A nurse is collecting data from a client who has pernicious anemia.
The nurse should identify that which of the following findings increases the client's risk for injury?

Uses a firm-bristled toothbrush.

Prescribed vitamin B12 IM.

Prescribed epoetin IV.

Sleeps 8 to 10 hr per night.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Using a firm-bristled toothbrush can increase the risk of gum injury or bleeding, especially in individuals with pernicious anemia who may have fragile gums due to vitamin B12 deficiency. This choice is correct because it identifies a risk factor for injury.

Choice B rationale:

Prescribing vitamin B12 intramuscularly (IM) is the appropriate treatment for pernicious anemia and does not increase the client's risk of injury. It is essential for addressing the underlying deficiency.

Choice C rationale:

Prescribing epoetin intravenously (IV) is used to stimulate the production of red blood cells and treat anemia, but it is not typically associated with an increased risk of injury. However, it should be administered as ordered by the healthcare provider.

Choice D rationale:

Sleeping 8 to 10 hours per night is beneficial for overall health and well-being. It does not increase the client's risk of injury. In fact, adequate sleep can help with tissue repair and overall recovery.

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Correct Answer is B

Explanation

Choice A rationale:

Instructing parents to avoid bringing fresh flowers into the room is not the primary intervention for a child with Clostridium difficile. While it is essential to maintain a clean environment, the most critical action is to implement proper infection control measures.

Choice B rationale:

This is the correct answer. Initiating contact precautions is crucial when caring for a child with Clostridium difficile. This includes using gloves and gowns to prevent the spread of the bacteria to others.

Choice C rationale:

Using a HEPA filtration system in the room is not the first-line intervention for managing Clostridium difficile. While it can help maintain air quality, it does not directly address the transmission of the bacteria.

Choice D rationale:

Using an N95 respirator is not the primary action in caring for a child with Clostridium difficile. Contact precautions, such as gloves and gowns, are more critical to prevent the spread of infection.

A. Relocate the sensor every 8 hrs. B. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading. C. Choose a finger with a capillary refill less than 2 sec. D. Place the sensor probe on the same extremity as an electronic blood pressure cuff.

Correct Answer is C

Explanation

Choice A rationale:

Relocating the sensor every 8 hours is not necessary when obtaining oxygen saturation readings unless there is a specific clinical reason to do so, such as skin irritation or poor perfusion at the sensor site. Frequent relocation can cause unnecessary disruption for the patient.

Choice B rationale:

Waiting 10 seconds after placing the probe before obtaining the oxygen saturation reading is not required. Modern pulse oximeters provide real-time readings, and there is no need to wait after placing the probe. The reading is usually stable within seconds.

Choice C rationale:

Choosing a finger with a capillary refill time of less than 2 seconds is an essential consideration when obtaining oxygen saturation readings. Capillary refill time is a measure of peripheral perfusion, and choosing a finger with good perfusion ensures accurate oxygen saturation measurements.

Choice D rationale:

Placing the sensor probe on the same extremity as an electronic blood pressure cuff is generally acceptable. However, it is crucial to ensure that the sensor does not interfere with the blood pressure cuff's function and that it is securely attached to the patient's finger for accurate readings.

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A nurse is collecting data from a client who has pernicious anemia.The nurse should identify that which of the following findings increases the client's risk for injury?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 2-year-old child who has Clostridium difficile.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is collecting data from a client who has pernicious anemia.
The nurse should identify that which of the following findings increases the client's risk for injury?