A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?
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Solution
Answer D is correct. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid, or by touch to the skin of the client. MRSA is cultured from the nasal passages of the client, so the client should be instructed to cover the nose and mouth when he sneezes or coughs. Answer C is incorrect because it is not necessary for the client to wear the mask at all times. The nurse should wear the mask.
During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?
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Solution
Answer B is correct. The client who is immune-suppressed and exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client, so answers A and C are incorrect. Answer D is incorrect because it is too late to place the client in isolation.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:
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Solution
Answer D is correct. Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. Answer A is incorrect because it does not pass water through a dialyzing membrane. Answer B is not correct because hemodialysis does not eliminate plasma protein from the blood. Answer C is incorrect because it does not lower the pH.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
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Solution
Answer A is correct. The primary reason for rapid, continuous rewarming of an area affected by frostbite is to lessen cellular damage. Answers B, C, and D are not primary reasons for rapid continuous rewarming, therefore they are incorrect.
An infant’s Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is:
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Solution
Answer C is correct. Infants with a 9 Apgar at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. Answer A is incorrect because it is most likely not related to the infant being cold. Answer B is incorrect because there is no evidence that the baby has bradycardia. Answer D is incorrect because there is no evidence that the baby is lethargic.
The nurse is performing tracheostomy care. If the client coughs out the inner cannula, the nurse should:
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Solution
Answer B is correct. Because there is an inner and an outer cannula, the nurse should simply replace the old one with a new, sterile one. Answer A is incorrect because there is no need to call the doctor. Answer C is incorrect because there is no need to hold open the stoma because there is an out cannula. Answer D is incorrect because there is no data to support the lack of respirations in the client.
A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here; they are trying to kill me.” Which assessment is most likely correct in relation to this statement?
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Solution
Answer C is correct. The statement “They are trying to kill me” indicates paranoid delusions. There is no data to indicate that the client is hearing voices, as stated in answer A. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, so answer B is incorrect. There is no data to indicate that the client is intoxicated, so answer D is incorrect.
The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?
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Solution
Answer A is correct. Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. Answers B, C, and D are incorrect because it is not unusual for the client to complain of muscles spasms, dizziness, or nausea following multiple traumas.
The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
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Solution
Answer C is correct. Head lag is associated with the pre-term newborn and is an expected finding in the newborn less than 36 weeks gestation. Answer A is incorrect because the presence of Mongolian spots are not associated with the pre-term newborn. Answers B and D are findings associated with the full-term newborn, therefore they are incorrect.
A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:
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Solution
Answer C is correct. A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. Answers A, B, and D are incorrect because a Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open. A t-tube is used to keep the common bile duct open.