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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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What is the earliest clinical manifestation in a client with acute disseminated intravascular coagulation (DIC)?
- A. Severe shortness of breath.
- B. Bleeding without history or cause.
- C. Orthopnea.
- D. Hematuria.
Correct Answer: B
Rationale: DIC causes widespread clotting and bleeding due to consumption of clotting factors and platelets. The earliest manifestation is often unexplained bleeding, such as petechiae or oozing from venipuncture sites. Shortness of breath, orthopnea, and hematuria are later or less specific signs.
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution:
- A. Provide essential fatty acids.
- B. Provides extra carbohydrates.
- C. Promotes effective metabolism of glucose.
- D. Maintains a normal body weight.
Correct Answer: A
Rationale: Fat emulsion solutions in TPN provide essential fatty acids to prevent deficiency. They do not primarily provide carbohydrates, promote glucose metabolism, or maintain body weight. CN: Pharmacological and parenteral therapies; CL: Apply
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.
Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home?
- A. Supplement the diet with daily multivitamins.
- B. Limit daily alcohol intake.
- C. Take a sleeping pill at bedtime.
- D. Limit contact with other people whenever possible.
Correct Answer: A
Rationale: Multivitamins (A) support nutrition in cirrhosis. Alcohol (B) must be avoided entirely. Sleeping pills (C) risk encephalopathy. Social isolation (D) is unnecessary.