Nokea
The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? Select all that apply.
- A. The client is pregnant.
- B. The client is an intravenous drug abuser.
- C. The client has multiple sexual partners.
- D. The client does not have available health care.
- E. The client does not have adequate bathroom facilities.
- F. The client spends her money on nonessential items.
Correct Answer: B,C,D
Rationale: IV drug use, multiple sexual partners, and lack of healthcare increase HIV risk. Pregnancy, bathroom facilities, and spending are not direct risk factors.
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The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement?
- A. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush.
- B. Notify the HCP for an order for an antifungal swish-and-swallow medication.
- C. Have the client gargle with an antiseptic-based mouthwash several times a day.
- D. Determine what types of food the client has been eating for the last 24 hours.
Correct Answer: B
Rationale: White, patchy lesions suggest oral candidiasis, common in AIDS, requiring antifungal medication. Brushing may worsen lesions, antiseptic mouthwash is insufficient, and diet history is secondary.
Which statement indicates the female client with systemic lupus erythematosus (SLE) understands the discharge instructions?
- A. I should wear sunscreen with at least a 5 SPF.
- B. I am not going to any activities with large crowds.
- C. I should not get pregnant because I have SLE.
- D. I must avoid using hypoallergenic products.
Correct Answer: C
Rationale: Avoiding pregnancy prevents SLE complications, indicating understanding. SPF 5 is inadequate, crowd avoidance is not standard, and hypoallergenic products are safe.
The nurse caring for a client diagnosed with Multi Organ Dysfunction Syndrome (MODS) is preparing to administer morning medications. Which medication would the nurse question?
- A. Cefazolin sodium IVPB every six (6) hours.
- B. Furosemide by mouth twice daily.
- C. Metoprolol IVP every four (4) hours and prn.
- D. Acetaminophen by mouth every four (4) hours prn.
Correct Answer: C
Rationale: Metoprolol IVP every 4 hours in MODS risks hypotension in cardiovascular dysfunction. Cefazolin, furosemide, and acetaminophen are appropriate.
The nurse is caring for a client diagnosed with Systemic Inflammatory Response syndrome after an extensive abdominal surgery. Which nursing interventions could prevent the development of Multi Organ Dysfunction Syndrome (MODS)?
- A. Place the client on strict intake and output.
- B. Administer pain medication via patient-controlled analgesia.
- C. Keep the head of the bed elevated at all times.
- D. Practice therapeutic communication.
Correct Answer: A
Rationale: Strict intake and output monitoring detects early renal dysfunction, preventing MODS progression. Pain control, head elevation, and communication are less specific.
The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Take with an over-the-counter medication for the stomach.
- B. Drink a full glass of water with each pill.
- C. If a dose is missed, double the medication at the next dosing time.
- D. Avoid taking the NSAID on an empty stomach.
Correct Answer: D
Rationale: Taking NSAIDs with food prevents gastric irritation. OTC stomach meds are not routine, water volume is secondary, and doubling doses is dangerous.