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The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first?
- A. Draw a serum for CD4 and complete blood count STAT.
- B. Administer oxygen to the client via nasal cannula.
- C. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB.
- D. Obtain a sputum specimen for culture and sensitivity.
Correct Answer: B
Rationale: Oxygen administration addresses immediate hypoxia in PCP, a priority per ABCs. Labs, antibiotics, and sputum collection are secondary.
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The nurse is caring for a client who has Systemic Inflammatory Response Syndrome (SIRS) following a major abdominal surgery. Which signs and symptoms would the nurse observe that indicate SIRS? Select all that apply.
- A. Bleeding times are increased and platelet counts decreased.
- B. Increased urine osmolality and decreased urine output.
- C. Four plus pitting edema of the lower extremities.
- D. Confusion, disorientation, delirium.
- E. Heart rate 78, blood pressure 124/84, and RR of 20.
Correct Answer: A,B,D
Rationale: SIRS presents with coagulopathy (bleeding/platelet issues), renal dysfunction (oliguria, high osmolality), and altered mental status. Pitting edema and normal vital signs are not diagnostic.
The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP washes her hands before and after performing vital signs on a client.
- B. The UAP dons sterile gloves prior to removing an indwelling catheter from a client.
- C. The UAP raises the head of the bed to a high Fowler's position for a client about to eat.
- D. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for catheter removal, risking improper technique and infection. Handwashing, Fowler’s position, and ice bag use are appropriate.
The nurse is caring for the client diagnosed with acquired immunodeficiency syndrome (AIDS) dementia. Which action by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse?
- A. The UAP is helping the client to sit on the bedside chair.
- B. The UAP is wearing sterile gloves when bathing the client.
- C. The UAP is helping the client shave and brush the teeth.
- D. The UAP is providing a back massage to the client.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for bathing, risking improper technique. Sitting, shaving, and massage are appropriate UAP tasks.
The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure?
- A. Monitor the client for hypotension.
- B. Apply pressure to the puncture site.
- C. Test the client's cerebrospinal fluid.
- D. Increase the client's fluid intake.
Correct Answer: D
Rationale: Increasing fluid intake post-lumbar puncture prevents spinal headache. Hypotension is not a primary concern, pressure is applied during the procedure, and CSF testing is lab-based.
The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included?
- A. Females taking birth control pills are protected from becoming infected with HIV.
- B. Protected sex is no longer an issue because there is a vaccine for the HIV virus.
- C. Adolescents with a normal immune system are not at risk for developing AIDS.
- D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.
Correct Answer: D
Rationale: Abstinence is the only certain way to prevent sexually transmitted HIV. Birth control pills, vaccines, and immune status do not eliminate risk.