Nokea
The nurse is caring for all of the following persons. Which one is most in need of restraints?
- A. An elderly man who is sitting in a chair
- B. A confused postoperative client who is picking at his nasal oxygen and nasogastric (NG) tube
- C. A confused woman who is in bed with the side rails up
- D. An adult who has just returned to the surgical floor from a postanesthesia care unit
Correct Answer: B
Rationale: The confused postoperative client risks dislodging critical tubes, necessitating restraints if non-restraint interventions fail. Others pose lower immediate risk.
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A client who had bowel surgery is to be NPO for several days. The nurse anticipates that the client will have an order for:
- A. diet therapy.
- B. enteral nutrition.
- C. parenteral nutrition.
- D. nasogastric tube feedings.
Correct Answer: C
Rationale: Parenteral nutrition provides nutrients intravenously for clients NPO post-bowel surgery, bypassing the gastrointestinal tract.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
An adult is admitted to the long-term care facility. She had a cerebrovascular accident and no longer needs acute care. The client has left side hemiplegia. Because of the type of deficit the client has, the nurse knows that this woman is at increased risk for which of the following?
- A. Speech and language deficits
- B. Slow and cautious behavior
- C. Difficulty with visual-spatial relationships
- D. Hearing deficits
Correct Answer: C
Rationale: Left hemiplegia from a right brain CVA increases risk for visual-spatial deficits, as the right hemisphere processes spatial awareness, unlike speech (left hemisphere), behavior, or hearing.
The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?
- A. Blurry vision in the affected eye
- B. Constipation
- C. Itching in the affected eye
- D. Sleeping on 2 pillows at night
Correct Answer: C
Rationale: Itching in the affected eye (C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (A) is expected initially, constipation (B) is unrelated, and sleeping elevated (D) is appropriate.
The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.