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The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?
- A. An 18-month-old with respiratory syncytial virus.
- B. A 4-year-old with Kawasaki disease.
- C. A 10-year-old with Lyme's disease.
- D. A 16-year-old with infectious mononucleosis.
Correct Answer: A
Rationale: acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children
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The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has Vectors are not supported in text mode. Please provide the text content you want to include, and I'll help format it appropriately. to have the CBI. Which of the following responses by the nurse is BEST?
- A. The CBI prevents urinary stasis and infection.
- B. The CBI dilutes the urine to prevent infection.
- C. The CBI enables urine to keep flowing.
- D. The CBI delivers medication to the bladder.
Correct Answer: C
Rationale: continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client
The nurse is caring for a client who is ordered to be on bed rest for a prolonged period of time. What should be included in the nursing care plan to prevent venous stasis?
- A. Deep breathe and cough every two hours
- B. Range-of-motion exercises every shift
- C. Antiembolism stockings on legs
- D. Turn every two hours
Correct Answer: C
Rationale: Antiembolism stockings promote venous return, preventing stasis in bedridden clients. Breathing exercises, ROM, and turning address other complications but not venous stasis directly.
The LPN/LVN has delegated basic hygienic care of several clients to a certified nursing assistant. Which action by the nurse will ensure that the clients receive the best care?
- A. Observe the nursing assistant during the performance of all care
- B. Ask the nursing assistant if there were any problems
- C. Check the nursing assistant's charting
- D. Observe the clients following administration of care by the nursing assistants
Correct Answer: D
Rationale: Observing clients post-care ensures care was performed correctly and identifies issues like skin integrity or comfort, ensuring quality. Constant observation, questioning, or charting checks are less direct.
The nurse is caring for an adult who has had nausea and vomiting for several days and is being admitted to the nursing care unit. The client can follow directions. IV fluids were started in the emergency department. Which action is the highest priority for the nurse at this time?
- A. Offer oral fluids every hour.
- B. Turn every two hours.
- C. Monitor urine output.
- D. Put client in a supine position.
Correct Answer: C
Rationale: Monitoring urine output is critical to assess hydration status and kidney function in a client with prolonged nausea and vomiting, as dehydration is a major risk. IV fluids address dehydration, making oral fluids less urgent, and turning or positioning are secondary.
A 63-year-old woman is taking digitalis, baby aspirin, potassium (K-Dur), and furosemide (Lasix) daily. She complains of multiple symptoms, which include muscle cramps and facial tics. Physical exam reveals positive Chvostek's and Trousseau's signs, hypotension, and confusion. The nurse suspects she has hypomagnesemia. What else should the nurse expect?
- A. Laboratory tests to reveal high serum calcium and potassium levels
- B. Laboratory tests to reveal low serum calcium and potassium levels
- C. Altered acid-base balance, which requires administration of NaHCO3 intravenously in addition to treatment for hypomagnesemia
- D. An order for an ECG to monitor brain function
Correct Answer: B
Rationale: Hypomagnesemia often accompanies low calcium and potassium, as seen with furosemide use, explaining symptoms like cramps and tetany.