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. Place face shields outside client rooms.
- B. Discontinue indwelling urinary catheters that are not medically necessary.
- C. Wipe down surfaces with hot, soapy water.
- D. Increase the frequency of cleaning and disinfection of client care areas.
Correct Answer: D
Rationale: Increased cleaning and disinfection of surfaces prevent norovirus spread via contaminated surfaces. Face shields, catheter discontinuation, and soapy water are less effective.
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The nurse has inserted an indwelling urethral catheter in a male client. The nurse should secure the catheter tubing to the client's
- A. Inner thigh.
- B. Upper thigh.
- C. Upper abdomen.
- D. Knee
Correct Answer: B
Rationale: Securing the catheter to the upper thigh prevents tension and dislodgement while allowing mobility. Inner thigh risks irritation, upper abdomen is impractical, and knee restricts movement.
The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern?
- A. Infection
- B. Thermoregulation
- C. Hemorrhage
- D. Altered body image
Correct Answer: C
Rationale: Hemorrhage is the greatest concern immediately post-colon resection due to the risk of significant blood loss from the surgical site, which can be life-threatening. Infection, thermoregulation, and altered body image are important but less immediate.
The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications?
- A. The development of an infection
- B. Hemorrhage
- C. Wound dehiscence
- D. Hematoma
Correct Answer: B
Rationale: Tachycardia with low blood pressure suggests hemorrhage, a life-threatening complication requiring immediate attention. Infection, dehiscence, and hematoma are less acute.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 6 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each assessment finding, click to specify if the finding indicates that the client's condition has improved, not changed, or worsened.
- A. Toileting access
- B. Medication organization
- C. Urinary patterns
- D. Activity tolerance
- E. Lower extremities
- F. Bathroom lighting
Correct Answer: A,B,C:Improved;D,E,F:Unchanged
Rationale: Improved toileting access, medication organization, and urinary patterns indicate better management. Activity tolerance, lower extremity symptoms, and bathroom lighting remain unchanged.
The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client?
- A. You must lay on your nonoperative side immediately following this surgery
- B. You can expect your lung function to return to normal within two to six hours
- C. You will want to avoid coughing after this surgery as you will be suctioned using a catheter
- D. You will be encouraged to get up and walk the same day as your surgery
Correct Answer: D
Rationale: Early ambulation post-pneumonectomy promotes lung expansion, prevents complications like pneumonia, and aids recovery. Lying on the nonoperative side is not universally required, lung function does not return to normal in hours, and coughing is encouraged to clear secretions, not avoided.