Nokea
Which of the following actions does NOT require the use of standard precautions?
- A. contact with blood
- B. contact with urine
- C. contact with sweat
- D. contact with vomit
Correct Answer: C
Rationale: Standard precautions are required for contact with blood, urine, and vomit due to potential infectious agents. Sweat is not considered a significant risk for transmission.
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A client with cancer is to undergo an intravenous pyelogram. The nurse should:
- A. Force fluids 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
- D. Cover the client's reproductive organs with an x-ray shield.
Correct Answer: B
Rationale: Voiding immediately before an IVP ensures the bladder is empty, improving visualization of the urinary tract.
A 4-year-old male is admitted to the unit with nephrotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
- A. Apply ice to the scrotum
- B. Elevate the scrotum on a small pillow
- C. Apply heat to the abdominal area
- D. Administer an analgesic
Correct Answer: B
Rationale: Elevating the scrotum reduces edema by promoting fluid drainage, decreasing discomfort.
The nurse is caring for a client who is postoperative day 1 following a total hip replacement. Which of the following positions should the nurse AVOID placing the client in?
- A. Supine with legs abducted.
- B. High Fowler’s with legs extended.
- C. Side-lying on the unaffected side.
- D. Prone with legs adducted.
Correct Answer: D
Rationale: prone position with legs adducted can cause hip dislocation; abduction is maintained post-hip replacement
A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in:
- A. 1 week
- B. 2 weeks
- C. 4 weeks
- D. 6 weeks
Correct Answer: C
Rationale: Haldol Decanoate is a long-acting depot injection typically administered every 4 weeks for maintenance therapy in schizophrenia.
The nurse is assessing elderly clients at a community center. Which of the following findings would be the most cause for concern?
- A. Complaint of dry mouth
- B. Loss of 1 inch of height in the last year
- C. Stiffened joints
- D. Rales bilaterally on chest auscultation
Correct Answer: D
Rationale: Rales bilaterally on chest auscultation suggest fluid in the lungs, which could indicate serious conditions like heart failure or pneumonia, requiring immediate attention. Dry mouth, height loss, and stiffened joints are common in aging but less urgent.