Nokea
The nurse is preparing to administer a medication to a client with a history of Clostridium difficile infection. Which precaution is most important?
- A. Wear a face mask during administration.
- B. Use a dedicated stethoscope for the client.
- C. Administer the medication in a private room.
- D. Clean the medication cart with alcohol wipes.
Correct Answer: B
Rationale: Using a dedicated stethoscope for a client with C. difficile prevents cross-contamination, as the infection spreads via contact with contaminated surfaces. A face mask is unnecessary, a private room is ideal but not always required, and alcohol wipes are ineffective against C. difficile spores. CN: Safety and infection control; CL: Synthesize
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In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain?
- A. Oral analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol).
- B. Intravenous opioids.
- C. Intramuscular opioids.
- D. Oral antianxiety agents such as lorazepam (Ativan).
Correct Answer: B
Rationale: Intravenous opioids are preferred in the acute phase for rapid, effective pain relief due to severe burn pain and potential impaired oral absorption.
The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room?
- A. Transfer the client to a cart with manually suspended traction.
- B. Call the surgeon to request an order to temporarily remove the traction.
- C. Send the client on his bed with extra help to stabilize the traction.
- D. Remove the traction and send the client on a cart.
Correct Answer: C
Rationale: Transporting on the bed with extra help maintains traction stability, preventing fracture displacement.
A client has returned to the medical surgical unit after having surgery to create an ileostomy. Which goal has the highest priority at this time?
- A. Providing relief from constipation.
- B. Assisting the client with self-care activities.
- C. Maintaining fluid and electrolyte balance.
- D. Minimizing odor formation.
Correct Answer: C
Rationale: Maintaining fluid and electrolyte balance is the highest priority post-ileostomy due to the risk of dehydration from high-output ileostomy effluent. Constipation is not a concern, and self-care or odor control are secondary to physiological stability. CN: Physiological adaptation; CL: Synthesize
A middle-aged man collapses in the emergency department waiting room. The triage nurse should first:
- A. Gently shake the victim and ask him to state his name.
- B. Perform the chin-tilt to open the victim's airway.
- C. Feel for any air movement from the victim's nose or mouth.
- D. Watch the victim's chest for respirations.
Correct Answer: A
Rationale: The first step in assessing an unresponsive patient is to check for responsiveness by gently shaking and calling out to the victim, per AHA guidelines, to determine if CPR or other interventions are needed.
A client on peritoneal dialysis reports cloudy effluent. The nurse should:
- A. Continue the exchange.
- B. Notify the physician.
- C. Increase dwell time.
- D. Administer pain medication.
Correct Answer: B
Rationale: Cloudy effluent suggests peritonitis, requiring immediate medical attention.