Nokea
The nurse has attended a continuing education conference about infection control precautions. It would indicate a correct understanding of the education if the nurse is observed?
- A. using dedicated client-care equipment for a client with Clostridium difficile.
- B. wearing a particulate respirator mask (N95) while caring for a client with epiglottitis, due to Haemophilus influenzae type b.
- C. placing a surgical mask on a client being transported with radiology who has infectious mononucleosis.
- D. keeping the door closed for a client with cryptococcal meningitis.
Correct Answer: A
Rationale: Dedicated equipment for C. difficile prevents transmission. N95 is not needed for epiglottitis, masks are not required for mononucleosis transport, and cryptococcal meningitis does not require a closed door.
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The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.
The nurse is planning care for a pediatric client being admitted with pulmonary tuberculosis (TB). Which of the following interventions should the nurse include in the client's plan of care?
- A. consult the infection control nurse
- B. room the client with an uninfected client 6 feet apart
- C. place the client with another client who has varicella in the shared airborne isolation room 6 feet apart
- D. place the client in a private room with monitored positive airflow
Correct Answer: A
Rationale: Consulting the infection control nurse ensures proper airborne precautions for TB. Cohorting or positive airflow is inappropriate.
The nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescription should the nurse clarify with the primary healthcare physician (PHCP)?
- A. Lispro insulin 5 units SubQ TID
- B. Glargine insulin 15 units SubQ QHS
- C. Vitamin B12 100 mcg IM Daily
- D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days
Correct Answer: A
Rationale: Lispro insulin is a rapid-acting insulin typically administered around mealtimes to manage postprandial glucose levels. Since the client is NPO, they are not eating, so administering lispro insulin could lead to hypoglycemia due to the absence of carbohydrate intake. The nurse should clarify this prescription with the PHCP to ensure safe management of the client’s blood glucose levels during the NPO period. Glargine insulin, a long-acting insulin, is appropriate for basal glucose control and does not require clarification. Vitamin B12 and clonidine are unrelated to food intake and safe for NPO status.
The nurse is performing a fall risk assessment on a group of clients. It would be appropriate for the nurse to identify the client at risk for falls who. Select all that apply.
- A. Is an older adult.
- B. Has a history of two previous falls
- C. Taking oral antibiotics.
- D. Experiences postural hypotension.
- E. Wearing non-slip shoes.
Correct Answer: A,B,D
Rationale: Older adults, those with prior falls, and postural hypotension increase fall risk. Oral antibiotics and non-slip shoes do not contribute to fall risk.
Health History
45-year-old female admitted for laparoscopic cholecystectomy. The client recently had a weight loss of ten kilograms through dieting, and cholelithiasis was subsequently discovered. The client is alert and oriented x 4. No known drug allergies. No surgical history. The client takes levothyroxine for hypothyroidism.
• Vital Signs
Oral temperature 97 F (36° C); Pulse 90 bpm; Respirations 18; BP 110/64 mm Hg; Oxygen saturation 96% on room air.
A nurse is caring for a client in a surgery center scheduled for laparoscopic cholecystectomy.Click to specify if the nursing intervention is completed during the preoperative, intraoperative, or postoperative phase. Each intervention may be completed in more than one phase. Each row must have at least one but may have more than one response option selected.
- A. Verify the client’s name and date of birth
- B. Verify the client’s nothing-by-mouth (NPO) status
- C. Administration of prophylactic antibiotic
- D. Obtaining laboratory work such as complete blood count, clotting studies, and pregnancy test
- E. Assessment of the surgical incision site for type and amount drainage
- F. Verifying that the informed consent has been completed
- G. Confirming the correct sponge and instrument count
Correct Answer:
Rationale: