Nokea
The nurse is caring for a child admitted with varicella (chickenpox). Which of the following actions should the nurse take?
- A. Have a designated blood pressure cuff in the client's room.
- B. Remove all gowns and gloves after exiting the client's room.
- C. Clean commonly touched surfaces with warm, soapy water.
- D. Wear a protective gown when transporting the client to other departments.
Correct Answer: A,B
Rationale: A designated BP cuff and removing PPE after exiting prevent varicella spread (airborne and contact). Soapy water is insufficient, and gowns during transport are unnecessary if precautions are followed.
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The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following?
- A. Wear gloves and a gown.
- B. Perform hand hygiene.
- C. Review the client's viral load.
- D. Obtain a disposable stethoscope.
Correct Answer: B
Rationale: Hand hygiene is required before entering any client’s room to prevent infection spread. Gloves/gown, viral load review, and disposable stethoscopes are not routinely needed for AIDS.
The nurse is assessing a client's peripheral vascular access device. The assessment shows that the site is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Which of the following complications is the client experiencing?
- A. Occlusion
- B. Infiltration
- C. Phlebitis
- D. Air embolism
Correct Answer: C
Rationale: Redness, warmth, pain, and edema indicate phlebitis, vein inflammation. Occlusion blocks flow, infiltration involves fluid leakage, and air embolism is unrelated.
The nurse cares for many clients at the end of life who experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life?
- A. Advocate for pain management unless life-threatening side effects occur.
- B. Advocate for pain management even if the life-threatening side effects hasten death.
- C. Prohibit the respiratory system from depressing drugs because this is euthanasia.
- D. Allow families to administer respiratory system depressing drugs to hasten death.
Correct Answer: B
Rationale: The ANA supports pain relief at end-of-life, even if side effects like respiratory depression hasten death, prioritizing comfort. Other options misalign with ethical standards.
The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply.
- A. Places a pair of scissors at the bedside for emergent discontinuation.
- B. Positions the client supine after applying both wrist restraints.
- C. Releases both restraints at the same time, every two hours.
- D. Informs the client of the behavior necessary to demonstrate to end the restraints.
- E. Ensures two fingers can be placed under each restraint.
Correct Answer: D,E
Rationale: Informing the client of expected behavior and ensuring a two-finger gap promote safety and compliance. Scissors are unsafe, supine positioning is not required, and simultaneous release is impractical.
The nurse is caring for a client with increased intracranial pressure (ICP). The nurse plans on positioning the client's head of bed at
- A. 25 degrees.
- B. 30-40 degrees.
- C. 10-20 degrees.
- D. 5-10 degrees.
Correct Answer: B
Rationale: A 30-40 degree elevation optimizes cerebral venous drainage, reducing ICP. Lower angles may increase ICP, and 25 degrees is suboptimal.