Nokea
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
- A. “A man should wear a latex condom during intimate sexual contact.”
- B. “I’ve heard about people who got AIDS from blood transfusions.”
- C. “I won’t donate blood because I don’t want to get AIDS.”
- D. “IV drug users can get HIV from sharing needles.”
Correct Answer: C
Rationale: The correct answer is C. This statement warrants clarification as donating blood does not put individuals at risk of getting HIV. Blood donation involves a sterile process that ensures safety. Choice A is correct as using condoms can help prevent the transmission of HIV. Choice B is incorrect because modern blood screening techniques have greatly reduced the risk of HIV transmission through blood transfusions. Choice D is also correct as sharing needles is a high-risk behavior for HIV transmission. In summary, only choice C is incorrect as donating blood does not pose a risk of acquiring HIV.
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When caring for a client with diabetes insipidus, the nurse expects to administer:
- A. Vasopressin (Pitressin Synthetic)
- B. Regular insulin
- C. Furosemide (Lasix)
- D. 10% dextrose
Correct Answer: A
Rationale: The correct answer is A: Vasopressin (Pitressin Synthetic). In diabetes insipidus, there is a deficiency of ADH (antidiuretic hormone), leading to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps retain water by reducing urine output. Administering vasopressin helps manage the symptoms of diabetes insipidus.
B: Regular insulin is used to manage diabetes mellitus, not diabetes insipidus.
C: Furosemide is a diuretic used to increase urine output, which would worsen the symptoms of diabetes insipidus.
D: 10% dextrose is a form of glucose and is not indicated in the treatment of diabetes insipidus.
Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
- A. Chest wall bulging
- B. Renal failure
- C. Difficulty swallowing
- D. Orthopnea CARING FOR CLIENTS WITH INFECTIOUS AND INFLAMMATORY DISORDERS OF THE HEART AND BLOOD VESSELS
Correct Answer: B
Rationale: The correct answer is B: Renal failure. Acute respiratory distress syndrome (ARDS) can lead to hypoxemia and respiratory acidosis, causing decreased perfusion to the kidneys and potentially leading to renal failure. Monitoring for signs of renal failure, such as decreased urine output and elevated creatinine levels, is crucial in managing clients with ARDS.
Incorrect choices:
A: Chest wall bulging is not a common complication of ARDS. It may be seen in conditions like tension pneumothorax.
C: Difficulty swallowing is not a typical complication of ARDS. It may be seen in neurological conditions or esophageal disorders.
D: Orthopnea is not a direct complication of ARDS. It is more commonly associated with heart failure or pulmonary edema.
Which of the ff would help a client with an allergic skin reaction to reduce itching and maintain skin intact? Choose all that apply
- A. Humidifying the environment
- B. Avoiding a skin lubricant
- C. Bathing with a bar soap that contains lye
- D. Wearing cotton gloves, esp during sleep
Correct Answer: D
Rationale: The correct answer is D. Wearing cotton gloves, especially during sleep, helps reduce itching by preventing scratching, which can further irritate the skin. Cotton is a breathable fabric that reduces friction and irritation.
A: Humidifying the environment may help in some cases, but it doesn't directly address the itching or maintaining skin integrity.
B: Avoiding a skin lubricant is not recommended as it can help moisturize the skin and reduce itching.
C: Bathing with a bar soap that contains lye can be harsh and drying, exacerbating the skin reaction.
A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:
- A. The client has no previous exposure to the antigens injected
- B. The results demonstrate the client has antibodies to the antigens
- C. The client is immunodeficient and won’t have a skin response
- D. The client isn’t allergic to the antigens and therefore doesn’t react
Correct Answer: C
Rationale: The correct answer is C because a lack of response to intradermal anergy testing suggests an inability to mount a normal delayed-type hypersensitivity response, indicating immunodeficiency. This could be due to conditions such as HIV, which impairs cell-mediated immunity.
Choice A is incorrect because absence of reaction does not necessarily indicate lack of previous exposure to antigens.
Choice B is incorrect as the absence of response doesn't confirm the presence of antibodies.
Choice D is incorrect because anergy testing is not used to assess allergy, but rather to evaluate cell-mediated immunity.
Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
- A. “Your urine will be collected in a pouch following surgery.”
- B. “You will have a nasogastric tube after surgery.”
- C. “Your bowel will be visualized with a laparoscope during surgery.”
- D. “You can drink liquids within 24 hours after surgery.”
Correct Answer: A
Rationale: The correct answer is A because an Ileostomy involves diverting the small intestine to an opening in the abdominal wall, so the urine will not be affected. The pouch collects waste from the small intestine. Nasogastric tube (B) is not typically required for an Ileostomy. Laparoscope (C) is used for visualizing the abdomen, not the bowel. Drinking liquids (D) so soon after surgery can be risky and is not recommended.