Nokea
The nurse is using contact precautions for the client with Clostridium difficile. While the nurse transfers the client from the bed to the commode, the client has loose stool that falls on the floor. After positioning the client on the commode, how should the nurse proceed to cleanse the floor?
- A. Wipe up the stool with toilet paper and then clean the area with soap and water
- B. Wipe up the stool with toilet paper and then clean the area with a 1:10 bleach-water solution
- C. Call housekeeping personnel to come clean the floor now with the unit's mop and bucket
- D. Wipe up the stool and apply the alcohol-based hand wash to cleanse the area of stool
Correct Answer: B
Rationale: B: Bleach solution effectively kills C. difficile spores. A: Soap and water are insufficient. C: Housekeeping delays action and risks spread. D: Alcohol is ineffective against C. difficile.
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The client's total WBC count is 20,000/mm3 two days after surgery. Which assessment finding should the nurse most associate with this laboratory result?
- A. Respiratory rate slow and shallow
- B. Skin incision pink, crusty, and intact
- C. Dark amber urine per urinary catheter
- D. Diminished lung sounds with crackles
Correct Answer: D
Rationale: D: Elevated WBC and crackles suggest a respiratory infection. A: Slow respiration is unrelated. B: Normal incision appearance doesn't correlate. C: Amber urine indicates dehydration, not infection.
A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct Answer: C
Rationale: The earliest sign of poor oxygenation is an increasing pulse rate as a part of the body's compensatory mechanism. Abnormal breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal.
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and bedding in hot water
- D. Application of pediculicides
Correct Answer: D
Rationale: Application of pediculicides. Treatment of head lice consists of application of pediculicides. Pediculicides vary, and the directions must be followed carefully.
As part of an infection-control policy, newly admitted clients are screened for possible undiagnosed or unsuspected infectious tuberculosis. Which questions should the nurse ask to accomplish this screening? Select all that apply.
- A. "Have you been exposed to someone with tuberculosis?"
- B. "What was the date of your last tuberculin skin test?"
- C. "Have you had a cough that lasted more than 3 weeks?"
- D. "Have you experienced blood in your urine or stools?"
- E. "Have you had a recent weight gain, fever, or night sweats?"
Correct Answer: A,B,C
Rationale: A: Exposure history is key for TB screening. B: Recent skin tests indicate prior screening. C: Prolonged cough is a TB symptom. D: Blood in urine/stools is unrelated. E: Weight loss, not gain, is associated with TB.
A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?
- A. What are you taking for pain and does it provide total relief?'
- B. Did your provider recommend that you be tested for Chlamydia?'
- C. Do you have any questions about your care?'
- D. Did you know a consequence of epididymitis is infertility?'
Correct Answer: B
Rationale: Did your provider recommend that you be tested for Chlamydia?' Epididymitis can result from Chlamydia infection, in which case the client's sexual partners should be tested as well. All of the questions should be asked, however, determining the reason for the client's referral is the most important to start with.