Nokea
What is a significant point about Shigella that the nurse should acknowledge upon identifying it in a stool culture?
- A. People who have been in contact with the client need to be tested.
- B. Shigella is an airborne infection.
- C. Shigella is a bacteria sometimes found in stagnant water.
- D. The nurse should wear a one-way breathing apparatus when giving client care.
Correct Answer: C
Rationale: Shigella is a bacteria sometimes found in stagnant water. Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best means of prevention when caring for a client with Shigella. The bacteria can be found in food and water contaminated by fecal material. Incidences of Shigella are reportable in many states. Choices A, B, and D are incorrect. While it is important for close contacts to be aware and practice good hygiene, testing is not routinely indicated. Shigella is not an airborne infection; it is transmitted through contaminated food or water. A one-way breathing apparatus is not necessary for caring for a patient with Shigella; standard precautions, including handwashing and gloves, are sufficient.
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When working with elderly clients, the healthcare provider should keep in mind that falls are most likely to happen to the elderly who are:
- A. in their 80s.
- B. living at home.
- C. hospitalized.
- D. living on only Social Security income.
Correct Answer: C
Rationale: The correct answer is 'hospitalized.' Elderly individuals are at a higher risk of falls, especially when they are in new environments like hospitals due to unfamiliarity with the surroundings, medications, and potential mobility challenges. Being in a hospital can disrupt their usual routines and increase the risk of falls. Choice A ('in their 80s') is not as directly related to the increased risk of falls in a hospital environment. Choice B ('living at home') is a common setting for the elderly but does not address the specific risk associated with being hospitalized. Choice D ('living on only Social Security income') is unrelated to the risk of falls based on the environment.
Which of the following enzymes is indicative of pancreatitis?
- A. alkaline phosphatase
- B. acid phosphatase
- C. creatine phosphokinase
- D. amylase
Correct Answer: D
Rationale: Amylase is elevated in conditions of pancreatic inflammation, such as pancreatitis. Pancreatitis is characterized by the inflammation of the pancreas, leading to the leakage of amylase into the bloodstream. Elevated levels of amylase are a key diagnostic marker for pancreatitis. Alkaline phosphatase is associated with liver and bone conditions, not pancreatitis. Acid phosphatase is more related to prostate health and is not specific to pancreatitis. Creatine phosphokinase is found in tissues like muscle and brain, and elevated levels are seen in conditions like muscle injury or heart attack, not pancreatitis.
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
- A. the client has been admitted to the hospital three times in the last 2 months.
- B. the client has a Foley catheter.
- C. the client's family is available to care for him 24 hours a day.
- D. the client is ordered to continue IV antibiotics 5 days post discharge.
Correct Answer: V
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.
Under what circumstances can an individual receive medical care without giving informed consent?
- A. when the durable power of attorney for health care is not available
- B. in an emergency, life-or-death situation
- C. when the physician is not available for discussion with the client
- D. when they (clients) are not able to speak for themselves
Correct Answer: B
Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence. Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.
When observing a dressing change by a graduate nurse on a Stage III pressure ulcer to the greater trochanter by the staff nurse, a need for further teaching is indicated after the following observation by the nurse:
- A. The new graduate nurse irrigates the pressure ulcer with 50cc of NS.
- B. The new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide.
- C. The new graduate packs the wound with sterile kerlix soaked in NS.
- D. The new graduate applies a Duoderm dressing over the wound after cleansing.
Correct Answer: B
Rationale: The correct answer is that the new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide. Pressure ulcers should not be cleaned with substances that are cytotoxic, such as hydrogen peroxide or betadine. This can cause further damage to the wound and delay the healing process. Choice A is incorrect because irrigating the pressure ulcer with normal saline is an appropriate practice. Choice C is incorrect because packing the wound with sterile kerlix soaked in normal saline is also an appropriate step. Choice D is incorrect because applying a Duoderm dressing after cleansing is a standard procedure in wound care.