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The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
- A. Has intercourse with just the spouse
- B. Makes a donation of a pint of whole blood
- C. Limits sexual contact to those without HIV antibodies
- D. Uses a'condom each time there is a sexual intercourse
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV.
2. It eliminates the risk of contracting HIV from multiple sexual partners.
3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV.
4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission.
Summary:
- Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV.
- Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.
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Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, “Why?” Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?
- A. Increased peristalsis
- B. Coughing
- C. Pneumonia
- D. Wound healing A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET K
Correct Answer: C
Rationale: The correct answer is C: Pneumonia. Early postoperative ambulation helps prevent pneumonia by promoting lung expansion, increasing oxygenation, and preventing atelectasis. A: Increased peristalsis is unrelated to ambulation. B: Coughing is important for airway clearance but not directly related to ambulation. D: Wound healing is influenced by various factors, but ambulation primarily impacts respiratory function.
Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Expiratory wheezes
- C. Friction rub
- D. Fluid in the involved area
Correct Answer: D
Rationale: The correct answer is D because pleural effusion is the accumulation of fluid in the pleural space. When auscultating the lungs of a client with pleural effusion, the examiner would note decreased or absent breath sounds over the area where the fluid has accumulated. This is due to the fluid blocking the transmission of sound through the lungs. Pronounced breath sounds (choice A) would not be present due to the fluid obstructing the normal sound transmission. Expiratory wheezes (choice B) are associated with airway obstruction, not fluid accumulation. Friction rub (choice C) is a dry, grating sound heard with inflammation of the pleura, not specifically related to pleural effusion.
What are the signs of organ rejection a nurse should closely monitor for when caring for a client after heart transplantation? Choose all that apply
- A. Low white blood cell count
- B. Dyspnea
- C. ECG changes
- D. Fever
Correct Answer: B
Rationale: The correct answer is B: Dyspnea. Dyspnea is a common sign of organ rejection after heart transplantation, indicating possible heart failure. Low white blood cell count (A) is not typically a direct sign of organ rejection. ECG changes (C) may occur but are not specific to organ rejection. Fever (D) is a non-specific symptom and can be caused by various factors. Dyspnea is a key indicator that the transplanted heart is not functioning properly and should be closely monitored.
The nurse knows which of the following is true about immunity?
- A. Antibody-mediated defense occurs through the T-cell system
- B. Cellular immunity is mediated by antibodies produced by the B-cells
- C. Antibodies are produced by the B-cells
- D. Lymphocytes increase with an allergic response
Correct Answer: C
Rationale: Rationale for Answer C: Antibodies are produced by the B-cells. B-cells are a type of lymphocyte that differentiate into plasma cells, which are responsible for producing antibodies in response to antigens. This process is a key component of the humoral immune response. Therefore, the statement that antibodies are produced by the B-cells is true.
Summary of Incorrect Choices:
A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity.
B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells.
D: Lymphocytes increasing with an allergic response is not directly related to the production of antibodies by B-cells. Allergic responses involve a different mechanism.
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
- A. Extremities
- B. Head
- C. Eyeball
- D. Chest and nostrils A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET L
Correct Answer: D
Rationale: The correct answer is D, "Chest and nostrils." This is because observing the movement of the chest and nostrils is the most reliable way to determine if a patient is breathing. The chest rises and falls with each breath, and the nostrils may flare or move as air is inhaled and exhaled. Monitoring these areas provides a direct indication of respiratory effort. Choices A, B, and C are incorrect because they do not directly reflect the act of breathing. Extremities, head, and eyeball movements are not reliable indicators of breathing function.