Nokea
The nurse is educating a group of caregivers about the West Nile virus. A participant asks, 'How can you get the West Nile virus?' The nurse explains that the virus can be transmitted by which source(s)?
- A. Mosquitoes
- B. Blood transfusions
- C. Transplanted organs
- D. Birds
- E. Horses
Correct Answer: A, B, C
Rationale: West Nile virus is transmitted by mosquitoes (A), blood transfusions (B), and organ transplants (C). Birds (D) and horses (E) are hosts but not direct vectors to humans.
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The nurse is assessing an adult female client for hypovolemia.
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Elevated hematocrit (55%) indicates hemoconcentration due to fluid loss in hypovolemia. Potassium (B) and BUN (D) are within normal ranges, and urine specific gravity (C) is normal, not elevated as expected in hypovolemia.
A client is admitted to the emergency department with a loss of consciousness with unknown etiology. The nurse expects to perform which laboratory test to assist in determining etiology?
- A. Total cholesterol
- B. Alkaline phosphatase
- C. Serum glucose
- D. Urinalysis
Correct Answer: C
Rationale: Serum glucose is critical to rule out hypoglycemia or hyperglycemia as causes of unconsciousness. Cholesterol (A), alkaline phosphatase (B), and urinalysis (D) are less urgent.
A client with a history of tuberculosis is admitted with complaints of hemoptysis. The nurse should give priority to:"
- A. Administering antibiotics
- B. Monitoring respiratory status
- C. Administering pain medication
- D. Monitoring blood pressure
Correct Answer: B
Rationale: Hemoptysis in tuberculosis indicates potential lung tissue damage, so monitoring respiratory status is critical to assess for airway compromise or worsening infection.
An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?
- A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.
- B. Disulfiram is most effective when prescribed as late as possible in a recovery program.
- C. Disulfiram works on the desensitization principle.
- D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.
Correct Answer: D
Rationale: When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. Disulfiram works on the classical conditioning principle. The effects of disulfiram can be felt when alcohol is ingested 1-2 weeks after disulfiram is discontinued.
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Palpate these pulses again in 15 minutes.
- B. Use a Doppler to determine presence and strength of these pulses.
- C. Document the finding that the pulses are not palpable.
- D. Call the physician and notify the physician of this finding.
Correct Answer: B
Rationale: Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present.