Nokea
The nurse is caring for a client with a history of meningitis.
- A. Which precaution is most appropriate for a client with bacterial meningitis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: B
Rationale: Droplet precautions are required for bacterial meningitis (e.g., Neisseria meningitidis) to prevent transmission via respiratory secretions. Standard precautions are insufficient, and contact or airborne precautions are incorrect.
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Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints?
- A. Prepare PRN dose of psychotropic medication.
- B. Check that the restraints have been applied correctly.
- C. Review hospital policy regarding duration of restraints.
- D. Monitor the client's needs for hydration and nutrition while restrained.
Correct Answer: B
Rationale: assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings would be of GREATest concern to the nurse?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium of 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium of 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration and electrolyte imbalance in cirrhosis. Options A, B, and D are normal or expected: ammonia 40 mcg/dL is controlled, potassium 3.5 mEq/L is normal, and sodium 140 mEq/L is normal.
The nurse is caring for a client who is postoperative day 1 after a cesarean section. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Lochia rubra with small clots.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, such as endometritis, a serious complication post-cesarean section requiring immediate evaluation. Options B, C, and D are expected: incision pain, lochia rubra, and urine output 50 mL/hour are normal on day 1.
A low-income client needing to satisfy essential protein needs.
Which of the following foods would the nurse encourage a low-income client to eat to satisfy essential protein needs?
- A. Legumes.
- B. Red meat.
- C. Seafood.
- D. Cheese.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-legumes are an economical source rich in protein (2) high in protein, but more expensive to purchase (3) high in protein, but more expensive to purchase (4) high in protein, but more expensive to purchase
A prenatal client tests positive for chlamydia in her ninth month. She asks why she should be treated since she does not have symptoms. The nurse should tell the client that if she is not treated before delivery, there is a risk of which problem?
- A. Transplacental infection of the fetus
- B. Neonatal ophthalmia
- C. Pregnancy-induced hypertension
- D. Congenital anomalies
Correct Answer: B
Rationale: Untreated chlamydia can cause neonatal conjunctivitis (ophthalmia neonatorum) during vaginal delivery, necessitating treatment to prevent infant complications.