26- The nurse is caring for a 5-year-old client with pertussis….

QuestionAnswered step-by-step26- The nurse is caring for a 5-year-old client with pertussis….26- The nurse is caring for a 5-year-old client with pertussis. Which of the following infection control precautions should the nurse implement? Place a surgical mask on the client during transport out of the client’s room. -Place the client in a private room with monitored negative air pressure. Restrict family members who are pregnant from visiting the client. Keep the door of the client’s room closed at all times.27- The nurse is caring for a client who wants to leave the facility against medical advice. Which of the following actions should the nurse take? Complete an incident report, and forward it to the risk management department. Inform the client that the client can leave after a family member is notified. Do not allow the client to leave until the primary health care provider performs a complete physical assessment. -Permit the client to leave after the client signs a release form.28- The nurse is caring for an adult client admitted 1 day ago following a stroke. Which of the following findings should be reported immediately? negative Babinski’s reflex -brisk pupillary response irregular respirations of 22 capillary refill time less than 2 seconds29- The charge nurse in a long-term care facility has just finished making the client care assignment for unlicensed assistive personnel (UAP). Which of the following statements by the charge nurse to UAP would provide the best direction regarding the assignment? -“The client with dehydration should drink at least 200 mL of fluid each hour while awake.” “The client with acute pancreatitis should be repositioned in bed frequently.” “Follow proper infection control precautions when caring for the client with scabies.” “Assist the client who had a total hip replacement 4 days ago to ambulate in the hallway twice this shift.”30- The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate for the nurse to assign to a UAP? administering an enema to the client with a fractured right hip removing sutures from the client who had an abdominal hysterectomy instructing the client with irritable bowel syndrome (IBS) about dietary restrictions -conducting a home safety assessment for the client with moderate Alzheimer’s disease (AD)31- The nurse is collecting data from a client who had percutaneous transluminal coronary angioplasty (PTCA) via the right femoral artery 2 hours ago. Which of the following findings would require immediate intervention? -diminished right dorsalis pedis pulse nausea after drinking a cup of water 0.8 in (2 cm) area of serosanguineous drainage on the right groin dressing right groin pain rated 3 on a scale of 0 (no pain) to 10 (severe pain)32- The nurse is contributing to a staff education conference about client rights in a mental health facility. Which of the following information should the nurse suggest including? Select all that apply. “A nurse can breach the client’s confidentiality if the client has threatened to harm another person.” “Mandatory outpatient treatment is legally required for all clients discharged from a mental health facility.” -“If the client is deemed incompetent a legal guardian is appointed and can provide informed consent for treatment.” -“The least restrictive environment means the client should be free of restraint and seclusion unless it is necessary.” -“The client can be detained at a facility for 30 days until a hearing can be conducted regarding the client’s commitment for treatment.”33- The nurse is reinforcing discharge instructions with a client who has heart failure. The client has prescriptions for a diuretic and a potassium supplement. Which of the following statements made by the client would indicate an understanding of the instructions? “I will take an extra diuretic pill with a glass of orange juice at night if I start gaining weight.” “I will include canned soups and frozen vegetables in my diet because they are easy to prepare and a good source of potassium.” -“I will increase my activities gradually, but if I get short of breath I will stop and rest.” “I will not take my diuretic pill, and I will call my doctor if my pulse is below 60.”34- The nurse is caring for a client with schizophrenia. Which of the following client behaviors would the nurse expect to observe? disorganized speech hand tremors -mood swings binge eating35- The nurse is talking with the caregiver of a client with diabetes mellitus (type 1). Which of the following statements by the caregiver would require follow-up? “I use an exchange list of foods to provide the client with varied meals.” -“I wait to obtain the client’s blood glucose on mornings when the client is not feeling well.” “I give the client the dose of insulin associated with the current blood glucose on the sliding scale.” “I devised the client’s meal plans based on my abilities with assistance from the diabetes nurse educator.”36- The nurse is contributing to a staff education conference about client confidentiality. Which of the following information should the nurse suggest including? Select all that apply. -“Written consent is not needed to acknowledge the hospitalization of the client to a visitor.” “Personal information will be revealed to the public from volunteers who participate in a research study.” “The client may see and copy the client’s medical record and may have amendments made to the document.” “Nurses may share a computer password with other team members who are assigned to care for the same client.” -“Clients’ medical records should not be displayed on a monitor where others may see the medical record.”37- The nurse is caring for a couple who just experienced a stillbirth. The client’s spouse says to the nurse, “I am tired and need to go home. I will probably take the baby’s bassinet back to the store while I am gone since we just started to buy furniture for the nursery.” Which of the following responses would be most appropriate for the nurse to make? -“Your wife needs you here with her.” “There will be plenty of time to return the bassinet.” “I can help you talk with your wife about the nursery.” “You need to get some rest instead of working.”38- The nurse is contributing to a staff education program about electroconvulsive therapy (ECT). Which of the following information should the nurse