Nokea
Which is the proper hand position for performing chest percussion?
- A. cup the hands
- B. use the side of the hands
- C. flatten the hands
- D. spread the fingers of both hands
Correct Answer: A
Rationale: The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task.
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What significant event occurs in the orientation phase of a nurse-client relationship?
- A. establishment of roles
- B. identification of transference phenomenon
- C. placement of the client within their family structure
- D. client agreement that the nurse has the authority in the relationship
Correct Answer: B
Rationale: In the orientation phase of a nurse-client relationship, the significant event is the identification of transference phenomenon. Transference phenomena are intensified in relationships with authority figures like nurses and physicians. Positive transferences may include a desire for affection and dependency, while negative transferences may involve hostility and competitiveness. It is crucial to recognize and address these transferences before progress and positive changes can be made in the working stage. The other choices are incorrect; the establishment of roles may occur in the working phase, placing the client within their family structure is not a key event in the orientation phase, and client agreement on the nurse's authority is not the primary focus during this phase.
Someone who has received a recent tattoo should be screened for:
- A. tuberculosis.
- B. herpes.
- C. hepatitis.
- D. syphilis.
Correct Answer: C
Rationale: Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed. Tuberculosis is an airborne pathogen, while herpes and syphilis are spread directly (such as through sexual contact).
Which of the following tests is commonly performed on newborns with jaundice?
- A. blood urea nitrogen
- B. magnesium
- C. bilirubin
- D. prolactin
Correct Answer: C
Rationale: Bilirubin levels are tested in newborns with jaundice to assess liver function and the severity of hyperbilirubinemia.
Which of the following actions should a nurse take first for a client who has just vomited 300 cc of bright red blood?
- A. Document the vomiting.
- B. Increase the IV fluids.
- C. Get a complete blood count.
- D. Check the blood pressure.
Correct Answer: D
Rationale: The blood pressure should be checked first for a client who has just vomited 300 cc of bright red blood, to determine whether the client is hypotensive. The other actions can be taken later.
The nurse is teaching a client about the use of Rifampin for prophylaxis after an exposure to meningitis. What change in bodily functions should the nurse advise the client about?
- A. The client's urine might turn blue
- B. The client remains infectious to others for 48 hours
- C. The client's contact lenses might be stained orange
- D. The client's skin might take on a crimson glow
Correct Answer: C
Rationale: Rifampin causes orange discoloration of body fluids, which can permanently stain soft contact lenses, requiring client education to prevent concern or damage.