Nokea
Which of the following statements applies to the care of the client hospitalized with influenza?
- A. The nurse should wear an N-95 mask when caring for the client.
- B. The client may cohort with another client hospitalized with the same diagnosis.
- C. Equipment used in the client's care should remain in the room until the client is discharged.
- D. The door to the client's room may remain open to the hallway.
- E. The nurse should wear a mask when direct care of the client is required.
Correct Answer: B, C, E
Rationale: Influenza requires droplet precautions: cohorting with same diagnosis (B), keeping equipment in the room (C), and wearing a mask for direct care (E). N-95 masks (A) are for airborne diseases (e.g., TB). The door should remain closed (D) to limit droplet spread.
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A client is being admitted with syndrome of inappropriate diuretic hormone. Which does the nurse expect to observe?
- A. Increased thirst
- B. Tachycardia
- C. Polyuria
- D. Hostility
- E. Muscle weakness
Correct Answer: B,D,E
Rationale: SIADH causes water retention, leading to hyponatremia, which can cause tachycardia (B), hostility (D), and muscle weakness (E). Increased thirst (A) and polyuria (C) are more associated with diabetes insipidus.
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest drainage system can be disconnected from suction during transport, but the tube must remain unclamped to allow air or fluid to escape, preventing pneumothorax. Portable suction is not always needed.
To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the:
- A. Finger
- B. Earlobe
- C. Extremity with noninvasive BP cuff
- D. Nose
Correct Answer: C
Rationale: A pulse oximeter should not be placed on an extremity with a blood pressure cuff, as cuff inflation can interrupt blood flow and cause inaccurate readings. Fingers, earlobes, and the nose are acceptable sites when circulation is adequate.
The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test?
- A. Creatine kinase
- B. Ammonia
- C. Myoglobin
- D. Troponin T
- E. Gamma-glutamyl transferase
- F. Bilirubin
Correct Answer: A, C, D
Rationale: Creatine kinase (A), myoglobin (C), and troponin T (D) are cardiac biomarkers elevated in myocardial infarction. Ammonia (B), gamma-glutamyl transferase (E), and bilirubin (F) are unrelated to acute cardiac events.
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
- A. I will keep candy with me just in case my blood sugar drops.'
- B. I need to stay out of the sun as much as possible.'
- C. I often skip dinner because I don't feel hungry.'
- D. I always wear my medical identification.'
Correct Answer: C
Rationale: Skipping meals, like dinner, can cause hypoglycemia in patients on glyburide, a sulfonylurea that stimulates insulin release. Keeping candy for hypoglycemia, avoiding sun (due to photosensitivity), and wearing ID are correct.