Nokea
The nurse is preparing to admit a client from the emergency department with tuberculosis. Which of the following should the nurse anticipate in caring for this client? Select all that apply.
- A. fall precautions
- B. droplet precautions
- C. airborne precautions
- D. standard precautions
- E. placement in a negative airflow room
- F. use of PPE, including an N95 mask or powered air purifying respirators (PAPRs)
Correct Answer: C, D, E, F
Rationale: Tuberculosis requires airborne precautions, standard precautions, negative airflow rooms, and N95/PAPR use due to respiratory transmission. Fall precautions are not specific, and droplet precautions are incorrect.
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The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.
- B. I should induce vomiting if my child swallows lighter fluid.
- C. Giving my child water or milk may help dilute the poison.
- D. Proper storage is the key to poison prevention in the home.
Correct Answer: B
Rationale: vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration
The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client's bedside table. There is no label to indicate the date or time of initial use. The nurse should:
- A. Lip the bottle and use a pack of sterile 4x4 for the dressing
- B. Obtain a new bottle and label it with the date and time of first use
- C. Ask the ward secretary when the solution was requested
- D. Label the existing bottle with the current date and time
Correct Answer: B
Rationale: Using an unlabeled, previously opened saline bottle risks contamination; a new, labeled bottle ensures sterility.
A client with hepatitis C is scheduled for a liver biopsy. Which would the nurse include in the teaching plan?
- A. The client should lie on the left side after the procedure.
- B. Cleansing enemas should be given the morning of the procedure.
- C. Blood coagulation studies might be done before the biopsy.
- D. The procedure is noninvasive and causes no pain.
Correct Answer: C
Rationale: Hepatitis C increases bleeding risk, so coagulation studies are done before a liver biopsy to ensure safety. The client lies on the right side post-procedure, enemas aren't needed, and the procedure is invasive with some pain.
A teenage client tells the nurse about her plans to be a lifeguard this summer. The nurse would be concerned if she saw the client was taking which medication? Select all that apply.
- A. tetrahydrozoline (Tetryzoline)
- B. isotretinoin (Accutane)
- C. levonorgestrel (Levora)
- D. sulfamethoxazole (Bactrim)
Correct Answer: B
Rationale: Isotretinoin (Accutane) causes photosensitivity, increasing sunburn risk, which is concerning for a lifeguard exposed to sunlight. Other medications do not pose significant outdoor risks.
The client with hyperemesis gravidarum is at risk for developing:
- A. Respiratory alkalosis without dehydration
- B. Metabolic acidosis with dehydration
- C. Respiratory acidosis without dehydration
- D. Metabolic alkalosis with dehydration
Correct Answer: B
Rationale: Hyperemesis gravidarum causes vomiting, leading to metabolic acidosis and dehydration from fluid and electrolyte loss.