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A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile.
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 home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system in his home.
Which of the following actions should the nurse take?
- A. Place the oxygen tank away from curtains or drapes.
- B. Store extra oxygen tanks in a closed closet.
- C. Lay the oxygen tank on its side when not in use.
- D. Increase the oxygen flow rate if the client reports shortness of breath.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Placing the oxygen tank away from curtains or drapes reduces the risk of fire hazards since oxygen supports combustion. This action ensures a safe environment for the client.
Summary:
B: Storing extra oxygen tanks in a closed closet is a good practice, but not directly related to immediate safety concerns like fire hazards.
C: Laying the oxygen tank on its side when not in use can cause damage to the tank and is not a safe storage method.
D: Increasing the oxygen flow rate without proper assessment can be dangerous and may worsen the client's condition.
A nurse is preparing a client for transfer to a long-term care rehabilitation facility following a below-the-knee amputation.
Which action should the nurse take to protect the client's confidentiality?
- A. Provide a verbal report of the client's condition to the paramedic performing the transfer
- B. Ensure that the client's medical records are securely transferred with the client to the new facility
- C. Give the client a copy of their medical records to take with them
- D. Share the client's condition only with the necessary healthcare providers at the rehabilitation facility
- E. Use a secure and private communication method to discuss the client's condition with the receiving facility
Correct Answer: E
Rationale: The correct answer is E: Use a secure and private communication method to discuss the client's condition with the receiving facility. This is the best action to protect the client's confidentiality because it ensures that sensitive information is shared in a confidential and secure manner, preventing unauthorized access. Verbal reports (choice A) can be overheard, risking confidentiality. While ensuring medical records are transferred securely (choice B) is important, discussing the client's condition directly with the necessary healthcare providers (choice D) is more immediate and can prevent unnecessary exposure of sensitive information. Giving the client a copy of their medical records (choice C) can compromise confidentiality if misplaced.
A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father.
Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
- A. Hypertension
- B. Primary glaucoma
- C. History of appendectomy
- D. Iron deficiency anemia
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to certain procedures due to the risk of complications such as increased bleeding or cardiovascular events. Primary glaucoma, history of appendectomy, and iron deficiency anemia are not contraindications for the procedure mentioned. Glaucoma and appendectomy are unrelated to the procedure, while iron deficiency anemia may not directly impact the safety of the procedure.
An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.
A nurse is caring for a client.
Laboratory Results
Week 1:
WBC count 8,000/mm³ (5,000 to 10,000/mm³)
Platelets 350,000/mm³ (150,000 to 400,000/mm³)
Potassium 3.7 mEq/L (3.5 to 5 mEq/L)
Week 2:
WBC count 3,800/mm³ (5,000 to 10,000/mm³)
Platelets 150,000/mm³ (150,000 to 400,000/mm³)
Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
Vital Signs
Week 2:
Temperature 38.6° C (101.5° F)
BP 114/56 mm Hg
Heart rate 102/min
Respiratory rate 24/min
Oxygen saturation 93% on room air
A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up?
- A. Potassium level
- B. Breath sounds
- C. WBC count
- D. Temperature
- E. Blood pressure
Correct Answer: C,D
Rationale: Decreased WBC count and elevated temperature suggest infection, requiring follow-up. Potassium levels remain within normal range, so no action is needed.