Nokea
The nurse is developing a plan of care for a client with pertussis. It would be appropriate for the nurse to include which interventions? Select all that apply.
- A. Wear a surgical mask when working within three feet of the client
- B. Provide disposable dishes for meals
- C. Keep the client's room door closed
- D. Provide the client with a portable fan
- E. Maintain negative air pressure
- F. Apply a N95 mask to the client during transport
- G. Place the client in a room near the nurse's station
Correct Answer: A,C,F
Rationale: Pertussis requires droplet precautions: surgical mask within 3 feet, closed door, and N95 for transport. Disposable dishes, fans, and negative pressure are not needed.
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The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse recognizes that the gastric pH confirming proper placement in the stomach is
- A. 3.4
- B. 7
- C. 5.9
- D. 8
Correct Answer: A
Rationale: A gastric pH of ≤5.5 (e.g., 3.4) confirms NGT placement in the stomach. Higher pH values (7 or 8) suggest intestinal or respiratory placement.
The nurse is caring for a client who has been on bed rest for 2 days following surgery. To prevent complications associated with the client's first ambulation, the nurse should plan to
- A. Encourage the client to increase fluid intake to at least 2,000 mL per day.
- B. Assist the client in performing range-of-motion (ROM) exercises.
- C. Teach the client how to use the incentive spirometer.
- D. Encourage the client to dangle their legs at the bedside.
Correct Answer: D
Rationale: Dangling legs at the bedside prevents orthostatic hypotension during first ambulation. Fluids, ROM, and spirometry are supportive but not specific to ambulation.
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is caring for a client with human immunodeficiency virus (HIV). It would be appropriate for the nurse to assign the client to a room with the client diagnosed with
- A. Infectious mononucleosis.
- B. Mycoplasma pneumonia.
- C. Gastroenteritis (rotavirus).
- D. Mumps (infectious parotitis).
Correct Answer: A
Rationale: HIV is not airborne or droplet-transmitted, so rooming with a client with mononucleosis (non-respiratory transmission) is safe. Mycoplasma, rotavirus, and mumps require specific precautions.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.