Nokea
A client with a marked depression of T cells.
To promote safety in the environment of a client with a marked depression of T cells, the nurse should
- A. keep a linen hamper immediately outside the room.
- B. restrict eating utensils to spoons made of plastic.
- C. provide masks for anyone entering the room.
- D. remove any standing water left in containers or equipment.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils, but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct-water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium
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The home care nurse is instructing a client recently diagnosed with tuberculosis.
- A. What is the most important instruction for a client with tuberculosis?
- B. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.
- C. It is necessary for the client to wear a mask at all times to prevent transmission of the disease.
- D. The family should support the client to help reduce feeling of low self-esteem and isolation.
- E. The client will be required to take prescribed medication for a duration of 6-9 months.
Correct Answer: D
Rationale: Adherence to a 6-9 month medication regimen is critical to cure tuberculosis and prevent drug resistance. While respiratory precautions, family support, and masks are important, long-term medication compliance is the most essential for treatment success.
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings would be of GREATest concern to the nurse?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium of 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium of 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration and electrolyte imbalance in cirrhosis. Options A, B, and D are normal or expected: ammonia 40 mcg/dL is controlled, potassium 3.5 mEq/L is normal, and sodium 140 mEq/L is normal.
A 26-year-old woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12.
The nurse determines that her EDC (estimated date of confinement) is
- A. February 1.
- B. February 15.
- C. February 19.
- D. March 14.
Correct Answer: B
Rationale: Strategy: Remember Naegele's rule. (1) should add seven days (2) correct-when using the Naegele rule, add seven days to first day of last menstrual period and subtract three months (3) incorrectly started with the last day of the menstrual cycle (4) incorrect
Promethazine hydrochloride (Phenergan) 25 mg IV push has been ordered for a patient. Before administering this medication to the patient, the nurse should check the
- A. color of the medication solution.
- B. patient's pulse and temperature.
- C. time of the last analgesic dose the patient received.
- D. patency of the patient's vein.
Correct Answer: D
Rationale: is very important to determine absolute patency of the vein; extravasation will cause necrosis
The nurse has just returned to the desk and has four phone messages to return.
- A. Which phone message should the nurse return first?
- B. A woman in her first trimester of pregnancy complaining of heartburn.
- C. A man complaining of heartburn that radiates to his jaw.
- D. A woman complaining of hot flashes and difficulty sleeping.
- E. A boy complaining of knee pain after playing basketball.
Correct Answer: B
Rationale: Heartburn radiating to the jaw in a man indicates possible chest pain, which could be a symptom of a myocardial infarction, a life-threatening condition requiring immediate medical attention. The other conditions (pregnancy-related heartburn, menopausal symptoms, and knee pain) are less urgent and can be addressed after ruling out a cardiac emergency.