Nokea
The nurse is seeing a client in the clinic who complains of a sore throat. The client asks for an antibiotic. How should the nurse respond? Select all that apply.
- A. You can try gargling with warm saline to relieve the discomfort.
- B. You should use a dehumidifier to dry out the air, which will soothe the throat.
- C. Most sore throats are caused by viruses, which cannot be treated with antibiotics.
- D. There are three or four antibiotics that we prescribe for a sore throat, so the doctor will decide which one you need.
- E. You should increase your fluid intake. Drink lots of water and try warm soup to help with the discomfort.
Correct Answer: A,C,E
Rationale: Gargling with saline (A), explaining viral etiology (C), and increasing fluids (E) are appropriate. Dehumidifiers (B) worsen throat dryness, and antibiotics (D) are not indicated without bacterial confirmation.
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The nurse is preparing to administer cefazolin to a client who is allergic to penicillin. The client states that penicillin causes him to itch and be slightly short of breath. Which response by the nurse is correct?
- A. administer the cefazolin as ordered
- B. call the pharmacy to substitute another medication
- C. hold the medication and notify the health care provider
- D. give the client diphenhydramine and then administer the cefazolin
Correct Answer: C
Rationale: Penicillin allergy with respiratory symptoms indicates potential cross-reactivity with cefazolin. Holding the medication and notifying the provider (C) is safest. Administering (A, D) risks anaphylaxis, and pharmacy substitution (B) requires a provider order.
The ED nurse receives a client who is bleeding profusely from a gunshot wound. Which action by the nurse will best help this client avoid complications of extreme blood loss?
- A. draw a type and match
- B. administer type O blood
- C. administer type AB+ blood
- D. ask the family to donate blood
Correct Answer: B
Rationale: Type O blood (B) is the universal donor and can be given immediately to prevent complications from blood loss. Type and match (A) delays treatment, AB+ (C) is not universal, and family donation (D) is impractical acutely.
The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm X 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. unstageable
Correct Answer: D
Rationale: A full-thickness wound with black collagen (eschar) is unstageable (D) because the depth cannot be assessed. Stage I (A) is non-blanchable redness, Stage II (B) is partial thickness, and Stage III (C) is full thickness without eschar.
The nurse is caring for a client who is HIV positive and gave birth to a full-term infant. The nurse is teaching the client about infections in HIV-positive infants. Which infection does the nurse understand is the most common opportunistic infection in children and infants with HIV?
- A. hepatitis C
- B. strep throat
- C. cytomegalovirus infection
- D. Pneumocystis jiroveci pneumonia
Correct Answer: D
Rationale: Pneumocystis jiroveci pneumonia (D) is the most common opportunistic infection in HIV-positive infants due to immune suppression. Hepatitis C (A), strep throat (B), and CMV (C) are less frequent.
Which assessment finding in a client with chronic kidney disease indicates late-stage symptoms?
- A. shortness of breath
- B. oliguria
- C. tea-colored urine
- D. edema in lower extremities
Correct Answer: B
Rationale: Oliguria (B) is a late-stage symptom of CKD due to severe renal impairment. Shortness of breath (A), edema (D), and tea-colored urine (C) occur earlier.