Nokea
The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first?
- A. Flush the skin with water and try to get the area to bleed.
- B. Notify the charge nurse and complete an incident report.
- C. Report to the employee health nurse for prophylactic medication.
- D. Follow up with the infection control nurse to have laboratory work done.
Correct Answer: A
Rationale: Flushing and inducing bleeding at the site immediately reduces viral load. Notification, prophylaxis, and lab work follow.
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Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply.
- A. Recommend the client not to engage in unprotected sexual activity.
- B. Instruct the client not to inform past sexual partners of HIV status.
- C. Tell the client to not donate blood, organs, or tissues.
- D. Suggest the client not get pregnant.
- E. Explain the client does not have to tell health-care personnel of HIV status.
Correct Answer: A,C,D
Rationale: Unprotected sex, blood/organ donation, and pregnancy risk HIV transmission or complications. Partner notification and informing healthcare personnel are recommended.
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 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.
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.
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.