Nokea
The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?
- A. Suggest that the client take warm showers two times per day
- B. Add baby oil to the client's bath water
- C. Apply powder to the client's skin
- D. Suggest a hot-water rinse after bathing
Correct Answer: B
Rationale: Adding baby oil to bath water helps moisturize the skin and alleviate pruritis caused by hepatitis, as it soothes dry, itchy skin without causing irritation.
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The nurse is performing an admission for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet drug, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect requiring attention.
A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring efficacy while minimizing toxicity; a level of 20 mcg/mL is within this range.
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
- A. Allow her to choose what foods she will eat
- B. Provide activities to foster her self-identity
- C. Encourage her to participate in morning exercise
- D. Provide a private room near the nurse's station
Correct Answer: B
Rationale: Activities fostering self-identity address the underlying issues of low self-esteem and perfectionism common in anorexia nervosa.
Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
- A. A 28-year-old with a history of alcohol use during the pregnancy
- B. A 24-year-old with a history of diabetes mellitus
- C. A 30-year-old with a history of smoking during the pregnancy
- D. A 32-year-old with a history of pregnancy-induced hypertension
Correct Answer: B
Rationale: Maternal diabetes increases the risk of respiratory distress syndrome in infants due to impaired surfactant production from fetal hyperglycemia.
The nurse is seeing a client in the clinic who has shingles (herpes zoster). The client is concerned about spreading the disease to others. How should the nurse respond?
- A. It is only possible to have one episode of the disease.
- B. Persons with leukemia are at higher risk.
- C. Persons of all ages should receive the zoster vaccine (Zostavax).
- D. Persons between 30 and 40 years old are at high risk.
Correct Answer: B
Rationale: Shingles is contagious to immunocompromised individuals, such as those with leukemia, via contact with active lesions. The vaccine is recommended for older adults, not all ages, and recurrence is possible.