Nokea
When planning care for a client who is HIV positive, the nurse should do what?
- A. Teach persons coming in contact with the client to wear a gown and mask at all times
- B. Teach persons to wear gloves when handling any of the client's body fluids
- C. Restrict visitors to immediate family
- D. Encourage the client to stay away from other persons as much as possible
Correct Answer: B
Rationale: Wearing gloves when handling body fluids follows standard precautions to prevent HIV transmission. Gowns and masks are not always necessary, and restricting visitors or isolating the client is not required.
You may also like to solve these questions
The client has undergone a lymph node biopsy to differentiate between Hodgkin’s and non-Hodgkin’s lymphoma. After reviewing the client’s lymph node biopsy results, which revealed that the client has Hodgkin’s lymphoma, the nurse should obtain which educational brochure?
- A. The brochure that includes an explanation of an elevated reticulocyte count
- B. The brochure that includes an explanation of CA-125 tumor markers
- C. The brochure that includes an explanation of an elevated WBC count
- D. The brochure that includes an explanation about Reed-Sternberg cells
Correct Answer: D
Rationale: A. Reticulocytes are found in a CBC, not from a lymph node biopsy, and are not indicative of either Hodgkin’s or non-Hodgkin’s lymphoma. B. CA-125 tumor markers are sometimes used in the management of ovarian cancer. C. WBCs are collected from a complete blood panel, not a lymph node biopsy, and could be indicative of other lymphomas and/or leukemia. D. The nurse should obtain the brochure that explains about Reed-Sternberg cells. The main diagnostic feature of Hodgkin’s lymphoma is the presence of Reed-Sternberg cells in a lymph node biopsy.
The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply.
- A. Monitor the client’s hemoglobin and hematocrit.
- B. Move the client to a room near the nurse’s desk.
- C. Limit the client’s dietary intake of green vegetables.
- D. Assess the client for numbness and tingling.
- E. Allow for rest periods during the day for the client.
Correct Answer: A,D,E
Rationale: Monitoring Hb/Hct (A), assessing numbness/tingling (D), and rest periods (E) address perfusion in anemia. Proximity to desk (B) is nonspecific, and limiting greens (C) is for anticoagulation, not anemia.
The client who was recently admitted with gastric cancer appears pale and weak and states feeling fatigued. In reviewing the client’s laboratory results, which component of the CBC should the nurse most associate with the client’s gastric cancer and identify as the causative factor for the fatigue?
- A. White blood cell 12,200/mm3
- B. Hemoglobin 7.9 g/dL
- C. Serum protein 5.9 g/dL
- D. Blood urea nitrogen 22 mg/dL
Correct Answer: B
Rationale: A. The elevation in the WBC (normal is 4500–10,000/mm3 or microL) is concerning because it could indicate an infection, but the elevation would not necessarily be related to the gastric cancer. B. The presenting symptoms are indicative of anemia, which is common in gastric cancer due to chronic blood loss, or as a result of pernicious anemia (due to loss of intrinsic factor). The low Hgb (normal is 12–15 g/dL) may be the causative factor for the fatigue. C. The serum protein is slightly low (normal is 6.0–8.0 g/dL) and could be indicative of nutritional problems associated with the gastric cancer, but it is not specific to the signs and symptoms described in the question, and it is not part of a CBC. D. The BUN (normal is 5–25 mg/dL) is within normal parameters and is measuring kidney function or hydration status. It is not part of the CBC.
The client who has renal cancer that has metastasized rates pain at a 9 on a 0 to 10 pain scale. Which medication should the nurse plan to administer now and then schedule to be administered at the prescribed dosing interval?
- A. Meperidine
- B. Propoxyphene
- C. Pentazocine
- D. Oxycodone
Correct Answer: D
Rationale: A. Meperidine (Demerol) is not recommended because it causes CNS toxicity from metabolites. It should not be used for the treatment of chronic pain. B. Propoxyphene
The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The crossmatch reveals the presence of antibodies that cannot be crossmatched. Which precaution should the nurse implement when initiating the transfusion?
- A. Start the transfusion at 10 to 15 mL/hr for 15 to 30 minutes.
- B. Re-crossmatch the blood until the antibodies are identified.
- C. Have the client sign a permit to receive uncrossmatched blood.
- D. Have the unlicensed assistive personnel stay with the client.
Correct Answer: A
Rationale: Uncrossmatched blood requires slow infusion (10–15 mL/hr) initially (A) to monitor reactions. Re-crossmatching (B) is impractical, consent (C) is for emergencies, and UAP (D) cannot monitor.