Nokea
A student nurse caring for a client while wearing a gown and gloves in addition to following standard precautions.
The nurse should determine that care is appropriate if the student nurse performs which of the following activities?
- A. Gives isoniazid (INH) to a client with tuberculosis.
- B. Administers an IM injection to a client with rubella.
- C. Delivers a food tray to a client with hepatitis.
- D. Changes the dressing for a client with a draining abscess.
Correct Answer: D
Rationale: Strategy: Determine how the organism of each disease is spread. (1) requires airborne precautions, particulate respirator (2) requires droplet precautions, nurse should wear a mask (3) requires standard precautions (4) correct-requires contact precautions
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The family of a 48-year-old woman who has multiple sclerosis and spends most of her time in bed or in a chair asks the nurse why they have been told they should have her take deep breaths and cough frequently. What should the nurse include in the reply?
- A. Deep breathing and coughing will help her to move her secretions so she will not develop pneumonia.
- B. Deep breathing and coughing help to prevent clots from developing in the lung.
- C. When she coughs, she increases the amount of oxygen going to the brain, preventing confusion.
- D. Deep breathing increases blood flow to the brain and helps to keep her from getting depressed.
Correct Answer: A
Rationale: Immobility in multiple sclerosis increases pneumonia risk; deep breathing and coughing mobilize secretions, preventing respiratory infections.
The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. I should report chest pain to my doctor.
- C. I should avoid taking this with antacids.
- D. I should stop this medication if my thyroid levels are normal.
Correct Answer: D
Rationale: Stopping levothyroxine when thyroid levels are normal is incorrect, as hypothyroidism requires lifelong replacement therapy. Options A, B, and C are correct: empty stomach dosing improves absorption, chest pain may indicate overdose, and antacids interfere with absorption.
A client who has a panic disorder is receiving paroxetine HCl (Paxil). The client has been taking the drug for one week and is still having severe panic attacks. The client tells the nurse that she thinks the drug is not working. What is the best response for the nurse to make?
- A. You should ask your physician for a different drug.
- B. The physician will probably add another drug to your regimen.
- C. You should stop taking the medication if it is not effective.
- D. It takes two to four weeks for Paxil to be effective.
Correct Answer: D
Rationale: Paroxetine, an SSRI, requires 2-4 weeks to reach therapeutic effect for panic disorder, explaining the continued symptoms.
The newborn infant of an HIV-positive mother is admitted to the nursery.
- A. What should the nurse include in the plan of care for a newborn of an HIV-positive mother?
- B. Standard precautions.
- C. Test ing for HIV.
- D. Transfer to an acute care nursery facility.
- E. Request AZT from the pharmacy.
Correct Answer: A
Rationale: Standard precautions are the immediate priority to protect staff and others from potential HIV transmission. HIV Test ing and AZT may be considered later, and transfer is unnecessary without clinical indication.
A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse 'I've made some decisions about my life.' What should be the nurse's initial response?
- A. You've made some decisions.
- B. Are you thinking about killing yourself?
- C. I'm so glad to hear that you've made some decisions.
- D. You need to discuss your decisions with your therapist.
Correct Answer: B
Rationale: Are you thinking about killing yourself? This validates suicidal ideation to assess the seriousness of the risk.