Nokea
Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?
- A. Place HIV-positive clients in strict isolation and limit visitors.
- B. Wear gloves when coming in contact with the blood or body fluids of any client.
- C. Conduct mandatory HIV testing of those who work with clients with AIDS.
- D. Freeze HIV blood specimens at -70°F to kill the virus.
Correct Answer: B
Rationale: The correct answer is B. The CDC guidelines recommend that healthcare workers wear gloves when coming in contact with blood or body fluids from any client since HIV can be infectious before the client becomes aware of their exposure and/or symptomatic. Choice A is incorrect because placing HIV-positive clients in strict isolation and limiting visitors is not a standard practice for HIV infection control. Choice C is incorrect as mandatory HIV testing for those working with AIDS clients is not a CDC recommendation for routine infection control. Choice D is incorrect because freezing HIV blood specimens at -70°F does not kill the virus; HIV can remain infectious even at very low temperatures.
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After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?
- A. Report the findings to the surgeon.
- B. Irrigate the indwelling urinary catheter.
- C. Apply manual pressure to the bladder.
- D. Increase the IV flow rate for 15 minutes.
Correct Answer: A
Rationale: In this situation, the nurse's priority action should be to report the findings to the surgeon. An adult should typically produce about 60 ml of urine per hour, so a dark, concentrated, and low urine output of 54 ml over 2 hours raises concerns. This change in urine output may indicate issues such as dehydration, renal problems, or inadequate fluid intake. Reporting this finding to the surgeon is crucial to ensure appropriate evaluation and intervention. Irrigating the catheter, applying manual pressure to the bladder, or increasing the IV flow rate are not appropriate actions based on the information provided and could potentially worsen the situation.
What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?
- A. Instruct the client to focus on a distant object behind the examiner and not move their eyes during the exam.
- B. Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
- C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
- D. For optimal visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
Correct Answer: C
Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:
- A. Preparing the client for a perfusion scan
- B. Attaching the client to a cardiac monitor
- C. Administering oxygen via nasal cannula
- D. Ensuring that the intravenous (IV) line is patent
Correct Answer: C
Rationale: When a client who has just undergone surgery experiences sudden chest pain, dyspnea, and tachypnea, indicating possible pulmonary embolism, the immediate priority for the nurse is to administer oxygen via nasal cannula. This intervention aims to improve oxygenation and alleviate respiratory distress, which is crucial in the setting of a potential pulmonary embolism. Preparing the client for a perfusion scan is not the immediate priority as stabilizing the client's respiratory status comes first. While attaching the client to a cardiac monitor is important for monitoring, administering oxygen takes precedence in this situation. Ensuring IV line patency is relevant for overall client care but is not the priority when a client is experiencing respiratory distress requiring immediate intervention.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
- A. Use a laryngoscope to check for a foreign body lodged in the airway.
- B. Reposition the head to ensure that the airway is properly opened.
- C. Turn the client to the side and administer three back blows.
- D. Perform a finger sweep of the mouth to clear any obstructions.
Correct Answer: B
Rationale: The most common reason for inadequate lung aeration during CPR is the incorrect positioning of the head, leading to airway obstruction. Therefore, the initial action should be to reposition the head to open the airway properly and attempt to ventilate again. Using a laryngoscope to check for foreign bodies in the airway (Choice A) is not the first step and could delay crucial interventions. Turning the client to the side and administering back blows (Choice C) is not indicated in this scenario as the focus is on ventilating the lungs. Performing a finger sweep of the mouth (Choice D) is not recommended as it may push obstructions further into the airway during CPR.
A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide?
- A. Lymph node involvement is not significant.
- B. Small tumors are aggressive and indicate poor prognosis.
- C. The tumor's estrogen receptor guides treatment options.
- D. Stage I indicates metastasis.
Correct Answer: C
Rationale: Treatment decisions and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer.