Nokea
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.
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A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
- A. Have the client wear a surgical mask during transport.
- B. Wear an N95 mask while providing care to the client.
- C. Administer an influenza immunization to the client.
- D. Place the client in a negative airflow room.
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10 ⁶ pL (4.2 to 5.4 x 10 ⁶ pL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm ³ (5,000 to 10,000/mm ³)
Platelet count 180,000/mm ³ (150,000 to 400,000/mm ³)
Vitamin B ₁₂ 159 pg/mL (160 to 950 pg/mL)
Complete the following sentence by using the lists of options.The first action the nurse should take is to followed by (Client with low Hct, Hgb, vegan diet)
- A. reinforce education about nutritional supplements
- B. collecting data about nutritional intake
- C. administer IV fluids
- D. notify the provider
- E. monitor vital signs
- F. prepare for transfusion
- G. document findings
Correct Answer: B,A
Rationale: Collecting nutritional data identifies deficiencies (e.g., B12, iron from vegan diet), followed by education on supplements.
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed for 1 hr after the feeding
- B. Administer the feeding solution at a cold temperature.
- C. Rotate the jejunostomy tube once per day.
- D. Flush the tube with 90 mL of sterile water before and after the feeding
Correct Answer: A
Rationale: Elevating the head for 1 hour prevents aspiration, essential for jejunostomy feeding safety. Cold solutions, rotation, and large flushes are not recommended.
A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
- A. Administer enemas 2 days before the procedure
- B. Do not eat or drink anything except water for 12 hr. before the procedure.
- C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
- D. Expect the provider to schedule another procedure to remove any polyps
Correct Answer: B
Rationale: A 12-hour fast with only water prepares the colon adequately for a colonoscopy, reflecting standard protocol and client understanding.
A nurse is preparing to administer filgrastim 6 mcg/kg subcutaneously to a client who weighs 110 lb. Available is filgrastim solution for injection 480 mcg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 0.3 mL
- B. 0.4 mL
- C. 0.5 mL
- D. 0.6 mL
Correct Answer: C
Rationale: To calculate the correct dose, convert the client's weight from pounds to kilograms (110 lb ÷ 2.2 = 50 kg). Filgrastim is dosed at 6 mcg/kg, so 6 mcg/kg × 50 kg = 300 mcg needed. The available concentration is 480 mcg in 0.8 mL. Set up the proportion: (300 mcg ÷ 480 mcg) × 0.8 mL = 0.5 mL. Option A (0.3 mL) underdoses at 180 mcg, Option B (0.4 mL) gives 240 mcg, and Option D (0.6 mL) overdoses at 360 mcg. Option C (0.5 mL) delivers exactly 300 mcg, matching the prescribed dose. Rounding to the nearest tenth, 0.5 mL is correct with no trailing zero, adhering to medication safety standards. This calculation ensures therapeutic efficacy (e.g., boosting white blood cells) while minimizing risks like overdose-related bone pain or underdose-related infection susceptibility, making C the precise and safe choice.