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The nurse is caring for clients in the student health center.
- A. What is the best response by the nurse to a client whose boyfriend Test ed positive for hepatitis B?
- B. That must have been a real shock to you.'
- C. You should be Test ed for hepatitis B.'
- D. You’ll receive the hepatitis B immune globulin (HBIG).'
- E. Have you had unprotected sex with your boyfriend?'
Correct Answer: D
Rationale: The nurse should first assess the client’s exposure risk, as hepatitis B is transmitted through sexual contact or parenteral routes. Asking about unprotected sex determines the need for Test ing or prophylaxis. Empathizing, recommending Test ing, or discussing HBIG are secondary to assessing exposure.
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When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing
- B. Ask the RN to assess the vital signs
- C. Measure the pulse oximetry
- D. Continue to monitor respirations
Correct Answer: D
Rationale: Continue to monitor respirations. A rate of 12/minute is acceptable post-cardioversion, requiring no immediate intervention.
The nurse is making patient assignments on the obstetrical unit.
Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrical unit from outpatient surgery?
- A. A patient at 16 weeks gestation admitted with hyperemesis receiving IV fluids.
- B. A patient at 26 weeks gestation in premature labor receiving terbutaline (Brethine).
- C. A patient at 32 weeks gestation with a placenta previa and ruptured membranes.
- D. A patient at 37 weeks gestation with pregnancy-induced hypertension and epigastric pain.
Correct Answer: A
Rationale: Strategy: LPN/LVN and 'pulled' RN receive stable patients with expected outcomes. (1) correct-monitor IV therapy, administer antiemetics and nutritional supplements (2) monitor patient's response to medication and the status of the fetus (3) prepare for delivery, closely monitor fetal response (4) indicates impending seizures, prepare for delivery
A client who is about to be discharged from the acute care facility is receiving warfarin (Coumadin). The nurse should plan to teach the client which of the following?
- A. Take the medication on a full stomach.
- B. Do not take any over-the-counter medications without checking with your physician.
- C. Take aspirin if you need an analgesic.
- D. Avoid prolonged exposure to the sun while taking warfarin.
Correct Answer: B
Rationale: Warfarin interacts with many over-the-counter medications, risking bleeding or reduced efficacy, so physician consultation is essential. Full stomach, aspirin, or sun exposure are not primary concerns.
A client is receiving a nitroglycerin infusion for unstable angina. What assessment would be a priority when monitoring the effects of this medication?
- A. Blood pressure
- B. Cardiac enzymes
- C. ECG analysis
- D. Respiratory rate
Correct Answer: A
Rationale: Since an effect of this drug is vasodilation, the client must be monitored for hypotension.
The nurse is caring for an adult who had a cervical laminectomy this morning. After an uneventful stay in the postanesthesia care unit, the client is returned to the nursing care unit. How should the client be positioned immediately upon return?
- A. Supine
- B. Prone
- C. Semi-reclining
- D. Side-lying
Correct Answer: C
Rationale: Semi-reclining reduces neck strain and swelling post-cervical laminectomy, promoting comfort and healing. Supine or prone may increase pressure, and side-lying is less optimal.