Nokea
Two days after admission, a client's sputum culture is reported as positive for tuberculosis.
While awaiting orders from the physician, the nurse should
- A. initiate measures to transfer the client to a tuberculosis unit.
- B. institute measures to initiate airborne precautions.
- C. arrange for all of the client's personal effects to be decontaminated.
- D. notify the client's family that they have been exposed to a contagious disease.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the physician will write appropriate transfer orders (2) correct-clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the physician's job to tell the family when indicated
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A client on chemotherapy has a WBC count of 1,200/mm^3. Which of the following nursing actions should the nurse take FIRST?
- A. Check temperature q 4 h.
- B. Monitor urine output.
- C. Assess for bleeding gums.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: A WBC count of 1,200/mm^3 indicates severe neutropenia, increasing infection risk. Checking temperature every 4 hours detects fever early, a priority. Options B, C, and D are secondary: urine output is unrelated, bleeding gums suggest thrombocytopenia, and blood cultures require fever.
A client receiving amphotericin B (Fungizone) 1 mg in 250 cc of 5% dextrose in water IV over a 2-hour period.
The nurse should be MOST concerned if which of the following was observed?
- A. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
- B. BP 90/60, complaints of fever and chills.
- C. Complaints of burning on urination, thirst, and dizziness.
- D. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L, total bilirubin 0.2 mg/dL.
Correct Answer: B
Rationale: Strategy: 'MOST concerned' indicates an untoward effect of the medication. (1) normal results, causes renal toxicity, BUN and creatine would be elevated, normal BUN 7-18 mg/dL, normal creatine 0.6-1.2 mg/dL (2) correct-monitor vital signs every 30 min (3) not side effect of medication (4) normal AST (formerly SGOT) 8-20 U/L, normal ALT (formerly SGPT) 8-20 U/L, normal bilirubin 0.1-1.0 mg/dL, may cause elevation, check liver function studies weekly, notify physician if elevated
Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.
Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
- A. Measure head circumference
- B. Place in airborne isolation
- C. Provide passive range of motion
- D. Provide an over-the-crib protective top
Correct Answer: A
Rationale: Measure head circumference. This monitors for complications like hydrocephalus in meningitis.
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision.
- A. Which behavior by the LPN/LVN indicates proper wet-to-dry dressing change technique?
- B. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- C. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- D. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- E. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Packing wet gauze into the incision without overlapping onto the skin prevents skin breakdown from prolonged moisture exposure. Cleansing should be from the center outward, dressings should be pre-soaked, and old dressings are removed dry to debride the wound.