Nokea
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.
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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.
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
- A. every four to six hours
- B. continuously
- C. in a bolus
- D. every hour
Correct Answer: B
Rationale: continuously. Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula.
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 caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag
- B. Perform a quick assessment of the client's condition
- C. Call the respiratory therapist for help
- D. Press the alarm re-set button on the ventilator
Correct Answer: B
Rationale: A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
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.