Nokea
A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines?
- A. pneumococcal vaccine
- B. hepatitis A vaccine
- C. Lyme disease vaccine
- D. typhoid vaccine
Correct Answer: A
Rationale: Children with HIV are at higher risk for pneumococcal infections, so the pneumococcal vaccine is recommended in addition to routine vaccines. The other vaccines are not indicated for this context.
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Which of the following foods is a complete protein?
- A. corn
- B. eggs
- C. peanuts
- D. sunflower seeds
Correct Answer: B
Rationale: Eggs are a complete protein. The remaining options are incomplete proteins.
The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:
- A. on the driver's license of the client.
- B. in the client's safety deposit box.
- C. in the client's last will and testament.
- D. on the client's insurance card.
Correct Answer: A
Rationale: In most states, indication of organ donor status is found on the driver's license. Evidence in a last will and testament or in a safety deposit box is not readily accessible for decision-making if the need arises. Insurance cards do not contain such information.
The team is in the client's room to insert a chest tube, and the nurse suspects that the attending physician who is going to perform the procedure is intoxicated. Which of the following actions is most appropriate?
- A. Report the concern to the charge nurse.
- B. Leave the room immediately so as not to be held liable for any complications.
- C. During the procedure, begin writing an incident report.
- D. Observe the physician while performing the procedure with extra attention to make sure no mistakes occur.
Correct Answer: A
Rationale: When there is a concern about a potentially unsafe health care provider, the nurse should intervene immediately and not allow the physician to continue with the procedure until the concern is investigated; the concern should be reported to the next person in the chain of command. An incident report can be written following reporting and an investigation.
Which of the following is not one of the four categories related to client care plans?
- A. privacy
- B. evaluation
- C. diagnosis
- D. outcome
Correct Answer: A
Rationale: The four categories of client care plans are diagnosis, intervention, outcome, and evaluation.
To provide optimal continuity of care, the nurse should do all of the following except:
- A. document current functional status.
- B. have the physician phone a report to the receiving facility.
- C. copy appropriate parts of the medical record for transport to the receiving facility.
- D. phone a report to the facility.
Correct Answer: B
Rationale: It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility to support continuity of care. Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A copy of select portions of the medical record (according to facility policy) is another form of communication and supports continuity. A physician might be asked to be involved if there are specific medical needs or orders that she believe are important, but is generally not involved.