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 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.
The nurse is caring for an elderly woman who had surgery on her right foot yesterday. The woman had a broken left arm three months ago and has osteoarthritis. Which type of assistive device will probably be most appropriate for this client?
- A. Quad cane
- B. Crutches
- C. Walker
- D. Tripod cane
Correct Answer: C
Rationale: A walker provides maximum stability for an elderly woman with recent foot surgery, prior arm injury, and osteoarthritis, ensuring safe ambulation.
A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply.
- A. Desire for adoption planning services
- B. Emotional response to the pregnancy
- C. Family/social support systems
- D. Nutritional habits and substance use
- E. Plan for finishing high school
Correct Answer: A,B,C,D,E
Rationale: All topics are critical: adoption planning, emotional response, support systems, nutrition/substance use, and education planning address the client’s immediate and long-term needs in a sensitive, holistic manner.
The nurse should initiate discharge planning for a client
- A. When the client or family demonstrate readiness to learn self care modalities
- B. When informed that a date for discharge has been determined
- C. Upon admission to a hospital unit or the emergency room
- D. When the client's condition is stabilized on the assigned unit
Correct Answer: C
Rationale: Upon admission to a hospital unit or the emergency room. Early discharge planning ensures continuity of care with shorter hospital stays.