Nokea
The nurse is teaching a client who recently had a femoral vein central line catheter placed. Which of the following information should the nurse include?
- A. You will need to avoid drinking more than 500 mL per day.
- B. You will clean the site daily with soap and water.
- C. You should not sit up more than 45 degrees.
- D. You can remove the dressing if it becomes itchy.
Correct Answer: B
Rationale: Daily cleaning with soap and water maintains hygiene at the femoral central line site. Fluid restriction, angle limitation, and patient removal of dressings are incorrect and unsafe.
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A client requests to change rooms after overhearing that their roommate is positive for the human immunodeficiency virus (HIV). The nurse should take which appropriate action?
- A. Relocate the client to a private room
- B. Ask the client to elaborate on their concern
- C. Notify the risk manager of the request
- D. Place an additional divider in-between the two beds
Correct Answer: B
Rationale: Asking the client to elaborate addresses potential misconceptions about HIV transmission, which occurs via blood or bodily fluids, not casual contact. Relocation, risk management, or dividers are unnecessary.
The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which personal protective equipment (PPE)? Select all that apply.
- A. Goggles
- B. Gown
- C. Gloves
- D. Shoe covers
- E. N95 respirator
- F. Surgical face mask
Correct Answer: B,C,E
Rationale: Disseminated herpes zoster requires airborne and contact precautions, necessitating a gown, gloves, and N95 respirator. Goggles, shoe covers, and surgical masks are insufficient.
The nurse is performing a physical assessment. When assessing a client's eyes for accommodation, which of the following actions would the nurse perform?
- A. Bring a penlight from the side of the client's face and briefly shine the light on the pupil.
- B. Ask the client to gaze at a distant object and then at a test object close to them.
- C. Obtain a tuning fork and place it in the middle of the client's forehead.
- D. Have the client stand twenty feet away from a Snellen chart.
Correct Answer: B
Rationale: Accommodation is tested by having the client shift gaze from a distant to a near object, observing pupil constriction and convergence. Penlight tests pupil response, tuning fork tests hearing, and Snellen tests vision.
The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?
- A. Blood pressure
- B. End-tidal carbon dioxide [ETCO2] level
- C. Respiratory rate
- D. Blood glucose
- E. Oxygen saturation
Correct Answer: A,B,C,E
Rationale: During moderate sedation, monitoring blood pressure, end-tidal CO2, respiratory rate, and oxygen saturation is essential to assess cardiovascular and respiratory status, ensuring patient safety. Blood glucose is not routinely monitored unless indicated by the patient’s condition.
The nurse is discussing infection control with a group of nursing students. It would be correct to state that airborne precautions are used for which condition? Select all that apply.
- A. Pulmonary tuberculosis
- B. Pertussis
- C. Rubeola
- D. Hepatitis A
- E. Rubella
Correct Answer: A,C
Rationale: Pulmonary TB and rubeola (measles) require airborne precautions due to airborne transmission. Pertussis and rubella require droplet precautions, and Hepatitis A is contact-based.