Nokea
Which of the ff precautions must a nurse take while caring for clients with HIV/AIDS to reduce occupational risks?
- A. Transport specimens of body fluid in leakproof containers
- B. Seek prescription for a fusion inhibitor to reduce risk of infection
- C. Avoid administering IV drugs
- D. Avoid cleaning the clients room, esp cleaning urine, stool, or vomit
Correct Answer: A
Rationale: The correct answer is A. Transporting specimens of body fluid in leakproof containers reduces the risk of exposure to HIV/AIDS. This precaution ensures that any potentially infectious material is securely contained. Choice B is incorrect as fusion inhibitors are not prescribed for reducing occupational risks. Choice C is incorrect as it does not directly address reducing occupational risks related to HIV/AIDS. Choice D is incorrect as it is essential for a nurse to clean the client's room, but with proper precautions in place to prevent exposure to bodily fluids.
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When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?
- A. When the client’s color does not improve
- B. When the client level of consciousness decreases
- C. When the client is in a state of respiratory arrest
- D. When the client cannot effectively use the diaphragm
Correct Answer: C
Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.
The nurse has been asked to prepare an intervention plan for a client, age 70, admitted for treatment of renal calculi. He complains of frequent pain due to increased pressure in the renal pelvis and is frightened of the excruciating pain. Which of the ff measures can the nurse include in the client’s nursing care plan? Choose all that apply
- A. Administer prescribed nephrotoxic drugs
- B. Encourage ambulation and liberal fluid
- C. Observe aseptic principles when changing intake
- D. Provide a comfortable position
Correct Answer: B
Rationale: The correct answer is B: Encourage ambulation and liberal fluid. Encouraging ambulation can help in the movement of kidney stones and alleviate pain. Liberal fluid intake helps in flushing out kidney stones and preventing further stone formation.
Incorrect options:
A: Administering prescribed nephrotoxic drugs can worsen kidney function and exacerbate the pain.
C: Observing aseptic principles when changing intake is important for infection prevention but not directly related to pain management for renal calculi.
D: Providing a comfortable position can offer temporary relief but does not address the underlying cause of kidney stone pain.
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: The correct answer is A: Applying the liquid test antigen. During a scratch test to detect allergies, the nurse's role is to apply the liquid test antigen onto the skin to observe the body's reaction. This antigen contains potential allergens that may trigger a response in allergic individuals. By applying this antigen, the nurse can assess if the patient develops a raised wheal or redness at the site, indicating an allergic reaction. This step is crucial in identifying specific allergens causing the patient's symptoms. Choices B, C, and D are incorrect as determining the type of allergy, measuring the length and width of the reaction, and documenting the findings are all important steps but do not directly relate to the initial action of applying the test antigen during a scratch test.
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James’ neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow.
Incorrect choices:
B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties.
C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties.
D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.
The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client’s blood and body fluids, the nurse uses standard precautions, which include:
- A. Wearing gloves to empty a bedpan
- B. Wearing gown, gloves, and protective eyewear when obtaining a urine specimen via catheterization
- C. Disposing of needles uncapped
- D. Wearing gloves when applying eyedrops
Correct Answer: A
Rationale: The correct answer is A. Standard precautions include wearing gloves when there is a potential for contact with blood or body fluids. Emptying a bedpan involves contact with bodily fluids, thus gloves are necessary to prevent exposure to pathogens.
Choice B is incorrect because wearing a gown and protective eyewear is not necessary for obtaining a urine specimen via catheterization unless there is a risk of splashing or spraying of fluids.
Choice C is incorrect as needles should always be disposed of in a proper sharps container with the cap secured to prevent accidental needlestick injuries.
Choice D is incorrect because applying eyedrops does not involve contact with blood or body fluids, so wearing gloves is not necessary according to standard precautions.