Nokea
A 34 year old client is diagnosed with AIDS. His pharmacologic management includes zidovudine (AZT). During a home visit, the client states, “I don’t understand how this medication works. Will it stop the infection?” What is the nurse’s best response?
- A. The medication helps to slow the disease process, but it won’t cure or stop it totally
- B. The medication blocks reverse transcriptase, the enzyme required fro HIV replication
- C. Don’t you know? There aren’t medication to stop or cure HIV
- D. No. it won’t stop the infection. In fact, sometimes the HIV can become immune to the drug itself
Correct Answer: B
Rationale: The correct answer is B. The nurse should explain that zidovudine (AZT) works by blocking reverse transcriptase, the enzyme necessary for HIV replication. This is the key mechanism of action for AZT in managing HIV.
Choice A is incorrect because it provides a partial truth - it does slow the disease process but does not provide the mechanism of action. Choice C is incorrect as it provides incorrect information that there are no medications to stop or cure HIV, which is not true. Choice D is incorrect as it provides misleading information about the drug becoming immune to HIV, which is not the primary concern in this context.
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When the LPN is assisting the patient to use an incentive spirometer, which of the following actions by the patient indicates that the patient needs further teaching on how to use the spirometer?
- A. Taking two normal breaths before use.
- B. Sitting upright before use.
- C. Inhaling deeply to reach target.
- D. Exhaling deeply to reach target.
Correct Answer: D
Rationale: The correct answer is D because exhaling deeply before using the spirometer is incorrect. The purpose of the incentive spirometer is to encourage deep inhalation to improve lung function. Exhaling deeply before using the spirometer goes against this goal and may hinder the effectiveness of the device. Choices A, B, and C are all correct actions when using the spirometer. Taking two normal breaths helps to prepare the lungs, sitting upright optimizes lung expansion, and inhaling deeply to reach the target helps to improve lung ventilation.
Which of the following nursing interventions is correctly categorized as collaborative?
- A. Administering medications as prescribed by the healthcare provider
- B. Ordering a low-sodium diet for a hypertensive client
- C. Providing health education about medication side effects
- D. Monitoring a client’s response to an intervention initiated by another healthcare professional
Correct Answer: D
Rationale: The correct answer is D because monitoring a client's response to an intervention initiated by another healthcare professional is a collaborative nursing intervention. This involves working together with other healthcare team members to assess the client's progress and adjust care as needed. It promotes continuity of care and ensures that the client's needs are met effectively.
A: Administering medications is typically an independent nursing intervention.
B: Ordering a low-sodium diet is within the scope of a nurse's independent practice.
C: Providing health education is often considered an independent nursing intervention unless it involves collaboration with other team members.
In summary, choice D is the correct answer as it exemplifies collaborative care within a healthcare team.
Which food should be avoided by the patient on a low-sodium diet?
- A. Apples
- B. Chicken
- C. Cheese
- D. Broccoli
Correct Answer: C
Rationale: The correct answer is C: Cheese. Cheese is high in sodium and should be avoided on a low-sodium diet. Sodium can contribute to high blood pressure and other health issues. Apples, chicken, and broccoli are all low in sodium and can be included in a low-sodium diet. Cheese is the only option that is high in sodium, making it the correct choice to avoid.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.
To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:
- A. A tracheostomy set
- B. A hypothermia blanket
- C. An intravenous set-up
- D. A syringe and edrophonium HCl(Tensilon)
Correct Answer: B
Rationale: The correct answer is B: A hypothermia blanket. This is important because hypothermia can lead to complications such as shivering, increased risk of infection, and altered drug metabolism. Checking for the hypothermia blanket ensures Mrs. Zeno's temperature is regulated, promoting safety.
A: A tracheostomy set is not directly related to Mrs. Zeno's immediate safety unless she has a tracheostomy in place.
C: An intravenous set-up is important for administering medications, fluids, or blood products, but it is not directly related to Mrs. Zeno's safety at the bedside.
D: A syringe and edrophonium HCl(Tensilon) is specific to a diagnostic test for myasthenia gravis, which may not be relevant to Mrs. Zeno's current condition or safety.