Nokea
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
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The nurse is supervising the NA caring for a group of clients with antibiotic-resistant organisms. Which observation of the NA's performance should prompt the supervising nurse to intervene?
- A. Uses an alcohol-based hand hygiene after emptying the urinary drainage bag of the client with vancomycin-resistant enterococci (VRE)
- B. Performs hand hygiene, then dons gloves to perform oral care for the client with B-lactamase-producing Klebsiella pneumoniae
- C. Uses an alcohol-based hand rub and wears gloves before and after taking the temperature of the client with penicillin G-resistant Streptococcus pneumoniae
- D. Tells visitors to use the alcohol-based hand wash when entering and leaving the room of the client with methicillin-resistant Staphylococcus aureus (MRSA)
Correct Answer: A
Rationale: A: Soap and water are required for VRE due to spore resistance to alcohol. B, C, D: These actions are appropriate for the respective organisms.
The charge nurse is planning a room assignment for the client with meningococcal meningitis. Which room and precautions should the nurse plan for this client?
- A. A private room with droplet precautions
- B. A private room with airborne precautions
- C. A semiprivate room with a roommate who has a similar diagnosis and standard precautions
- D. A semiprivate room with a roommate who has a similar diagnosis and contact precautions
Correct Answer: B
Rationale: B: Meningococcal meningitis requires airborne precautions and a private room due to possible airborne transmission. A, C, D: These are insufficient or inappropriate.
The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
- A. I can't lie in one position for more than thirty minutes.'
- B. I am allergic to shrimp.'
- C. I suffer from claustrophobia.'
- D. I developed a severe headache after a spinal tap.'
Correct Answer: B
Rationale: I am allergic to shrimp.' A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could even include seizures.
Which information should the nurse reinforce to the parents of a child recently diagnosed with Kawasaki disease?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes.'
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.'
- C. Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent.'
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.'
Correct Answer: C
Rationale: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent, particularly Japanese. Other findings in the initial phase are extremely red eyes (conjunctivitis), a rash on the main part of the body (trunk) and in the genital area, red, dry, cracked lips; a red, swollen tongue resembling a strawberry; swollen, red skin on the palms of the hands and the soles of the feet; swollen lymph nodes in the neck.
The client who has airborne precautions asks the nurse not to shut his door. Which response by the nurse is most appropriate?
- A. "If I open the door you will need to always wear a mask."
- B. "The door must be kept closed, but I can open the curtains."
- C. "Don't worry; I can leave the door open if it's bothering you."
- D. "I'm sorry, but I can only leave the door partially open."
Correct Answer: B
Rationale: B: Keeping the door closed contains airborne pathogens; opening curtains reduces isolation feelings. A, C, D: Open or partially open doors risk pathogen spread.