Nokea
The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse's teaching?
- A. Adding fresh ground pepper to my food will improve the flavor.
- B. Meat should be thoroughly cooked to the proper temperature.
- C. Eating cheese and yogurt will prevent AIDS-related diarrhea.
- D. It is important to eat four to five servings of fresh fruits and vegetables a day.
Correct Answer: B
Rationale: Thoroughly cooking meat reduces the risk of foodborne infections, which is critical for clients with AIDS due to their weakened immune systems.
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The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.
- A. monitor daily weights and intake and output
- B. monitor serum electrolytes and glucose levels daily
- C. change IV tubing every 48 hours or per facility protocol
- D. change the IV site dressing every 24 hours or per facility protocol
- E. if TPN is unavailable, OK to give D10W or D20W until TPN becomes available
Correct Answer: A, B, C
Rationale: Monitoring weights, intake/output, electrolytes, glucose, and changing tubing per protocol are standard TPN management practices. Dressings are typically changed every 7 days or per protocol, and D10W/D20W are not suitable substitutes for TPN.
The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated with morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opioid analgesics?
- A. Naloxone (Narcan)
- B. Ketorolac (Toradol)
- C. Acetylsalicylic acid (aspirin)
- D. Atropine sulfate (Atropine)
Correct Answer: A
Rationale: Naloxone reverses opioid overdose, critical for managing respiratory depression from morphine.
The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?
- A. Allow the client to keep the plant
- B. Place the plant by the window
- C. Water the plant for the client
- D. Tell the family members to take the plant home
Correct Answer: D
Rationale: A low WBC (neutropenia) increases infection risk, so the plant, which may harbor bacteria or fungi, should be removed.
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.
The physician has ordered 2 units of whole blood for a client following surgery. To provide for client safety, the nurse should:
- A. Obtain a signed permit for each unit of blood
- B. Use a new administration set for each unit transfused
- C. Administer the blood using a $Y$ connector
- D. Check the blood type and Rh factor three times before initiating the transfusion
Correct Answer: B
Rationale: Using a new administration set for each unit prevents contamination and ensures accurate delivery, enhancing transfusion safety.