Nokea
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct interventions for placing a client on isolation precautions include A, B, C, and E. A) Wearing an N95 mask is crucial for airborne precautions. B) Placing a container for soiled linens inside the room prevents contamination. C) A negative airflow room helps contain airborne pathogens. E) Wearing a sterile water-resistant gown within close proximity to the client prevents transmission. D is incorrect as the mask should be removed inside the client's room. Choices F and G are likely blank options or not relevant to isolation precautions.
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A nurse is caring for a client who has a terminal illness, and the client's partner indicates effective coping. The nurse should recognize that which of the following statements is an indication of effective coping?
- A. I am not worried because I will have hope that he will be okay.
- B. I am relying on support from our family during this time.
- C. We can plan our family reunion once he recovers and comes home.
- D. We don't see any reason to start discussing funeral arrangements right now.
Correct Answer: B
Rationale: The correct answer is B: "I am relying on support from our family during this time." This statement indicates effective coping because it acknowledges the importance of seeking and utilizing support from family members, which can help reduce feelings of isolation and provide emotional strength. By relying on family support, the client's partner is demonstrating a healthy coping mechanism that promotes resilience and emotional well-being during a challenging situation.
Choice A is incorrect because relying solely on hope without acknowledging the need for support may not address the partner's emotional needs effectively. Choice C is incorrect as it demonstrates denial of the terminal illness and avoidance of the current reality. Choice D is incorrect as it suggests avoidance of discussing important end-of-life decisions, which can hinder effective coping and planning.
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
- A. Critical pathway
- B. Situation background assessment and recommendation (SBAR)
- C. Transfer report
- D. Medication administration record (MAR)
Correct Answer: B
Rationale: The correct answer is B: Situation background assessment and recommendation (SBAR). SBAR is a structured communication tool used in healthcare to provide a concise and focused way of relaying important information between healthcare team members. It helps ensure continuity of care by including essential details such as the patient's situation, background information, assessment findings, and recommendations for further care. SBAR improves communication efficiency, reduces errors, and enhances patient safety.
Choices A, C, and D are incorrect because:
A: Critical pathway is a care plan outlining evidence-based guidelines for patient care but does not provide the detailed communication needed for continuity of care.
C: Transfer report is focused on the transfer of a patient between units or facilities and may not include all the necessary information for continuity of care during a shift change.
D: Medication administration record (MAR) is a document used to record medication administration and does not encompass the comprehensive patient information needed for effective shift handoff.
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
- A. Use a bed exit alarm system.
- B. Raise four side rails while the client is in bed.
- C. Apply one soft wrist restraint.
- D. Dim the lights in the client's room.
Correct Answer: A
Rationale: The correct answer is A: Use a bed exit alarm system. This intervention is crucial in minimizing the risk of injury for a client with dementia as it alerts the nurse when the client attempts to get out of bed, preventing falls. This approach promotes client safety by allowing timely intervention. Raising four side rails (B) may restrict the client's movement and cause agitation or attempts to climb over the rails, increasing the risk of injury. Applying a soft wrist restraint (C) is considered a restrictive measure and should be avoided unless absolutely necessary due to the risk of causing emotional distress and physical harm to the client. Dimming the lights (D) in the client's room may increase confusion and disorientation, leading to a higher risk of falls.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
- A. I can place an extension cord across my living room to plug in my television.
- B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
- C. I will place my alarm clock on my bedroom dresser across the room.
- D. I will replace the old throw rug in my kitchen with a new one.
Correct Answer: B
Rationale: Correct Answer: B - "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
Rationale: This statement demonstrates understanding as it shows awareness of potential hazards (low-hanging tree) that could obstruct safe walker use. By hiring someone to trim the tree, the client is proactively ensuring a safe environment for mobility with the walker.
Summary of Incorrect Choices:
A: Placing an extension cord across the living room poses a tripping hazard, which is unsafe for walker use.
C: Placing the alarm clock on the bedroom dresser is unrelated to walker safety.
D: Replacing the throw rug in the kitchen is beneficial but not directly related to walker safety.