Nokea
A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?
- A. Use a space heater to keep the workspace warm.
- B. Take a multivitamin that contains vitamin D daily.
- C. Keep both hands elevated during work breaks.
- D. Obtain a keyboard designed to limit wrist flexion.
Correct Answer: A
Rationale: A warm workspace prevents vasospasm, reducing Raynaud's attacks during work.
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While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
- A. Hematocrit.
- B. Platelet count.
- C. White blood cell (WBC) count.
- D. Blood pH level.
Correct Answer: C
Rationale: WBC count indicates infection, as purulent drainage suggests bacterial colonization requiring prompt intervention.
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
- A. Get an influenza vaccine every year as soon as available.
- B. Using salt, herbs, and spices will Improve the flavor of foods.
- C. Restrict alcoholic beverages to no more than 1-2 per week.
- D. Eat a protein snack 30 minutes before any exercise workout.
Correct Answer: B
Rationale: Using herbs and spices reduces reliance on sugars and fats, supporting glycemic control in diabetes.
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?
- A. Remove the ink marks of the portal after each radiation treatment.
- B. Protect the skin of the radiation portal site from sunlight exposure.
- C. Apply moisture lotions daily to the radiation portal site.
- D. Avoid washing the skin inside the radiation portal site.
Correct Answer: B
Rationale: Protecting the portal site from sunlight prevents exacerbated skin reactions during radiation therapy.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Decrease the flow rate.
- B. Irrigate the catheter manually.
- C. Discontinue infusing solution.
- D. Monitor catheter drainage.
Correct Answer: B
Rationale: Manual irrigation clears clots, maintaining catheter patency and preventing obstruction post-TURP.
History and Physical
Nurses’ notes
Laboratory Results
Flow Sheet
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
- A. Administer antiemetic
- B. Monitor for adverse reaction to antibiotics
- C. Increase IV fluids to 150 mL/hr
- D. Initiate airborne isolation
- E. Repeat CD4+ T-cell count STAT
Correct Answer: A,B,C
Rationale: Antiemetics , antibiotic monitoring , and increased fluids address emesis, treatment safety, and hydration in Pneumocystis pneumonia.