Nokea
The nurse is part of an infection control committee that is responding to an outbreak of norovirus in the long-term care facility. Which recommendation should the nurse make to prevent further transmission of this outbreak?
- A. Clients wear surgical masks while ambulating in the hallway.
- B. Replace boxes of clean gloves with sterile gloves.
- C. Review hand hygiene expectations with dietary staff.
- D. Screen visitors for any respiratory symptoms such as cough or fever.
Correct Answer: C
Rationale: Norovirus spreads via fecal-oral route, so reinforcing hand hygiene, especially among dietary staff, is critical. Masks, sterile gloves, and respiratory screening are less relevant.
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The nurse is starting a peripheral vascular access device for a client. The nurse inserted the device into the vein and observed a flashback of blood in the chamber. The nurse should then
- A. Advance the VAD approximately 3 inches (7.62 cm) into the vein and loosen the stylet.
- B. Remove the stylet and secure the catheter using a transparent dressing.
- C. Advance the VAD approximately 1/4 inch (0.6 cm) into the vein and loosen the stylet.
- D. Remove the stylet and release the tourniquet.
Correct Answer: D
Rationale: After observing a blood flashback, the nurse should remove the stylet and release the tourniquet to prevent hematoma formation, then secure the catheter. Advancing further risks vein damage or dislodgement, and securing without releasing the tourniquet is incorrect.
Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic?
- A. Autologous donations require a health care provider's (HCP) order
- B. There is no age limitation for autologous blood donations
- C. I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery
- D. My autologous blood donation will be screened for infectious diseases
Correct Answer: B
Rationale: There are age limitations for autologous blood donations, typically excluding very young or elderly patients due to health risks. The other statements are correct: a provider’s order is required, donations can start five weeks and stop 72 hours before surgery, and blood is screened for infectious diseases.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The nurse observes unlicensed assistive personnel (UAP) give a bed bath using 4% chlorhexidine (CHG) wipes. Which observation requires follow-up?
- A. The UAP uses one wipe for washing each major body part
- B. The UAP rinses the skin after bathing with the CHG solution
- C. The UAP washes the client's face with warm water and mild soap
- D. The UAP allows the CHG solution to dry on the client's skin
Correct Answer: B
Rationale: Rinsing CHG wipes removes their antimicrobial effect. Using separate wipes, washing the face separately, and allowing CHG to dry are correct.
Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic?
- A. Autologous donations require a health care provider's (HCP) order
- B. There is no age limitation for autologous blood donations
- C. I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery
- D. My autologous blood donation will be screened for infectious diseases
Correct Answer: B
Rationale: There are age limitations for autologous blood donations, typically excluding very young or elderly patients due to health risks. The other statements are correct: a provider’s order is required, donations can start five weeks and stop 72 hours before surgery, and blood is screened for infectious diseases.