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When examining an 80-year-old client with chronic COPD receiving home health care, the nurse notes that over the previous 48 hours the client has developed scattered painful pustular lesions on the right arm near the elbow (see photo), on the back of the neck, the face, and on both legs. Which of the following does the nurse suspect is the most likely cause of the lesions?
- A. Psoriasis
- B. Herpes zoster
- C. MRSA
- D. Contact dermatitis
Correct Answer: C
Rationale: Painful pustular lesions in a client with chronic illness suggest MRSA (C), a common healthcare-associated infection. Psoriasis (A) presents with scaly plaques, herpes zoster (B) follows a dermatomal pattern, and contact dermatitis (D) is typically itchy, not pustular.
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A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
- A. Gastric distress
- B. Changes in hearing
- C. Red discoloration of body fluids
- D. Changes in color vision
Correct Answer: D
Rationale: Ethambutol can cause optic neuritis, leading to changes in color vision, a serious side effect requiring immediate medical attention.
The client with varicella will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Varicella (chickenpox) is a viral infection, and antivirals like acyclovir are commonly prescribed to reduce severity and duration.
The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions should the nurse implement?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with earphones.
- C. Instruct the client to ignore the voices completely.
- D. Ask the client to describe the voices in detail.
Correct Answer: B
Rationale: listening to music can distract the client and reduce the intensity of auditory hallucinations
The nurse is assessing a client with a history of heart failure who is receiving furosemide (Lasix). Which of the following findings would indicate a need to withhold the medication?
- A. Potassium level of 2.8 mEq/L.
- B. Blood pressure of 130/80 mmHg.
- C. Heart rate of 80 beats per minute.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: hypokalemia is a side effect of furosemide; a potassium level of 2.8 mEq/L is low and requires intervention before administering the medication
The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
- A. Allow the client to keep the fruit
- B. Place the fruit next to the bed for easy access by the client
- C. Offer to wash the fruit for the client
- D. Ask the family members to take the fruit home
Correct Answer: D
Rationale: A white blood cell count of 450 indicates severe immunosuppression, so the fruit should be removed to prevent infection from potential contaminants.