Nokea
The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern?
- A. Infection
- B. Thermoregulation
- C. Hemorrhage
- D. Altered body image
Correct Answer: C
Rationale: Hemorrhage is the greatest concern immediately post-colon resection due to the risk of significant blood loss from the surgical site, which can be life-threatening. Infection, thermoregulation, and altered body image are important but less immediate.
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The nurse is preparing to prime a new line of IV tubing. The nurse understands that priming intravenous tubing is crucial because it prevents which treatment complication?
- A. Medication toxicity
- B. Infiltration
- C. Air embolism
- D. Extravasation
Correct Answer: C
Rationale: Priming IV tubing removes air, preventing air embolism, a potentially fatal complication. Other complications are unrelated to priming.
The charge nurse is preparing for an influx of clients with measles (rubeola) in the emergency department. To prevent the spread of this infection, the nurse recommends
- A. The distribution of respirator masks (N95) to nursing staff.
- B. Disposable face shields outside client rooms.
- C. The placement of bleach wipes to disinfect commonly touched surfaces.
- D. The removal of alcohol-based hand rubs.
Correct Answer: A
Rationale: Measles requires airborne precautions, including N95 respirators for staff. Face shields, bleach wipes, and removing hand rubs are not specific to airborne transmission.
The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
Which of the following actions is most effective at reducing the incidence of health-care-associated infections?
- A. Screen all newly admitted clients for colonization or infection with MRSA.
- B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms.
- C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.
- D. Require nursing staff to wear gowns to change wound dressings for all clients.
Correct Answer: C
Rationale: Alcohol-based hand rub availability is the most effective way to reduce healthcare-associated infections by promoting frequent hand hygiene. MRSA screening, automatic antibiotics, and universal gown use are less effective or inappropriate.
The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply.
- A. Empty their bladder before bed.
- B. Take more naps throughout the day.
- C. Eat a high amount of calories before bed.
- D. Plan vigorous exercise earlier in the day.
- E. Use multiple nightlights in the bedroom.
Correct Answer: A,D
Rationale: Emptying the bladder and exercising early promote sleep. Naps, high-calorie meals, and multiple lights disrupt sleep hygiene.