Nokea
Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm?
- A. Ozone
- B. Nitrous oxide
- C. Carbon monoxide
- D. Carbon dioxide
Correct Answer: C
Rationale: Carbon monoxide detectors are widely available, inexpensive, and similar to smoke alarms, detecting a colorless, odorless gas that poses a significant health risk. Ozone, nitrous oxide, and carbon dioxide detectors are less common in homes.
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The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?
- A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.
- B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor.
- C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position.
- D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.
Correct Answer: A
Rationale: Using the gait belt to guide the client against the nurse’s leg minimizes injury. Letting go, instructing a side-lying fall, or using a narrow base increases risk.
The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply.
- A. A client who had rectal surgery and a post-operative abscess
- B. A child who has pneumonia
- C. An older client who is post-myocardial infarction (MI)
- D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia
- E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)
Correct Answer: A,D,E
Rationale: Rectal temperature is contraindicated in rectal surgery/abscess (due to trauma risk), neutropenia (infection risk), and DIC (bleeding risk). Pneumonia and post-MI do not contraindicate rectal measurement.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with droplet precautions? Select all that apply.
- A. Clostridium difficile
- B. Cryptococcal meningitis
- C. Mycoplasma pneumonia
- D. Haemophilus influenzae, type b pneumonia
- E. Rheumatic fever
- F. Varicella Zoster
- G. Scabies
Correct Answer: C,D
Rationale: Mycoplasma pneumonia and Haemophilus influenzae pneumonia require droplet precautions. Others require contact or standard precautions.
The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
- A. Nasogastric tube (NGT)
- B. Bottle of sterile water
- C. Suction equipment
- D. Tracheostomy
Correct Answer: C
Rationale: Cheiloplasty is a surgical repair of a cleft lip, which can affect the infant’s ability to feed and maintain a clear airway. Suction equipment is essential at the bedside to clear secretions or blood from the oral cavity, preventing airway obstruction and ensuring airway patency. A nasogastric tube is not typically required unless feeding difficulties are severe. Sterile water is not a priority for immediate postoperative care, and a tracheostomy is not indicated for this procedure.
The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take?
- A. Place a box of disposable respirators inside the client's room.
- B. Remove alcohol-based sanitizers from the client's room.
- C. Assign the client to a private room with a positive airflow.
- D. Remove the portable fan from the client's bedside table.
Correct Answer: D
Rationale: Removing the portable fan prevents the spread of airborne Mycobacterium tuberculosis. A negative airflow room is required, and respirators should be stored outside the room.