Nokea
The nurse is caring for an older adult receiving prescribed antibiotics for an infection. The client reports frequent watery stools that are foul-smelling. To prevent the spread of any potential secondary infection, the nurse should
- A. Place the client on contact (enteric) precautions.
- B. Place a surgical mask on the client during transport.
- C. Place face shields outside of the client's room.
- D. Keep the door to the client's room closed.
Correct Answer: A
Rationale: Foul-smelling, watery stools suggest possible Clostridium difficile, requiring contact (enteric) precautions to prevent spread. Masks, face shields, and closed doors are not specific to enteric infections.
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The nurse is part of a committee tasked with reducing medical errors in the nursing unit. Which of the following recommendations should the nurse make to the committee? Select all that apply.
- A. Increase the number of verbal orders given from primary healthcare providers
- B. Nurse-to-nurse bedside handoff reporting
- C. Handoff reporting using the ISBAR framework
- D. Ensure staff are taking uninterrupted breaks
- E. Increase the lighting around the medication dispensing machines
Correct Answer: B,C,D,E
Rationale: Bedside handoffs, ISBAR framework, breaks, and better lighting reduce errors. Verbal orders increase error risk.
The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
- A. Positive gag reflex
- B. Hypoactive bowel sounds
- C. Blood pressure 90/60 mm Hg
- D. Incisional pain '2' on a scale of 0 to 10
- E. Urinary output of 240 mL since surgery
Correct Answer: A,D,E
Rationale: A positive gag reflex indicates airway protection, mild incisional pain (2/10) suggests adequate pain control, and sufficient urinary output (240 mL) indicates renal function, all supporting discharge readiness. Low blood pressure (90/60 mm Hg) suggests instability, and hypoactive bowel sounds are expected but not a discharge criterion.
The nurse is preparing a staff education program about physiological responses of stress. Which of the following is a physiological alteration that can occur with stress?
- A. Decreased visual acuity
- B. Increased peristalsis
- C. Decreased glucocorticoids
- D. Hyperglycemia
Correct Answer: D
Rationale: Stress triggers hyperglycemia via cortisol release. Visual acuity and peristalsis are not directly affected, and glucocorticoids increase, not decrease.
The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The nurse should take which action to prepare for the surge in clients? Select all that apply.
- A. Work to arrange timely discharge and admission for appropriate clients.
- B. Establish a holding area for discharged clients not able to go home.
- C. Modify the nurse/client ratio to accommodate the surge levels.
- D. Instruct staff to switch from electronic to paper documentation.
- E. Prepare to provide frequent updates to local media.
Correct Answer: A,B
Rationale: Timely discharges/admissions and a holding area optimize resources. Modifying nurse ratios, switching to paper documentation, or media updates are not primary actions.
The nurse is discussing infection control practices in the nursing unit. Which client requires droplet precautions? A client with Select all that apply.
- A. Diagnosed with rubella.
- B. A new diagnosis of pharyngeal diphtheria.
- C. Receiving chemotherapy via an implanted port.
- D. Pulmonary tuberculosis receiving nebulizer treatments.
- E. A skin abscess that tested positive for Klebsiella.
Correct Answer: A,B
Rationale: Rubella and pharyngeal diphtheria require droplet precautions due to respiratory transmission. TB requires airborne, chemotherapy does not require isolation, and Klebsiella abscess requires contact precautions.