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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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Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome?
- A. An exaggerated startle reflex and memory changes.
- B. Cogwheel rigidity and inability to initiate voluntary movement.
- C. Sudden severe unilateral facial pain and inability to chew.
- D. Progressive ascending paralysis of the lower extremities and numbness.
Correct Answer: D
Rationale: Guillain-Barré syndrome presents with ascending paralysis and numbness due to peripheral nerve demyelination. Startle reflex, rigidity, and facial pain suggest other conditions.
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.
Which referral should the nurse implement for a client with severe multiple allergies?
- A. Registered dietitian.
- B. Occupational therapist.
- C. Recreational therapist.
- D. Social worker.
Correct Answer: A
Rationale: A dietitian helps identify food allergens, critical for severe allergies. Other therapists are less relevant.
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 Multi Organ Dysfunction Syndrome (MODS) has renal, cardiovascular, and pulmonary dysfunction issues. Which statement by the nurse indicates an understanding of the client's prognosis?
- A. As long as the client is maintained on a ventilator, then the prognosis can be up to 60% recovery.
- B. The client will have less than a 2% potential for recovery from the MODS.
- C. When three or more body systems fail, the mortality rate can be 70% to 80%.
- D. More than one body system in failure reduces the recovery rate to 80% to 90%.
Correct Answer: C
Rationale: MODS with three or more organ failures has a 70–80% mortality rate. Ventilator use, 2% recovery, and 80–90% recovery are inaccurate.