Nokea
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.
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The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach?
- A. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in.
- B. The HIV virus can be eradicated from the host body with the correct medical regimen.
- C. It is difficult for the HIV virus to replicate in humans because it is a monkey virus.
- D. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.
Correct Answer: A
Rationale: HIV is a retrovirus that persists in the host, integrating into DNA. It cannot be eradicated, is not a monkey virus, and infects CD4 cells, not red blood cells.
The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected?
- A. Complete metabolic panel and liver function tests.
- B. Complete blood count and antinuclear antibody tests.
- C. Cholesterol and lipid profile tests.
- D. Blood urea nitrogen and glomerular filtration tests.
Correct Answer: B
Rationale: CBC and ANA tests detect anemia, leukopenia, and autoantibodies, supporting SLE diagnosis. Metabolic, lipid, and renal tests are less specific initially.
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.
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 is caring for clients on a medical floor. Which client should the nurse assess first?
- A. The client diagnosed with RA complaining of pain at a '3' on a 1-to-10 scale.
- B. The client diagnosed with SLE who has a rash across the bridge of the nose.
- C. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV.
- D. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.
Correct Answer: C
Rationale: Antineoplastic drugs (e.g., methotrexate) pose risks like toxicity, requiring immediate assessment. Mild pain, rashes, and scleroderma are less acute.