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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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The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would best measure learning?
- A. Performance on written tests
- B. Responses to verbal questions
- C. Completion of a mailed survey
- D. Reported behavioral changes
Correct Answer: D
Rationale: Reported behavioral changes. If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.
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 nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (ALS). Which of these pieces of equipment is the priority for the client to have access to in the home?
- A. A wheelchair
- B. A hospital bed with trapeze
- C. A communication board
- D. A suction machine
Correct Answer: C
Rationale: In late-stage ALS, clients often lose the ability to speak due to muscle weakness. A communication board is critical to ensure the client can express needs and maintain communication.
A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
- A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves shaving her legs.'
- B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
- C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
- D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct Answer: C
Rationale: Patient confidentiality should be observed, especially in public places. The nurse should tell the nursing student do not discuss confidential information in public.
Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct Answer: A
Rationale: Of the choices given, only staphylococcus is considered a normal resident of the body.