Nokea
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.
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A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
- A. Respond to family members about a client's condition.
- B. Determine which clients should be seen first.
- C. Clean and dress client abdominal wounds.
- D. Take vital signs on clients as they are admitted.
Correct Answer: D
Rationale: Taking vital signs is within the AP's scope, unlike triage or wound care.
The client consumed alcohol 2 days after taking disulfiram.
A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?
- A. Constipation
- B. Dry skin
- C. Hypotension
- D. Urinary retention
Correct Answer: C
Rationale: Disulfiram-alcohol reaction causes hypotension among other symptoms.
The partner of a client who is receiving hospice care.
A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?
- A. My husband won't need medication for breakthrough pain while using music therapy.
- B. I will discontinue music therapy when my husband is no longer responsive.
- C. Playing music will increase my husband's alertness.
- D. Music will distract my husband's awareness of the pain.
Correct Answer: D
Rationale: Music therapy distracts from pain perception, aiding management.
The child has pertussis.
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?
- A. Facial erythema
- B. Peeling of the hands and feet
- C. Fever
- D. Beefy, red tongue
Correct Answer: C
Rationale: Fever is a common symptom of pertussis.
The client has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication.
A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make?
- A. Take the medication with calcium-fortified orange juice.
- B. Take the medication with crackers.
- C. Take the medication and then lay down for 30 min.
- D. Take the medication with an antacid.
Correct Answer: B
Rationale: Taking doxycycline with crackers reduces GI upset without affecting absorption.