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The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is key for hepatitis A, syringe disposal (B) applies to needle-sharing, and alpha-interferon (C) is a treatment, not a preventive measure.
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During the preoperative interview, the nurse obtains information about the client's medication history. Which of the following is not necessary to record about the client?
- A. Current use of medications, herbs, and vitamins.
- B. Over-the-counter medication use in the last 6 weeks.
- C. Steroid use in the last year.
- D. Use of all drugs taken in the last 18 months.
Correct Answer: D
Rationale: Recording all drugs taken in the last 18 months is excessive, as many may no longer be relevant to surgical risks. Current medications, recent over-the-counter drugs, and steroid use are critical due to their potential impact on surgery.
On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dL. The nurse should:
- A. Withhold all medications as ordered.
- B. Administer the insulin dose dictated by the sliding scale.
- C. Call the physician for specific orders based on the glucose level.
- D. Notify the surgery department.
Correct Answer: C
Rationale: A glucose level of 300 mg/dL indicates significant hyperglycemia, which poses risks during surgery. Calling the physician for specific orders ensures appropriate insulin administration while adhering to NPO and surgical protocols.
A client with terminal cancer wishes to die at home. The nurse should:
- A. Arrange for home hospice services.
- B. Encourage hospitalization for better care.
- C. Advise against it due to lack of equipment.
- D. Inform the client it's not possible.
Correct Answer: A
Rationale: Arranging home hospice services supports the client's wish to die at home, providing necessary care and support in a comfortable environment.
The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?
- A. 59 mg/dL.
- B. 75 mg/dL.
- C. 108 mg/dL.
- D. 119 mg/dL.
Correct Answer: A
Rationale: A blood glucose level of 59 mg/dL is below the normal range (<70 mg/dL) and indicates hypoglycemia, requiring immediate intervention.
One goal of care for a client with PVD is to decrease anxiety, so as to decrease or prevent vasoconstriction of the:
- A. Arteries
- B. Capillaries
- C. Lymphatics
- D. Veins
Correct Answer: A
Rationale: Anxiety can trigger sympathetic nervous system activation, causing arterial vasoconstriction, which worsens ischemia in PVD. Reducing anxiety helps maintain arterial dilation and blood flow. Capillaries, lymphatics, and veins are less affected by this mechanism.