recommend including? “ECT is commonly used to treat depression prior to prescribing antidepressant medications.” “ECT may be administered to clients on an outpatient basis.” “Auditory hallucinations are a common side effect of ECT.” -“ECT lowers the level of norepinephrine in the central nervous system.”39- The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the nurse would provide a UAP with the best directions about the assignment? “The client is at risk for infection. Take the vital signs and report back to me if the temperature is above 100.5° F (38.1° C).” “The client has hemiplegia. Assist the client to eat breakfast.” -“All the clients who have been assigned to you will need to have vital signs obtained and intake and output recorded.” “The clients who had total knee replacements need to begin physical therapy. Plan the clients’ care around the therapy.”40- The nurse is contributing to a staff education program about impaired nurses. The nurse should recommend including that nurses who abuse substances typically -deny that there is a problem with substances have been practicing nursing for less than 5 years abstain from using substances while at work do not hold a management position41- The nurse is talking with a client who is an ophthalmologist and was recently diagnosed with Parkinson’s disease. The client tells the nurse, “I know I will not be able to perform any procedures now. I will miss that because I found it so rewarding.” Which of the following responses would be most appropriate for the nurse to make? “Do you work in a group practice?” “I can sense your feelings of loss.” -“You may learn to enjoy other aspects of your profession.” “What are some of the other elements of your profession?”42- The nurse is collecting data about a client’s sleep and rest patterns. Which of the following statements by the client would be a priority to follow up? “I take a nap in the afternoon if I feel tired after work.” “I watch television at night when I have difficulty falling asleep.” -“I wake up feeling tired even though I sleep 7 to 8 hours each night.” “I often wake up once or twice during the night but fall back to sleep quickly.”43- The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate for the nurse to assign to a UAP? Select all that apply. inserting hearing aids for the client who has returned from a surgical procedure and is unable to move the arms obtaining the pain rating from the client with a colostomy who received acetaminophen 1 hour ago -obtaining vital signs from the client with moderate Alzheimer’s disease (AD) -documenting intake and output for the client who has a urinary tract infection (UTI) -weighing the client with bulimia nervosa (BN) prior to breakfast44- The nurse is contributing to a staff development conference about informed consent. Which of the following information should the nurse suggest including? Select all that apply. “The client may not withdraw consent once the informed consent form has been signed.” “The student nurse assigned to the client may witness and sign an informed consent form if a staff nurse is not available.” “The nurse is responsible for explaining the procedure to the client prior to asking for the informed consent form to be signed.” -“The client who is a minor and enlisted in the military is considered legally capable of signing their own informed consent form.” -“The nurse’s signature on an informed consent form indicates that the client has voluntarily given consent for the treatment or procedure.”45- The nurse is caring for a client who is wearing antiembolism stockings. Which of the following findings should the nurse recognized is likely to impede venous return? -Sequential compression devices (SCD) have been applied over the stockings. Powder was applied to the client’s legs prior to application of the stockings. The tops of the stockings have rolled down. The stockings are too large for the client.46- The nurse is caring for a client who practices Orthodox Judaism and is expected to die during the shift. Which of the following would the nurse expect to observe after the client dies? -One of the client’s family members will remain with the client. Several small drops of oil will be placed on the client’s lips and forehead. The client’s spiritual advisor will fold the client’s hands across the client’s chest. The client’s spouse will request that staff members wrap the client in a red cloth.47- The nurse is preparing to administer an intramuscular injection to a client. The client asks why the medication is being administered in the ventrogluteal site instead of the deltoid site. The nurse’s response should be based on the understanding that -the ventrogluteal site provides a large muscle mass for injection intramuscular injections are not painful when given in the ventrogluteal site the deltoid muscle should be used only for immunizations there is a risk of injuring the sciatic nerve when injecting in the deltoid muscle48- The nurse has reinforced teaching with the son of a female client who is being discharged after a stroke. The client will continue rehabilitation at the son’s home. The nurse is aware that one of the family members is a 10-month-old infant. Which of the following statements by the son would indicate a correct understanding of the teaching? “We need to schedule my mother’s physical therapy during times that our baby normally is taking a nap.” “We should make sure that my mother’s bed is located close to the door of her bedroom.” “Because of our baby, we should remove my mother’s raised toilet seat from the toilet after each use.” -“If we get a hospital bed for my mother, we will need to look under the bed before we lower the height of the bed.”49- The nurse is collecting data from a client who is at 30 weeks gestation. The client tells the nurse, “It seems like I have been incontinent of urine for the last few days.” Which of the following should the nurse make available in the client’s examination room? electronic fetal monitor (EFM) sterile urine container -Nitrazine paper clean, cotton-tipped applicators50- The nurse is collecting data from a client in labor who just had an amniotomy performed. The fetal heart rate (FHR) is 92. Which of the following would be consistent with the findings? polyhydramnios imminent delivery -fetal cardiac anomaly prolapsed umbilical cordHealth ScienceScienceNursingNUR 2003CShare Question