Nokea
The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?
- A. Obtain permission from the nursing supervisor to transport the client without protective equipment.
- B. Place protective goggles over the client's eyeglasses after first positioning the face mask.
- C. Instruct the client about the need to wear a fitted respirator-style mask when leaving the room.
- D. Secure a surgical face mask over the bridge of the client's nose just below the eyeglasses.
Correct Answer: D
Rationale: Surgical mask ensures droplet precaution compliance.
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During the prodromal stage of an infection, which is the priority nursing intervention?
- A. Develop a plan for gradually increasing activity and mobility.
- B. Begin discharge planning and teaching.
- C. Implement precautions to prevent disease transmission.
- D. Offer the client frequent fluids and ice chips.
Correct Answer: C
Rationale: Precautions prevent infection spread.
Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Share personal values to put the client at ease.
- D. Begin with questions that are less sensitive in nature.
Correct Answer: D
Rationale: Less sensitive questions build rapport.
A bedfast female client awakens during the night, reporting to the nurse that she is 'uncomfortable.' What action should the nurse implement first?
- A. Engage the client in relaxation exercises.
- B. Offer to sit with the client until she relaxes.
- C. Administer a prescribed PRN analgesic.
- D. Assist the client to a different position.
Correct Answer: D
Rationale: Repositioning often relieves discomfort.
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Temperature.
- B. Blood pressure.
- C. Heart rate.
- D. Respiratory rate.
Correct Answer: D
Rationale: Cyanosis indicates oxygenation issues, requiring respiratory assessment.
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
- A. Muscle strength and tone.
- B. Presence of rebound phenomenon.
- C. Limitations to range of motion.
- D. Degree of neurosensory impairment.
Correct Answer: D
Rationale: Neurosensory impairment risks burns.