Nokea
The nurse is caring for a client who has subclavian central venous access. Which nursing intervention is most important to prevent the spread of infection to this client?
- A. Frequent hand hygiene
- B. No artificial nails
- C. Use of chlorhexidine bath wipes
- D. Wearing personal protective equipment
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective intervention to prevent infection in central venous access, reducing pathogen transmission. No artificial nails and chlorhexidine wipes are supportive, but hand hygiene is primary. PPE is situational.
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The nurse is caring for a client who is attempting to leave the hospital against medical advice. The client is competent to make decisions. Which of the following actions would be essential for the nurse to take?
- A. Provide the client with a copy of the client’s medical record
- B. Tell the client that discharge forms must be signed before leaving
- C. Inform the client that the client cannot return for medical care after leaving
- D. Ensure the health care provider explains the risks of leaving the hospital to the client
Correct Answer: D
Rationale: Ensuring the provider explains risks ensures informed decision-making, protecting the client and minimizing liability. Medical records are not immediately provided, forms are procedural, and barring future care is incorrect.
The nurse is reviewing recommended dietary modifications with the parents of a 6-month-old client with phenylketonuria. Which of the following information should the nurse include? Select all that apply.
- A. A low-phenylalanine diet is required
- B. Meat and dairy products should not be introduced into the diet
- C. Phenylketonuria is self-limiting and dietary modifications are temporary
- D. Specially prepared infant formula is necessary
- E. Tyrosine should be removed from the diet
Correct Answer: A,B,D
Rationale: Phenylketonuria requires a lifelong low-phenylalanine diet, avoiding meat and dairy, and using special formula to prevent neurological damage. It is not self-limiting, and tyrosine is needed, not removed.
The nurse is reinforcing teaching for a client with hyperlipidemia who has a new prescription for simvastatin. The nurse should instruct the client to take simvastatin
- A. at noon immediately following a meal
- B. in the morning on an empty stomach
- C. at bedtime without regard to food
- D. in the afternoon with a snack
Correct Answer: C
Rationale: Simvastatin is most effective at bedtime, when cholesterol synthesis peaks, and can be taken with or without food. Morning or afternoon dosing reduces efficacy.
The client taking a bronchodilator tells the nurse that he is going to begin a smoking cessation program when he is discharged. The nurse should tell the client to notify the doctor if his smoking pattern changes because he will:
- A. Need his medication dosage adjusted
- B. Require an increase in antitussive medication
- C. No longer need annual influenza immunization
- D. Not derive as much benefit from inhaler use
Correct Answer: A
Rationale: Changes in smoking patterns should be discussed with the physician because they have an impact on the amount of medication needed. Answer B is incorrect because clients with COPD are placed on expectorants, not antitussives. Answer C is incorrect because an annual influenza vaccine is recommended for all those with lung disease. Answer D is incorrect because benefits from inhaler use should be increased when the client stops smoking.
The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.
- A. Advising measles vaccination for susceptible family members
- B. Applying calamine lotion to reduce itching
- C. Placing a tracheostomy tray at the bedside
- D. Placing the client in a negative pressure isolation room
- E. Using an N95 respirator mask during client contact
Correct Answer: A,D
Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).