Nokea
The nurse is providing discharge instructions to a client with Clostridium difficile. Which of the following instructions should the nurse include?
- A. Your family will need prophylactic antibiotics for two weeks.
- B. Disinfect your countertops and other surfaces with isopropyl alcohol.
- C. Wear a disposable surgical mask when you are out in public.
- D. If possible, use chlorine bleach when laundering underwear.
Correct Answer: D
Rationale: Chlorine bleach is effective in killing Clostridium difficile spores during laundering, which is critical for preventing reinfection and spread.
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The nurse is triaging a client who reports recent international travel. The primary healthcare provider (PHCP) suspects the client may have severe acute respiratory syndrome (SARS). The nurse should initially
- A. place the client on contact and airborne precautions.
- B. obtain blood, urine, and sputum for culture.
- C. prepare the client for a chest radiograph (x-ray).
- D. infuse 0.9 saline at 100mL/hr.
Correct Answer: A
Rationale: SARS requires contact and airborne precautions to prevent transmission due to its respiratory spread.
The nurse is educating a client who has been prescribed acyclovir for newly diagnosed shingles. Which information would be the most important for the nurse to include?
- A. Take this medication 30 minutes before meals
- B. Continue taking this medication until the rash resolves
- C. If a dose is missed, take it with the next scheduled dose
- D. Increase fluid intake while taking this medication
Correct Answer: D
Rationale: Increasing fluid intake helps prevent nephrotoxicity, a potential side effect of acyclovir, which can affect kidney function, especially in patients with shingles who may be dehydrated.
The nurse is assessing a client with hepatitis A. Which of the following would be an expected finding? Select all that apply.
- A. Pruritus
- B. Bloody stools
- C. Abdominal pain
- D. Scleral icterus
- E. Periumbilical bruising
Correct Answer: A,C,D
Rationale: Pruritus, abdominal pain, and scleral icterus are common symptoms of hepatitis A due to liver inflammation and jaundice.
The nurse has instructed a client newly diagnosed with the human immunodeficiency virus (HIV). Which of the following statements by the client would indicate effective understanding? This disease is caused by a retrovirus leading to?
- A. encapsulation of CD4+ T-cells.
- B. inflammation of the CD4+ T-cells.
- C. abnormal proliferation of CD4+ T-cells.
- D. viral integration into the CD4+ T-cells.
Correct Answer: D
Rationale: HIV, a retrovirus, integrates its genetic material into CD4+ T-cells, leading to immune dysfunction.
The nurse in the emergency department (ED) is triaging a client who reports recent international travel to West Africa and has signs and symptoms of conjunctival injection, fever, rash, vomiting, and blood in their stool. The nurse is concerned that this client may have?
- A. pulmonary tuberculosis.
- B. encephalitis.
- C. Ebola virus disease.
- D. inhalation anthrax.
Correct Answer: C
Rationale: Ebola virus disease is associated with recent travel to West Africa and symptoms like fever, rash, vomiting, and hemorrhagic signs such as bloody stools.