Nokea
A child was exposed to the hepatitis A virus, became ill, and made a full recovery 2 years ago. The child is now immune to the hepatitis A virus and will likely be protected for the rest of her life. This type of immunity is referred to as
- A. active artificial immunity.
- B. naturally acquired active immunity.
- C. artificially acquired passive immunity.
- D. naturally acquired passive immunity.
Correct Answer: B
Rationale: Recovery from hepatitis A infection confers lifelong immunity via naturally acquired active immunity, as the body produces its own antibodies.
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The home health nurse is visiting a client with Paget's disease. An important part of preventive care for the client with Paget's disease is:
- A. Keeping the environment free of clutter
- B. Advising the client to see the dentist regularly
- C. Encouraging the client to take the influenza vaccine
- D. Telling the client to take a daily multivitamin
Correct Answer: A
Rationale: Paget's disease increases fracture risk, so keeping the environment clutter-free reduces fall risks, a key preventive measure.
A client with emphysema has been receiving oxygen at 3 L per minute by nasal cannula. The nurse knows that the goal of the client's oxygen therapy is achieved when the client's PaO2 reading is:
- A. 50-60 mm Hg
- B. 70-80 mm Hg
- C. 80-90 mm Hg
- D. 90-98 mm Hg
Correct Answer: B
Rationale: For clients with emphysema, a PaO2 of 70-80 mm Hg indicates adequate oxygenation without suppressing the respiratory drive.
The nurse is performing an admission for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet drug, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect requiring attention.
The charge nurse considers both patient-related and staff-related factors when making daily assignments. All of the following are patient-related factors EXCEPT
- A. mechanical ventilation use.
- B. complex medication regimen.
- C. isolation precaution requirements.
- D. nurse-to-client ratio.
Correct Answer: D
Rationale: Nurse-to-client ratio is a staff-related factor, affecting workload distribution. Ventilation, medications, and isolation are patient-specific needs.
The nurse is serving on the performance improvement committee, which has agreed to some changes in procedures on the basis of evidence-based research. If the committee wants to convince staff members to comply with the changes, which of the following actions should the committee carry out first?
- A. Identify and gain support of key staff.
- B. Explain the consequences of failure to comply.
- C. Determine a reward system for compliance.
- D. Clearly outline expectations in written format.
Correct Answer: A
Rationale: Gaining key staff support (A) builds buy-in and facilitates change adoption. Consequences (B), rewards (C), or written expectations (D) follow.