Nokea
The nurse is caring for a client with a history of tuberculosis.
- A. Which precaution is most appropriate for a client with active tuberculosis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: D
Rationale: Airborne precautions are required for active tuberculosis to prevent transmission via respiratory droplets. Standard, droplet, and contact precautions are insufficient.
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A woman is scheduled for a breast biopsy. She is crying and says, 'I am so upset because I watched my mother die from ovarian cancer.' What is the most appropriate nursing diagnosis?
- A. Fear
- B. Anxiety
- C. Ineffective family coping
- D. Spiritual distress
Correct Answer: A
Rationale: Fear of cancer due to her mother's death is the most specific diagnosis, addressing her emotional response to the biopsy.
Which of the following findings distinguishes a hydrocele from an inguinal hernia?
- A. The swelling cannot be reduced and is translucent.
- B. The swelling cannot be reduced and is opaque.
- C. The swelling can be reduced and is translucent.
- D. The swelling can be reduced and is opaque.
Correct Answer: A
Rationale: A hydrocele is non-reducible, translucent swelling due to fluid around the testis, unlike an inguinal hernia, which is often reducible and opaque.
On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:
- A. Decrease the rate of the intravenous infusion.
- B. Change the type of intravenous fluid being administered.
- C. Change the urinary catheter.
- D. Increase the rate of the intravenous infusion.
Correct Answer: D
Rationale: The urinary output should be maintained between 30 ml and 50 ml per hour. The first action should be to increase the IV rate to prevent increased acidosis. Answer A would lead to diminished output, so it is incorrect. There is no indication that the type of IV fluid is not appropriate as is suggested by answer B, making it incorrect. Answer C would not increase the client's output and would place the client at greater risk for infection, so it is incorrect.
The nurse is assigned a team with another registered nurse and an LPN.
Which of the following patients should the nurse assign to the LPN?
- A. A 67-year-old man who is NPO and scheduled for a transurethral resection of the prostate (TURP) in 3 hours.
- B. A 53-year-old woman with an IV of 0.9% NaCl at 100 cc/h who had a lumbar laminectomy two days ago.
- C. A 40-year-old woman with a Hemovac drain and a large surgical dressing from a mastectomy 2 days ago who is showing signs of depression.
- D. A 27-year-old woman scheduled for discharge later today after receiving chemotherapy through a portacath for treatment of leukemia.
Correct Answer: B
Rationale: Strategy: The LPN/LVN is assigned stable patients with expected outcomes. (1) needs preoperative teaching and assessment (2) correct-basic care needs can be met by the LPN/LVN, don't make patient assignments based on equipment (3) needs therapeutic intervention, teaching, and assessment (4) needs assessment and teaching
While a client is receiving TPN, it is MOST important for the nurse to monitor
- A. vital signs and level of consciousness.
- B. arterial blood gases and liver enzymes.
- C. serum glucose and electrolytes.
- D. skin turgor and daily weights.
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.