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A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
- A. Excessive thrombosis and bleeding
- B. Clotting of the mucous membranes
- C. Increase in platelet count
- D. Excessive red blood cell count
Correct Answer: A
Rationale: The correct answer is A: Excessive thrombosis and bleeding. In DIC, there is a widespread activation of the clotting cascade leading to formation of microthrombi, causing excessive clotting. However, as the clotting factors are depleted, bleeding can occur. This results in a paradoxical situation of both thrombosis and bleeding. B is incorrect as clotting of mucous membranes is not specific to DIC. C is incorrect as platelet count is usually decreased in DIC due to consumption. D is incorrect as excessive red blood cell count is not a characteristic of DIC.
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A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Rest frequently throughout the day.
- B. Increase physical activity gradually.
- C. Take medication with meals.
- D. Drink fluids to stay hydrated.
Correct Answer: A
Rationale: The correct answer is A: Rest frequently throughout the day. This is important for a client with hepatitis B to allow the body to heal and conserve energy. Choice B may be harmful as excessive physical activity can strain the liver. Choice C is incorrect as medication for hepatitis B is usually taken on an empty stomach. Choice D is important but not specific to hepatitis B management.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A nurse works with an AP assigned to bathe a client with herpes zoster. The AP asks if it is contagious. What should the nurse say?
- A. Herpes zoster is not contagious to people who have had chickenpox.
- B. Herpes zoster spreads through the air.
- C. Herpes zoster is highly contagious to everyone.
- D. Herpes zoster only spreads through blood contact.
Correct Answer: A
Rationale: The correct answer is A. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Individuals who have had chickenpox in the past are not at risk of getting shingles from someone with herpes zoster. The virus is not transmitted through the air (choice B) or through blood contact only (choice D). It is not highly contagious to everyone (choice C). By explaining to the AP that herpes zoster is not contagious to individuals who have had chickenpox, the nurse provides accurate information and helps alleviate concerns about the spread of the virus.
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. As soon as the nurse can prepare the client and the administration set
- B. At 1200
- C. At 1300
- D. At 1400
Correct Answer: A
Rationale: The correct answer is A: As soon as the nurse can prepare the client and the administration set. It is important to start the infusion promptly to maximize the effectiveness of the blood transfusion. Delaying the infusion can lead to potential complications. Options B, C, and D are incorrect because they suggest delayed start times, which can be detrimental to the patient's health. Starting the infusion as soon as possible ensures that the patient receives the necessary blood components in a timely manner.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with a ventilated ceiling fan
- C. A room with a window and curtains that close
- D. A shared room with other tuberculosis clients
Correct Answer: A
Rationale: The correct answer is A: A room with air exhaust directly to the outdoor environment. This is the appropriate room assignment for a client with active tuberculosis because it helps prevent the spread of airborne infectious particles. The air exhaust system ensures that contaminated air is not recirculated within the unit, reducing the risk of transmission to other patients and staff.
Choice B (A room with a ventilated ceiling fan) is incorrect because a ceiling fan does not provide sufficient ventilation to prevent the spread of tuberculosis.
Choice C (A room with a window and curtains that close) is also incorrect as it does not address the need for proper ventilation and containment of infectious particles.
Choice D (A shared room with other tuberculosis clients) is clearly incorrect as it would increase the risk of transmission among the clients.
In summary, the correct room assignment for a client with active tuberculosis should prioritize containment and ventilation to minimize the risk of spreading the infection to others.