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When caring for a client with diarrhea due to Shigella, which of the following precautions should the nurse take?
- A. Wash hands before and after contact with the client
- B. Wear a surgical mask
- C. Use a face shield
- D. Wear a gown and gloves only
Correct Answer: A
Rationale: The correct precaution for Shigella infection is to wash hands thoroughly before and after contact with the client. Shigella is transmitted through the fecal-oral route, so hand hygiene is crucial in preventing its spread. Wearing a surgical mask or face shield is not necessary for Shigella as it is not primarily transmitted through respiratory droplets. While wearing a gown and gloves is important for standard precautions, the key precaution specific to Shigella is proper hand hygiene.
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A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?
- A. Administer a bronchodilator
- B. Obtain a peak flow reading
- C. Provide supplemental oxygen
- D. Assess the client's respiratory rate
Correct Answer: A
Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.
A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?
- A. "I kind of like this boy in my class, but he doesn't like me back."
- B. "I want to hang out with the kids in the science club, but the jocks pick on them."
- C. "I am so fat, I skip meals to try to lose weight."
- D. "My dad wants me to be a lawyer like him, but I just want to dance."
Correct Answer: C
Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.
The nurse is providing discharge instructions to a client who has been prescribed an iron supplement. Which statement by the client indicates a need for further teaching?
- A. I should take the supplement with milk to increase absorption.
- B. I should expect my stools to turn black while taking this supplement.
- C. I should take the supplement with a full glass of water.
- D. I should take the supplement on an empty stomach.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare professional is admitting a client who has influenza. Which of the following types of transmission precautions should the healthcare professional initiate?
- A. Airborne
- B. Droplet
- C. Contact
- D. Protective environment
Correct Answer: B
Rationale: Droplet precautions should be initiated for clients with infections that spread via droplet nuclei larger than 5 microns in diameter, such as influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. In the case of influenza, the virus is primarily spread through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne precautions are used for pathogens that remain infectious over long distances, typically smaller than 5 microns, like tuberculosis. Contact precautions are for diseases transmitted by direct or indirect contact, and protective environment precautions are for immunocompromised individuals to protect them from environmental pathogens.
A client with a new colostomy is being taught how to irrigate the ostomy. The healthcare provider realizes that the client needs further teaching when the client:
- A. Positions the irrigating solution bag 30 inches below the stoma
- B. Uses an open system for irrigation
- C. Irrigates the colostomy twice a day
- D. Cleans the stoma with harsh chemicals
Correct Answer: A
Rationale: The correct answer is A. Positioning the irrigating solution bag 30 inches below the stoma would cause discomfort and ineffective irrigation as the bag should be positioned at a lower level. Option B is incorrect because a closed system for irrigation is the preferred method for colostomy irrigation. Option C is incorrect as colostomy irrigation is typically done once a day unless otherwise instructed by a healthcare provider. Option D is incorrect as the stoma should be cleaned with mild soap and water to prevent skin irritation and damage.