Nokea
The nurse is caring for a client with suspected acute rheumatic fever. Which of the following questions would be most important for the nurse to ask the client?
- A. Do you typically take all of your antibiotics when they are prescribed?
- B. Has anyone in your family had rheumatic fever?
- C. What has your temperature been over the past several days?
- D. Have you recently had a streptococcal throat infection?
Correct Answer: D
Rationale: Recent streptococcal infection (D) is the primary trigger for rheumatic fever, making it the most important question. Antibiotic compliance (A), family history (B), and fever (C) are relevant but less critical.
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Which of the following situations is most likely to produce sepsis in the neonate?
- A. Maternal diabetes
- B. Prolonged rupture of membranes
- C. Cesarean delivery
- D. Precipitous vaginal birth
Correct Answer: B
Rationale: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
The nurse is caring for a 12-month-old client who is HIV-positive and severely immunosuppressed. Which of the following scheduled immunizations should the nurse anticipate administering to the client? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis A
- C. Measles, mumps, rubella
- D. Pneumococcal conjugate vaccine
- E. Varicella
Correct Answer: A,D
Rationale: Hib (A) and PCV (D) are inactivated vaccines, safe for immunosuppressed children. MMR (C) and varicella (E) are live vaccines, contraindicated. Hepatitis A (B) is not routine at 12 months.
The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.
- A. Ensuring bed alarm remains activated
- B. Initiating an hourly rounding schedule
- C. Inserting an indwelling urinary catheter
- D. Moving client to a room close to the nurses' station
- E. Raising all side rails of the client's bed
Correct Answer: A,B,D
Rationale: Bed alarms (A), hourly rounding (B), and proximity to the nurses' station (D) enhance safety and monitoring. Catheters (C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.
The nurse is reviewing the medication administration record for a 70-year-old client. Which of the following prescribed medications places the client at increased risk for injury? Select all that apply.
- A. diphenhydramine
- B. amitriptyline
- C. simvastatin
- D. famotidine
- E. diazepam
Correct Answer: A,B,E
Rationale: Diphenhydramine (A), amitriptyline (B), and diazepam (E) cause sedation or confusion, increasing fall risk in the elderly. Simvastatin (C) and famotidine (D) do not significantly increase injury risk.
A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless and has been given IV morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas results best indicate that the client is in acute respiratory failure and needs immediate intervention?
- A. PaO2 49 mm Hg (6.5 kPa), PaCO2 60 mm Hg (8.0 kPa)
- B. PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa)
- C. PaO2 70 mm Hg (9.3 kPa), PaCO2 30 mm Hg (4.0 kPa)
- D. PaO2 86 mm Hg (11.5 kPa), PaCO2 25 mm Hg (3.33 kPa)
Correct Answer: A
Rationale: PaO2 < 50 mm Hg and PaCO2 > 50 mm Hg (A) indicate acute respiratory failure, requiring immediate intervention. Other options show less severe hypoxemia or normal values.