Nokea
The nurse is caring for a client diagnosed with active pulmonary tuberculosis. Which elements of transmission-based precautions are required for the nurse when providing routine care? Select all that apply.
- A. Gown
- B. Goggles or face shield
- C. Hand hygiene
- D. N95 particulate respirator
- E. Surgical mask
Correct Answer: C,D
Rationale: Active pulmonary tuberculosis requires airborne precautions, including hand hygiene and an N95 respirator. A surgical mask is insufficient.
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The practical nurse (PN) is collaborating with the registered nurse to conduct a developmental assessment of a 9-month-old client during a well-child visit. Which statement by the infant's parent should cause the PN concern?
- A. Our child needs help to grasp and bring teething toys to the mouth.
- B. Our child says 'mamama' to our dog.
- C. Our child screams when approached by unfamiliar people.
- D. Our child uses both hands for support to be able to sit upright.
Correct Answer: A
Rationale: By 9 months, infants should independently grasp objects. This indicates a potential fine motor delay requiring further evaluation.
The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?
- A. The axillary pads are torn and show signs of wear
- B. The client has a 30-degree bend at the elbow when walking
- C. The crutches and injured foot are moved simultaneously in a 3-point gait
- D. There is a 3 finger-width space noted between the axilla and axillary pad
Correct Answer: A
Rationale: Torn axillary pads can cause discomfort and injury, indicating a need for replacement and further teaching.
The nurse is talking with a female client about collecting a clean-catch urine specimen. Which of the following information should the nurse include? Select all that apply.
- A. Avoid touching the inside of the specimen container.
- B. Position the specimen container before initiating your stream of urine.
- C. Cleanse your vulva from front to back with single-use antiseptic towelettes.
- D. Spread your labia using your nondominant hand before cleansing your perineum and urinating.
- E. Remove the lid from the specimen container and place it on the counter with the sterile side facing down.
Correct Answer: A,C,D
Rationale: Avoiding contamination, proper cleansing, and spreading the labia are critical for a clean-catch specimen. The lid should be placed sterile side up, and the container should be positioned midstream.
Which of the following meals would be best tolerated by the client receiving Leukeran?
- A. Peanut butter sandwich, orange juice, and Jell-0
- B. Warm pea soup, apricot fruit slush, and ice cream
- C. Lasagna with meat sauce, salad, and tea
- D. Steak, baked potato, and milk
Correct Answer: B
Rationale: Leukeran can cause nausea, so bland, cool foods like pea soup, fruit slush, and ice cream are better tolerated than heavy or acidic meals.
The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.
- A. I should rinse my mouth with water before collecting the sputum.
- B. I will be careful not to touch the inside of the specimen cup or lid.
- C. I will inhale deeply a few times and then cough forcefully.
- D. It is best to collect the sputum mid-day when my secretions are loose.
- E. It is helpful if I am sitting upright when I collect the sputum.
Correct Answer: A,B,C,E
Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.