Nokea
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
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The clinic nurse encounters the client who has a congested cough and rhinorrhea. The nurse follows droplet precautions/cough protocol by taking which action? Select all that apply.
- A. Offering the client sterile disposable tissues
- B. Wearing a mask while examining the client
- C. Offering the client water to drink while waiting
- D. Teaching how to cover the mouth when coughing
- E. Performing hand hygiene before and after client contact
- F. Separating the client by at least 3 feet from others in the area
Correct Answer: B,D,E,F
Rationale: B: A mask is required during examination to prevent droplet transmission. D: Teaching cough etiquette reduces spread. E: Hand hygiene prevents pathogen transmission. F: Maintaining 3 feet distance reduces droplet spread. A: Sterile tissues are unnecessary. C: Water does not limit transmission.
The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for mycobacterium tuberculosis. Which action should be taken by the nurse?
- A. Prepare a statement for the hospital spokesperson to release to the news agencies
- B. Recommend that only staff with recent negative tuberculin skin tests provide care
- C. Implement measures to notify the local or state health department about the case
- D. Notify the nearest infectious disease facility and prepare the client for transfer
Correct Answer: C
Rationale: C: TB is a reportable disease, requiring health department notification. A: Media release is inappropriate. B: All staff can provide care with precautions. D: Transfer is unnecessary.
The HCP documents that the client has a generalized infection. Which specific assessment finding should the nurse expect?
- A. Redness and warmth at the site
- B. Swelling and pain at the site
- C. Hypertension and bradycardia
- D. Fever and widespread muscle aches
Correct Answer: D
Rationale: D: Generalized infections cause systemic symptoms like fever and muscle aches. A, B: These are localized signs. C: Hypotension and tachycardia are more likely.
The nurse is completing a variance report after finding a plastic bag at the nurse's station with contents and the sticker illustrated. The nurse should document finding a plastic bag with a symbol indicating that the contents of the bag include which type of item?
- A. Potentially infectious specimen
- B. Radioactive medication
- C. Flammable substance
- D. Poisonous substance
Correct Answer: A
Rationale: A: The biohazard symbol indicates potentially infectious material. B, C, D: Other symbols (trefoil, NFPA diamond) denote radiation, flammability, or toxicity.
The nurse observes that the NA enters the client room, provides direct care, and then exits without performing any hand hygiene. Which is the appropriate initial action of the nurse?
- A. Inform the nurse manager about the NA's performance.
- B. File a facility incident or variance report immediately.
- C. Talk to the NA immediately about performing hand hygiene.
- D. Tell the client to remind all staff to perform hand hygiene.
Correct Answer: C
Rationale: C: Immediate discussion with the NA addresses the issue directly and promotes compliance. A, B: These are secondary actions. D: Client involvement is inappropriate.