Nokea
The nurse in an ambulatory care clinic is admitting a 27-year-old client with severe systemic lupus erythematosus (SLE). In assessing the client's health history, the nurse knows to question which of the following statements?
- A. I avoid being outside on sunny days.
- B. The medications I take make me bloated.
- C. My work schedule is down to four hours a day.
- D. I get an eye exam annually.
Correct Answer: D
Rationale: Annual eye exams may not be sufficient for SLE, as the condition and its treatments can cause frequent eye complications, requiring more regular monitoring.
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The nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge home. Which of the following statements by the client indicates a need for further teaching by the nurse?
- A. I do not need to limit my time in public places.'
- B. I may share food from serving dishes with others at a restaurant.'
- C. I may use public restrooms.'
- D. I may donate blood.'
Correct Answer: D
Rationale: AIDS patients cannot donate blood due to HIV transmission risk. Public activities and restrooms pose minimal risk, and sharing serving dishes is safe if not directly contaminated.
Which clients can be assigned to share a room in the emergency department during the disaster?
- A. A client having auditory hallucinations and the client with ulcerative colitis
- B. The client who is pregnant and the client with a broken arm
- C. A child who is cyanotic with severe dypsnea and a client with a frontal head injury
- D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct Answer: B
Rationale: The pregnant client and the client with a broken arm have stable conditions, making them suitable to share a room.
A client is admitted with suspected Legionnaires' disease. Which factor increases the risk of developing Legionnaires' disease?
- A. Treatment of arthritis with steroids
- B. Foreign travel
- C. Eating fresh shellfish twice a week
- D. Doing volunteer work at the local hospital
Correct Answer: A
Rationale: Steroid use increases the risk of Legionnaires' disease by suppressing the immune system, making individuals more susceptible to Legionella infection.
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
- A. Attempt to replace the cord
- B. Place the client on her left side
- C. Elevate the client's hips
- D. Cover the cord with a dry, sterile gauze
Correct Answer: C
Rationale: Elevating the hips relieves pressure on the prolapsed cord, maintaining fetal oxygenation.