Nokea
The nurse is caring for a client diagnosed with C. diff. The client has soiled the bed and the nurse is preparing to change it. Which action by the nurse is correct in regard to handling soiled linens that have been exposed to C. diff?
- A. throw the linens in the trash can in the soiled utility room
- B. leave the dirty linens in a bag in the client's room until he is discharged
- C. place the items in a red biohazard bag and place them in the soiled utility room
- D. place the soiled linen in a regular dirty linen bag and place in the soiled utility room
Correct Answer: D
Rationale: C. diff-contaminated linens should be placed in a regular dirty linen bag, as they are processed with high-temperature washing to kill spores, not treated as biohazard waste.
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The nurse is serving on the performance improvement committee, which has agreed to some changes in procedures on the basis of evidence-based research. If the committee wants to convince staff members to comply with the changes, which of the following actions should the committee carry out first?
- A. Identify and gain support of key staff.
- B. Explain the consequences of failure to comply.
- C. Determine a reward system for compliance.
- D. Clearly outline expectations in written format.
Correct Answer: A
Rationale: Gaining key staff support (A) builds buy-in and facilitates change adoption. Consequences (B), rewards (C), or written expectations (D) follow.
The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such clients is:
- A. Setting realistic limits
- B. Encouraging the client to express remorse for behavior
- C. Minimizing interactions with other clients
- D. Encouraging the client to act out feelings of rage
Correct Answer: A
Rationale: Setting realistic limits helps manage the manipulative and impulsive behaviors common in antisocial personality disorder, promoting safety and structure.
A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: B
Rationale: Laryngeal edema is a critical concern with facial and head burns due to the risk of airway obstruction.
The nurse is seeing a client in the clinic who has shingles (herpes zoster). The client is concerned about spreading the disease to others. How should the nurse respond?
- A. It is only possible to have one episode of the disease.
- B. Persons with leukemia are at higher risk.
- C. Persons of all ages should receive the zoster vaccine (Zostavax).
- D. Persons between 30 and 40 years old are at high risk.
Correct Answer: B
Rationale: Shingles is contagious to immunocompromised individuals, such as those with leukemia, via contact with active lesions. The vaccine is recommended for older adults, not all ages, and recurrence is possible.
The nurse is assessing a client who is 36 hours postpartum. Which of the following findings would indicate a need for further evaluation?
- A. Fundus firm and 2 cm below the umbilicus.
- B. Moderate lochia serosa.
- C. Mild perineal discomfort.
- D. Temperature of 100.4°F (38°C).
Correct Answer: D
Rationale: a temperature of 100.4°F may indicate infection, such as endometritis, and requires further evaluation