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Questions 164

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Question 1 of 5

The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection?

Correct Answer: D

Rationale: Chlorhexidine cloths effectively reduce MRSA. Antibacterial soap is less specific, delaying the bath is unnecessary, and a bath basin risks contamination.

Question 2 of 5

The nurse is providing care in the home to a person who has AIDS. Which behavior, if observed by the nurse, indicates a need for further instruction?

Correct Answer: C

Rationale: Sharing razors risks bloodborne HIV transmission, requiring education. Using shared dishes, bathrooms, or cooking poses no significant risk with standard precautions.

Question 3 of 5

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?

Correct Answer: C

Rationale: Botulinum toxin can cause muscle weakness, leading to dysphagia and respiratory issues . Abdominal , urinary , or motor symptoms are not typical.

Question 4 of 5

A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply.

Correct Answer: A,C,E

Rationale: Cystic fibrosis causes chronic hypoxemia , frequent infections , and vitamin deficiencies due to malabsorption. Diabetes insipidus is unrelated, and obesity is unlikely due to high metabolic demand.

Question 5 of 5

After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?

Correct Answer: D

Rationale: Calf asymmetry of 4 cm suggests deep vein thrombosis, a critical postoperative complication. Pain is nonspecific, negative Homan sign is unreliable, and varicose veins are less urgent.

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