Nokea
An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
- A. lamivudine/zidovudine (Combivir).
- B. famciclovir (Famvir).
- C. ciprofloxacin (Cipro).
- D. voriconazole (Vfend)
Correct Answer: D
Rationale: Voriconazole is an antifungal effective against Fusarium. Combivir (antiretroviral), famciclovir (antiviral), and ciprofloxacin (antibacterial) are not appropriate.
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The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
- A. Apply the new tie before removing the old one.
- B. Have a helper present.
- C. Hold the tracheotomy with the nondominant hand while removing the old tie.
- D. Ask the doctor to suture the tracheostomy in place.
Correct Answer: A
Rationale: Applying the new tie before removing the old one ensures the tracheotomy tube remains secure, preventing accidental dislodgement.
An infant with a ventricular septal defect is discharged with a prescription for lanoxin elixir 0.01 mg PO q 12 hrs. The bottle is labeled 0.10 mg per 1/2 tsp. The nurse should instruct the mother to:
- A. Administer the medication using a nipple
- B. Administer the medication using the calibrated dropper in the bottle
- C. Administer the medication using a plastic baby spoon
- D. Administer the medication in a baby bottle with 1oz. of water
Correct Answer: B
Rationale: The calibrated dropper ensures accurate dosing of Lanoxin (digoxin), critical for preventing toxicity in infants.
The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:
- A. Place the client in a prone position 15-30 minutes twice a day
- B. Keep the foot of the bed elevated on shock blocks
- C. Place trochanter rolls on either side of the affected leg
- D. Keep the client's leg elevated on two pillows
Correct Answer: A
Rationale: Prone positioning helps stretch hip flexors, preventing contractures after AKA by maintaining proper alignment.
Upon admission to the hospital, a client reports having 'the worst headache I've ever had.' The nurse should give the highest priority to:
- A. Administering pain medication
- B. Starting oxygen
- C. Performing neuro checks
- D. Inserting a Foley catheter
Correct Answer: C
Rationale: A sudden, severe headache may indicate a serious condition like subarachnoid hemorrhage. Neuro checks are the priority to assess for neurological changes.
The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?
- A. Slow the transfusion rate and administer diphenhydramine.
- B. Stop the transfusion and notify the physician.
- C. Increase the transfusion rate to complete it quickly.
- D. Administer acetaminophen for discomfort.
Correct Answer: B
Rationale: itching and hives indicate an allergic reaction; stopping the transfusion and notifying the physician is the priority