Nokea
A client with AIDS shows symptoms of herpes simplex stomatitis. Which drug therapy can be anticipated for the client?
- A. Lypressin (Vasopressin)
- B. Liothyroxine (Triostat)
- C. Acyclovir (Zovirax)
- D. Dexamethasone (Maxidex)
Correct Answer: C
Rationale: Acyclovir is an antiviral drug used to treat herpes simplex infections, including stomatitis in AIDS patients.
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The nurse is caring for a client who has gastroesophageal reflux disease and has been receiving long-term omeprazole therapy. The nurse should recognize that the client is at highest risk for developing
- A. jaw necrosis
- B. vision changes
- C. gait disturbance
- D. Clostridoides difficile infection
Correct Answer: D
Rationale: Long-term omeprazole increases risk of C. difficile due to altered gut flora. Jaw necrosis , vision changes , and gait disturbance are not associated.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the charge nurse.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.
The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.
- A. A visitor talking in the waiting room states that the client has alcoholism
- B. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home
- C. The nursing assistant tells a client that the hospital roommate went for a gallbladder test
- D. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions
- E. Two LPNs are discussing a possible cure for AIDS on a crowded elevator
Correct Answer: A,B,C
Rationale: Visitor disclosure , taking reports home , and sharing roommate info violate confidentiality. Isolation precautions and general discussion do not.
The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?
- A. Heart rate
- B. Muscle tone
- C. Cry
- D. Color
Correct Answer: D
Rationale: Color. Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.
After obtaining a nutritional assessment of an elderly client, the nurse determines that the client's diet lacks sufficient protein. Which foods represent low-cost sources of protein?
- A. Potatoes and beef
- B. Peas and beans
- C. Tomatoes and beets
- D. Pork and rice
Correct Answer: B
Rationale: Peas and beans are low-cost, high-protein foods. Beef and pork are expensive, and potatoes, tomatoes, beets, and rice are low in protein.