Nokea
The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply:
- A. Wear gloves when handling tissues containing sputum
- B. Wear a face mask at all times
- C. Keep the client in strict isolation
- D. When the client leaves the room for tests, have all people in contact with him wear a mask
- E. Keep the client's door open to allow fresh air into room and prevent social isolation
- F. Wash hands after direct contact with the client or contaminated articles
Correct Answer: A,B,F
Rationale: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in his room; masks must be discarded before leaving the client's room. Hand washing is required after direct contact with the client or contaminated articles. Strict isolation isn't required if the client adheres to special respiratory precautions. The client, not the people in contact with him, must wear a mask when leaving the room for tests. The client should be in a negative-pressure, private room, and the door should remain closed at all times to prevent the spread of infection.
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The importance of monitoring blood sugar, activity level, and insulin doses is to
adjust the activity level based on the blood sugar level.
- A. adjust the diet and insulin doses as the activity level increases or decreases.
- B. adjust the diet and activity level based on the blood sugar level.
- C. adjust the insulin doses based on the sugar level in the urine.
Correct Answer: B
Rationale: If a patient injects too much insulin, exercises too much in relation to carbohydrate consumed, or does not eat enough or at the appropriate times, the blood glucose level can fall low enough to cause hypoglycemia. Adjusting diet and insulin doses based on activity level helps maintain balance.
A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Positioning the patient with the head of the bed elevated 60°-90° (high Fowler’s position) facilitates swallowing and allows gravity to aid the passage of the nasogastric (NG) tube through the esophagus into the stomach. This position reduces the risk of aspiration and eases tube insertion. Lower elevations (30°-45°), side-lying, or flat positions do not optimize swallowing or tube advancement as effectively.
A client with mastoiditis has a left mastoidectomy with tympanoplasty. The nurse should observe the client for signs of damage to the sixth crania nerve, which include:
- A. Inability to chew
- B. Inability to look laterally
- C. Inability to swallow
- D. Loss of scalp sensation
Correct Answer: B
Rationale: The sixth cranial nerve (abducens) controls lateral eye movement, so damage would result in an inability to look laterally.
An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice?
- A. Bologna sandwich, pudding, milk
- B. Frankfurter, baked potato, milk
- C. Chicken strips, corn on the cob, milk
- D. Grilled cheese sandwich, apple, milk
Correct Answer: C
Rationale: This menu is lowest in sodium. Ideally, low fat milk would be available.
A client who had previously signed the consent for liver biopsy has changed his mind and no longer wants the procedure.
The best initial response by the nurse would be:
- A. Why did you originally sign the consent?
- B. Can you tell me why you decided to refuse the procedure?
- C. You are obviously afraid about something concerning the procedure.
- D. Although the procedure is very important, I understand why you changed your mind.
Correct Answer: B
Rationale: Exploring the reason for refusal respects the patient's autonomy and facilitates informed decision-making.