Nokea
When caring for a client with diarrhea due to shigellosis, what precautions should the nurse implement?
- A. Wear a gown when caring for the client.
- B. Wear gloves only.
- C. Use standard precautions only.
- D. Wear a mask and face shield.
Correct Answer: A
Rationale: The correct answer is to wear a gown when caring for the client. Shigellosis is highly contagious, and contact precautions are essential to prevent the spread of infection. Wearing gloves alone may not provide adequate protection as the client's diarrhea can contain infectious pathogens that can easily spread. Standard precautions include hand hygiene, but specific precautions for shigellosis require wearing a gown to protect against contact with infectious material. Wearing a mask and face shield are not necessary for shigellosis, as the primary mode of transmission is through the fecal-oral route, and these precautions are not indicated for this type of transmission.
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When teaching a client how to administer medication through a jejunostomy tube, which of the following instructions should the nurse include?
- A. Flush the tube before and after each medication.
- B. Mix medications with enteral feeding.
- C. Push tablets through the tube slowly.
- D. Mix crushed medications before dissolving them in water.
Correct Answer: A
Rationale: The correct answer is to flush the tube before and after each medication administration. This helps prevent clogging and ensures the medication is delivered properly. Mixing medications with enteral feeding (choice B) is incorrect as medications should be administered separately. Pushing tablets through the tube (choice C) is not recommended as they should be properly dissolved before administration. Mixing all crushed medications before dissolving them in water (choice D) is incorrect; medications should be dissolved individually to avoid interactions or inconsistencies in dosages.
What action should the nurse take if she observes an unlicensed assistive personnel (UAP) soaking a client's foot in a basin of warm water placed on the bed during a total bed bath for a confused and lethargic client?
- A. Remove the basin of water from the client's bed immediately
- B. Remind the UAP to dry between the client's toes completely
- C. Advise the UAP that this procedure may damage the skin
- D. Add skin cream to the basin of water while the foot is soaking
Correct Answer: A
Rationale: The correct action for the nurse to take is to remove the basin of water from the client's bed immediately. Soaking a client's foot in a basin of water placed on the bed can lead to spills, create infection risks, and is not a safe practice. It is essential to prioritize the safety and well-being of the client by ensuring a safe environment during care procedures. Choices B, C, and D are incorrect as they do not address the immediate risk associated with the situation. Reminding the UAP to dry between the client's toes, advising about potential skin damage, or adding skin cream do not mitigate the immediate hazards of having a basin of water on the bed.
The client is being taught how to use a peak flow meter. The nurse explains that this device should be used to:
- A. Determine oxygen saturation
- B. Measure forced expiratory volume
- C. Monitor the atmosphere for the presence of allergens
- D. Provide metered doses for inhaled bronchodilator
Correct Answer: B
Rationale: A peak flow meter is used to measure forced expiratory volume, which helps in monitoring asthma. This measurement provides valuable information about how well the client's lungs are functioning and how narrow their airways are. Choice A is incorrect because determining oxygen saturation is typically done using a pulse oximeter. Choice C is incorrect as a peak flow meter is not used to monitor the atmosphere for allergens but rather to assess lung function. Choice D is incorrect as providing metered doses for inhaled bronchodilators is the function of a metered-dose inhaler, not a peak flow meter.
When planning to insert a peripheral IV catheter for an older adult client, which of the following actions should the nurse plan to take?
- A. Insert the catheter at a 45° angle
- B. Place the client's arm in a dependent position
- C. Shave excess hair from the insertion site
- D. Initiate IV therapy in the veins of the hand
Correct Answer: B
Rationale: Placing the client's arm in a dependent position is the correct action when inserting a peripheral IV catheter for an older adult client. This position helps veins dilate due to gravity, facilitating easier insertion of the IV catheter. Choice A is incorrect because catheters are typically inserted at a lower angle, around 10-30 degrees. Choice C is unnecessary unless excessive hair impedes the insertion process. Choice D is incorrect as veins in the hand are generally smaller and more prone to complications, making them less ideal for IV therapy in older adults.
A client has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Abdominal cramping
- B. Increased thirst
- C. Elevated blood pressure
- D. Elevated heart rate
Correct Answer: A
Rationale: Abdominal cramping is a common manifestation of hyponatremia (low sodium levels). When sodium levels drop, it can lead to changes in the body's water balance, affecting cell function and causing symptoms like abdominal cramping. Increased thirst (choice B) is more commonly associated with hypernatremia (high sodium levels) due to the body's attempt to dilute the excess sodium. Elevated blood pressure (choice C) and elevated heart rate (choice D) are not typically direct manifestations of low sodium levels and are more commonly seen in conditions like dehydration or shock.