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The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or dehydration, requiring urgent attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical symptoms.
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The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply.
- A. I will need to dispose of my old clothing when I return home.
- B. I should always cover my mouth and nose when sneezing.
- C. I'll be important that I isolate myself from family when possible.
- D. I should use paper tissues to cough in and dispose of them promptly.
- E. I can use regular plates and utensils whenever I eat.
Correct Answer: B,D,E
Rationale: Covering the mouth when sneezing (B), using tissues for coughing and disposing of them (D), and using regular utensils (E) prevent tuberculosis spread. Disposing of clothing is unnecessary. Isolation is only needed until the client is non-infectious (after 2–3 weeks of treatment).
The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? Select all that apply.
- A. Avoiding being silhouetted against strong light.
- B. Not blocking out the person's view of the speaker's mouth.
- C. Facing the client when talking.
- D. Having bright light behind so the individual can see.
- E. Ensuring the client is familiar with the subject material before discussing.
- F. Talking to the client while doing other nursing procedures.
Correct Answer: A,B,C
Rationale: To facilitate lip-reading, the nurse should avoid strong backlighting, not block the view of the mouth, and face the client directly to ensure clear visibility of facial expressions and lips.
An overweight client taking warfarin (Coumadin) has a nursing diagnosis of ineffective tissue perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin
- B. Encourage a reduced-calorie, reduced-fat diet
- C. Inspect the involved areas daily for new ulcerations
- D. Instruct the client to limit activities of daily living (ADLs)
- E. Use an electric razor to shave
Correct Answer: B,C,E
Rationale: Rationales: B) A reduced-calorie, reduced-fat diet helps manage weight and reduce atherosclerosis progression, improving arterial blood flow. C) Daily inspection for ulcerations is essential in PVD to detect early skin breakdown due to poor perfusion. E) Using an electric razor minimizes the risk of cuts and bleeding, which is critical for a client on warfarin. A) Applying lanolin or petroleum jelly is not directly related to improving tissue perfusion. D) Limiting ADLs is incorrect, as moderate activity promotes circulation unless contraindicated.
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?
- A. To promote oxygen intake.
- B. To strengthen the diaphragm.
- C. To strengthen the intercostal muscles.
- D. To promote carbon dioxide elimination.
Correct Answer: D
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.
The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication?
- A. valacyclovir
- B. zidovudine
- C. amphotericin b
- D. metronidazole
Correct Answer: B
Rationale: Zidovudine (AZT) is used during labor in HIV-positive clients to reduce the risk of perinatal transmission of HIV. Choice A (valacyclovir) is for herpes, Choice C (amphotericin B) is for fungal infections, and Choice D (metronidazole) is for bacterial/parasitic infections.