Nokea
Which of the following is contraindicated for a client with seizure precautions?
- A. Encouraging him to perform his own personal hygiene.
- B. Allowing him to wear his own clothing.
- C. Assessing oral temperature with a glass thermometer.
- D. Encouraging him to be out of bed.
Correct Answer: C
Rationale: Using a glass thermometer is contraindicated due to the risk of breakage and injury during a seizure. Personal hygiene, wearing own clothing, and being out of bed are safe and promote independence.
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The nurse is providing follow-up care to a client with tuberculosis who does not regularly take his medication. Which nursing action would be most appropriate for this client?
- A. Ask the client's spouse to supervise the daily administration of the medications.
- B. Visit the client weekly to ask him whether he is taking his medications regularly.
- C. Notify the physician of the client's noncompliance and request a different prescription.
- D. Remind the client that tuberculosis can be fatal if it is not treated promptly.
Correct Answer: A
Rationale: Having a spouse supervise medication administration ensures adherence, critical for tuberculosis treatment. Weekly visits are insufficient. Changing prescriptions doesn't address noncompliance. Fear-based reminders are less effective than direct support.
The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which of the following laboratory findings should be reported to the surgeon?
- A. Red blood cells, 4.5 million/mm³.
- B. Creatinine, 2.6 mg/dL.
- C. Hemoglobin, 12.2 g/dL.
- D. Blood urea nitrogen, 15 mg/dL.
Correct Answer: B
Rationale: A creatinine level of 2.6 mg/dL indicates renal impairment, which can affect anesthesia and surgical outcomes. This must be reported to the surgeon. The other values are within normal ranges.
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition?
- A. Widening pulse pressure.
- B. Decrease in the pulse rate.
- C. Dilated, fixed pupils.
- D. Decrease in level of consciousness (LOC).
Correct Answer: A,B,C,D
Rationale: All listed changes are critical signs of increasing ICP. Widening pulse pressure (Cushing's triad), bradycardia, dilated fixed pupils, and decreased LOC indicate neurological deterioration requiring immediate notification of the health care provider for intervention.
A client has been admitted with active rectal bleeding. He has been typed and cross-matched for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission the client faints when getting up to go to the bedside commode. The nurse notifies the health care provider, who orders a unit of blood immediately. The nurse should expect which type of packed RBCs will be used for immediate transfusion?
- A. A negative.
- B. B negative.
- C. AB negative.
- D. O negative.
Correct Answer: D
Rationale: In an emergency situation requiring immediate transfusion, such as when a client with active bleeding faints, O negative blood is used because it is the universal donor type. O negative blood can be safely transfused to any patient regardless of their blood type, minimizing the risk of a transfusion reaction when there is no time for type and cross-match verification.