Nokea
The nurse at the prenatal clinic is reinforcing education to a client who is HIV positive. Which information is appropriate for the nurse to include?
- A. Prescribed antiretroviral therapy should be continued during pregnancy
- B. Tetanus-diphtheria-acellular pertussis vaccine should be avoided until after birth
- C. The infant should be exclusively breastfed for 6 months to receive maternal antibodies
- D. The infant will not require treatment for HIV after birth
Correct Answer: A
Rationale: Continuing antiretroviral therapy (A) during pregnancy reduces HIV transmission to the infant. Tdap vaccine (B) is recommended in pregnancy. Breastfeeding (C) is contraindicated in HIV-positive mothers in high-resource settings. Infants (D) require prophylaxis post-birth.
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The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first?
- A. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear
- B. 4-year-old post adenotonsillectomy who is now reporting ear pain
- C. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics
- D. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow
Correct Answer: A
Rationale: A foreign object in the ear (A) poses an immediate risk of injury or infection, requiring urgent attention. Ear pain post-adenotonsillectomy (B) is common and less urgent. School clearance (C) and returning to sports (D) are non-emergent.
There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles?
- A. A client diagnosed with varicella and a client with pertussis
- B. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure
- C. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum
- D. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis
- E. Two clients diagnosed with tuberculosis
Correct Answer: D
Rationale: PID and coffee ground emesis (D) are non-infectious, making them suitable roommates. Varicella, pertussis, TB (A, E), and COPD with sputum (C) pose infection risks. AIIR (B) is for airborne infections, incompatible with heart failure.
Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?
- A. Measure the vital signs
- B. Palpate the abdomen
- C. Assess for breath sounds
- D. Verify tube patency
Correct Answer: D
Rationale: Tube patency should be checked prior to all feedings. The feeding should not be attempted if the tube is not patent.
A client admitted to the floor 3 days after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's first action should be to:
- A. Apply O2 at 2 L/minute via mask.
- B. Begin chest compressions.
- C. Place the client in high Fowler's position.
- D. Administer a prescribed sedative.
Correct Answer: C
Rationale: The symptoms suggest a pulmonary embolus, a medical emergency. Placing the client in high Fowler's position facilitates breathing. Oxygen is secondary, chest compressions are inappropriate without cardiac arrest, and sedatives could worsen respiratory distress.
Prior to administering a feeding, the nurse checks for placement of a feeding tube. What is the best way to do this?
- A. Check for residual
- B. Measure the pH of aspirated gastrointestinal fluid
- C. Inject 10 to 20 mL of air while auscultating over the epigastric area
- D. Ask the client to talk or hum
Correct Answer: B
Rationale: Measuring the pH of aspirated fluid (pH <5.5) confirms gastric placement, the most reliable method to prevent aspiration.