Nokea
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.
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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 works on a medical-surgical unit and is responsible for assessing the client's vital signs. Which of the following clients can have their temperature measured orally? Select all that apply.
- A. A 61-year-old woman who had oral surgery
- B. A 44-year old man with chest pain on oxygen via nasal canula
- C. An 83-year-old woman with diarrhea
- D. A 29-year-old client with an earache
- E. A 6-year-old client with a sore throat and difficulty swallowing
Correct Answer: B,C,D
Rationale: Oral temperature is safe for clients with chest pain, diarrhea, or earache, as they have no oral contraindications. Oral surgery and difficulty swallowing contraindicate oral measurement.
The nurse is teaching a client how to ambulate using a walker. The nurse should
- A. Have the client stand on the side of the walker to have them properly fitted.
- B. Position the top of the walker so it lines up with the client's wrist crease.
- C. Ensure the client's feet are close together while holding onto the walker handgrips.
- D. Instruct the client to lean forward over the walker so they do not lose balance.
- G. None
Correct Answer: B
Rationale: The walker’s top aligns with the wrist crease for proper height. Standing on the side, close feet, or leaning forward are unsafe or incorrect for fitting or use.
The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside?
- A. Trach kit
- B. Scissors
- C. Obturator
- D. Yankauer suctioning
Correct Answer: B
Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding and has balloons that can cause airway obstruction if inflated improperly. Scissors must be at the bedside to cut the tube in an emergency. Trach kits, obturators, and Yankauer suction are not relevant.
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.