Nokea
A student nurse is assigned to care for a client in a protective environment room. The nurse knows to intervene upon observing which of the following deliveries by the nursing student?
- A. indwelling catheterization kit
- B. flower bouquet
- C. tray of food containing disposable plate and utensils
- D. oral medication
Correct Answer: B
Rationale: Flowers can introduce allergens or pathogens, which are contraindicated in a protective environment. Other items are safe if sterile or disposable.
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The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
- A. Withholding oral intake after midnight
- B. Telling the client that no special preparation is needed
- C. Explaining that a small dose of radioactive isotope will be used
- D. Giving an oral suspension of glucose 1 hour before the test
Correct Answer: B
Rationale: A blood test for H. pylori requires no special preparation, such as fasting or administration of substances.
Which of the following groups of neonates should be screened for hearing loss?
- A. Premature neonates.
- B. Neonates with risk factors for hearing loss.
- C. Neonates with abnormal Apgar scores.
- D. All neonates.
Correct Answer: D
Rationale: Universal newborn hearing screening is recommended for all neonates (D) to detect hearing loss early. Premature neonates (A), those with risk factors (B), or abnormal Apgar scores (C) are included but not exclusive.
After several hospitalizations for respiratory ailments, a 6-month-old has been diagnosed as having HIV. The infant's respiratory ailments were most likely due to:
- A. Pneumocystis carinii
- B. Cytomegalovirus
- C. Cryptosporidiosis
- D. Herpes simplex
Correct Answer: A
Rationale: Pneumocystis carinii (now Pneumocystis jirovecii) is a common cause of pneumonia in HIV-infected infants.
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?
- A. Slow the transfusion
- B. Document the finding as the only action
- C. Stop the blood transfusion and turn on the normal saline
- D. Assess the client's pupils
Correct Answer: A
Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.
A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in:
- A. 1 week
- B. 2 weeks
- C. 4 weeks
- D. 6 weeks
Correct Answer: C
Rationale: Haldol Decanoate is a long-acting depot injection typically administered every 4 weeks for maintenance therapy in schizophrenia.