Nokea
The nurse is bathing a client who has contact isolation ordered. The nurse wears gloves. What else is needed?
- A. Face mask
- B. Sterile gloves
- C. Isolation cap
- D. Isolation gown
Correct Answer: D
Rationale: An isolation gown prevents contact transmission, required alongside gloves for bathing a client in contact isolation.
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Immediately after surgery the client with an above-the-knee amputation of the right leg refuses to look at the operative site. The most immediate diagnosis that can be made is:
- A. Self-care deficit
- B. Potential for infection
- C. Disturbance in self-concept
- D. Cognitive deficit
Correct Answer: C
Rationale: Refusing to look at the operative site suggests a disturbance in self-concept, as the client may be struggling with acceptance of the altered body image post-amputation.
A client with suspected Addison's disease is scheduled for a rapid corticotrophin stimulation test. Which of the following will the nurse include in her teaching?
- A. The need to limit fluid intake
- B. The need for periodic blood samples
- C. The need for collection of a 24-hour urine
- D. The need for frequent IV injections
Correct Answer: B
Rationale: The rapid corticotrophin stimulation test requires periodic blood samples to measure cortisol levels before and after ACTH administration.
A client experiencing alcohol withdrawal.
Which finding would indicate to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms?
- A. Increasing lethargy.
- B. Uncoordinated motor movements.
- C. Elevated pulse rate.
- D. Improved orientation to time and place.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to alcohol withdrawal. (1) would indicate a need for less sedation and a thorough physical assessment (2) suggests neurological trauma or damage (3) correct-pulse rate is a good indicator of client's progress through withdrawal, increasingly elevated pulse signals impending alcohol withdrawal delirium, requiring more sedation (4) suggests that the client is improving and will subsequently require less sedation
The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
- A. 1-2 inches
- B. 3-4 inches
- C. 5-6 inches
- D. 7-9 inches
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.
A female client is diagnosed with human papillomavirus (HPV).
Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness?
- A. I will need to take antibiotics for at least a week.'
- B. I will use only prescribed douches to avoid a recurrence.'
- C. I will return for a Pap smear in six months.'
- D. I will avoid using tampons for eight weeks.'
Correct Answer: C
Rationale: Strategy: Determine the 'hidden meaning' of the answer choices. (1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct-several strains of the human papillomavirus (HPV) are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome