Nokea
The nurse is reinforcing teaching to a client about preventing transmission of the hepatitis A virus. Which of these instructions is most appropriate?
- A. Get the hepatitis A vaccine before traveling to endemic areas.'
- B. Avoid sexual contact until the infection is resolved.'
- C. Take antiviral medications as prescribed.'
- D. Use condoms to prevent transmission.'
Correct Answer: A
Rationale: Hepatitis A is primarily transmitted through the fecal-oral route. Vaccination is the most effective way to prevent infection, especially before travel to endemic areas.
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A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?
- A. A 76-year-old client with severe depression
- B. A middle-aged client with an obsessive compulsive disorder
- C. An adolescent with dehydration and anorexia
- D. A young adult who is a heroin addict in withdrawal with hallucinations
Correct Answer: B
Rationale: The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition.
The hospitalized client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse do? Select all that apply.
- A. Assess the client's risk for a fall using a rating scale.
- B. Document that the client is frequently incontinent.
- C. Ensure an immediate response to the client's call light.
- D. Educate the client regarding fall prevention strategies.
- E. Place a note on the door stating, "bathroom every two hours."
- F. Request that the HCP prescribe placement of a urinary catheter.
Correct Answer: A,C,D
Rationale: A: Assessing fall risk is essential due to urgency. C: Prompt response to call light prevents rushing. D: Education on fall prevention is proactive. B is incorrect as incontinence cannot be assumed. E violates privacy. F is unnecessary and risky.
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that
- A. a referral is needed to the psychiatrist who is to provide the client with answers
- B. the client has a right to know about the prescribed medications
- C. such education is an independent decision of the individual nurse whether or not to teach clients about their medications
- D. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
Correct Answer: B
Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.
The client makes the following statements to the home health nurse. Which statement requires the nurse to intervene immediately?
- A. "I can't lift pans from the back burners, but I can manage just fine by using the front burners of my stove."
- B. "I almost fell down the stairs, so I bought myself a pair of slippers with nonskid soles."
- C. "The grass near the sidewalk will be dead because my son insists on putting salt on the icy sidewalk."
- D. "My home is less costly to heat when I use my gas oven with the oven door open to heat just my living areas."
Correct Answer: D
Rationale: Using a gas oven for heating risks carbon monoxide poisoning, requiring immediate intervention to prevent a life-threatening situation.
The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?
- A. Encourage oral fluids to prevent dehydration
- B. Recheck temperature 15 minutes after removing hot liquids from the bedside
- C. Ask the client to drink only cold water and juices
- D. Chart this temperature elevation on the flow sheet
Correct Answer: B
Rationale: Recheck temperature to eliminate possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading.