Nokea
The nurse is completing a client's intake and output record for the shift. How many mL should the nurse record as the client's net fluid balance for the shift?
Correct Answer: 890
Rationale: Without specific intake/output data, a general approach is assumed: net fluid balance is calculated as total intake (IV, oral, etc.) minus total output (urine, emesis, etc.). For example, if intake is 2000 mL and output is 1800 mL, the balance is 200 mL. The nurse must sum all recorded values accurately.
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The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
- A. Adhesive bandaging should remain on the lesions to prevent virus shedding
- B. Blood tests will be drawn to ensure that the virus is eradicated
- C. Condoms should be used during intercourse until the lesions are healed
- D. Gloves should be used to apply the medication to the lesions
Correct Answer: D
Rationale: Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorte
the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a
herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the
body even when active lesions are healed; however, it is still contagious, even when dormant. The infection
can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be
used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital
herpes; treatment is aimed at relieving symptoms and preventing the spread of infection
An adult who has cholecystitis reports clay-colored stools and moderate jaundice. The nurse knows that which is the best explanation for the presence of clay-colored stools and jaundice?
- A. There is an obstruction in the pancreatic duct.
- B. There are gallstones in the gallbladder.
- C. Bile is no longer produced by the gallbladder.
- D. There is an obstruction in the common bile duct.
Correct Answer: D
Rationale: Clay-colored stools and jaundice result from a common bile duct obstruction, preventing bile flow to the intestines and causing bilirubin buildup in the blood. The gallbladder stores, not produces, bile, and pancreatic or gallbladder issues are less directly related.
The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis?
- A. Anal itching that is worse at night
- B. Intestinal bleeding with anemia
- C. Poor appetite with weight loss
- D. Red, scaly, blistered rings on skin
Correct Answer: A
Rationale: Pinworms cause anal itching, worse at night (A), due to female worms laying eggs. Bleeding (B), appetite loss (C), and skin lesions (D) are not typical, suggesting other conditions like hookworms or dermatitis.
The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.
- A. Do not leave a tourniquet on more than 1 minute while looking for a vein
- B. Draw the specimen while the skin is still wet with the alcohol prep
- C. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes
- D. Use a highly visible vein on the ventral side of the client's wrist
- E. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution
Correct Answer: A,C
Rationale: A tourniquet left on too long (A) can cause hemoconcentration, so it should be removed after 1 minute. Pulsating blood (C) indicates arterial puncture, requiring immediate needle withdrawal and pressure to prevent hematoma. Wet alcohol (B) can cause hemolysis, and the ventral wrist (D) is a risky site due to nerves and arteries. Vigorous shaking (E) damages blood cells, so gentle inversion is preferred.
An adult has started on continuous ambulatory peritoneal dialysis. Which nursing instruction is of highest priority?
- A. Explain the principles of osmosis and diffusion and how dialysis works
- B. Teach the client aseptic technique
- C. Plan to withhold all drugs during dialysis
- D. Encourage the client to eat a high-sodium, high-potassium diet
Correct Answer: B
Rationale: Aseptic technique is critical in peritoneal dialysis to prevent peritonitis, a serious complication. Understanding dialysis mechanics, withholding drugs, or diet are secondary.