Nokea
The nurse has instructed a client newly diagnosed with the human immunodeficiency virus (HIV). Which of the following statements by the client would indicate effective understanding? This disease is caused by a retrovirus leading to?
- A. encapsulation of CD4+ T-cells.
- B. inflammation of the CD4+ T-cells.
- C. abnormal proliferation of CD4+ T-cells.
- D. viral integration into the CD4+ T-cells.
Correct Answer: D
Rationale: HIV, a retrovirus, integrates its genetic material into CD4+ T-cells, leading to immune dysfunction.
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The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 35-year-old male client with sepsis.
Item 1 of 1
Vital Signs
Orders
Laboratory Results
1744: T 102.5° F (39.2° C), P 112, RR 20, BP 90/60
The nurse should prioritize administering
- A. 0.9% sodium chloride (normal saline)
- B. acetaminophen.
- C. azithromycin.
- D. regular insulin
Correct Answer: A
Rationale: In sepsis, administering normal saline is a priority to restore intravascular volume and improve blood pressure.
The nurse is visiting the home of a client with Clostridium difficile. Which infection control measure should the nurse include?
- A. Ask the client to wear a surgical mask during the visit.
- B. Obtain vital signs with a disposable blood pressure cuff.
- C. Interview the client while maintaining 3 feet distance.
- D. Use sterile gloves when performing venipuncture.
Correct Answer: B
Rationale: Using a disposable blood pressure cuff prevents the spread of Clostridium difficile spores, which can persist on surfaces.
The nurse is assessing her prenatal client for sexually transmitted infections (STIs) by looking for risk factors. Which of the following are risks of acquiring an STI? Select all that apply.
- A. Low socioeconomic status
- B. A monogamous relationship
- C. A past history of working in the sex industry
- D. Illicit drug use
- E. History of cancer
- F. Previous history of STIs
Correct Answer: A,C,D,F
Rationale: Low socioeconomic status, sex work, illicit drug use, and previous STIs increase STI risk due to behavioral and social factors.
The nurse has attended a staff education program about indwelling urinary catheter-associated infections (CAUTI). Which nursing intervention is most effective in preventing a CAUTI in hospitalized clients?
- A. Implementing strict sterile technique during catheter insertion and maintenance.
- B. Using antibacterial indwelling urinary catheters for all clients requiring urinary catheterization.
- C. Limiting the duration of indwelling urinary catheter use and promptly removing them when no longer needed
- D. Administering prophylactic antibiotics to all clients with indwelling urinary catheters in place.
Correct Answer: C
Rationale: Limiting catheter duration is the most effective way to prevent CAUTI, as prolonged use increases infection risk.
The nurse is triaging a client who reports recent international travel. The primary healthcare provider (PHCP) suspects the client may have severe acute respiratory syndrome (SARS). The nurse should initially
- A. place the client on contact and airborne precautions.
- B. obtain blood, urine, and sputum for culture.
- C. prepare the client for a chest radiograph (x-ray).
- D. infuse 0.9 saline at 100mL/hr.
Correct Answer: A
Rationale: SARS requires contact and airborne precautions to prevent transmission due to its respiratory spread.