which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions
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NCLEX-PN

NCLEX Question of The Day

1. Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?

Correct answer: A

Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.

2. A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min via nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations?

Correct answer: A

Rationale: In clients with COPD and chronic respiratory acidosis, they are compensating for low oxygen and high carbon dioxide levels. Hypoxia acts as the main stimulus to breathe in individuals with chronic hypercapnia. When oxygen is administered, it can decrease the respiratory drive by eliminating the hypoxic drive and reducing the stimulus to breathe. Therefore, delivering oxygen at 1 L/min via nasal cannula helps prevent respiratory depression by maintaining the hypoxic drive to breathe. The other options are incorrect: COPD clients do not depend on a low carbon dioxide level as they are chronically hypercapnic, they do not retain hydrogen ions with high oxygen doses, and they do not thrive on a high oxygen level.

3. Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?

Correct answer: B

Rationale: When a client is being treated with antiepileptic drugs (AEDs), it is essential to monitor for potential side effects on blood parameters. Some AEDs can lead to blood dyscrasia, which includes conditions like aplastic anemia and megaloblastic anemia. Therefore, drawing a complete blood count and differential helps in identifying these adverse effects early. Choices A, C, and D are incorrect because the primary concern when monitoring blood parameters in clients on AEDs is the risk of blood dyscrasia, not changes in hematocrit due to vascular volume, white blood cell reduction, or immune modulation.

4. Elderly persons with pernicious anemia should be instructed:

Correct answer: D

Rationale: Elderly persons with pernicious anemia, a condition characterized by vitamin B12 deficiency due to lack of intrinsic factor, should be informed about the potential side effects of B12 injections. Diarrhea is a known transient side effect of B12 injections, along with pain and burning at the injection site, and peripheral vascular thrombosis. Increasing dietary intake of B12-rich foods would not be sufficient due to the malabsorption issue in pernicious anemia. Follow-up is essential in managing pernicious anemia, so instructing patients they do not need to return for follow-up is incorrect. While oral B12 may be a suitable option for some cases, it is not the preferred choice for pernicious anemia where malabsorption is the primary issue.

5. A client has been taking a drug (Drug A) that is highly metabolized by the cytochrome P-450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome P-450 system. You should monitor this client for:

Correct answer: C

Rationale: When a client is taking a drug (Drug A) metabolized by the cytochrome P-450 system and is then started on another drug (Drug B) that induces this system, the metabolism of Drug A is increased. This results in decreased therapeutic effects of Drug A as it is broken down more rapidly. Monitoring is required to address potential reduced efficacy. The therapeutic effect of Drug A is diminished, not enhanced. Inducing the cytochrome P-450 system does not directly increase the adverse effects of Drug B. Although Drug B is an inducer, its therapeutic effects are not decreased as it is not metabolized faster.

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