Nokea
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.
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A throat culture is ordered for an adult who has a sore throat. The nurse asks the client if he has taken any medications to treat himself. Which medication, if reported by the client, would be of greatest concern to the nurse?
- A. Aspirin
- B. A throat lozenge
- C. Acetaminophen
- D. An antibiotic
Correct Answer: D
Rationale: Antibiotics can alter throat culture results by reducing bacterial growth, potentially leading to a false negative, the greatest concern.
The nurse is inserting an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? Select all that apply.
- A. Use the nondominant hand to gently spread the labia folds
- B. Apply sterile gloves and place the drape under the client's buttocks.
- C. Insert and advance the catheter 2 in (5 cm) and then inflate the balloon
- D. Place the client on the back with the knees flexed and hips rotated externally.
- E. Cleanse the labia majora and labia minora before cleansing the urinary meatus
Correct Answer: A,B,D
Rationale: Spreading labia aids visualization. Sterile gloves and drape maintain sterility. Proper positioning facilitates insertion. Advancing only 2 inches is insufficient (should be 5-7 cm) before balloon inflation. Cleansing should start with the meatus , not labia.
The nurse is administering a cleansing enema to a client the night before bowel surgery. When administering the enema, the client reports cramping and pain. Which of the following actions should the nurse take?
- A. Slowly raise the height of the solution container
- B. Tell the client that the process will not take much longer
- C. Temporarily stop instilling the solution, then resume at a slower rate
- D. Withdraw the tube approximately 2 cm and continue the instillation
Correct Answer: C
Rationale: Pausing and slowing the flow reduces cramping by allowing the bowel to adjust. Raising the container increases pressure, reassurance doesn't address pain, and withdrawing the tube is unnecessary.
A client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 160/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
- A. Potassium 5.2 mEq/l
- B. Calcium 13 mg/dl
- C. Inorganic phosphorus 1.7 mEq/l
- D. Sodium 138 mEq/l
Correct Answer: B
Rationale: Hypercalcemia is a common occurrence with cancer of the bone. The potassium level is elevated but does not relate to the diagnosis, so answer A is incorrect. Answers C and D are both normal levels, so they are incorrect.
Laboratory Results
Glucose - Fasting
70–110 mg/dL
(3.9–6.1 mmol/L) 650 mg/dL
(36.1 mmol/L)
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?
- A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours
- B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy
- C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L)
- D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure
Correct Answer: C
Rationale: 0.45% saline is appropriate for gastroenteritis to replace fluids. 0.9% saline bolus treats anaphylactic shock. Mannitol reduces intracranial pressure. A 1000 mL bolus for DKA is excessive; smaller boluses (e.g., 250-500 mL) are safer to avoid fluid overload.