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Select the 3 client statements that indicate an understanding of the teaching.

"I can expect my contact lenses to turn red or orange.”

“I should notify my provider if I start taking new over-the-counter or prescription medications.”

“I will need to have someone observe me when I take my medication."

“I will need to have a repeat Mantoux test in 4 weeks."

“I am no longer contagious."

“I will need to take my medications for a total of 6 weeks."

"I can continue my current alcohol intake."

Answer and Explanation

Correct Answer : A,B,C

A. "I can expect my contact lenses to turn red or orange.”
Rifampin causes red-orange discoloration of body fluids, including tears, sweat, urine, and saliva. This effect is harmless but can stain soft contact lenses permanently, so clients should be advised to use glasses instead.

B. “I should notify my provider if I start taking new over-the-counter or prescription medications.”
Rifampin is a potent enzyme inducer that can alter the metabolism of many drugs, including oral contraceptives and anticoagulants. The provider should be informed of any new medications to avoid potential drug interactions and ensure therapeutic effectiveness.

C. “I will need to have someone observe me when I take my medication.”
Directly observed therapy (DOT) is recommended to ensure adherence to tuberculosis treatment. A healthcare provider or designated individual supervises medication intake to improve compliance and reduce the risk of drug resistance.

D. “I will need to have a repeat Mantoux test in 4 weeks.”
A repeat Mantoux test is unnecessary for diagnosing active tuberculosis, as this condition is confirmed through sputum cultures and chest X-ray findings. Mantoux testing is primarily used for screening latent TB infections.

E. “I am no longer contagious.”
Clients with active tuberculosis remain contagious until they complete at least two weeks of effective multidrug therapy and show clinical improvement. Until then, infection control measures such as respiratory isolation should be followed.

F. “I will need to take my medications for a total of 6 weeks.”
The standard treatment for active tuberculosis lasts at least six months, typically involving a four-drug regimen for the first two months, followed by two drugs for the remaining four months. A six-week course is insufficient for eradication.

G. "I can continue my current alcohol intake."
Alcohol should be avoided due to the hepatotoxic effects of isoniazid, rifampin, and pyrazinamide. Combining alcohol with these medications increases the risk of liver damage, requiring clients to abstain or limit intake.

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Correct Answer is C

Explanation

A) Report the healing status of the client's surgical site to the provider:
While this is an important aspect of the nurse’s responsibilities, it does not involve the client in decision-making. Reporting the healing status is a task that requires clinical assessment, but it doesn't allow the client to have a role in making decisions about their care or treatment options.

B) Assist the client to perform exercises and ambulate on the unit:
Assisting the client with exercises and ambulation is important for recovery, but it doesn’t directly involve the client in decision-making. The nurse is providing physical assistance, but this action is more about carrying out the care plan rather than consulting or involving the client in making decisions about their care.

C) Consult the client about options proposed by the physical therapist:
This option best involves the client in decision-making. It allows the nurse to discuss with the client the different options proposed by the physical therapist and gives the client the opportunity to make informed decisions about their own care. This approach supports patient autonomy and ensures the client is an active participant in their rehabilitation process.

D) Ask the client to rate their pain on a scale from 0 to 10 every 12 hr:
While assessing pain is important for managing the client’s comfort, it doesn’t necessarily involve the client in decision-making. The client is providing information, but the nurse is still the one determining the course of action regarding pain management based on that input. It is more about assessment than collaboration in decision-making.

A. "For a client who has Clostridium difficile. I will cleanse my hands with an alcohol based rub. B. ‘’Droplet precautions require that I wear a gown and gloves when providing client care." C. ‘’Following a blood spill, I should use a bleach solution with a ratio of 1 to 20. D. "Soiled dressings should be placed in a biohazard trash receptacle."

Correct Answer is D

Explanation

A) "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub.":
This statement is incorrect. When caring for a client with Clostridium difficile (C. diff), hand hygiene must be performed using soap and water, not an alcohol-based rub. Alcohol does not effectively kill C. diff spores. Handwashing with soap and water is essential to reduce the spread of this infection, as alcohol-based hand sanitizers are ineffective against C. diff spores.

B) "Droplet precautions require that I wear a gown and gloves when providing client care.":
This statement is incorrect. Droplet precautions require wearing a surgical mask to protect against large respiratory droplets that may be expelled during coughing or sneezing. Gowns and gloves are not routinely necessary unless there is a risk of contact with body fluids or secretions. Contact precautions, not droplet precautions, would require a gown and gloves.

C) "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20.":
This statement is partially correct but not fully optimal. For blood spills, the correct bleach solution ratio for disinfection is typically 1 part bleach to 9 parts water (a 1:10 ratio) rather than 1:20. The bleach solution must be strong enough to effectively kill pathogens and viruses, so a 1:9 dilution is preferred.

D) "Soiled dressings should be placed in a biohazard trash receptacle.":
This statement is correct. Soiled dressings, particularly those that are contaminated with blood, bodily fluids, or pathogens, should always be disposed of in a biohazard trash receptacle. This ensures the safe and appropriate handling of potentially infectious materials and helps prevent the spread of infection.

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Select the 3 client statements that indicate an understanding of the teaching.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 3 days postoperative following surgical repair of a hip fracture. Which of the following actions should the nurse take to involve the client in decision making?

Correct Answer is C

Explanation

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse in an acute facility is assisting with the development of an in-service about reducing environmental stressors to improve client’s sleep. Which of the following instructions should the nurse include?

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

A nurse is reviewing laboratory results for a client who has metabolic alkalosis. Which of the following blood gas values should the nurse expect?

A nurse is caring for a client who delivered a newborn by caesarean section birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse take

A nurse is reinforcing teaching with client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following reponses should the nurse make?