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The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter?
- A. Have the client wear a mask
- B. Have the client wear gloves
- C. Wear a mask
- D. Wear an isolation gown
Correct Answer: A
Rationale: Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room.
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The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
- A. Additional potassium will be given IV
- B. Blood for coagulation studies will be drawn
- C. Total parenteral nutrition (TPN) will be started
- D. Serum lipase levels will be evaluated
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) will be started. The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
Which of the following individuals may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer's disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 72-year-old female scheduled for a heart transplant
- D. a 6-month-old baby needing bowel surgery
Correct Answer: C
Rationale: The 72-year-old female, presumed competent, can give informed consent. Those with advanced Alzheimer's, non-emancipated minors, and infants cannot legally consent. Coordinated Care
A nurse who is a native English speaker admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially
- A. Request a Spanish interpreter
- B. Speak through the family or co-workers
- C. Use pictures, letter boards, or monitoring
- D. Assess the client's ability to speak English
Correct Answer: D
Rationale: Assess the client's ability to speak English. Despite the cultural heritage, the nurse cannot make assumptions. Stereotyping is to be avoided. The nurse should assess the client's comfort and ability in speaking English.
The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the most concerning?
- A. Pain and pallor in one foot
- B. Pain in both knees
- C. Splinter hemorrhages in the nail beds
- D. Temperature of 38.2°C (100.8°F)
Correct Answer: A
Rationale: Pain and pallor in one foot suggest an embolic event, a serious complication of infective endocarditis that could lead to tissue ischemia or infarction, requiring urgent intervention. Knee pain, splinter hemorrhages, and mild fever are less immediately threatening.
The nurse is contributing to the plan of care for a newly admitted client with schizophrenia who is experiencing persecutory delusions. Which of the following interventions should the nurse suggest including in the client's plan of care?
- A. Explore the meaning behind the client's delusions
- B. Focus on the client's feelings related to the delusions
- C. Gently attempt to convince the client that the delusions are false
- D. Present the client with logical arguments to discredit the delusions
Correct Answer: B
Rationale: Focusing on the client's feelings related to delusions helps build trust and validates their emotional experience without reinforcing the delusion. Exploring meanings or challenging delusions directly can escalate distress or resistance, as delusions are fixed beliefs in schizophrenia.