Nokea
The nurse is discussing infection control with a group of nursing students. Which conditions require contact precautions?
- A. Rubeola
- B. Psoriasis
- C. Pediculosis
- D. Rubella
- E. Scabies
- F. Clostridium difficile
Correct Answer: C, E, F
Rationale: Pediculosis, scabies, and Clostridium difficile require contact precautions due to direct contact transmission.
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A client is receiving allopurinol and asks what they should know about taking this medicine. The nurse would be most correct in stating which of the following?
- A. Facial swelling is expected in the first few days of therapy.
- B. Drink at least 3000 mL of water per day.
- C. Do not eat while taking this medication.
- D. This medication begins working immediately.
Correct Answer: B
Rationale: Allopurinol requires high fluid intake (3000 mL/day) to prevent kidney stone formation.
The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
- A. Narrowed and flattened
- B. Concave and bowl-shaped
- C. Dry and reddish-purple
- D. Pinkish-red and moist
Correct Answer: B
Rationale: A retracted stoma appears concave and bowl-shaped, indicating it has pulled below the skin surface.
A nurse is taking care of a client with acute peritonitis. The nurse should do which of the following to meet the client's nutritional needs?
- A. administer feedings via nasogastric (NG) tube
- B. administer gastric enteral feedings
- C. feed the client orally
- D. administer parenteral nutrition
Correct Answer: D
Rationale: Acute peritonitis often requires bowel rest due to inflammation, making oral or enteral feedings inappropriate. Parenteral nutrition is indicated to meet nutritional needs.
The nurse is caring for a client three hours postpartum after delivering a term newborn infant. Which assessment finding would indicate an early sign of postpartum hemorrhage?
- A. Heart rate change from 80 to 125 bpm
- B. Blood pressure change from 125/90 to 119/82 mmHg
- C. A decrease in respiratory rate from 22 to 16 breaths per minute
- D. Saturation of one peri-pad since delivery
Correct Answer: A
Rationale: Tachycardia (heart rate increase to 125 bpm) is an early sign of postpartum hemorrhage due to compensatory response to blood loss.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
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Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
The nurse is most concerned about the client developing ___ due to ___ and ___
- A. ischemic stroke
- B. intra-abdominal hemorrhage
- C. neurological assessment
- D. anticoagulant use
- E. pulse
- F. anticoagulant use
- G. atrial fibrillation
Correct Answer: A, D, G
Rationale: Warfarin use and atrial fibrillation increase the risk of ischemic stroke, especially with a history of trauma and neurological symptoms.