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A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
- A. Electrocardiogram
- B. Chest X-ray
- C. Echocardiogram
- D. MRI of the chest
Correct Answer: D
Rationale: The correct answer is D. MRI of the chest should be clarified because the magnetic field can interfere with the function of the pacemaker, potentially causing harm to the patient. An electrocardiogram, chest X-ray, and echocardiogram are safe imaging tests that do not interfere with the pacemaker. Therefore, D is the correct answer that should be clarified to ensure patient safety.
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A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
- A. Abdominal cramps and diarrhea
- B. Persistent cough and chest pain
- C. Flu-like symptoms and night sweats
- D. Severe fatigue and weight loss
Correct Answer: C
Rationale: The correct answer is C: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often resemble flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This occurs because the virus is rapidly replicating in the body and the immune system is reacting to it. The other choices, abdominal cramps and diarrhea (A), persistent cough and chest pain (B), and severe fatigue and weight loss (D), are more commonly associated with later stages of HIV infection or other conditions. Therefore, the nurse should include flu-like symptoms and night sweats in the explanation of initial symptoms to accurately inform the client.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Chest pain
- B. Hypotension
- C. Generalized urticaria
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. It is caused by histamine release in response to the foreign blood product. Chest pain (A) is more indicative of a possible cardiac issue. Hypotension (B) may suggest a hemolytic reaction due to rapid destruction of red blood cells. Fever (D) is a common symptom of a febrile non-hemolytic transfusion reaction. Other choices are incorrect as they are not specific to an allergic reaction.
A nurse is providing teaching for a client who has hypertension and a prescription change from metoprolol to metoprolol/hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?
- A. With the new medication, I should experience fewer side effects.
- B. I can expect an increase in my blood pressure.
- C. I should expect the medication to work immediately.
- D. I will stop taking the medication when I feel better.
Correct Answer: A
Rationale: The correct answer is A. By stating that with the new medication, the client should experience fewer side effects, the client demonstrates understanding that the addition of hydrochlorothiazide may help reduce side effects compared to taking metoprolol alone. This indicates comprehension of the teaching provided by the nurse.
Choice B is incorrect because the client should not expect an increase in blood pressure with the new medication regimen.
Choice C is incorrect as it typically takes time for medications to reach their full effectiveness, so immediate results are not expected.
Choice D is incorrect because stopping medication when feeling better can lead to a worsening of hypertension and other health issues.
Overall, choice A is the best response as it shows an understanding of the medication change and its potential benefits.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through direct contact with infected body fluids.
- B. It is transmitted through casual contact.
- C. It is transmitted through airborne droplets.
- D. It is only transmitted through sexual contact.
Correct Answer: A
Rationale: The correct answer is A because HIV is primarily transmitted through direct contact with infected body fluids such as blood, semen, vaginal fluids, and breast milk. This includes activities like unprotected sexual intercourse, sharing needles, and mother-to-child transmission during childbirth or breastfeeding. Casual contact (choice B) is not a common mode of transmission, and HIV is not transmitted through airborne droplets (choice C). While sexual contact is a significant mode of transmission, HIV can also be transmitted through other means involving infected body fluids. Thus, option D is incorrect as it is too limiting.
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
- A. Do not apply heat to the area of irradiation.
- B. Use sunscreen on the irradiated area.
- C. Apply lotion generously to the irradiated area.
- D. Rub the area with an alcohol-based lotion.
Correct Answer: A
Rationale: Correct Answer: A. Do not apply heat to the area of irradiation.
Rationale: Heat can increase skin sensitivity and damage during radiation therapy. It is important to avoid any source of heat on the irradiated area to prevent further skin irritation and burns.
Summary:
B. Using sunscreen is not necessary for radiation therapy as it does not protect against radiation.
C. Applying lotion generously can interfere with the radiation treatment and cause skin irritation.
D. Rubbing the area with an alcohol-based lotion can further irritate the skin and is not recommended during radiation therapy.