Nokea
The nurse places a hospitalized client with a diagnosis of active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room?
- A. Wash the hands.
- B. Wash the hands and wear a gown and gloves.
- C. Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth.
- D. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and nose when coughing or sneezing.
Correct Answer: C
Rationale: Tuberculosis is a highly communicable disease caused by Mycobacterium tuberculosis. The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Option 1 is an incomplete action. Option 2 is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of contaminating clothing. Option 4 is an incorrect statement because special precautions are needed.
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The nurse employed in a home health agency is religiously opposed to homosexuality and cannot care for a client diagnosed with human immunodeficiency virus (HIV). The nurse then leaves the client's home. Which statement accurately identifies the nurse's rights and actions? Select all that apply.
- A. The nurse has the moral right to leave the client's home at any time.
- B. The nurse has a legal right to inform the client of any barriers to providing care.
- C. The nurse has a duty to protect self from client care situations that are morally repellent.
- D. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner.
- E. The nurse has the right to refuse to care for any client on religious grounds if competent care coverage is arranged.
Correct Answer: D,E
Rationale: The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy does not apply if it interferes with the rights of the client. Refusal to provide care may be acceptable if that refusal does not put the client's safety at risk and the refusal is primarily associated with religious objections, not personal objection, to lifestyle or medical diagnosis. There is no legal obligation to inform the client of the nurse's personal objections to the client. The nurse also has an obligation to observe the principle of nonmaleficence (neither causing nor allowing harm to befall the client).
The nurse is preparing to administer a first dose of prescribed pentamidine isethionate intravenously to a client. Before administering the dose, which safety measure should the nurse consider for this client?
- A. Assign to a private room.
- B. Establish a supine position.
- C. Place on respiratory precautions.
- D. Assist to a semi-Fowler's position.
Correct Answer: B
Rationale: Pentamidine isethionate is an antiinfective medication and can cause severe and sudden hypotension, even with administration of a single dose. The client should be lying down during administration of this medication. The blood pressure is monitored frequently during administration. Assigning to a private room, instituting respiratory precautions, or assisting to a semi-Fowler position are all unnecessary interventions.
Which findings documented in the history of an older client should require the nurse to implement an accident prevention protocol? Select all that apply.
- A. Range of motion is limited.
- B. Peripheral vision is decreased.
- C. Transmission of hot impulses is delayed.
- D. The client reports incidences of nocturia.
- E. High-frequency hearing tones are perceptible.
- F. Voluntary and autonomic reflexes are slowed.
Correct Answer: A,B,C,D,F
Rationale: The physiological changes that occur during the aging process increase the client's risk for accidents. Musculoskeletal changes include a decrease in muscle strength and function, lessened joint mobility, and limited range of motion. Sensory changes include a decrease in peripheral vision and lens accommodation, delayed transmission of hot and cold impulses, and impaired hearing as high-frequency tones become less perceptible. Nervous system changes include slowed voluntary and autonomic reflexes. Genitourinary changes may include nocturia.
The nurse is planning to instruct a client with a diagnosis of chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction is most important for the nurse to incorporate in a teaching plan?
- A. Turn the head slowly when spoken to.
- B. Remove throw rugs and clutter in the home.
- C. Drive at times when the client does not feel dizzy.
- D. Walk to the bedroom and lie down when vertigo is experienced.
Correct Answer: B
Rationale: The client should maintain the home in a clutter-free state and have thrown rugs removed because the effort of trying to regain balance after slipping could trigger the onset of vertigo. To further prevent vertigo attacks, the client should change position slowly and should turn the entire body, not just the head, when spoken to. The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. If vertigo does occur, the client should immediately sit down or lie down (rather than walking to the bedroom) or grasp the nearest piece of furniture.
A new nurse is learning the functions of the unit's nurse manager. Which functions are included? Select all that apply.
- A. Recruiting new employees
- B. Conducting regular staff meetings
- C. Assisting staff in meeting annual goals
- D. Monitoring professional standards of practice on the nursing unit
- E. Delegating problem-solving of client or family complaints to all nursing staff
- F. Writing prescriptions for primary health care providers (HCPs) when conducting rounds
Correct Answer: A,B,C,D
Rationale: Responsibilities of the nurse manager (middle manager) include recruiting new employees (interviewing and hiring), conducting regular staff meetings, assisting staff in meeting annual goals for the unit and systems needed to accomplish goals, monitoring professional standards of practice on the nursing unit, developing an ongoing staff development plan, conducting routine staff evaluations, acting as a role model, submitting staff schedules for the unit, conducting regular client rounds and problem-solving client and family complaints, establishing and implementing a unit quality improvement plan, and conducting rounds with primary HCPs. The nurse is not responsible for writing prescriptions for HCPs when conducting rounds; the HCP is responsible for writing prescriptions.