Nokea
An adult has received an injection of immunoglobulin. The client asks what this injection will do for him. The nurse's reply includes the information that he will develop which type of immunity as a result of this injection?
- A. Active natural immunity
- B. Active artificial immunity
- C. Passive natural immunity
- D. Passive artificial immunity
Correct Answer: D
Rationale: Immunoglobulin provides preformed antibodies, conferring passive artificial immunity. Active immunity requires the body to produce antibodies, and natural immunity involves natural exposure.
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The nurse is assessing cranial nerve XI. The nurse should:
- A. open a vial of cloves and ask the client to identify the scent.
- B. shine a flashlight in the client's eyes and observe the pupils.
- C. ask the client to shrug his shoulders.
- D. use the Snellen chart and have the client identify letters.
Correct Answer: C
Rationale: Cranial nerve XI (spinal accessory) controls neck and shoulder muscles; shoulder shrugging tests its function, unlike scent (I), pupil response (III), or vision (II).
The nursing team consists of an RN who has been practicing for 6 months, a LPN/LVN who has been practicing for 15 years, and a nursing assistant who has been caring for clients for 3 years. The RN should care for which of the following clients?
- A. A client 1-day postoperative after an internal fixation of a fractured left femur.
- B. A client receiving diltiazem (Cardizem) and phenytoin (Dilantin).
- C. A client who is to receive 2 units of packed cells prior to an upper endoscopy procedure.
- D. A client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.
Correct Answer: C
Rationale: Blood transfusions require RN assessment and teaching due to risks like transfusion reactions. Options A, B, and D can be assigned to the nursing assistant (postop care) or LPN (medication administration, bipolar care), as they involve standard procedures.
The nurse is planning discharge for a client who suffered a mild myocardial infarction (MI) and smokes one pack of cigarettes per day.
Which of the following recommendations by the nurse would be BEST?
- A. Participation in a program such as 'Nicotine Avoidance.'
- B. Avoidance of aerobic physical activity.
- C. Instillation of a humidifier in the home heating system.
- D. Strict adherence to a low-calorie, low-sodium, high-lipid diet.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-smoking is definitely a modifiable risk factor, self-help program can significantly aid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet
A client receiving tetracycline.
The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
- A. Take the medication with milk or antacids to decrease GI problems.
- B. The medication should always be taken with meals.
- C. Use a maximum-protection sunscreen when outdoors.
- D. Crackers and juice will help decrease gastric irritation.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tetracycline should never be taken with milk or antacids as these inhibit the medication's action (2) should take with full glass of water at least one hour before or two hours after meals (3) correct-because of problems related to photosensitivity, sunscreen, wide-brimmed hats, and long sleeves should be worn when client is at risk for sun exposure (4) should take with full glass of water at least one hour before or two hours after meals
The nurse is caring for a manic client in the seclusion room, and it is time for lunch.
- A. What is the most appropriate action for the nurse to take for a manic client in the seclusion room at lunchtime?
- B. Take the client to the dining room with 1:1 supervision.
- C. Inform the client he may go to the dining room when he controls his behavior.
- D. Hold the meal until the client is able to come out of seclusion.
- E. Serve the meal to the client in the seclusion room.
Correct Answer: D
Rationale: For safety, a manic client in seclusion should remain in the seclusion room and have meals served there to maintain a controlled environment. Taking the client to the dining room risks escalation, delaying the meal is unnecessary, and linking meals to behavior control is inappropriate.