Nokea
The nurse is caring for a client who has a Clostridioides difficile infection. Which of the following infection control precautions should the nurse implement? Select all that apply.
- A. Apply sterile gloves before providing client care.
- B. Request that the client be placed in a private room.
- C. Use an alcohol-based hand sanitizer for hand hygiene.
- D. Wear a single-use, protective gown when providing client care.
- E. Ensure surgical masks are worn by staff members who enter the client's room.
Correct Answer: B, D
Rationale: A private room (B) and protective gown (D) are required for contact precautions. Sterile gloves (A) are unnecessary, alcohol-based sanitizer (C) is ineffective against C. difficile spores, and surgical masks (E) are not required.
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A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, 'I'm so worried that my future spouse is going to call off our engagement.' What is the best response by the nurse?
- A. Are you concerned about how the surgery will affect your sexuality?'
- B. If you are concerned about infertility, you could always bank your sperm.'
- C. The cancer is at an early stage. You are going to be fine.'
- D. What have you and your future spouse discussed about your condition?'
Correct Answer: D
Rationale: Asking about discussions with the spouse (D) encourages the client to share concerns and clarifies the situation. Options A, B, and C assume specific fears or provide reassurance without exploration.
Which of the following clients does the nurse identify as being at high risk for developing colorectal cancer? Select all that apply.
- A. Client who has a diet high in red meat and low in fiber
- B. Client who is morbidly obese
- C. Client with a 15-year history of ulcerative colitis
- D. Client with a 40-year history of cigarette smoking
- E. Client with a family history of colorectal cancer
Correct Answer: A, C, E
Rationale: High red meat/low fiber diet (A), ulcerative colitis (C), and family history (E) are established risk factors for colorectal cancer. Obesity (B) and smoking (D) have weaker associations.
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
- A. They can expect the child will be mentally retarded
- B. Administration of thyroid hormone will prevent problems
- C. This rare problem is always hereditary
- D. Physical growth/development will be delayed
Correct Answer: B
Rationale: Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement corrects this condition.
The nurse enters an infant's room and observes that the infant is responsive but is choking and turning blue. Which of the following actions should the nurse take?
- A. Initiate CPR
- B. Perform abdominal thrusts.
- C. Initiate back slaps and chest thrusts.
- D. Perform a blind sweep of the infant's mouth.
Correct Answer: C
Rationale: Back slaps and chest thrusts (C) are the appropriate intervention for a choking infant. CPR (A) is for cardiac arrest, abdominal thrusts (B) are for older children, and blind sweeps (D) are dangerous.
A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.
- A. Document this communication in the electronic health record
- B. Encourage the client to discuss this decision with the health care proxy
- C. Facilitate completion of an advance directive that reflects the client's decision
- D. Obtain a signed informed consent from the client
- E. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order
Correct Answer: A, B, C
Rationale: Documenting in the EHR (A), discussing with the proxy (B), and completing an advance directive (C) ensure the client's wishes are communicated. Informed consent (D) is irrelevant, and DNR (E) is not indicated.