Nokea
The nurse is talking with a client recently diagnosed with HIV infection about home and lifestyle alterations. Which of the following statements indicate that the client correctly understands the teaching? Select all that apply.
- A. I should avoid eating raw or undercooked meats and eggs to prevent infections
- B. I need to make sure my family members understand not to borrow my shaving razors
- C. I do not need to use barrier methods of protection if my sexual partner is also HIV positive
- D. I have started to use latex-free condoms during sexual intercourse because I have a latex allergy
Correct Answer: A,B,D
Rationale: Avoiding raw foods, not sharing razors, and using latex-free condoms reduce infection and transmission risks. Barrier methods are still needed with HIV-positive partners to prevent superinfection.
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The nurse is assessing a client's home in preparation for discharge. Which of the following should be given priority consideration?
- A. Family understanding of client needs
- B. Financial status
- C. Location of bathrooms
- D. Proximity to emergency services
Correct Answer: A
Rationale: Functional communication patterns between family members are fundamental to meeting the needs of the client and family.
All of the following need to be done. Which should the nurse do first?
- A. A client who had surgery earlier today asks for pain medication.
- B. A client who is two days postoperative needs a dressing change.
- C. A client who had a cerebrovascular accident needs a bed bath.
- D. A client scheduled for surgery tomorrow needs an enema.
Correct Answer: A
Rationale: Pain management for a client post-surgery today is a priority to promote comfort and recovery. Dressing changes, bed baths, and preoperative enemas are less urgent.
The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate?
- A. Anticipate the use of clean technique during the circumcision
- B. Apply a snug-fitting diaper following the procedure
- C. Offer a bottle during the procedure
- D. Wrap the newborn’s upper body in a blanket for the circumcision
Correct Answer: D
Rationale: Wrapping the upper body keeps the newborn warm and secure during circumcision. Sterile technique is required, snug diapers risk irritation, and feeding during the procedure poses a choking risk.
The nurse reinforces teaching to a parent of a 2-month-old client regarding administration of an oral liquid medication. The nurse knows that the parent understands the teaching when the parent performs which action?
- A. Administers the medication in small amounts at the back of the cheek using a syringe
- B. Allows the client to sip the medication from a cup
- C. Expels the medication from a dropper onto the back of the tongue
- D. Mixes the medication in the infant’s bottle of formula
Correct Answer: A
Rationale: Administering small amounts at the back of the cheek with a syringe ensures safe delivery and reduces choking risk in a 2-month-old. Cups, tongue administration, and mixing with formula are unsafe or ineffective.
A laboring woman prefers to lie in the supine position during labor. The nurse teaches her that this is not a good position for which reason?
- A. It will cause more back pressure.
- B. Her baby will not come down well into the pelvis.
- C. Her blood pressure may drop and cause the baby's heart rate to drop.
- D. Contractions will be too close together, not giving her a rest.
Correct Answer: C
Rationale: Supine position can compress the vena cava, causing maternal hypotension and reduced fetal perfusion, leading to fetal heart rate drops.