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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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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.
Which of these comments by a client would indicate the need for further teaching regarding safety with warfarin (Coumadin)?
- A. I need to stop the medication 3 days before my dental appointment.'
- B. I will report any bruising or bleeding to my doctor.'
- C. I plan to eat more green leafy vegetables this week.'
- D. I will check with my doctor before taking any new medication.'
Correct Answer: C
Rationale: Green leafy vegetables are high in vitamin K, which can counteract the anticoagulant effects of warfarin, requiring further teaching to ensure safe dietary practices.
The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used?
- A. an antibiotic such as Metronidazole and a protease inhibitor (Saquinivir)
- B. two non-nucleoside reverse transcriptase inhibitors
- C. one protease inhibitor such as Nelfinavir
- D. two protease inhibitors
Correct Answer: B
Rationale: Unless there is drug resistance, the initial prophylaxis based on CDC recommendations is 2 NNRTIs.
The hospitalized client tells the nurse about feeling a strong shock when turning on an electric hair dryer. What should the nurse do first?
- A. Assess the client's heart rhythm and apical pulse
- B. Disconnect the hair dryer from the electrical outlet
- C. Assess the client's skin for signs of electrical burn
- D. Tag and send the hair dryer for inspection
Correct Answer: A
Rationale: Assessing the client's heart rhythm is the priority, as an electrical shock can cause dysrhythmias due to the body's conductivity.
The nurse is caring for a client who has just returned from the operating room after a cholecystectomy. Which of these findings requires immediate follow-up by the nurse?
- A. A temperature of 100.4°F (38°C)
- B. Pulse rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Oxygen saturation of 88%
Correct Answer: D
Rationale: An oxygen saturation of 88% indicates hypoxia, requiring immediate intervention to prevent respiratory compromise.