Nokea
The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication?
- A. Passive range of motion
- B. Sequential compression devices (SCDs)
- C. Early ambulation
- D. Prophylactic antibiotics
Correct Answer: C
Rationale: Early ambulation promotes lung expansion and secretion clearance, reducing pneumonia risk. Other options are less effective for this purpose.
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You are educating a mother about the association between autism and the MMR vaccine. You know that the mother understands your instructions when she says:
- A. My child should not get the vaccine since it is known to cause autism.
- B. My child should get the individual immunizations for measles, mumps, and rubella since the individual vaccines do not cause autism.
- C. My child should get the MMR immunization since there is no evidence that it causes autism.
- D. My child should not get the immunization because it contains mercury.
Correct Answer: C
Rationale: Extensive research shows no link between MMR and autism, and MMR does not contain mercury. Individual vaccines are not standard, and avoiding vaccination is unsafe.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
- A. Hepatitis C
- B. Cryptococcal meningitis
- C. Clostridium difficile
- D. Scabies
- E. Rheumatic fever
- F. Botulism
- G. Hepatitis B
Correct Answer: C,D
Rationale: Clostridium difficile and scabies require contact precautions due to direct or indirect transmission. Others require standard precautions.
The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then
- A. activate the fire alarm.
- B. extinguish the fire.
- C. contact the nursing supervisor.
- D. close the door to the client's room.
Correct Answer: A
Rationale: Following the RACE protocol (Rescue, Alarm, Contain, Extinguish), after rescuing the client, the nurse should activate the fire alarm to alert others and initiate emergency response.
The nurse is helping the unlicensed assistive personnel pass meal trays. When providing a meal tray for a client diagnosed with pheochromocytoma, which dietary item should the nurse remove?
- A. Macaroni and cheddar cheese
- B. Watermelon slices
- C. Caffeine free cola
- D. Baked chicken
Correct Answer: C
Rationale: Pheochromocytoma requires avoiding stimulants like caffeine, even in decaffeinated cola, which may contain trace amounts. Other items are safe.
The nurse is starting a peripheral vascular access device for a client. The nurse inserted the device into the vein and observed a flashback of blood in the chamber. The nurse should then
- A. Advance the VAD approximately 3 inches (7.62 cm) into the vein and loosen the stylet.
- B. Remove the stylet and secure the catheter using a transparent dressing.
- C. Advance the VAD approximately 1/4 inch (0.6 cm) into the vein and loosen the stylet.
- D. Remove the stylet and release the tourniquet.
Correct Answer: D
Rationale: After observing a blood flashback, the nurse should remove the stylet and release the tourniquet to prevent hematoma formation, then secure the catheter. Advancing further risks vein damage or dislodgement, and securing without releasing the tourniquet is incorrect.