Nokea
The nurse is observing a staff member collecting a sputum specimen from a client with active tuberculosis. The nurse should intervene if the staff member is observed
- A. leaving unused supplies in the client's room after the procedure
- B. putting on clean gloves before putting on a protective gown
- C. leaving a dedicated, disposable stethoscope in the client's room
- D. putting on an N95 respirator mask and face shield before entering the client's room
Correct Answer: A
Rationale: Leaving supplies (A) in a TB room risks contamination. Gloves before gown (B), dedicated stethoscope (C), and N95 with face shield (D) are appropriate.
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The nurse is caring for a client with heart failure who develops a persistent, dry cough after starting enalapril. Which of the following new prescriptions would the nurse anticipate for this client?
- A. Alprazolam
- B. Guaifenesin
- C. Lisinopril
- D. Valsartan
Correct Answer: D
Rationale: A dry cough is a common side effect of ACE inhibitors like enalapril, so switching to an ARB like valsartan (D) is anticipated. Alprazolam (A), guaifenesin (B), and lisinopril (C, another ACE inhibitor) are inappropriate.
A client scheduled for electroconvulsive therapy tells the nurse, 'I'm so afraid. What will happen to me during the treatment?' Which of the following statements is most therapeutic for the nurse to make?
- A. You will be given medicine to relax you during the treatment
- B. The treatment will produce a controlled tonic clinic seizure
- C. The treatment can produce nausea and headache
- D. You can expect to be sleepy and confused for a time after the treatment
Correct Answer: A
Rationale: Explaining that medication will relax the client addresses their fear and provides reassurance about the procedure's safety, making it the most therapeutic response.
The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include?
- A. Arrange furniture to allow for free movement
- B. Keep frequently used items within easy reach
- C. Lock doors leading to stairwells and outside areas
- D. Place an identifying symbol on the bathroom door
- E. Provide a dark room free of shadows for sleeping
Correct Answer: A,B,C,D
Rationale: Clear pathways (A), accessible items (B), locked doors (C), and bathroom symbols (D) enhance safety. A dark room (E) may increase confusion or fear.
The nurse is caring for a newborn who has a large myelomeningocele. It would be a priority for the nurse to
- A. check the newborn's anus for muscle tone
- B. cover the area with a sterile, moist dressing
- C. measure the occipital frontal circumference
- D. place the newborn in the supine position
Correct Answer: B
Rationale: A myelomeningocele requires a sterile, moist dressing (B) to prevent infection and drying. Checking anus tone (A), measuring head circumference (C), and supine positioning (D) are secondary or contraindicated.
The nurse has attended a staff education program about obtaining blood specimens from newborns via heel stick. Which of the following statements by the nurse would require follow-up?
- A. Nonnutritive sucking may help alleviate pain during the puncture.
- B. I will obtain the blood specimen from the center of the newborn's heel.
- C. I will wipe away the first drop of blood prior to obtaining the specimen.
- D. The heel area should be warmed for 3 to 5 minutes prior to the puncture.
Correct Answer: B
Rationale: The center of the heel (B) should be avoided to prevent bone injury; lateral or medial aspects are used. Sucking (A), wiping the first drop (C), and warming (D) are correct.