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A client who is recovering from hepatitis A has fatigue and malaise. The client asks the nurse, 'When will my strength return?' Which of the following responses by the nurse is most appropriate?
- A. Your fatigue should be gone by now. We will evaluate you for a secondary infection.
- B. Your fatigue is an adverse effect of your drug therapy. It will disappear when your treatment regimen is complete.
- C. It is important for you to increase your activity level. That will help decrease your fatigue.
- D. It is normal for you to feel fatigued. The fatigue should go away in the next 2 to 4 months.
Correct Answer: D
Rationale: Fatigue is common during recovery from hepatitis A and typically resolves in 2-4 months (D). Secondary infection (A) is not indicated. Fatigue is not drug-related (B), and increasing activity prematurely (C) may worsen symptoms.
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A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Excessive sweating above the injury level.
- D. Numbness in the lower extremities.
Correct Answer: C
Rationale: Excessive sweating above the injury level is a hallmark symptom of autonomic dysreflexia, a medical emergency.
A client is being discharged with nasal packing in place. The nurse should instruct the client to:
- A. Perform frequent mouth care.
- B. Use normal saline nose drops daily.
- C. See normal enough with mouth mouth.
- D. Gargle every 4 hours with salt water.
Correct Answer: A
Rationale: Frequent mouth care prevents dryness and infection due to mouth breathing with nasal packing. Saline drops are not needed with packing in place. The third option is unclear. Gargling is not routinely required.
The nurse is assessing a client who is receiving a transfusion of platelets. The client's blood type is A-negative, and the client is receiving O-positive platelets. Which of the following actions should the nurse take?
- A. Assess the client for fluid volume deficit
- B. Document the assessment findings
- C. Stop the transfusion
- D. Notify the primary health care provider
Correct Answer: C
Rationale: Platelets from O-positive donors can cause an Rh incompatibility reaction in an A-negative client, as Rh-positive platelets may sensitize the client. The nurse should stop the transfusion and notify the provider. Fluid volume deficit is unrelated, and documenting without stopping the transfusion is inadequate.
A nurse is caring for a client with a central venous catheter (CVC) in place. Which action by the nurse is most effective in preventing central line-associated bloodstream infections (CLABSI)?
- A. Performing hand hygiene before and after any manipulation of the CVC.
- B. Monitoring the client's temperature every 4 hours.
- C. Administering prophylactic antibiotics.
- D. Ensuring the client maintains strict bed rest to prevent catheter movement.
Correct Answer: A
Rationale: Hand hygiene is the most effective measure to prevent CLABSI by reducing microbial contamination.
Which of the following is an environmental factor and increases the risk of cancer?
- A. Gender.
- B. Nutrition.
- C. Immunologic status.
- D. Age.
Correct Answer: B
Rationale: Nutrition is an environmental factor that influences cancer risk, as diets high in processed foods or low in fiber can increase the risk of cancers like colon cancer.