Nokea
The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which order with the primary healthcare provider (PHCP)
- A. Urine analysis (UA)
- B. Head CT Scan
- C. Regular diet
- D. Ammonia level
Correct Answer: C
Rationale: A regular diet prescription should be questioned because of the client's medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order.
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The charge nurse is responding to an outbreak of influenza in a long-term care facility. To prevent the spread of this infection, the nurse recommends
- A. Having clients wear respirator masks (N95) while ambulating in the hallway.
- B. Placing air purifiers in the corridors.
- C. Obtaining prescriptions for antiviral medications for those infected.
- D. Isolating those infected using droplet precautions.
Correct Answer: C,D
Rationale: Antiviral medications and droplet precautions for infected clients control influenza spread. Client N95 masks and air purifiers are less effective.
The nurse is observing infection control practices in the nursing unit. Which of the following findings requires follow-up? Select all that apply.
- A. Doors kept closed for clients with contact precautions
- B. Gloves being worn by staff to pass meal trays
- C. Disposable dishes being used for clients on isolation precautions
- D. Bedside fan being removed from a room with negative pressure
- E. Alcohol-based hand sanitizers for a client with C. diff
Correct Answer: B,E
Rationale: Gloves are not required for passing meal trays unless direct contact with infectious material is anticipated. Alcohol-based sanitizers are ineffective against C. difficile; soap and water are required.
The nurse is teaching a client who recently had a femoral vein central line catheter placed. Which of the following information should the nurse include?
- A. You will need to avoid drinking more than 500 mL per day.
- B. You will clean the site daily with soap and water.
- C. You should not sit up more than 45 degrees.
- D. You can remove the dressing if it becomes itchy.
Correct Answer: B
Rationale: Daily cleaning with soap and water maintains hygiene at the femoral central line site. Fluid restriction, angle limitation, and patient removal of dressings are incorrect and unsafe.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.