Nokea
The nurse is admitting a client directly from a health provider's office. The client has a rash and has been diagnosed with measles. Which room assignment by the nurse indicates an understanding of the disease process of measles?
- A. a private negative-pressure room
- B. a semiprivate room with a client who has a broken femur
- C. a semiprivate room with a client diagnosed with type 1 diabetes
- D. a private room at the end of the hall away from the nurses' station
Correct Answer: A
Rationale: Measles requires airborne precautions, necessitating a private negative-pressure room to prevent transmission.
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The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first?
- A. reposition the client
- B. draw a potassium level
- C. notify the health care provider
- D. prepare the client for a cesarean section
Correct Answer: A
Rationale: Repositioning the client is the first step to improve fetal oxygenation if the fetal heart tone strip shows distress, as it is non-invasive and may resolve the issue.
The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following?
- A. Atropine sulfate (Atropine) IV.
- B. Isoproterenol (Isuprel) IV.
- C. Verapamil (Calan) IV.
- D. Lidocaine hydrochloride (Xylocaine) IV.
Correct Answer: D
Rationale: Lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6-10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia
The nurse is caring for a homeless client diagnosed with right-sided heart failure. The nurse anticipates that upon discharge the client will need assistance regarding medications, locating a shelter, and follow-up to ensure that the client can obtain transportation to the next appointment with the cardiologist. The nurse understands that this is an example of which content area of care management?
- A. advocacy
- B. delegation
- C. ethical practice
- D. continuity of care
- E. advance directive
Correct Answer: D
Rationale: Arranging post-discharge support for medications, shelter, and follow-up ensures continuity of care for a vulnerable client.
Ideally, the first dose of what vaccine is given at birth?
- A. IPV
- B. Hib
- C. DTaP
- D. hepatitis B
Correct Answer: D
Rationale: The hepatitis B vaccine is recommended at birth to prevent perinatal transmission and establish early immunity.
Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
- A. Obeying adults is seen as correct behavior.
- B. Showing respect for parents is seen as important.
- C. Pleasing others is viewed as good behavior.
- D. Behavior is determined by consequences.
Correct Answer: D
Rationale: Kohlberg's preconventional stage for preschoolers involves moral decisions based on consequences, such as avoiding punishment or gaining rewards.