Nokea
When communicating with a client who is hearing impaired, what should the nurse do?
- A. Face the client and speak slowly
- B. Speak loudly and clearly
- C. Use written communication only
- D. Avoid using gestures or body language
Correct Answer: A
Rationale: When communicating with a client who is hearing impaired, it is important to face the client and speak slowly. This helps the individual lip-read and understand the communication more easily. Speaking loudly can distort speech and make it harder for the person to understand. Written communication may not always be practical or accessible for the client, especially in real-time interactions. Gestures and body language can actually aid in communication by providing visual cues and context. Therefore, the best approach is to face the client, speak clearly at a moderate pace, and use gestures and body language to enhance understanding.
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When documenting client care, which of the following abbreviations should be used?
- A. SS for sliding scale
- B. BRP for bathroom privileges
- C. OJ for orange juice
- D. SQ for subcutaneous
Correct Answer: B
Rationale: When documenting client care, it is crucial to use standardized abbreviations to ensure clear communication and prevent misunderstandings. BRP for bathroom privileges is a recognized and commonly used abbreviation in healthcare settings. Choice A, SS for sliding scale, is not a standard abbreviation and can lead to confusion as it could be mistaken for other meanings. Choice C, OJ for orange juice, is informal and may not be universally understood in a healthcare context. Choice D, SQ for subcutaneous, is a valid abbreviation but may not be as relevant in the context of documenting client care compared to BRP, which is more specific and widely accepted.
A healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective environment
Correct Answer: C
Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.
When orienting a newly licensed nurse on taking a telephone prescription, which statement indicates understanding of the process?
- A. A second nurse enters the prescription into the client's medical record.
- B. Another nurse should listen to the phone call.
- C. The provider can clarify the prescription when they sign the health record.
- D. I should omit the 'read back' if this is a one-time prescription.
Correct Answer: A
Rationale: The correct answer is A because a second nurse should verify and enter the prescription into the client's medical record to ensure accuracy. This step is crucial to prevent errors in transcription and administration. Choice B is incorrect as having another nurse listen to the phone call does not ensure accurate transcription. Choice C is incorrect because the provider clarifying the prescription upon signing the health record does not replace the need for proper documentation. Choice D is incorrect because the 'read back' process is essential for all telephone prescriptions to confirm accuracy and prevent errors in transcription or administration.
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?
- A. Reassure the client that he will become accustomed to the stoma's appearance in time.
- B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
- C. Offer to contact a member of the local ostomy support group to help him with his concerns.
- D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
Correct Answer: B
Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.
A healthcare professional is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the healthcare professional implement to prevent infection?
- A. Thread the catheter up to the hub
- B. Use a sterile technique throughout the procedure
- C. Clean the insertion site with alcohol only
- D. Use gloves but not a mask during the procedure
Correct Answer: B
Rationale: Using a sterile technique throughout the procedure is essential to prevent infection when inserting an IV catheter. This includes maintaining aseptic conditions, using sterile equipment, and following proper hand hygiene practices. Choice A is incorrect because threading the catheter up to the hub does not specifically address infection prevention. Choice C is incorrect as cleaning the insertion site with alcohol only may not provide adequate disinfection, as it is essential to use an antiseptic solution to reduce microbial load. Choice D is incorrect as wearing gloves alone is not sufficient protection against infection; a mask should also be worn to prevent the spread of microorganisms through respiratory secretions.