Nokea
A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should the nurse have at the client's bedside at all times?
- A. Suction equipment
- B. Padded tongue blades
- C. Backboard
- D. Wrist restraints
Correct Answer: A
Rationale: Suction equipment clears airways during a seizure, preventing aspiration. Tongue blades are outdated, and restraints or backboards are not standard bedside items for seizure care.
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A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
- A. Isopropyl alcohol
- B. Bleach
- C. Hydrogen peroxide
- D. Chlorhexidine
Correct Answer: B
Rationale: A 1:10 bleach solution is the standard for decontaminating blood spills in AIDS care, effectively killing HIV. Other agents are less effective against bloodborne pathogens.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Inform the client of the adverse effect of diarrhea.
- B. Monitor the client for weight loss.
- C. Advise the client about increased dry mouth.
- D. Check the client for increased hypopigmentation under the patch.
Correct Answer: C
Rationale: Clonidine, an antihypertensive, commonly causes dry mouth as a side effect, and advising the client about this is appropriate for the care plan. Diarrhea, weight loss, and hypopigmentation are not typical effects associated with transdermal clonidine.
A nurse is reinforcing teaching with an older adult client who is postoperative following a transurethral resection of the prostate. Which of the following statements should the nurse include in the teaching?
- A. You should take ibuprofen for discomfort.
- B. You should wait 6 weeks before resuming sexual intercourse.
- C. You may tub bathe until the catheter is removed.
- D. You may drive after 1 week.
- E. Avoid drinking water.
- F. Expect bright red urine indefinitely.
- G. Ignore bladder spasms.
Correct Answer: B
Rationale: Waiting 6 weeks allows healing; ibuprofen may increase bleeding, tub baths risk infection, and driving depends on recovery.
A nurse is contributing to the plan of care for a client who has HIV. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Encourage fluids with meals.
- C. Offer small, frequent meals.
- D. Suggest fresh fruits and vegetables.
Correct Answer: C
Rationale: Clients with HIV often experience nutritional challenges due to symptoms like nausea, fatigue, or opportunistic infections, necessitating a tailored dietary plan. Option A, pureed foods, is suited for swallowing difficulties, not a general HIV need, so it's inappropriate. Option B, encouraging fluids with meals, may dilute gastric juices and worsen digestion or appetite, countering nutritional goals. Option C is correct small, frequent meals help maintain energy, combat weight loss, and accommodate reduced appetite or early satiety common in HIV, supporting immune function and medication tolerance. Option D, fresh fruits and vegetables, sounds healthy but risks infection (e.g., from unwashed produce) in immunocompromised clients, requiring caution or cooking instead. Small, frequent meals align with evidence-based HIV care, optimizing calorie intake and nutrient absorption without overwhelming the digestive system, making it the most effective and safe intervention for this population.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Finding: Dyspnea
- A. Dyspnea
- B. Tingling sensation to right foot
- C. Increased pain at incision site
- D. Swelling at incision site
Correct Answer:
Rationale: Dyspnea is a hallmark of fat embolism syndrome due to pulmonary involvement.