Nokea
Your 54-year-old male HIV-positive patient has just expired. How should you care for this deceased patient?
- A. Bathe the patient, but it is still necessary to use standard precautions because the patient is deceased.
- B. Place the patient in a negative pressure isolated area of the morgue.
- C. Double shroud the patient to prevent the spread of infection.
- D. Bathe the patient using the same standard precautions you used when he was alive.
Correct Answer: D
Rationale: Even after a patient has expired, standard precautions should be maintained to prevent the spread of infection. Bathing the deceased patient should be done using the same standard precautions followed when the patient was alive. This includes using personal protective equipment and following proper infection control procedures. Choices A, B, and C are incorrect because standard precautions must still be adhered to even after the patient has passed away to ensure safety and prevent the transmission of infections.
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You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?
- A. It is normal among adolescents.
- B. It indicates that the patient has an intact peripheral nervous system.
- C. It indicates that the patient has an intact central nervous system.
- D. It is not a normal finding.
Correct Answer: D
Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.
A nurse working on a med-surg unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
- A. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
- B. A client with type 1 DM who uses an insulin pump
- C. A client who is receiving heparin and has an aPTT of 34 seconds
- D. A client with orthostatic hypotension receiving IV fluids
Correct Answer: C
Rationale: The nurse should schedule an interdisciplinary conference for a client who is receiving heparin and has an aPTT of 34 seconds to ensure comprehensive care coordination. In this case, the need for a conference may be to discuss potential adjustments in heparin therapy, monitor for adverse effects, or ensure proper anticoagulation levels. Choices A, B, and D do not specifically indicate the need for interdisciplinary collaboration related to the client's condition or treatment. Therefore, they are not the priority for scheduling an interdisciplinary conference.
Which technique or method is used to determine whether or not the patient has an irregular pulse?
- A. Apical pulse
- B. Inspection
- C. Auscultation
- D. Percussion
Correct Answer: A
Rationale: An apical pulse check is used to determine if the patient has an irregular pulse. The apical pulse is located at the point of maximal impulse (PMI) and is assessed using a stethoscope. Choice B, inspection, involves visual examination and is not used to assess pulse irregularities. Choice C, auscultation, involves listening to internal sounds using a stethoscope, which can be used to assess heart sounds but not specifically for pulse irregularities. Choice D, percussion, is a technique used to assess the density of body tissues or detect abnormal masses and is not used to determine pulse irregularities.
Which of the following strategies can help reduce healthcare-associated infections?
- A. Using outdated medical equipment
- B. Implementing strict hygiene protocols
- C. Increasing patient wait times
- D. Reducing nursing staff
Correct Answer: B
Rationale: Correct Answer: Implementing strict hygiene protocols can help reduce healthcare-associated infections. By maintaining high standards of hygiene, such as proper handwashing, sterilization of equipment, and cleanliness of the environment, the spread of infections can be minimized. Choices A, C, and D are incorrect. Using outdated medical equipment can increase the risk of infections due to lack of proper maintenance and sterilization. Increasing patient wait times may lead to frustration but does not directly impact infection rates. Reducing nursing staff can compromise patient care and monitoring but is not specifically related to reducing healthcare-associated infections.
A client has a new diagnosis of chlamydia. Which of the following actions should the nurse take?
- A. Report the infection to the local health department
- B. Apply an antiviral cream to lesions
- C. Instruct the client to use condoms until the treatment is completed
- D. Initiate contact precautions
Correct Answer: A
Rationale: The correct answer is to report the infection to the local health department. Chlamydia is a reportable disease, meaning healthcare providers are required to report cases to public health authorities for tracking and control measures. Choice B is incorrect because chlamydia is a bacterial infection, not a viral infection, so antiviral cream would not be effective. Choice C is important advice for preventing the spread of chlamydia but is not the priority in this scenario. Choice D is not necessary for chlamydia, as it is primarily transmitted through sexual contact.