Nokea
The nurse is planning care for a client diagnosed with Mycoplasma pneumonia. The nurse should plan to
- A. place the client in a private room with negative airflow.
- B. wear a surgical mask within 3 feet of the client.
- C. wear gloves when in contact with the client.
- D. provide disposable meal trays and utensils.
Correct Answer: B
Rationale: Mycoplasma pneumonia requires droplet precautions, including a surgical mask within 3 feet. Negative airflow, gloves, and disposable trays are not required.
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The nurse is teaching a client how to ambulate using a cane. Which action should the nurse take?
- A. Stand on the client's unaffected (stronger) side during ambulation
- B. Instruct the client to look down at their feet as they ambulate
- C. Instruct the client to move the weaker leg to the cane after placing the cane forward.
- D. Advance the cane 6-10 inches with each step
Correct Answer: A
Rationale: Standing on the stronger side provides support. Looking down risks falls, the stronger leg moves first, and advancement is 12-16 inches.
The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which personal protective equipment (PPE)? Select all that apply.
- A. Goggles
- B. Gown
- C. Gloves
- D. Shoe covers
- E. N95 respirator
- F. Surgical face mask
Correct Answer: B,C,E
Rationale: Disseminated herpes zoster requires airborne and contact precautions, necessitating a gown, gloves, and N95 respirator. Goggles, shoe covers, and surgical masks are insufficient.
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)?
- A. Glycosylated hemoglobin (HbA1c) of 7.2% [5.7-6.4%]
- B. International Normalized Ratio (INR) of 3.5 [0.9-1.2 seconds]
- C. Hematocrit (Hct) of 42% [Male: 42-52% Female: 37-47%]
- D. Blood urea nitrogen (BUN) level of 5 [10-20 mg/dL]
Correct Answer: B
Rationale: An INR of 3.5 indicates a high bleeding risk, critical for surgical safety, and must be reported to the PHCP. Elevated HbA1c, normal hematocrit, and low BUN are less urgent but may still require attention.
The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside?
- A. One liter of 0.9% saline
- B. Sterile gloves
- C. Portable ultrasound
- D. Suction equipment
Correct Answer: D
Rationale: Severe pre-eclampsia increases seizure risk (eclampsia), requiring suction equipment at the bedside to manage airway secretions during a seizure. Saline, gloves, and ultrasound are not immediate priorities for seizure management.
The nurse is teaching a client who recently had a femoral vein central line catheter placed. Which of the following information should the nurse include?
- A. You will need to avoid drinking more than 500 mL per day.
- B. You will clean the site daily with soap and water.
- C. You should not sit up more than 45 degrees.
- D. You can remove the dressing if it becomes itchy.
Correct Answer: B
Rationale: Daily cleaning with soap and water maintains hygiene at the femoral central line site. Fluid restriction, angle limitation, and patient removal of dressings are incorrect and unsafe.