Nokea
The nurse is performing an assessment on a client. Which of the following findings would support a diagnosis of peripheral neuropathy in the lower extremities?
- A. Abnormal gait
- B. Absent or decreased pulses
- C. Swelling around the ankles
- D. Decreased hair growth
Correct Answer: A
Rationale: Abnormal gait is a hallmark of peripheral neuropathy due to sensory or motor deficits. Absent pulses indicate vascular issues, swelling suggests edema, and decreased hair growth is non-specific.
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The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client
- A. Trendelenburg's position.
- B. Semi-Fowler's position.
- C. Left lateral position.
- D. Right lateral with the head of the bed lowered.
Correct Answer: C
Rationale: The left lateral position allows the enema solution to flow into the sigmoid colon via gravity. Other positions are less effective or impractical.
The nurse is performing hand hygiene. Which actions should the nurse take when washing their hands with soap and water? Select all that apply.
- A. Use a paper towel to turn off the faucet.
- B. Keep the hands and forearms lower than the elbows during washing.
- C. Wash hands using hot water.
- D. Rinse the hands and wrists by keeping the hands down and elbows up.
- E. Wash hands for 5 to 10 seconds.
Correct Answer: A,B,D
Rationale: Using a paper towel, keeping hands lower, and rinsing correctly prevent contamination. Hot water is harsh, and washing should last 40-60 seconds.
The nurse is preparing to remove an intrajugular central venous catheter. It would be appropriate to place the client in which position for this procedure?
- A. Reverse Trendelenburg
- B. Left lateral
- C. Trendelenburg
- D. High-Fowler's
Correct Answer: C
Rationale: Trendelenburg position (head down) reduces the risk of air embolism during intrajugular catheter removal by increasing venous pressure. Other positions do not minimize this risk effectively.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
- A. Hepatitis C
- B. Cryptococcal meningitis
- C. Clostridium difficile
- D. Scabies
- E. Rheumatic fever
- F. Botulism
- G. Hepatitis B
Correct Answer: C,D
Rationale: Clostridium difficile and scabies require contact precautions due to direct or indirect transmission. Others require standard precautions.
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.