When collecting a sputum specimen from a client with tuberculosis, what action should the nurse take?
- A. Obtain the specimen immediately upon the client waking up.
- B. Wait one day to collect the specimen if the client cannot provide sputum.
- C. Ask the client to provide 15 to 20 ml of sputum.
- D. Wear sterile gloves when collecting the specimen.
Correct Answer: A
Rationale: The correct answer is to obtain the specimen immediately upon the client waking up. Collecting sputum early in the morning provides the best sample for tuberculosis testing. Option B is incorrect because waiting a day can decrease the accuracy of the specimen. Option C is incorrect as it does not specify the optimal timing for specimen collection. Option D is incorrect as sterile gloves should be worn for infection control but do not specifically relate to the timing of specimen collection.
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A nurse is preparing to administer a dose of vancomycin IV to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse take?
- A. Administer the medication over 15 minutes.
- B. Monitor the client's urine output every 8 hours.
- C. Check the client's creatinine level before administering the medication.
- D. Assess the client for a history of allergies to antibiotics.
Correct Answer: C
Rationale: The correct action for the nurse to take is to check the client's creatinine level before administering vancomycin. Vancomycin is known to be nephrotoxic, so assessing the client's renal function before administering the medication is crucial to prevent further kidney damage. Administering the medication over 15 minutes (Choice A) is not the priority in this scenario as renal function assessment takes precedence. Monitoring urine output (Choice B) is important for assessing renal function but checking creatinine level directly provides more accurate information. Assessing for allergies to antibiotics (Choice D) is also important but not as essential as checking the creatinine level due to the nephrotoxic nature of vancomycin.
A client is taking sucralfate. Which of the following client statements indicates an understanding of the teaching?
- A. I should take this medication 1 hour before meals.
- B. I should take this medication 30 minutes after meals.
- C. I should take this medication only when I have symptoms of heartburn.
- D. I should take this medication with a glass of milk.
Correct Answer: A
Rationale: The correct answer is A. Sucralfate is most effective when taken 1 hour before meals to protect the stomach lining. Option B is incorrect because sucralfate should not be taken after meals. Option C is incorrect because sucralfate is typically taken on a regular schedule, not just when symptoms occur. Option D is incorrect because sucralfate should not be taken with milk, as it can interfere with its effectiveness.
A nurse is providing care to a client who has thrombocytopenia. Which of the following actions should the nurse take?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct Answer: C
Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener helps prevent constipation, reduces the need for straining during bowel movements, and ultimately decreases the risk of bleeding. Choice A is incorrect as flossing daily does not directly address the issue of bleeding risk associated with thrombocytopenia. Choice B is incorrect as removing fresh flowers from the client's room is more related to the risk of infection rather than bleeding in thrombocytopenia. Choice D is incorrect as avoiding serving raw vegetables does not directly impact the risk of bleeding in clients with thrombocytopenia.
A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?
- A. Allow the client enough time to perform rituals
- B. Give the client autonomy in scheduling activities
- C. Discourage the client from exploring irrational fears
- D. Provide negative reinforcement for ritualistic behaviors
Correct Answer: A
Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.
A client has thrombocytopenia. What action should the nurse include?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct Answer: C
Rationale: The correct action for the nurse when caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is characterized by a low platelet count, leading to increased bleeding tendencies. Providing a stool softener helps prevent constipation, reducing the likelihood of straining during bowel movements and subsequent bleeding. Encouraging the client to floss daily (choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (choice B) pertains more to infection control than addressing thrombocytopenia. Avoiding serving raw vegetables (choice D) is not directly associated with managing thrombocytopenia symptoms.