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A woman is admitted to the hospital for antibiotic therapy for pelvic inflammatory disease. She is in pain, with a rating of 7 on a scale of 0 to 10. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Administer Tylenol immediately
- B. Apply a heating pad to the lower abdomen.
- C. Position the client in a semi-Fowler's position.
- D. Teach the client to increase intake of fluids.
Correct Answer: C
Rationale: Positioning the client in a semi-Fowler's position can be delegated to a UAP to help alleviate discomfort. Administering medication, applying a heating pad, and teaching are tasks reserved for the nurse, as they require clinical judgment or specialized training.
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A client being treated for syphilis visits the office with a possible allergic reaction to benzathine penicillin G. What abnormal findings would the nurse expect to document? (Select all that apply.)
- A. Red rash
- B. Shortness of breath
- C. Heart irregular
- D. Chest tightness
- E. Anxiety
Correct Answer: A,B,D,E
Rationale: Allergic reactions to benzathine penicillin G may include rash, shortness of breath, chest tightness, and anxiety, indicating possible anaphylaxis or serum sickness. Heart irregularity is not typically associated with allergic reactions to penicillin.
A 26-year-old client with multiple sexual partners is being assessed for symptoms of dysuria and vaginal discharge. Because the results from the culture of the cervical cells are not available, the client will be treated for both Chlamydia and gonorrhea. Which question by the nurse is best?
- A. Do you have a history of sexually transmitted disease?
- B. When was your last sexual encounter?
- C. What did your symptoms begin?
- D. What are the names of your recent sexual partners?
Correct Answer: D
Rationale: Identifying and treating sexual partners is critical to prevent the spread of Chlamydia and gonorrhea. While history, timing of last encounter, and symptom onset are useful, contacting and treating partners is the priority to break the chain of transmission.
A nurse is assessing a client who presents with a scale in rash over the palms and soles of the feet and the feel, a client is assessing a client who presents with a scale in syphilis. Which statement of the nurse is appropriate?
- A. Reasure the client that this stage is not infectious unless she is pregnant.
- B. Assess the client that he is not being generalized weakness.
- C. Data gives and further assess the clients, lesions.
- D. Take a history regarding any cardiovascular symptoms.
Correct Answer: C
Rationale: The client's symptoms suggest secondary syphilis, characterized by a rash on the palms and soles due to spirochetes in the bloodstream. Further assessment of lesions is critical to confirm the diagnosis and guide treatment. Reassuring about non-infectiousness is incorrect, as secondary syphilis is highly infectious, and cardiovascular symptoms are more relevant in tertiary syphilis.
A client with pelvic inflammatory disease is seen by the nurse 72 hours after starting oral antibiotics. Which finding leads the nurse to take immediate action?
- A. Feelings of anger that her partner infected her
- B. Loss stood over the line 2 days
- C. Auroxia and nausea
- D. Chills and a temperature of 101 F
Correct Answer: D
Rationale: Chills and a fever of 101°F suggest a persistent infection, requiring immediate adjustment of antibiotic therapy. Anger is a normal emotional response, and gastrointestinal symptoms like anorexia and nausea are common antibiotic side effects, but they do not warrant urgent action compared to signs of ongoing infection.
A 19-year-old college student seeks information from the school's nurse about how to avoid sexually transmitted diseases (STDs) without abstinence as a choice. Which statement by the nurse is best?
- A. Urinating after intercourse will eliminate the risk of infection.
- B. A vaccine can prevent the sexually transmitted by some amount of the human papilloma virus (HPV).
- C. Oral contraception can prevent pregnancy and STDs.
- D. Good handwashing helps prevent infection associated with STDs.
Correct Answer: B
Rationale: The HPV vaccine (Gardasil) protects against high-risk HPV strains, reducing the risk of cervical cancer and genital warts. Urination after intercourse may reduce but does not eliminate infection risk. Oral contraceptives do not prevent STDs, and handwashing, while hygienic, is not a primary STD prevention method.