Nokea
A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?
- A. Impetigo contagiosa
- B. Neisseria gonorrhoeae
- C. Human papillomavirus
- D. Sarcoptes scabiei
Correct Answer: B
Rationale: Neisseria gonorrhoeae (gonorrhea) is a reportable disease per public health regulations.
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The client delivered a newborn by cesarean birth 1 day ago.
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?
- A. You can apply counterpressure to your back with each position change.
- B. You should change positions as little as possible.
- C. You can splint the incision with a pillow when changing positions.
- D. You should use patterned-paced breathing when changing positions.
Correct Answer: C
Rationale: Splinting the incision with a pillow reduces pain during movement.
A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Persistent uterine contractions
- B. Increased fetal movement
- C. Rigid abdomen
- D. Bright red vaginal bleeding
Correct Answer: D
Rationale: Bright red vaginal bleeding is characteristic of placenta previa.
A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
- A. Educate the infant's guardians about exchange transfusion.
- B. Administer granulocyte colony-stimulating factor.
- C. Initiate droplet precautions.
- D. Monitor the infant's lymphocyte count.
Correct Answer: D
Rationale: Monitoring lymphocyte count tracks HIV progression in infants.
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?
- A. Believes that his brother's death will be reversible
- B. Alienates himself from his peers
- C. Believes his bad behavior is causing his brother's death
- D. Regresses to an earlier developmental level
Correct Answer: A
Rationale: School-age children often see death as reversible, like sleep.
The nurse notes that the skin around the catheter's insertion site is edematous and cool.
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?
- A. Document the infiltration
- B. Apply a warm compress
- C. Elevate the arm
- D. Stop the infusion
Correct Answer: D
Rationale: Stopping the infusion prevents further fluid extravasation.