Nokea
The nurse is talking with the parent of a 14-month-old client who was exposed to measles 2 days ago. The client has not received the measles, mumps, and rubella (MMR) vaccine. Which of the following statements would be most appropriate for the nurse to make?
- A. An MMR vaccine can be administered to your baby within 72 hours of exposure.
- B. If not experiencing symptoms now, your baby most likely did not contract the virus.
- C. You should monitor your baby's temperature twice daily for the next 7 days.
- D. Your baby can contract measles only by direct contact with the rash of an infected person.
Correct Answer: A
Rationale: Post-exposure MMR vaccination within 72 hours can prevent measles in unvaccinated individuals. Monitoring temperature or assuming no symptoms means no infection is incorrect, as measles has an incubation period. Measles spreads via respiratory droplets, not just rash contact.
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A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?
- A. I will arrange for a conference with you and the UAP within the next week
- B. I can assure you that I will look into the matter
- C. I would like for you to approach the UAP about the problem the next time it occurs
- D. I will add this concern to the agenda for the next unit meeting
Correct Answer: C
Rationale: Helping staff manage conflict is part of the manager's role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible.
The nurse is providing home care for an immobile client who has a stage IV decubitus ulcer that is not healing. Assuming that all of the following are available, which person would be most appropriate to consult regarding care of the wound?
- A. Physician
- B. Physical therapist
- C. IV therapist
- D. Enterostomal therapist
Correct Answer: D
Rationale: An enterostomal therapist specializes in wound and ostomy care, making them the most appropriate consultant for managing a non-healing stage IV decubitus ulcer. Physicians oversee care, physical therapists focus on mobility, and IV therapists manage infusions.
The nurse understands that during the 'tension building' phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
- A. Anger
- B. Helplessness
- C. Calm
- D. Explosiveness
Correct Answer: B
Rationale: Helplessness. Victims feel depressed and helpless despite efforts to please the batterer.
The practical nurse and the charge nurse work together to assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat argumentative cellulitis. Which of the 4 room assignments is the best option for this client?
- A. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge
- B. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device
- C. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism
- D. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine
Correct Answer: A
Rationale: The postoperative client in Room 1 is stable and awaiting discharge, posing the least risk of complications or infection to the client with cellulitis. Other roommates have conditions (dementia, embolism, immunosuppression) that could complicate care or increase infection risk.
An adult who has osteoarthritis tells the clinic nurse that her joints have been more painful lately and her head aches and her ears are 'making funny buzzing sounds.' What question should the nurse ask the client?
- A. How long have you had arthritis?
- B. Have you recently been exposed to loud noises?
- C. What do you think is causing your joints to hurt more lately?
- D. What medication have you been taking for your painful joints?
Correct Answer: D
Rationale: New symptoms with increased joint pain suggest possible medication side effects (e.g., NSAIDs causing tinnitus), making medication history critical.