Nokea
The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
- A. I use a sliding scale to adjust regular insulin to my sugar level.'
- B. Since my eyesight is so bad, I ask the nurse to fill several syringes.'
- C. I keep my regular insulin bottle in the refrigerator.'
- D. I always make sure to shake the NPH bottle hard to mix it well.'
Correct Answer: D
Rationale: I always make sure to shake the NPH bottle hard to mix it well.' The bottle should be rolled gently, not shaken.
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The nurse and NA are caring for the client with hepatitis A. The nurse determines that the NA understands correct infectious precautions for this client when observing what action?
- A. Wears a mask, gown, and gloves when taking the client's vital signs
- B. Wears a gown and gloves when changing the client's incontinent briefs
- C. Wears gloves when providing urinary catheter and perineal care
- D. Wears a gown and gloves when asking the client about snack food options
Correct Answer: B
Rationale: B: Gown and gloves are required for contact precautions during incontinent brief changes due to fecal transmission risk. A: Masks are unnecessary as hepatitis A is not airborne. C: Gloves alone are insufficient; a gown is needed. D: PPE is not required for non-contact interactions.
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag
- B. Perform a quick assessment of the client's condition
- C. Call the respiratory therapist for help
- D. Press the alarm re-set button on the ventilator
Correct Answer: B
Rationale: A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
The NA is preparing to provide care for four clients. The nurse should direct the NA to utilize contact precautions for which client?
- A. Client with influenza
- B. Client with mumps
- C. Client with gonorrhea
- D. Client with a draining abscess
Correct Answer: D
Rationale: D: A draining abscess requires contact precautions due to potential infectious drainage. A, B: These require droplet precautions. C: Gonorrhea needs standard precautions.
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
- A. every four to six hours
- B. continuously
- C. in a bolus
- D. every hour
Correct Answer: B
Rationale: continuously. Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula.
A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the health care provider
- B. Readjust the traction
- C. Administer the ordered prn medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: Notify the health care provider. The findings are indicative of circulatory impairment. The health care provider must be notified immediately.