Nokea
The nurse is developing a care plan for a client with hepatitis A. The nurse knows that the primary routes of transmission of this hepatitis virus are which of the following? Select all that apply.
- A. sputum
- B. blood
- C. feces
- D. contaminated food
Correct Answer: C,D
Rationale: Hepatitis A is transmitted primarily via the fecal-oral route, through contaminated food or water (D) and feces (C).
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The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?
- A. Hyperventilation per mechanical ventilation
- B. Insertion of a ventricular shunt
- C. Furosemide (Lasix)
- D. Solu medrol
Correct Answer: A
Rationale: Hyperventilation reduces PaCO2, causing cerebral vasoconstriction, which decreases cerebral blood flow and edema. The other options address pressure or fluid but not vasoconstriction.
A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
- A. Reverse the direction of the blood flow
- B. Allow better blood supply to the lungs
- C. Relieve pressure on the ventricles
- D. Prevent the need for further correction
Correct Answer: B
Rationale: The modified Blalock-Taussig procedure creates a shunt to improve pulmonary blood flow in Tetralogy of Fallot, enhancing lung oxygenation.
A client with Lyme's disease is being treated with Achromycin (tetracycline HCl). The nurse should tell the client that the medication will be rendered ineffective if taken with:
- A. Antacids
- B. Salicylates
- C. Antihistamines
- D. Sedative-hypnotics
Correct Answer: A
Rationale: Antacids containing calcium, magnesium, or aluminum can bind tetracycline, reducing its absorption and effectiveness.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?
- A. A pair of forceps
- B. A torque wrench
- C. A pair of wire cutters
- D. A screwdriver
Correct Answer: B
Rationale: A torque wrench is needed to adjust and maintain the tension of crutchfield tongs for cervical stabilization.
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- A. Reluctance to swallow
- B. Drooling of blood-tinged saliva
- C. An axillary temperature of 99°F
- D. Respiratory stridor
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy indicates airway obstruction, a life-threatening complication requiring immediate reporting.