Nokea
The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss?
- A. Instruct the children to always keep a tissue or handkerchief with them.
- B. Explain that children current with immunizations will not get a cold.
- C. Tell the children they should go to the doctor if they get a cold.
- D. Demonstrate to the students how to wash hands correctly.
Correct Answer: D
Rationale: Handwashing (D) is the most effective way to prevent cold transmission. Tissues (A) are secondary, immunizations (B) don’t prevent colds, and doctor visits (C) are unnecessary for most colds.
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Which collaborative intervention should the nurse implement when caring for the client diagnosed with bronchiectasis?
- A. Prepare the client for an emergency tracheostomy.
- B. Discuss postoperative teaching for a lobectomy.
- C. Administer bronchodilators with postural drainage.
- D. Obtain informed consent form for chest tube insertion.
Correct Answer: C
Rationale: Bronchodilators with postural drainage (C) is a collaborative intervention for bronchiectasis to open airways and clear secretions, involving nursing and respiratory therapy. Tracheostomy (A) and lobectomy (B) are not standard. Chest tubes (D) are for pneumothorax, not bronchiectasis.
An adult client is to have a sputum for culture. When is the best time for the nurse to collect the specimen?
- A. In the morning right after he awakens
- B. Immediately after breakfast
- C. Two hours after eating
- D. Shortly before he retires for the evening
Correct Answer: A
Rationale: The sputum has collected during the night, making it most concentrated and ideal for culture early in the morning.
The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement?
- A. Standard Precautions.
- B. Contact Precautions.
- C. Droplet Precautions.
- D. Airborne Precautions.
Correct Answer: D
Rationale: TB is transmitted via airborne droplets, requiring airborne precautions (D) with negative-pressure rooms. Standard (A), contact (B), and droplet (C) are insufficient.
How should the nurse position the client while undergoing a thoracentesis?
- A. Lithotomy position
- B. Sitting
- C. Prone
- D. Supine
Correct Answer: B
Rationale: Sitting upright with arms supported allows access to the pleural space and minimizes complications during thoracentesis.
The nurse identified the client problem 'decreased cardiac output' for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care?
- A. Monitor the client's arterial blood gases.
- B. Assess skin color and temperature.
- C. Check the client for signs of bleeding.
- D. Keep the client in the Trendelenburg position.
Correct Answer: A
Rationale: ABGs (A) monitor oxygenation, supporting cardiac output in PE. Skin color (B) is secondary, bleeding (C) relates to anticoagulation, and Trendelenburg (D) is contraindicated.