Nokea
A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
- A. The client is at risk for opportunistic diseases.
- B. The client is no longer communicable.
- C. The client's viral load is extremely low so he is relatively free of circulating virus.
- D. The client's T-cell count is extremely low.
Correct Answer: C
Rationale: A viral load of 200 copies/ml is low, indicating effective treatment and minimal circulating virus.
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A client receiving high doses of hydromorphone (Dilaudid®) develops acute respiratory depression with a drop in blood pressure. Which of the following treatments is most indicated?
- A. Naloxone
- B. Naproxen
- C. Flumazenil
- D. Nortriptyline
Correct Answer: A
Rationale: Naloxone (A) reverses opioid-induced respiratory depression. Naproxen (B), flumazenil (C), and nortriptyline (D) are not appropriate.
The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
- A. Maintaining the client's systolic blood pressure at 70 mmHg or greater
- B. Maintaining the client's urinary output greater than 300 cc per hour
- C. Maintaining the client's body temperature of greater than 33°F rectal
- D. Maintaining the client's hematocrit at less than 30%
Correct Answer: A
Rationale: Adequate blood pressure ensures organ perfusion for donation.
The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet?
- A. Roasted chicken
- B. Noodles
- C. Cooked broccoli
- D. Custard
Correct Answer: C
Rationale: Cooked broccoli is high in fiber and should be avoided on a low-roughage diet for diverticulitis to prevent irritation.
As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?
- A. The baby is sleeping.
- B. The umbilical cord is compressed.
- C. There is head compression.
- D. There is uteroplacental insufficiency.
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency, reducing fetal oxygenation during contractions.
If a nurse accidentally punctures a finger with a needle after withdrawing blood from a client, which of the following actions should be carried out first?
- A. Notify a supervisor.
- B. Wash the puncture area with soap and water.
- C. Apply pressure to the wound.
- D. File an incident/injury report.
Correct Answer: B
Rationale: Washing the puncture with soap and water (B) is the first step to reduce infection risk. Other actions (A, C, D) follow.