Nokea
The nurse in the emergency department is preparing to receive a client exposed to inhalation anthrax. The nurse recognizes that this client requires
- A. Droplet precautions.
- B. Airborne precautions.
- C. Standard precautions.
- D. Contact precautions.
Correct Answer: C
Rationale: Inhalation anthrax is not transmissible person-to-person, requiring only standard precautions. Droplet, airborne, or contact precautions are unnecessary.
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The nurse is observing a student prepare to perform a sterile procedure. Which action by the student would require follow-up? The student
- A. reaches over the sterile field to grab sterile gloves.
- B. establishes the sterile field on a dry surface.
- C. uses slow movements when setting up sterile drapes.
- D. keeps the sterile field at their waist level.
Correct Answer: A
Rationale: Reaching over the sterile field risks contamination and requires follow-up.
The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care?
- A. Apply sequential compression devices
- B. Apply an extra sheet to the bed
- C. Position the client on a donut pillow
- D. Encourage the consumption of high-protein foods
Correct Answer: D
Rationale: High-protein foods support tissue repair and collagen synthesis, critical for preventing pressure ulcers in at-risk clients. Sequential compression devices prevent thromboembolism, not pressure ulcers. An extra sheet does not reduce pressure, and donut pillows can increase pressure on surrounding tissues, worsening the risk.
The nurse is teaching parents about fire safety in the home. Which of the following recommendations should the nurse make? Select all that apply.
- A. Use smoke detectors instead of carbon monoxide detectors
- B. Teach your child what the smoke detector sounds like and what to do when one is heard
- C. Teach children how to light a candle in the event of power failure
- D. Practice escaping from your home at least twice a year
- E. Ensure that electrical wiring is under rugs, not above them
- F. If a house fire occurs, call emergency services before evacuating
Correct Answer: B,D
Rationale: Teaching children about smoke detector sounds and escape actions, and practicing escape plans twice yearly, enhance fire safety. Both types of detectors are needed, candles pose risks, wiring under rugs is hazardous, and evacuation precedes calling services.
The nurse is reviewing medical-surgical concepts with a group of nursing students. When discussing pain, it is appropriate for the nurse to categorize pain that occurs with short duration as
- A. Chronic pain
- B. Acute pain.
- C. Referred pain.
- D. Neuropathic pain.
Correct Answer: B
Rationale: Acute pain is short-duration, typically linked to injury or surgery. Chronic pain is persistent, referred pain is felt elsewhere, and neuropathic pain involves nerve damage.
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside?
- A. Overhead trapeze
- B. Abduction pillow
- C. Transfer board
- D. Continuous passive motion (CPM)
Correct Answer: A
Rationale: An overhead trapeze assists with safe repositioning and mobility post-lumbar spinal fusion, reducing strain on the surgical site. Abduction pillows are used for hip surgeries, transfer boards aid general transfers, and CPM is for joint surgeries, not spinal fusion.