Nokea
Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, 'I do not want to become a druggie.' How would you respond to this client's comment?
- A. That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse.
- B. The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse.
- C. A lot of people prefer to be brave and stick it out so you are not alone.
- D. You have a right to refuse any and all treatments, so just do without it.
Correct Answer: B
Rationale: Addressing pain complications and reassuring low addiction risk educates and encourages treatment. Dismissing concerns, normalizing endurance, or supporting refusal are non-therapeutic.
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The nurse is part of an infection control committee that is responding to an outbreak of norovirus in the long-term care facility. Which recommendation should the nurse make to prevent further transmission of this outbreak?
- A. Place face shields outside client rooms.
- B. Discontinue indwelling urinary catheters that are not medically necessary.
- C. Wipe down surfaces with hot, soapy water.
- D. Increase the frequency of cleaning and disinfection of client care areas.
Correct Answer: D
Rationale: Increased cleaning and disinfection of surfaces prevent norovirus spread via contaminated surfaces. Face shields, catheter discontinuation, and soapy water are less effective.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.
The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following?
- A. Wear gloves and a gown.
- B. Perform hand hygiene.
- C. Review the client's viral load.
- D. Obtain a disposable stethoscope.
Correct Answer: B
Rationale: Hand hygiene is required before entering any client’s room to prevent infection spread. Gloves/gown, viral load review, and disposable stethoscopes are not routinely needed for AIDS.
The nurse is preparing to administer intravenous chemotherapy to a client with cancer. While preparing the infusion in the client's room, the bag rips and leaks on the floor. The nurse should initially?
- A. obtain a chemotherapy spill kit.
- B. evacuate the client from the area.
- C. complete an incident report.
- D. request guidance from the pharmacy.
Correct Answer: A
Rationale: A chemotherapy spill kit is the initial action to safely clean hazardous material.
The nurse is caring for a child admitted with varicella (chickenpox). Which of the following actions should the nurse take?
- A. Have a designated blood pressure cuff in the client's room.
- B. Remove all gowns and gloves after exiting the client's room.
- C. Clean commonly touched surfaces with warm, soapy water.
- D. Wear a protective gown when transporting the client to other departments.
Correct Answer: A,B
Rationale: A designated BP cuff and removing PPE after exiting prevent varicella spread (airborne and contact). Soapy water is insufficient, and gowns during transport are unnecessary if precautions are followed.