Nokea
The nurse is assessing a client with suspected tuberculosis. Which precaution should be implemented?
- A. Standard precautions
- B. Airborne precautions
- C. Droplet precautions
- D. Contact precautions
Correct Answer: B
Rationale: Tuberculosis is transmitted via airborne droplets, requiring airborne precautions (e.g., N95 mask, negative pressure room). Standard, droplet, and contact precautions are insufficient.
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The clinic nurse is teaching a co-worker regarding medication administration. The nurse is aware that which of the following medications are category X medications and should not be taken by the client during pregnancy?
- A. Menocycline
- B. Tazorac
- C. Devonex
- D. Levothyroxine
- E. Cefozolin
Correct Answer: A, B
Rationale: Category X medications, like minocycline (A) and tazarotene (Tazorac, B), are contraindicated in pregnancy due to fetal harm. Calcipotriene (Devonex, C), levothyroxine (D), and cefazolin (E) are safer (categories B or C).
The client is diagnosed with a pleural effusion. Which intervention should the nurse anticipate?
- A. Insertion of a chest tube
- B. Thoracentesis
- C. Bronchoscopy
- D. Nebulizer treatment
Correct Answer: B
Rationale: Thoracentesis is used to remove fluid from a pleural effusion, relieving respiratory distress. Chest tubes are for pneumothorax or persistent effusions, bronchoscopy is diagnostic, and nebulizers are irrelevant.
A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:
- A. Gently pull the infant away
- B. Withdraw the breast from the infant's mouth
- C. Compress the areolar tissue until the infant drops the nipple from her mouth
- D. Insert a clean finger into the baby's mouth beside the nipple
Correct Answer: D
Rationale: Inserting a finger into the infant's mouth breaks suction, allowing nipple removal without trauma. Other methods risk nipple injury.
The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
- A. Temperature of 100.2°F
- B. Blood pressure of 110/70 mmHg
- C. Respiratory rate of 24 breaths per minute
- D. Itching and rash on the trunk
Correct Answer: D
Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?
- A. Right coronary artery
- B. Left main coronary artery
- C. Circumflex coronary artery
- D. Left anterior descending coronary artery
Correct Answer: A
Rationale: Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in most individuals. Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. Occlusion of the circumflex artery does not cause bradycardia. Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function.