Nokea
A female client is concerned that she is in a 'high-risk' group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
- A. Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.'
- B. It's OK for you to donate because the blood bank has a test that is 100% effective.'
- C. You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.'
- D. It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.'
Correct Answer: C
Rationale: The AIDS virus cannot be transmitted to the donor through the blood donation procedure. The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. For reasons of confidentiality, information about individuals infected with AIDS is not made public.
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A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Hold the child's discharge for 1 hour.
- B. Notify the physician immediately.
- C. Discharge the child as the physician ordered.
- D. Administer an antiemetic as necessary.
Correct Answer: B
Rationale: Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should be notified immediately so that a serum theophylline level can be ordered.
A 1000-mL dose of D5W 1/2 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?
- A. 75 gtt/min
- B. 100 gtt/min
- C. 125 gtt/min
- D. 150 gtt/min
Correct Answer: C
Rationale: 125 gtt/min.
The nurse is caring for a client with diabetes mellitus. Which instruction should be given to the client?
- A. Tell the client to avoid stairs
- B. Tell the client to decrease her intake of sodium
- C. Instruct the client to weigh daily
- D. Tell the client to report numbness and tingling in her feet and toes
Correct Answer: D
Rationale: Numbness and tingling in the feet and toes may indicate diabetic neuropathy a serious complication requiring prompt reporting. Avoiding stairs reducing sodium or daily weighing are not specific to diabetes management unless indicated.
A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, 'I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?' The RN could suggest which one of the following?
- A. Push-ups
- B. Jumping jacks
- C. Leg lifts
- D. Kegel exercises
Correct Answer: D
Rationale: Kegel exercises are appropriate early postpartum as they strengthen pelvic floor muscles, promoting recovery without excessive strain.
The nurse is caring for a client with a history of peptic ulcer disease. Which food should the client avoid?
- A. Spicy foods
- B. Apples
- C. Rice
- D. Milk
Correct Answer: A
Rationale: Spicy foods can irritate the gastric mucosa, exacerbating peptic ulcer disease. Apples, rice, and milk (in moderation) are generally safe.