Nokea
The nurse is teaching a continuing education course on communicable diseases. Which of the following statements should the nurse make about diphtheria? Select all that apply.
- A. The organism that causes this condition is Corynebacterium diphtheriae.
- B. Vaccination is available starting at two months of age.
- C. Transmission of the cutaneous diphtheria is via direct contact with the infected person.
- D. Airborne precautions are required for individuals with pharyngeal diphtheria.
- E. Diphtheria is caused by a virus and is highly contagious.
Correct Answer: A,B,C,D
Rationale: Diphtheria is caused by Corynebacterium diphtheriae, vaccinated via DTaP at two months, cutaneous form spreads by contact, and pharyngeal diphtheria requires airborne precautions. It is bacterial, not viral.
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The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's? Select all that apply.
- A. behavioral status.
- B. skin integrity.
- C. bowel sounds.
- D. neurovascular status.
- E. need for restraint.
Correct Answer: A,B,D,E
Rationale: Behavioral status, skin integrity, neurovascular status, and need for restraint must be assessed to ensure safety and appropriateness of restraints. Bowel sounds are unrelated.
The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client
- A. Exercises both extremities simultaneously.
- B. Knows their heart rate should be monitored while exercising.
- C. Practices forced resistance against stable objects.
- D. Swings their limbs through the full range of motion.
Correct Answer: C
Rationale: Isometric exercises involve static muscle contraction against resistance, like pushing against a stable object. Simultaneous exercise, heart rate monitoring, and full range of motion are not specific to isometrics.
The nurse is discussing mass casualties with a group of nursing students. Which statement by the student would indicate effective understanding? Select all that apply.
- A. Mass casualties are events that overwhelm local medical capabilities.
- B. When a mass casualty occurs, there is a need to increase the staff at the hospital.
- C. Many local agencies will collaborate to handle a mass casualty situation.
- D. An example of a mass casualty event is a fight between visitors in the intensive care unit.
- E. Staff preferences for client assignments should prioritize over client needs.
Correct Answer: A,B,C
Rationale: Mass casualties overwhelm resources, require more staff, and involve multi-agency collaboration. A visitor fight is not a mass casualty, and client needs take priority.
The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using
- A. soft wrist restraints.
- B. mitten restraints.
- C. elbow restraints.
- D. waist belt restraint.
Correct Answer: A
Rationale: Soft wrist restraints are appropriate for preventing harm in violent clients while allowing some movement. Other options are less suitable.
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Contain the spill using plastic-backed absorbent sheets or spill pads.
- B. Wear sterile gloves when cleaning the spill.
- C. Immediately remove any contaminated clothing and wash the affected skin with soap and water.
- D. Research the appropriate cleaning agent based on the spilled drug.
- E. Leave the spill area unattended until a supervisor arrives.
- F. Implement airborne precautions after the spill has been cleaned.
Correct Answer: A,C
Rationale: Containing the spill and decontaminating skin/clothes are critical. Sterile gloves are unnecessary, researching during a spill delays action, leaving unattended is unsafe, and airborne precautions are irrelevant.