Nokea
The nurse is taking care of a client with Clostridium difficile (C. difficile). The nurse should do which of the following to prevent the spread of infection? Select all that apply.
- A. Wear a particulate respirator.
- B. Wear sterile gloves when providing care.
- C. Cleanse hands with alcohol-based hand sanitizer.
- D. Wash hands with soap and water.
- E. Wear a protective gown when in the client's room.
Correct Answer: D,E
Rationale: To prevent the spread of C. difficile, washing hands with soap and water (D) is essential as alcohol-based sanitizers are ineffective against its spores, and wearing a protective gown (E) prevents contamination. A respirator (A) is unnecessary, sterile gloves (B) are not required (clean gloves suffice), and alcohol sanitizer (C) is ineffective. CN: Safety and infection control; CL: Create
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The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:
- A. For administration of oxygen.
- B. To promote formation of lung scar tissue.
- C. To insert antibiotics into the pleural space.
- D. To remove air and fluid.
Correct Answer: D
Rationale: A chest tube in pneumothorax removes air and fluid from the pleural space, restoring lung expansion. It is not used for oxygen, scar tissue, or antibiotics.
The nurse should teach the client with Addison's disease that the adverse effect of bronze-colored skin is thought to be caused by which of the following?
- A. Hypersensitivity to sun exposure.
- B. Increased serum bilirubin level.
- C. Adverse effects of the glucocorticoid therapy.
- D. Increased secretion of adrenocorticotropic hormone (ACTH).
Correct Answer: D
Rationale: Bronze-colored skin in Addison's disease results from increased ACTH, which stimulates melanin production.
The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which one of the following interventions should the nurse consider?
- A. Have the client hyperextend the neck when swallowing.
- B. Tell the client to place the chin firmly against the chest when eating.
- C. Thicken all liquids before offering to the client.
- D. Place the client on a clear liquid diet.
Correct Answer: C
Rationale: Thickening liquids reduces aspiration risk in Parkinson's patients with dysphagia, as coughing indicates swallowing difficulty. Hyperextending the neck or a clear liquid diet increases aspiration risk, and chin tuck is less universally effective.
A 36-year-old female is scheduled to receive external radiation therapy and a cesium implant for cancer of the cervix. Which of the following statements would be most accurate to include in the teaching plan about the potential effects of radiation therapy on sexuality?
- A. You can have sexual intercourse while the implant is in place.
- B. You may notice some vaginal dryness after treatment is completed.
- C. You may notice some vaginal relaxation after treatment is completed.
- D. You will continue to have normal menstrual periods during treatment.
Correct Answer: B
Rationale: Vaginal dryness is a common side effect of cervical radiation due to mucosal changes, and should be included in the teaching plan to prepare the client.
The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication?
- A. valacyclovir
- B. zidovudine
- C. amphotericin b
- D. metronidazole
Correct Answer: B
Rationale: Zidovudine (AZT) is used during labor in HIV-positive clients to reduce the risk of perinatal transmission of HIV. Choice A (valacyclovir) is for herpes, Choice C (amphotericin B) is for fungal infections, and Choice D (metronidazole) is for bacterial/parasitic infections.