Nokea
The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
- A. Coarse tremors
- B. Intrajugular central vascular access device
- C. Wearing a wrist watch
- D. Cardiac pacemaker
Correct Answer: A
Rationale: Coarse tremors can interfere with accurate electronic blood pressure readings. Intrajugular devices, wrist watches, and pacemakers do not typically contraindicate use.
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The nurse is teaching a parenting class on infant car seat safety. Which statements should the nurse include? Select all that apply.
- A. Place the car seat rear-facing in the back seat and at 90 degrees.
- B. The car seat straps should fit snugly over the shoulders.
- C. Infants should ride in a car seat, rear-facing, in the back seat, until six months.
- D. Rolled blankets may be needed between the crotch and legs to prevent slouching.
- E. You may add padding underneath the infant to increase their comfort.
Correct Answer: B,D
Rationale: Snug straps and rolled blankets for positioning are correct. Rear-facing should be until at least 2 years, not 90 degrees, and padding underneath is unsafe.
The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first?
- A. Administer PRN analgesic.
- B. Obtain STAT EKG.
- C. Encourage ambulation.
- D. Discuss the pain with the patient.
Correct Answer: D
Rationale: Discussing the pain assesses its nature, as shoulder discomfort post-cesarean may indicate referred pain from diaphragmatic irritation. Analgesics, EKG, or ambulation are premature without assessment.
A client is rushed to the emergency department after exposure to radioactive materials in a workplace accident. The client's supervisor phoned ahead and informed the charge nurse of the chemical with which the client came in contact. What should be the initial action of the nurse?
- A. Remove all the client's clothing and decontaminate the client.
- B. Ask the client what happened during the accident.
- C. Decontaminate the room where the client was staying.
- D. Save the clothing for analysis.
Correct Answer: A
Rationale: Removing clothing and decontaminating the client is the initial action to minimize radiation exposure.
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.
The nurse plans to care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personal protective equipment (PPE)?
- A. boot (shoe) covers
- B. face shield
- C. surgical mask
- D. gown
Correct Answer: C
Rationale: Haemophilus influenzae, type b meningitis requires droplet precautions, which include wearing a surgical mask when within 3 feet of the client. Boot covers, face shields, and gowns are not specifically required unless additional risks (e.g., splashing) are present.