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The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response?
- A. Close the door and discuss the UAP's action after coming out of the room.
- B. Make the UAP come back outside the room and then reenter, closing the door.
- C. Say nothing to the UAP but report the incident to the nursing supervisor.
- D. Enter the client's room and discuss the matter with the UAP immediately.
Correct Answer: A
Rationale: Closing the door (A) maintains airborne precautions, and discussing later ensures education without disrupting care. Reentering (B) is unnecessary, reporting (C) escalates prematurely, and discussing inside (D) risks exposure.
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An adult with tuberculosis has started taking rifampin (Rimactane). Which side effect is the client most likely to experience when taking this drug?
- A. Reddish-orange color of urine, sputum, and saliva
- B. Erythema and urticaria
- C. Tinnitus and deafness
- D. Peripheral neuritis
Correct Answer: A
Rationale: Rifampin commonly causes a harmless reddish-orange discoloration of body fluids.
The ABG analysis results reveal that the client's partial pressure of arterial carbon dioxide (PaCO2) is 65 mm Hg. The nurse recognizes that this is abnormal because normal PaCO2 levels fall between which values?
- A. 7.35 and 7.45
- B. 80 and 100 mm Hg
- C. 35 and 45 mm Hg
- D. 22 and 26 mm Hg
Correct Answer: C
Rationale: Normal PaCO2 levels are 35 to 45 mm Hg; a value of 65 mm Hg indicates hypercapnia, common in COPD.
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication?
- A. The client's partial thromboplastin time (PTT) is 38.
- B. The client's international normalized ratio (INR) is 5.
- C. The client's prothrombin time (PT) is 22.
- D. The client's erythrocyte sedimentation rate (ESR) is 10.
Correct Answer: B
Rationale: An INR of 5 (B) is above the therapeutic range (2–3 for pulmonary embolus), indicating excessive anticoagulation and bleeding risk, so warfarin should be questioned. PTT (A) is for heparin, not warfarin. PT (C) alone is not standardized. ESR (D) is irrelevant to anticoagulation.
A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
- A. Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.'
- B. Lay down and tilt your head backward. Grasp the end of your nose between your fingers.'
- C. Sit up and lean backwards. Put pressure on the side of your nose with your hand.'
- D. Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.'
Correct Answer: A
Rationale: Sitting with the head tilted forward and grasping the soft part of the nose prevents aspiration of blood and effectively stops bleeding.
The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first?
- A. Administer oxygen 10 L via nasal cannula.
- B. Place the client in high Fowler's position.
- C. Obtain a STAT pulse oximeter reading.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: High Fowler’s position (B) improves breathing in suspected PE, a priority. Oxygen (A), SpO2 (C), and lung sounds (D) follow to support and assess.