Nokea
The nurse is aware that a common mode of transmission of clostridium difficile is:
- A. Use of unsterile surgical equipment
- B. Contamination with sputum
- C. Through the urinary catheter
- D. Contamination with stool
Correct Answer: D
Rationale: C. difficile is transmitted via fecal-oral route through contaminated stool.
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The charge nurse notices another nurse on the floor reading the chart of a client who is not under her care. When confronted, the nurse says, 'This client is my neighbor, and I'm just concerned about him.' Which is the correct response by the charge nurse?
- A. As long as you don't share any information, it's okay.'
- B. Why don't you just let his nurse update you on his status?'
- C. You should not be reading the client's chart if you are not involved in his care.'
- D. Go with the doctor when he rounds on this client so you will be able to answer the family's questions.'
Correct Answer: C
Rationale: Accessing a chart without a care-related purpose violates HIPAA and patient privacy, regardless of personal relationships.
When assessing a client's skin, the nurse notes a scattered red rash on the trunk. The individual lesions are about 0.5 cm in diameter and are flat, nonpalpable, and circumscribed. How would this type of lesion be classified?
- A. Papule
- B. Nodule
- C. Macule
- D. Patch
Correct Answer: C
Rationale: A flat, nonpalpable lesion ≤1 cm is a macule (C). Papules (A) are raised, nodules (B) are deeper and larger, and patches (D) are larger flat lesions.
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain a culture of:
- A. Blood
- B. Nasopharyngeal secretions
- C. Stool
- D. Genital secretions
Correct Answer: D
Rationale: Gonorrhea is diagnosed by culturing genital secretions.
An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
The nurse is caring for a client with cancer who is exhibiting signs and symptoms that death is near. The client's daughter says that she does not want her mother to receive morphine because it will hasten her death. What response by the nurse is most appropriate?
- A. We always give morphine to clients at the end-of-life stage.
- B. We can give oxygen instead of morphine to help with breathing and distress.
- C. Morphine will reduce anxiety and reduce the sensation of air hunger in your mother.
- D. We will wait until the very end to give the morphine and use nonpharmacologic measures instead.
Correct Answer: C
Rationale: Morphine alleviates air hunger and anxiety in end-of-life care, improving comfort without necessarily hastening death, addressing the daughter’s concerns therapeutically.