Nokea
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. Flu-like symptoms and night sweats
- B. Fungal and bacterial infections
- C. Pneumocystis lung infection
- D. Kaposi’s sarcoma
Correct Answer: A
Rationale: The correct answer is A: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often present as flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This is known as acute retroviral syndrome and occurs within the first few weeks after exposure to the virus. These symptoms are nonspecific and can easily be mistaken for other common illnesses. Fungal and bacterial infections (B), Pneumocystis lung infection (C), and Kaposi’s sarcoma (D) are not initial symptoms of HIV infection. Fungal and bacterial infections typically occur in later stages of HIV when the immune system is severely compromised. Pneumocystis lung infection and Kaposi’s sarcoma are opportunistic infections seen in advanced stages of HIV, usually when the CD4 count is significantly low.
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A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room.
- B. A private room.
- C. A semi-private room with a client who has pediculosis capitis.
- D. A positive-pressure isolation room.
Correct Answer: B
Rationale: The correct answer is B: A private room. This is appropriate for a client with scabies to prevent the spread of the infestation to others. A private room allows for isolation and reduces the risk of transmission to other clients.
A: A negative-pressure isolation room is typically used for clients with airborne infections to prevent the spread of pathogens outside the room. Scabies is not transmitted through the air.
C: Placing the client in a semi-private room with a client who has pediculosis capitis (head lice) is not ideal as both conditions are caused by different parasites and may increase the risk of cross-contamination.
D: A positive-pressure isolation room is used for clients who need protection from outside pathogens, not for containing contagious conditions like scabies.
In summary, a private room is the best choice for a client with scabies to prevent transmission to others, while the other options are not appropriate due to the nature of scabies and the need for isolation.
A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
- A. Decrease the infusion rate on the IV.
- B. Document that the client experienced an anaphylactic reaction to the medication.
- C. Change the IV infusion site.
- D. Apply cold compresses to the neck area.
Correct Answer: A
Rationale: The correct answer is A: Decrease the infusion rate on the IV. Flushing of the neck and tachycardia are common signs of "Red Man Syndrome," a potential adverse reaction to vancomycin infusion. Decreasing the infusion rate can help alleviate these symptoms. Documentation (B) of an anaphylactic reaction is inaccurate because these symptoms are not indicative of an anaphylactic reaction. Changing the IV site (C) is unnecessary as the symptoms are likely due to the medication itself. Applying cold compresses (D) is not effective for this reaction.
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?
- A. Insert a nasogastric tube.
- B. Administer an antiemetic.
- C. Auscultate bowel sounds.
- D. Encourage the client to ambulate.
Correct Answer: B
Rationale: The correct answer is B: Administer an antiemetic. Nausea and vomiting are common side effects of morphine sulfate. Administering an antiemetic will help relieve these symptoms without interfering with the pain control provided by the PCA pump. Inserting a nasogastric tube (choice A) is not indicated as there is no indication of bowel obstruction. Auscultating bowel sounds (choice C) is not the priority in this situation. Encouraging the client to ambulate (choice D) may help with bowel motility but addressing the nausea and vomiting is the immediate concern.
A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
- A. Administer the medications 5 minutes apart.
- B. Hold pressure on the conjunctival sac for 2 minutes following application of drops.
- C. It is not necessary to remove contact lenses before administering medications.
- D. Administer the medications by touching the tip of the dropper to the sclera of the eye.
Correct Answer: A
Rationale: The correct answer is A: Administer the medications 5 minutes apart. Timolol and pilocarpine are both used to treat glaucoma but work differently. Timolol is a beta-blocker that reduces intraocular pressure while pilocarpine constricts the pupil to improve drainage. Administering them 5 minutes apart prevents one medication from washing out the other. Choice B is incorrect as pressure on the conjunctival sac is not necessary. Choice C is incorrect as contact lenses should be removed before administering eye drops. Choice D is incorrect as touching the dropper tip to the eye can lead to infections.
A nurse is preparing to administer ciprofloxacin to a client. The nurse should identify that the medication is treatment for exposure to which of the following agents?
- A. Smallpox
- B. Anthrax
- C. Ebola virus
- D. Sarin gas
Correct Answer: B
Rationale: The correct answer is B: Anthrax. Ciprofloxacin is an antibiotic commonly used to treat anthrax, which is a bacterial infection caused by Bacillus anthracis. The rationale behind this choice is that ciprofloxacin is effective in treating anthrax infections by inhibiting the growth of the bacteria. Smallpox (A), Ebola virus (C), and Sarin gas (D) are not treated with ciprofloxacin as they are caused by a virus, a different virus, and a nerve gas, respectively.