Nokea
Which actions should be utilized prior to performing a tub bath on the 80 year-old client?
- A. Fill the tub one-half full of water at should be 46°C.
- B. Put a rubber mat on the bottom of the tub.
- C. Maintain water flow pressure during the bath.
- D. Check water temperature using a bath thermometer.
- E. Wash and dry the client's back moving from shoulders to buttocks.
- F. Perform back massage upon completion of the bath.
Correct Answer: B, D
Rationale: For an 80-year-old client, safety and comfort are priorities during a tub bath. A rubber mat (B) prevents slipping, crucial for elderly clients with reduced mobility. Checking water temperature with a bath thermometer (D) ensures the water is safe (typically 38-40°C, as 46°C is too hot). Filling the tub half full at 46°C (A) risks burns, and maintaining water flow pressure (C) is unnecessary and unsafe. Washing the back (E) and performing a massage (F) occur during or after the bath, not prior.
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The client is admitted with a diagnosis of gastroenteritis. Which precaution should the nurse implement?
- A. Standard precautions
- B. Contact precautions
- C. Droplet precautions
- D. Airborne precautions
Correct Answer: B
Rationale: Gastroenteritis is often caused by pathogens like norovirus, requiring contact precautions to prevent fecal-oral transmission. Standard precautions are insufficient, and droplet or airborne are not indicated.
Nimodipine (Nimotop) is ordered for the client with a ruptured cerebral aneurysm. What does the nurse recognize as a desired effect of this drug?
- A. Prevent the influx of calcium into cells.
- B. Restore a normal blood pressure reading.
- C. Prevent the inflammatory process.
- D. Dissolve the clot that has formed.
Correct Answer: A
Rationale: Nimodipine, a calcium channel blocker, prevents calcium influx into cells, reducing vasospasm post-aneurysm rupture. It doesn’t normalize BP (B), prevent inflammation (C), or dissolve clots (D).
The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?
- A. Change the nurse's assignment to another client.
- B. Explain to the nurse that there is no risk to the client.
- C. Ask the nurse if the chickenpox have crusted.
- D. Ask the nurse if she has ever had the chickenpox.
Correct Answer: D
Rationale: The charge nurse should first ask if the nurse has had chickenpox or been vaccinated, as immunity prevents transmission to the immunocompromised leukemia client. If non-immune, the assignment should be changed. Asking about crusting or explaining no risk is incorrect, as varicella is contagious until lesions crust.
The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Decreased temperature
Correct Answer: B
Rationale: Frequent vomiting in bulimia exposes teeth to stomach acid, leading to dental caries (tooth decay), a common clinical finding.
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Only contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.