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Which of these actions is the primary nursing intervention designed to limit transmission of a client's Salmonella infection?
- A. Wash hands thoroughly before and after client contact
- B. Wear gloves when in contact with body secretions
- C. Double glove when in contact with feces or vomitus
- D. Wear gloves when disposing of contaminated linens
Correct Answer: A
Rationale: Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary means of contamination. Thorough handwashing can prevent the spread of salmonella.
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The client with DM is receiving care in the home for a foot ulcer. The home health nurse documents the narrative note illustrated. Which problem should be the nurse's priority on the return visit?
- A. Impaired skin integrity related to left foot ulcer
- B. Potential for injury related to improper footwear
- C. Potential altered nutrition: less than body requirements related to nausea
- D. Ineffective therapeutic regimen management related to not taking medications as prescribed
Correct Answer: B
Rationale: Improper footwear increases the risk of injury or falls, which is critical for a diabetic client with reduced foot sensation and a healing ulcer.
When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:
- A. Pregnancy tests might be unreliable while taking the drug.
- B. She must use a reliable form of birth control.
- C. She should not take the Category X drug on days she has intercourse.
- D. She must follow up with an endocrinologist.
Correct Answer: B
Rationale: Category X drugs have many practice limitations when prescribed and dispensed to women. For example, the prescription is valid for only seven days, and if not filled, it expires. The FDA provides a pregnancy-prevention program for clients taking Isotretinoin (Accutane). Prior to prescribing a Category X drug, a pregnancy test should be performed.
The client that the nurse is ambulating becomes dizzy and feels faint. Place the nurse's actions in the correct order to prevent the client from falling.
- A. Support and ease the client to the floor by sliding the client down the forward leg
- B. Call for help
- C. Bend at the knees and pull the client toward the forward leg
- D. Assess the client for injuries
- E. Protect the client's head from hitting objects on the floor
- F. Assume a broad stance with the stronger leg somewhat behind the other leg
Correct Answer: B,F,C,A,E,D
Rationale: The sequence ensures safety: call for help (B), establish a stable stance (F), lower the client safely (C, A), protect the head (E), and assess injuries (D).
The nurse should perform which intervention when a client is restrained?
- A. Remove the restraints and provide skin care hourly.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes.
- D. Tie the restraint to the side rails.
Correct Answer: C
Rationale: The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them.
Clinic employees were taught to recognize the hazards of various chemicals using the National Fire Protection Association's (NFPA) diamond label and coding system. What should the nurse determine about the substance that has the label illustrated?
- A. It is extremely flammable.
- B. It can become explosive if mixed with water.
- C. It has no special hazard.
- D. It could cause a serious health injury.
Correct Answer: D
Rationale: The blue diamond with a 3 indicates a serious health hazard, capable of causing significant injury.