the decision should respect the client's autonomy.
A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:
- A. The client has no previous exposure to the antigens injected
- B. The results demonstrate the client has antibodies to the antigens
- C. The client is immunodeficient and won't have a skin response
- D. The client isn't allergic to the antigens and therefore doesn't react
Correct Answer: C
Rationale: A client with HIV undergoing intradermal anergy testing with Candida and mumps antigens is suspected to be immunodeficient, making them unable to mount a normal skin response to these antigens. In an immunodeficient individual, the immune system is weakened, leading to a lack of response when exposed to these antigens. A lack of induration or reaction in the 3 days following the test suggests that the client's immune system is not able to mount a normal response, indicating immunodeficiency. The absence of a reaction does not necessarily indicate lack of exposure (Option A), presence of antibodies (Option B), or the absence of allergies (Option D), but rather points to a compromised immune system in an individual with HIV.