Nokea
The nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection?
- A. 51-year-old client who received a permanent pacemaker 48 hours ago
- B. 60-year-old client who had a myocardial infarction 24 hours ago
- C. 74-year-old client with stroke and an indwelling urinary catheter for 3 days
- D. 75-year-old client with dementia and dehydration who is on IV fluids
Correct Answer: C
Rationale: An indwelling urinary catheter increases the risk of catheter-associated urinary tract infections, a common nosocomial infection, especially in older adults with prolonged catheter use.
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The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting is:
- A. 40-60 mm Hg
- B. 60-80 mm Hg
- C. 80-120 mm Hg
- D. 120-140 mm Hg
Correct Answer: C
Rationale: Suction pressure of 80-120 mm Hg is recommended for adult tracheostomy suctioning to effectively remove secretions without causing trauma.
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
- A. A social worker from the local hospital
- B. A physical therapist to improve fine motor coordination
- C. An activity therapist from the community center
- D. Another client with diabetes mellitus and takes insulin
Correct Answer: B
Rationale: A physical therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.
The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching?
- A. I am glad that I can continue to take my kava supplement each morning.
- B. If I can't sleep, I will take some melatonin with my evening dose of clonazepam.
- C. If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself.
- D. When my anxiety is getting really intense, I will drink some valerian tea to help me relax.
Correct Answer: C
Rationale: Lavender essential oil in a diffuser is a safe, non-pharmacological method to reduce restlessness, compatible with clonazepam without risk of interaction.
A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted?
- A. Improvement in short-term memory
- B. Improvement in spontaneous activity
- C. Reduction in number of visual hallucinations
- D. Reduction of dizziness with standing
Correct Answer: B
Rationale: Carbidopa-levodopa treats Parkinson's symptoms like bradykinesia, improving spontaneous activity, which is the primary therapeutic goal.
The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to ambulate in the hallway every shift
- B. Encourage the client to increase sodium intake
- C. Maintain the client in semi-Fowler position
- D. Provide an alternating air pressure mattress for the client
- E. Use music to provide a distraction for the client
Correct Answer: C,D,E
Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.