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The nurse is admitting a client who has cryptococcosis pneumonia. When caring for this client, which of the following actions should the nurse take?
- A. Ensure a hand sanitizing station is near the client's room.
- B. Wear a surgical mask when working within three feet of the client.
- C. Provide disposable dishware for client meals.
- D. Place the client in a private room with monitored negative airflow.
Correct Answer: A
Rationale: Cryptococcosis pneumonia requires standard precautions, including hand hygiene. Masks, disposable dishware, and negative airflow are not needed.
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The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
The charge nurse is performing safety rounds on clients in the nursing unit. Which observation by the charge nurse requires follow-up? A client with
- A. An indwelling urinary catheter bag secured to the bed frame.
- B. Delirium tremens having a peripheral vascular access device (VAD) inserted.
- C. Right-sided weakness with their cane on the left side of the bed.
- D. A belt restraint was applied and secured over the chest.
Correct Answer: C,D
Rationale: A cane on the left side for right-sided weakness is inaccessible, and a belt restraint over the chest is unsafe, risking respiratory compromise. Catheter bag placement and VAD in delirium tremens are appropriate.
Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating?
- A. A toddler playing with his 9-year-old brother's construction set.
- B. A 5-year-old eating yogurt for a snack.
- C. An infant asleep in her crib without a blanket.
- D. A 3-year-old drinking a glass of juice.
Correct Answer: A
Rationale: A toddler playing with small construction set pieces is at high risk for choking due to the size and accessibility of the objects.
The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client
- A. Advances the walker 6-10 inches.
- B. Has their elbow flexed 15-30 degrees.
- C. Tilts the walker forward to help stand up from a chair.
- D. Advances the walker and then the affected leg.
Correct Answer: C
Rationale: Tilting the walker forward to stand is unsafe, risking falls. Advancing 6-10 inches, 15-30 degree elbow flexion, and proper stepping sequence are correct.
The nurse is caring for a client with a port. Which of the following actions would be appropriate to take? Select all that apply.
- A. Access the port using sterile technique.
- B. Flush the port with heparin prior to de-access.
- C. Access the port using a 16-gauge catheter.
- D. Have the client wear a mask during the dressing change.
- E. Aspirate for blood return prior to medication administration.
Correct Answer: A,B,E
Rationale: Sterile technique, heparin flushing, and aspirating for blood return are standard for port care. A 16-gauge catheter is too large, and a client mask is unnecessary.