Nokea
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through direct contact with infected body fluids.
- B. It is transmitted through casual contact.
- C. It is transmitted through airborne droplets.
- D. It is only transmitted through sexual contact.
Correct Answer: A
Rationale: The correct answer is A because HIV is primarily transmitted through direct contact with infected body fluids such as blood, semen, vaginal fluids, and breast milk. This includes activities like unprotected sexual intercourse, sharing needles, and mother-to-child transmission during childbirth or breastfeeding. Casual contact (choice B) is not a common mode of transmission, and HIV is not transmitted through airborne droplets (choice C). While sexual contact is a significant mode of transmission, HIV can also be transmitted through other means involving infected body fluids. Thus, option D is incorrect as it is too limiting.
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A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Pallor and numbness distal to the fistula site
- C. Redness and warmth at the fistula site
- D. Pain in the fistula site
Correct Answer: B
Rationale: The correct answer is B: Pallor and numbness distal to the fistula site. This is indicative of venous insufficiency in a client with an arteriovenous fistula. Venous insufficiency occurs when there is inadequate venous return to the heart, leading to decreased blood flow and oxygen delivery to the tissues. Pallor and numbness are signs of decreased blood flow, which can occur when the fistula is not functioning properly. Cold and numbness (choice A) may indicate arterial insufficiency, not venous. Redness and warmth (choice C) are signs of inflammation, not venous insufficiency. Pain in the fistula site (choice D) may be due to other reasons like infection or nerve compression, not necessarily venous insufficiency.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?
- A. Creatinine
- B. Bilirubin
- C. Amylase
- D. Albumin
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, there is inflammation of the pancreas leading to leakage of pancreatic enzymes like amylase into the blood. Elevated amylase levels are a hallmark of acute pancreatitis. Creatinine (A) is related to kidney function, bilirubin (B) to liver function, and albumin (D) to protein status. In acute pancreatitis, the focus is on pancreatic enzymes like amylase.
A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching?
- A. A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer.
- B. A CA 125 test is used to detect pregnancy.
- C. A CA 125 test is used to diagnose cervical cancer.
- D. A CA 125 test is used to screen for prostate cancer.
Correct Answer: A
Rationale: The correct answer is A: A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. This is because CA 125 is a biomarker that is commonly elevated in ovarian cancer patients. Monitoring CA 125 levels helps healthcare providers assess the effectiveness of treatment and detect any recurrence of the disease.
Choice B is incorrect because a CA 125 test is not used to detect pregnancy. Choice C is incorrect because a CA 125 test is not used to diagnose cervical cancer; it is primarily associated with ovarian cancer. Choice D is incorrect because a CA 125 test is not used to screen for prostate cancer; it is specific to ovarian cancer.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Serum sodium
- B. Serum glucose
- C. Troponin I
- D. White blood cell count
Correct Answer: C
Rationale: The correct answer is C: Troponin I. Troponin I is a specific marker for myocardial damage. After a myocardial infarction, the damaged heart muscle releases troponin I into the bloodstream, leading to elevated levels. This helps in diagnosing and monitoring the extent of myocardial damage.
A: Serum sodium levels are not typically affected by a myocardial infarction.
B: Serum glucose levels may be elevated due to stress response but are not specific to myocardial infarction.
D: White blood cell count may be elevated in response to inflammation caused by myocardial infarction, but it is not as specific as troponin I.