Nokea
The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
- A. Send the staff member home.
- B. Assess the staff member's compliance with standard precautions.
- C. Assign the staff member only to clients with chronic diseases.
- D. Re-assign the staff member to clean the supply closet.
Correct Answer: A
Rationale: extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis, highly contagious; infected employees cannot work until symptoms have resolved in 3-7 days
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The nurse is caring for clients in the hospital. Which of the following nursing activities BEST promotes rest for an elderly hospitalized client?
- A. Place a clock at the bedside.
- B. Restrict visitors so that the client is alone during the evening.
- C. Tell the client how to call for help if needed.
- D. Postpone explanation of further tests that the client will need.
Correct Answer: C
Rationale: elderly client who feels isolated and unable to obtain help if needed cannot rest properly
A 45-year-old client with newly diagnosed IDDM (insulin-dependent diabetes mellitus) is being seen by the home health nurse. The physician has placed him on a 1,800-calorie ADA diet, ordered the client to self-administer 15 units of NPH insulin each day before breakfast, and check his blood sugar qid. When the nurse visits the client at 5 PM, the nurse discovers that the client has not eaten since noon and has just returned from jogging. The client's vital signs are: BP 110/80, pulse 120, respirations 18, temperature 98.2°F (36.8°C). When the client obtains his blood sugar reading, the nurse would expect it to be?
- A. 250 mg/dL.
- B. 160 mg/dL.
- C. 90 mg/dL.
- D. 50 mg/dL.
Correct Answer: D
Rationale: hypoglycemia symptoms are cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, headache, slurred speech, coma
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which of the following instructions should the nurse include?
- A. Use oxygen only when feeling short of breath.
- B. Store oxygen tanks near an open flame.
- C. Avoid smoking while using oxygen.
- D. Use a humidifier with oxygen at high flow rates.
Correct Answer: C
Rationale: Smoking near oxygen risks fire, a critical safety concern. Options A, B, and D are incorrect or unsafe.
A 56-year-old woman has a subclavian triple lumen catheter that is used for administration of total parenteral nutrition (TPN). The physician has ordered that all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should
- A. clamp off the lumen and label it as 'clotted off.'
- B. gradually increase the pressure on the irrigating solution.
- C. aspirate blood from the lumen to restore patency.
- D. secure the lumen with a Luer-Lock cap and notify the physician.
Correct Answer: D
Rationale: streptokinase may used to dissolve clot, if unsuccessful, lumen is labeled as clotted off
A client comes to the clinic complaining of severe facial pain. In order to collect subjective data from the client, it is MOST important for the nurse to
- A. obtain the client's vital signs.
- B. interview the client.
- C. inspect the face for grimacing.
- D. administer pain medication.
Correct Answer: B
Rationale: subjective data is collected in the health history or interview