Nokea
The nurse has attended a continuing education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed
- A. wearing gloves when obtaining vital signs.
- B. cohorting two clients with influenza in the same room.
- C. wearing a surgical mask when caring for a client with suspected rabies.
- D. initiating droplet precautions for a client with viral pneumonia.
Correct Answer: B,D
Rationale: Cohorting influenza clients and initiating droplet precautions for viral pneumonia align with infection control guidelines. Gloves for vital signs and a mask for rabies are not standard.
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The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student
- A. Positions the handgrips so that the axillae support the client's body weight.
- B. Demonstrates the proper crutch stance at 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot.
- C. Observes two to three finger widths between the crutch pad and the client's axilla.
- D. Instructs the client to dry crutch tips with a paper towel if they become wet.
Correct Answer: A
Rationale: Axillary weight-bearing risks nerve damage; weight should be on hands. Proper stance, axilla gap, and drying tips are correct.
The nurse is caring for a client who has nausea related to prescribed chemotherapy treatments. The nurse should recommend that the client. Select all that apply.
- A. Consume foods and liquids at room temperature.
- B. Drink a large amount of fluid with meals.
- C. Consume foods without aromas
- D. Eat smaller portion sizes throughout the day.
- E. Delay taking the prescribed antiemetic until the nausea is severe.
Correct Answer: A,C,D
Rationale: Room-temperature foods, low-aroma foods, and smaller portions reduce nausea. Large fluid intake with meals worsens nausea, and antiemetics should be taken proactively.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 6 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each assessment finding, click to specify if the finding indicates that the client's condition has improved, not changed, or worsened.
- A. Toileting access
- B. Medication organization
- C. Urinary patterns
- D. Activity tolerance
- E. Lower extremities
- F. Bathroom lighting
Correct Answer: A,B,C:Improved;D,E,F:Unchanged
Rationale: Improved toileting access, medication organization, and urinary patterns indicate better management. Activity tolerance, lower extremity symptoms, and bathroom lighting remain unchanged.
The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following?
- A. Wear gloves and a gown.
- B. Perform hand hygiene.
- C. Review the client's viral load.
- D. Obtain a disposable stethoscope.
Correct Answer: B
Rationale: Hand hygiene is required before entering any client’s room to prevent infection spread. Gloves/gown, viral load review, and disposable stethoscopes are not routinely needed for AIDS.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.