Nokea
The nurse is caring for a client with HIV. The nurse understands that which of the following are true regarding transmission-based precautions? Select all that apply.
- A. Donning an N95 respiratory mask decreases the risk of transmitting HIV
- B. Gown, gloves, and face shield are necessary for every client encounter
- C. Neutropenic precautions are implemented based on laboratory results
- D. The client's urine is a bodily fluid that can transmit HIV
- E. The nurse should perform hand hygiene before and after providing client care
Correct Answer: C,D,E
Rationale: Neutropenic precautions depend on lab results (e.g., low white blood cell count). Urine can transmit HIV if blood is present. Hand hygiene is standard for all encounters. N95 masks are for airborne diseases, not HIV. Full PPE isn't needed unless splashing of bodily fluids is likely.
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The physician has ordered an irrigation of the client's left ear for the removal of cerumen. To prevent vestibular stimulation, the fluid should be degrees Fahrenheit:
- A. 68
- B. 76
- C. 98
- D. 120
Correct Answer: C
Rationale: Cerumen is removed using a mixture of water and hydrogen peroxide at body temperature. Answers A and B are incorrect because they are too cold. Answer D is incorrect because it is too hot.
The nurse is preparing to administer ear drops to an adult client. It would require follow-up if the nurse
- A. instills the ear drops at room temperature
- B. instills the ear drops by placing the dropper into the ear canal
- C. pulls the pinna of the client's ear up and back before instillation
- D. places a cotton ball loosely in the outermost auditory canal after instillation
Correct Answer: B
Rationale: Placing the dropper into the ear canal risks injury and contamination. Ear drops should be instilled by holding the dropper above the canal. Other actions are correct: room-temperature drops prevent discomfort, pulling the pinna straightens the canal, and a cotton ball retains the medication.
The nurse is preparing teaching for a client with Parkinson disease. Which of the following techniques are appropriate when communicating with a client with Parkinson disease? Select all that apply.
- A. Encourage the client to speak slowly and pause to take deep breaths periodically
- B. Identify and promote the client's capabilities and strengths throughout the sessions
- C. Provide client teaching during times of day when the client has the most energy
- D. Reserve discussion of important or complex teaching for the client's caregiver
- E. Schedule teaching sessions at times with low risk of rushing or interruptions
Correct Answer: A,B,C,E
Rationale: Speaking slowly aids clarity, promoting strengths builds confidence, teaching during high-energy times optimizes learning, and uninterrupted sessions enhance focus. Complex teaching should include the client, not just the caregiver, to respect autonomy.
The nurse is caring for assigned clients. Which of the following clients is at highest risk for developing delirium?
- A. 32-year-old client with gastroenteritis, dehydration, and a low-grade fever
- B. 55-year-old client with coronary artery disease who had coronary artery bypass surgery four days ago
- C. 60-year-old client with type 2 diabetes mellitus who had bilateral above-the-knee amputations two months ago
- D. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis
Correct Answer: D
Rationale: The 80-year-old with COPD, respiratory failure, and urosepsis has multiple delirium risk factors: advanced age, infection, and chronic illness. Younger clients with less severe conditions have lower risk.
Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.
- A. I will clarify with my health care provider before taking enteric-coated medications.
- B. I will irrigate the colostomy to promote regular bowel movements.
- C. I will limit eating foods such as broccoli and cauliflower to reduce odor.
- D. I will restrict my fluid intake to 2,000 milliliters of fluid a day.
- E. I will wait for the pouch to become completely full before emptying the contents.
Correct Answer: A,C
Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.