Nokea
Which of the following infection control precautions should the nurse take?
- A. Remove the protective gown while in the client's room.
- B. Place the client in a private room with contact precautions.
- C. Perform hand hygiene using an alcohol-based sanitizer.
- D. Wear an N95 mask when entering the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a private room with contact precautions. This is the most appropriate infection control measure for preventing the spread of infections. Placing the client in a private room helps to prevent transmission to other individuals. Contact precautions involve using gloves and gowns when in contact with the client or their environment, further reducing the risk of transmission. Choices A, C, and D are incorrect. Removing the protective gown while in the client's room (A) increases the risk of contamination. Hand hygiene using an alcohol-based sanitizer (C) is important but alone is not sufficient for contact precautions. Wearing an N95 mask when entering the client's room (D) is not necessary unless the client has airborne precautions.
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A nurse is Inserting an indwelling urinary catheter to a male client. Which of the following actions should the nurse take?
- A. Cleanse the tip of the penis in a side to side motion
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Perform the cleansing procedure with a fresh swab two times
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps straighten the urethra, allowing for easier insertion of the catheter. Lifting the penis also reduces the risk of trauma or injury during the procedure. Cleaning the tip of the penis in a side-to-side motion (choice A) can introduce bacteria into the urethra. Picking up the catheter 13 cm (5 in) from its tip (choice B) may contaminate the sterile end. Performing the cleansing procedure with a fresh swab two times (choice C) is not necessary and may increase the risk of irritation to the client's skin.
Which of the following torts should the charge nurse identify as having occurred?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Negligence
Correct Answer: A
Rationale: The charge nurse should identify assault as having occurred. Assault is the intentional act that causes a person to fear they will be harmed. In this case, if a healthcare provider threatens a patient with a procedure without their consent, it constitutes assault. Battery, on the other hand, is the intentional harmful or offensive touching of a person without consent. False imprisonment involves restraining a person against their will, which is not described in the scenario. Negligence refers to a failure to exercise reasonable care, and it does not apply here as the situation involves intentional actions.
Which of the following interventions should the nurse include in the plan?
- A. Speak in a neutral tone when addressing the client.
- B. Force the client to take the prescribed medication.
- C. Encourage the client to discuss their delusions.
- D. Use humor to lighten the mood and build trust.
Correct Answer: A
Rationale: The correct answer is A: Speak in a neutral tone when addressing the client. This intervention is important as it helps maintain a calm and non-threatening environment, promoting effective communication with the client. Speaking in a neutral tone also conveys respect and understanding, which can help build trust and rapport.
Choice B is incorrect because forcing the client to take medication can lead to resistance and worsen the therapeutic relationship. Choice C may not be appropriate as encouraging a client to discuss delusions without proper training or expertise in addressing such issues could potentially exacerbate the situation. Choice D, using humor, may not be suitable in this context as it may not be well received by a client experiencing delusions.
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Zinc
- B. Calcium
- C. Folate
- D. Iron
Correct Answer: C
Rationale: The correct answer is C: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the development of the baby's brain and spinal cord. Zinc (A) is important for overall health but not specifically for preventing neural tube defects. Calcium (B) is crucial for bone health, not neural tube development. Iron (D) is vital for preventing anemia but not directly related to neural tube defects.
Which action should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance
- C. Report the findings to the appropriate authorities, following facility protocol
- D. Take photographs of the injuries if permitted, as part of the documentation process
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment
Correct Answer: C
Rationale: The correct action for the nurse to address suspicion of elder abuse is to report the findings to the appropriate authorities, following facility protocol (Choice C). This is because reporting to the authorities is crucial to protect the elderly individual from further harm and ensure that the necessary interventions are implemented.
- Choice A: Privately interviewing the client may jeopardize the safety of the elderly individual and may not be the most effective immediate action.
- Choice B: Documenting the injuries is important but reporting to authorities takes precedence in cases of suspected elder abuse.
- Choice D: Taking photographs of the injuries may be helpful for documentation but should not delay reporting to authorities.
- Choice E: Ensuring the client is not left alone with the suspected abuser is important but is not as urgent as reporting the abuse to the authorities.
In conclusion, reporting the findings to the appropriate authorities is the most critical and immediate action to address suspicion of elder abuse.