Nokea
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Season foods with spices.
- C. Provide a high-calorie diet.
- D. Administer an antiemetic after each meal.
Correct Answer: C
Rationale: A high-calorie diet addresses malnutrition in AIDS clients, supporting nutritional needs and immune function.
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A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?
- A. Administer a glycerin suppository.
- B. Ambulate the client in the hallway.
- C. Request the client to be NPO.
- D. Offer an analgesic medication.
Correct Answer: B
Rationale: Ambulating the client first promotes bowel motility, addressing hypoactive bowel sounds and cramping, a common postoperative issue.
A nurse is reinforcing teaching with a client who has herpes simplex virus type 2. Which of the following statements by the client indicates an understanding of the teaching?
- A. I am only contagious while the lesions are present.
- B. The virus cannot spread to areas other than the genital area.
- C. I can have unprotected sex as long as I am taking acyclovir.
- D. The lesions may reoccur in times of stress.
Correct Answer: D
Rationale: Herpes simplex virus type 2 can recur during stress due to immune suppression, indicating client understanding.
A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter.
- A. Apply pressure to the venipuncture site with sterile gauze.
- B. Perform hand hygiene.
- C. Clamp the IV tubing.
- D. Withdraw the catheter from the client's vein.
- E. Remove the dressing and tape from the venipuncture site.
Correct Answer: B,E,C,A,D
Rationale: The sequence is: hand hygiene, remove dressing/tape, clamp tubing, apply pressure, withdraw catheter-ensuring safety and preventing bleeding.
A nurse is reinforcing teaching with a client who is to take a fecal occult blood test at home. Which of the following instructions should the nurse include in the teaching?
- A. Apply five drops of developer to each smear.
- B. Use the same part of stool for each sample.
- C. Ensure the sample contains no urine.
- D. Wait 10 min before applying the developing solution.
Correct Answer: C
Rationale: Ensuring the sample is free of urine prevents contamination, which could lead to inaccurate fecal occult blood test results.
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
- A. Perform suctioning.
- B. Instill saline into the tubing.
- C. Increase the humidification.
- D. Check the cuff pressure.
Correct Answer: A
Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.