Nokea
The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.
- A. Advising measles vaccination for susceptible family members
- B. Applying calamine lotion to reduce itching
- C. Placing a tracheostomy tray at the bedside
- D. Placing the client in a negative pressure isolation room
- E. Using an N95 respirator mask during client contact
Correct Answer: A,D
Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).
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The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?
- A. Eliminate green, leafy, vitamin K-rich vegetables from your diet
- B. Mild bruising or redness may occur at the injection site
- C. You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort
- D. You will need PT/INR assessments at regular intervals while on enoxaparin therapy
Correct Answer: B
Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.
The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include?
- A. Baked salmon with rice, steamed vegetables, and dinner roll
- B. Breaded pork chops, corn on the cob, and steamed snow peas
- C. Grilled chicken, green beans, and mashed potatoes
- D. Spaghetti with Italian tomato sauce and meatballs
Correct Answer: C
Rationale: Grilled chicken, green beans, and mashed potatoes are gluten-free, suitable for celiac disease. Dinner rolls, breaded pork chops, and spaghetti contain gluten, which must be avoided.
The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply.
- A. Dodgeball
- B. Reading a book
- C. Stationary bicycling
- D. Swimming
- E. Yoga
Correct Answer: C,D,E
Rationale: Stationary bicycling, swimming, and yoga are low-impact, joint-friendly activities for JIA. Dodgeball risks joint stress, and reading, while safe, is not a physical activity.
The nurse is caring for a client who has a chest tube connected to a wet suction closed chest drainage system. The nurse should recognize the drainage system is working correctly when gentle, continuous bubbling is present in the
- A. air leak gauge
- B. collection chamber
- C. water seal chamber
- D. suction control chamber
Correct Answer: D
Rationale: Gentle, continuous bubbling in the suction control chamber indicates proper suction in a wet suction system. Bubbling in the water seal suggests an air leak, and the collection chamber does not bubble.
The nurse is reinforcing instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required?
- A. I am looking forward to our summer vacation at the beach
- B. I plan to eat more fruits and vegetables to prevent constipation
- C. I should not drive until I know how this drug affects me
- D. I will drink at least 6-8 glasses of water daily
Correct Answer: A
Rationale: Planning a beach vacation suggests unawareness of oxybutynin’s heat intolerance side effect, increasing dehydration risk. Preventing constipation, avoiding driving, and adequate hydration are correct.