Nokea
Which practice is recommended to prevent human immune deficiency virus
(HIV) transmission by health care workers?
- A. Wearing a mask within three feet of the client
- B. Intentional
- C. Using standard precautions
- D. Proliferative
Correct Answer: C
Rationale:
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A nurse is providing teaching to an older client who has osteoarthritis that is
affecting the knees. What statement by the client indicates a correct
understanding of the teaching?
- A. I can use either heat or ice to help relieve the discomfort
- B. The purpose of drug therapy is to stop the disease progression.'
- C. I will start a daily running program to get more exercise.'
- D. I should avoid physical activity to prevent further injury.'
Correct Answer: A
Rationale:
What is the nurse's priority action for a client with compromised immunity?
- A. Wash hands before entering the client's room
- B. Take the client's vital signs every 4 hours
- C. Determine whether it is temporary or permanent
- D. Teach the family members to receive the flu shot annually
Correct Answer: A
Rationale:
A client is in skeletal traction. With the nurse's assessment, it is noted that the
pairs appear red, swollen and there is purulent drainage. What action does the
nurse take first?
- A. Collect a culture of the purulent fluid
- B. Cleanse the skin around the pins
- C. Administer an antibiotic
- D. Instruct the client to complete exercise of the affected extremity
Correct Answer: A
Rationale:
The client is at risk for impaired skin integrity related to the need for several
weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best
action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are
still present
Correct Answer: D
Rationale:
The client complains of fatigue and joint pain and reports that they are
unable to walk due to pain in the knees. What is the most appropriate statement
by the nurse?
- A. "You just have arthritis and should take some ibuprofen."?
- B. "You should avoid walking. This might be osteoporosis."?
- C. "Please tell me more about when your pain started."?
- D. "You need to lose weight or the pain won't go away."?
Correct Answer: C
Rationale: