Nokea
If the nurse is providing education to a male client who is HIV positive, which of the following information should the nurse include? Select all that apply.
- A. Need to use condoms for every sexual encounter.
- B. Need to tell sexual or needle-sharing partners about HIV status.
- C. Signs and symptoms indicating increased viral load and infections.
- D. Importance of maintaining a healthy lifestyle.
- E. Availability of support groups.
Correct Answer: A,B,C,D,E
Rationale: HIV education includes condoms (A), disclosing status (B), monitoring symptoms (C), healthy lifestyle (D), and support groups (E) to manage disease and prevent transmission.
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A client has a rate-responsive permanent pacemaker in his upper chest. The nurse understands rate-responsive to mean which of the following?
- A. A pacemaker function prevents excessive changes in the pacing rate.
- B. The pacing rate increases above the normal pacing rate with sudden bradycardia.
- C. The pacemaker switches from atrial tracking mode to nontracking mode with atrial fibrillation.
- D. The pacing rate increases when the sensors note increased activity.
Correct Answer: D
Rationale: A rate-responsive pacemaker increases the pacing rate when sensors detect increased activity (D), mimicking normal heart rate response. Other options (A, B, C) describe different pacemaker functions.
The nurse is assessing a client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Hypovolemia causes hemoconcentration, increasing hematocrit (e.g., 55% is elevated). Potassium, urine specific gravity, and BUN within normal ranges don't confirm volume deficit.
A client is receiving end-of-life care and tells the nurse that he has not always lived the way he should have or treated his children well. Which of the following responses is the most appropriate?
- A. What kinds of things have you done?'
- B. There are things that you regret.'
- C. I'm sure those things don't matter anymore.'
- D. It's not too late to ask for forgiveness.'
Correct Answer: B
Rationale: Reflecting that the client has regrets (B) is empathetic and opens further discussion without judgment. Asking for details (A), dismissing concerns (C), or suggesting forgiveness (D) may not be appropriate.
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
- A. prepare to administer IV fluids
- B. notify the health care provider
- C. order a mechanical soft diet for the client
- D. administer the next dose of lithium when it is due
- E. observe the client for confusion and slurred speech
Correct Answer: A, B, E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity (therapeutic range: 0.6–1.2 mEq/L). The nurse should prepare IV fluids, notify the provider, and monitor for symptoms like confusion and slurred speech. A soft diet is unnecessary, and the next dose should be held.
A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is having the desired effect?
- A. Neutrophil count of 60%
- B. Basophil count of 0.5%
- C. Monocyte count of 2%
- D. Reticulocyte count of 1%
Correct Answer: D
Rationale: Increased reticulocyte count indicates effective B12 therapy for anemia.