Nokea
The nurse is talking with a client who has human immunodeficiency virus (HIV). Which of the following statements by the client would indicate a correct understanding of the condition? Select all that apply.
- A. I should receive the influenza vaccine every year
- B. I will ask my roommate to clean the cat litter box for me
- C. I should ask for my steak to be cooked thoroughly with no pink inside
- D. I can eat the raw vegetables I grew in my garden if my HIV viral load is undetectable
- E. I will use bottled water when brushing my teeth if I travel to an area with poor sanitation
Correct Answer: A,B,C,E
Rationale: Flu vaccine, avoiding cat litter (toxoplasmosis risk), thorough cooking, and bottled water in unsanitary areas reduce infection risk in HIV. Raw vegetables pose a risk, even with undetectable viral load.
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The nurse is talking with a client who has breast cancer and is receiving tamoxifen. Which of the following statements by the client would require immediate follow-up?
- A. I have been experiencing frequent hot flashes
- B. I have been experiencing vaginal dryness
- C. I have had a decreased interest in sexual intercourse
- D. I have noticed that my menses are heavy
Correct Answer: D
Rationale: Heavy menses while on tamoxifen may indicate endometrial hyperplasia or cancer, a serious side effect requiring immediate evaluation. Hot flashes, vaginal dryness, and decreased libido are common, less urgent side effects.
Which tasks can the licensed practical nurse appropriately delegate to unlicensed assistive personnel? Select all that apply.
- A. Assist the nurse in ambulating a client 1 day post abdominal surgery
- B. Measure and empty drainage output into a bulb drain
- C. Monitor for redness and swelling at a client’s IV insertion site
- D. Provide extra blankets at the client’s request
- E. Take family members to the waiting room after a client goes into surgery
Correct Answer: A,B,D,E
Rationale: Assisting with ambulation, measuring drainage, providing blankets, and escorting family are within UAP scope with proper training. Monitoring IV sites requires nursing judgment and is not delegable.
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.
The nurse is talking with a client with unilateral facial paralysis. Which of the following statements by the client would require follow-up? Select all that apply.
- A. I may chew food on either side of my mouth because it does not hurt
- B. I need to use my fingers to close my eyelid after instilling eye drops
- C. I should prepare meals that include soft, high-calorie foods
- D. I will place tape on my affected eyelid before I go to sleep
- E. I will put ice on the affected side of my face when it hurts
Correct Answer: A,E
Rationale: Chewing on the affected side risks injury due to impaired sensation, and ice may worsen symptoms in conditions like Bell’s palsy. Closing the eyelid, taping at night, and soft foods are appropriate for facial paralysis management.
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.