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The nurse is observing a nursing assistant providing care. Which action indicates that the nursing assistant understands universal precautions?
- A. The nursing assistant washes hands first thing in the morning before giving care to any client and again after all morning care is completed.
- B. The nursing assistant wears gloves during all client contact.
- C. The nursing assistant wears a gown when changing linen soiled with urine and feces.
- D. The nursing assistant changes gloves between clients but does not wash hands if gloves have been worn.
Correct Answer: C
Rationale: Wearing a gown for soiled linen contact adheres to universal precautions, preventing contamination. Limited hand washing, excessive gloves, or no hand washing post-gloves are incorrect.
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A client with diabetes phones the clinic stating, 'I have a terrible cold and I don't know what to do about taking my insulin.' Which of the following should be included in the nurse's teaching regarding the client's insulin needs?
- A. Infections decrease insulin needs, so she should withhold insulin injections until her cold symptoms improve.
- B. Infections cause a drop in blood glucose levels, so she should base her insulin needs on the results of urine glucose tests.
- C. Infections cause alterations and increase insulin needs, so she should check her blood glucose levels and urine ketones at least every 4 hours.
- D. Infections cause no change in insulin requirements, but she should avoid crowds and overfatigue.
Correct Answer: C
Rationale: Infections increase insulin resistance, raising insulin needs. Frequent glucose and ketone monitoring ensures proper management. Withholding insulin or relying on urine tests is dangerous, and infections do alter insulin requirements.
A 9-year-old client has terminal cancer, but the parents do not want the child to know the prognosis. Over the past days, the child has started asking questions such as what dying is like and whether the child will die. Which of the following actions by the nurse is most appropriate?
- A. Encourage the parents to openly discuss the child's questions
- B. Notify the health care provider about the child's questions
- C. Remind the child that everyone is trying to help the child get better
- D. Tell the child to ask the parents the questions about death
Correct Answer: A
Rationale: Encouraging parental discussion supports the child's emotional needs and honesty. Notifying the provider , reassuring falsely , or redirecting avoid addressing the child's questions.
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.
The hospital nurse administers CPR to an adult male who is found unconscious, has no pulse, and is not breathing. What is the ratio of chest compressions to respirations for one-person rescue?
- A. Fifteen chest compressions to one breath
- B. Fifteen chest compressions to two breaths
- C. Thirty chest compressions to two breaths
- D. Thirty chest compressions to two breaths
Correct Answer: C
Rationale: Current CPR guidelines recommend 30 chest compressions to 2 breaths for one-person adult resuscitation, optimizing circulation and oxygenation.
A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings?
- A. A reported history of recent trauma
- B. Abdominal bruising
- C. External signs of trauma
- D. Irritability and vomiting
Correct Answer: D
Rationale: Shaken baby syndrome often presents with irritability and vomiting due to intracranial injury, without external trauma , abdominal bruising , or reported trauma .