Nokea
What action should this nurse take to avoid spreading nosocomial infections?
- A. Remove the face mask.
- B. Remove the hair covering.
- C. Wash her hands before tying the strings on the mask.
- D. Tie the dangling strings of the mask around her neck.
Correct Answer: C
Rationale: Hand hygiene is critical to prevent nosocomial infections. Washing hands before handling the mask ensures the nurse does not contaminate it or transfer pathogens. Removing protective gear or tying strings improperly could increase infection risk.
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To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to:
- A. Rinse the mouth with saline solution.
- B. Perform frequent toothbrushing.
- C. Clean the teeth with an electric toothbrush.
- D. Floss the teeth thoroughly.
Correct Answer: A
Rationale: Saline mouth rinses are gentle and safe post-transsphenoidal hypophysectomy, avoiding irritation to the surgical site.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?
- A. An obstruction is present in the chest tube.
- B. The client is developing subcutaneous emphysema.
- C. The chest tube system is functioning properly.
- D. There is a leak in the chest tube system.
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates a patent chest tube system, reflecting pleural pressure changes. Obstruction, emphysema, or leaks would show different signs.
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following?
- A. An intestinal obstruction has developed.
- B. Additional ulcers have developed.
- C. The esophagus has become inflamed.
- D. The ulcer has perforated.
Correct Answer: D
Rationale: Sudden, sharp midepigastric pain with a rigid, boardlike abdomen strongly suggests ulcer perforation, a life-threatening complication requiring urgent intervention. The other options do not align with these clinical manifestations.
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to:
- A. Immerse her hands in cold water during an episode
- B. Wear light garments when the temperature gets below 50°F (10°C)
- C. Wear gloves when handling ice or frozen foods
- D. Live in a cold climate
Correct Answer: C
Rationale: Wearing gloves when handling ice or frozen foods prevents cold-induced vasospasm in Raynaud's. Cold water worsens symptoms, light garments are insufficient in cold temperatures, and living in a cold climate increases episode frequency.