Nokea
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 35-year-old male client with sepsis.
Item 1 of 1
Vital Signs
Orders
Laboratory Results
1744: T 102.5° F (39.2° C), P 112, RR 20, BP 90/60
The nurse should prioritize administering
- A. 0.9% sodium chloride (normal saline)
- B. acetaminophen.
- C. azithromycin.
- D. regular insulin
Correct Answer: A
Rationale: In sepsis, administering normal saline is a priority to restore intravascular volume and improve blood pressure.
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The nurse is conducting a continuing education course on hepatitis B. It would be appropriate for the nurse to identify which complications are associated with hepatitis B? Select all that apply.
- A. hypertension
- B. hepatocellular carcinoma
- C. liver cirrhosis
- D. ascites
- E. thrombocytopenia
Correct Answer: B,C,D,E
Rationale: Hepatitis B can lead to hepatocellular carcinoma, liver cirrhosis, ascites, and thrombocytopenia due to chronic liver damage.
The nurse is providing discharge instructions to a client with hepatitis A. Which of the following instructions should the nurse include?
- A. You will need to take daily showers or baths with chlorhexidine.
- B. It is important to clean common surfaces with warm soapy water.
- C. You will need to have repeat stool testing to determine if you are still infectious.
- D. Check with your primary healthcare provider prior to taking any medications.
Correct Answer: D
Rationale: Clients with hepatitis A should consult their healthcare provider before taking medications due to potential liver toxicity risks.
The nurse is assessing a client with suspected Lyme disease. Which of the following findings would support a diagnosis of Lyme disease? Select all that apply.
- A. lymphadenopathy
- B. fatigue
- C. petechial rash
- D. arthralgias
- E. hemoptysis
Correct Answer: B,D
Rationale: Fatigue and arthralgias are common symptoms of Lyme disease, supporting the diagnosis.
The nurse is talking to a group of women about the dangers and ways of acquiring toxic shock syndrome (TSS). The nurse would mention that all of the following women have a high risk of acquiring TSS, except for:
- A. A teenage girl using an absorbent tampon.
- B. A 29-year-old woman using a cervical cap.
- C. A 31-year-old woman using a diaphragm.
- D. A 35-year-old woman using oral contraceptives.
Correct Answer: D
Rationale: Oral contraceptives do not increase the risk of TSS, unlike tampons, cervical caps, and diaphragms, which can promote bacterial growth if left in place too long.
The nurse is triaging a client who reports recent international travel. The primary healthcare provider (PHCP) suspects the client may have severe acute respiratory syndrome (SARS). The nurse should initially
- A. place the client on contact and airborne precautions.
- B. obtain blood, urine, and sputum for culture.
- C. prepare the client for a chest radiograph (x-ray).
- D. infuse 0.9 saline at 100mL/hr.
Correct Answer: A
Rationale: SARS requires contact and airborne precautions to prevent transmission due to its respiratory spread.