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The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?
- A. Universal blood and body fluid precautions
- B. Body systems isolation
- C. Laminar flow room during active infection
- D. Needle and syringe precautions
Correct Answer: A
Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious.
Incorrect choices:
B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC.
C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV.
D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.
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The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.
For which of the following problems should the nurse monitor in the patient with multiple myeloma?
- A. Uncontrolled bleeding
- B. Liver engorgement
- C. Respiratory distress
- D. Pathological fractures
Correct Answer: D
Rationale: The correct answer is D: Pathological fractures. In multiple myeloma, abnormal plasma cells can weaken the bones, leading to fractures even with minimal trauma. The nurse should monitor for signs of bone pain, decreased mobility, and pathological fractures to prevent complications.
Uncontrolled bleeding (A) is not typically associated with multiple myeloma. Liver engorgement (B) is more commonly seen in conditions like congestive heart failure or liver disease. Respiratory distress (C) is not a common manifestation of multiple myeloma.
Therefore, the nurse should focus on monitoring for pathological fractures as a priority in a patient with multiple myeloma.
A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:
- A. Maintain standard precautions
- B. Prepare for the possibility that the baby may be delivered by CS.
- C. Notify the obstetrician and nurse midwife about the vesicles as soon as possible.
- D. Apply antibiotic ointment to the vesicles and place the mother in reverse isolation
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor.
2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences.
3. Standard precautions should always be maintained to prevent the spread of infections.
4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.
A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?
- A. Comply with the timing of antiviral medication around meals
- B. Avoid exposure to harsh sunlight for about 2hrs after taking the medication
- C. Have the medications with plenty of fruit juice
- D. Have an increased dose of the medications if the symptoms worsen
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Timing: Antiviral medications should be taken as prescribed to maintain consistent drug levels in the body.
2. Around meals: Taking medications with or without food can affect absorption, so timing around meals helps with consistency.
3. Compliance: Following the timing instructions increases medication effectiveness and reduces the risk of drug resistance.
Other Choices:
B) Avoiding harsh sunlight: Not directly related to medication administration; may be a precaution for other reasons.
C) Having medications with fruit juice: This is not a standard instruction for antiviral medications; may not be suitable for all medications.
D) Increasing dose for worsening symptoms: This is dangerous and should only be done under healthcare provider supervision; self-adjusting medication doses can be harmful.
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
- A. Increased weight, hypertension, and insomnia
- B. Vaginal bleeding, jaundice, and inflammation
- C. Stupor, breast lumps, and pain
- D. Dyspnea, numbness, and headache
Correct Answer: A
Rationale: The correct answer is A. Prednisone is a corticosteroid that can cause adverse reactions such as increased weight due to fluid retention, hypertension due to sodium retention, and insomnia due to its stimulating effects. Vaginal bleeding, jaundice, inflammation, stupor, breast lumps, pain, dyspnea, numbness, and headache are not commonly associated with prednisone use. Monitoring for weight changes, blood pressure, and sleep patterns is essential when administering prednisone to a client with rheumatoid arthritis for early detection and management of adverse reactions.