Nokea
In planning an educational session for a patient with HIV, the nurse would include which of the following as a method of transmission for HIV? i.Saliva iv.Semen ii.Tears v.Blood iii.Breast milk
- A. 1, 4, 2005
- B. 1, 2, 4, 5
- C. 3, 4, 2005
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: 3, 4, 2005. HIV can be transmitted through breast milk, blood, and semen due to the presence of the virus in these bodily fluids. Saliva, tears, and other body fluids do not typically contain enough of the virus to transmit HIV. Therefore, choices A, B, and D are incorrect as they include saliva, tears, and other non-transmissible fluids. It is crucial for the nurse to educate the patient on the modes of transmission to prevent the spread of HIV.
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A client has squamous cell cancer of the right lung that has metastasized to the brain. In addition to chemotherapy for lung cancer, the physician prescribes lomustine (CeeNU), 100 mg/m2 as a single dose, to treat the brain metastasis. What are the major administration and excretion routes of lomustine?
- A. Oral administration and urinary
- B. I.V. administration and urinary excretion
- C. I.V administration and fecal excretion
- D. Oral administration and fecal excretion
Correct Answer: B
Rationale: The correct answer is B: I.V. administration and urinary excretion. Lomustine is typically administered intravenously, allowing for rapid systemic distribution. The drug is metabolized in the liver and excreted primarily through the kidneys, thus the urinary route. This choice is correct as lomustine's pharmacokinetics align with this pattern.
A: Oral administration and urinary - While some drugs are administered orally, lomustine is not typically given orally due to poor bioavailability.
C: I.V. administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect.
D: Oral administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect.
A client who is receiving a blood transfusion begins to experience chills, shortness of breath, nausea, excessive perspiration, and a vague sense of uneasiness. What is the nurse’s first best action?
- A. Report the signs and symptoms to the
- B. Monitor the client’s vital signs
- C. Assess respiratory status
- D. Stop the infusion
Correct Answer: D
Rationale: The correct answer is D: Stop the infusion. This is the best action because the client is likely experiencing a transfusion reaction. Stopping the infusion immediately is crucial to prevent further complications. Reporting the signs and symptoms to the healthcare provider (A) can cause a delay in addressing the reaction. While monitoring vital signs (B) and assessing respiratory status (C) are important, stopping the infusion takes precedence to ensure the client's safety and prevent a severe reaction.
On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
- A. Radiation therapy
- B. Chemotherapy
- C. Major surgery
- D. None
Correct Answer: C
Rationale: The correct initial treatment for stage IV ovarian cancer is major surgery (Choice C). This is because at this advanced stage, surgery is typically performed to debulk the tumor and remove as much cancerous tissue as possible, followed by chemotherapy to target any remaining cancer cells. Radiation therapy (Choice A) is not typically the initial treatment for ovarian cancer. Chemotherapy (Choice B) is often used in combination with surgery, but surgery is usually the first line of treatment for stage IV disease. Choosing no treatment (Choice D) would be detrimental as the cancer is advanced and requires immediate intervention.
A 17-year-old student enters the emergency department with a nosebleed that won’t quit. Which of the following positions is recommended for the patient with a nosebleed?
- A. Lying down with feet elevated
- B. Sitting up with neck extended
- C. Lying down with a small pillow under the head
- D. Sitting up leaning slightly forward
Correct Answer: D
Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.
A patient was diagnosed with hiatal hernia. She frequently has regurgitation and a sour taste on his mouth especially after eating large meals. Which action by the client shows understanding of her treatment regimen?
- A. elevate her legs when she is sleeping
- B. drink more fluids with her meals
- C. increase the roughage in her diet
- D. avoid caffeine, alcohol, and chocolate
Correct Answer: D
Rationale: The correct answer is D: avoid caffeine, alcohol, and chocolate. This helps to reduce acid reflux symptoms associated with hiatal hernia. Caffeine, alcohol, and chocolate can relax the lower esophageal sphincter, leading to increased reflux. Elevating legs (choice A) does not address the underlying issue. Drinking more fluids (choice B) can exacerbate symptoms by increasing stomach volume. Increasing roughage (choice C) may worsen symptoms due to increased gastric distension. By avoiding triggers like caffeine, alcohol, and chocolate, the client can effectively manage her symptoms.