Nokea
Which client is at risk for opportunistic diseases such as pneumocystis pneumonia?
- A. The client with cancer who is being treated with chemotherapy
- B. The client with Type I diabetes
- C. The client with thyroid disease
- D. The client with Addison's disease
Correct Answer: A
Rationale: Chemotherapy suppresses the immune system, increasing the risk of opportunistic infections like pneumocystis pneumonia.
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The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved by rest.
Correct Answer: A
Rationale: Rest reduces spasticity and involuntary movements in cerebral palsy.
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
- A. Insulin requirements moderate as the pregnancy progresses.
- B. A decreased need for insulin occurs during the second trimester.
- C. Elevations in human chorionic gonadotrophin decrease the need for insulin.
- D. Fetal development depends on adequate insulin regulation.
Correct Answer: D
Rationale: Adequate insulin regulation is critical for fetal development in diabetic pregnancies.
A nurse is observing a local softball game when one of the players is hit in the nose with a ball. The player's nose is visibly deformed and bleeding. The best way for the nurse to control the bleeding is to:
- A. Tilt the head back and pinch the nostrils
- B. Apply a wrapped ice compress to the nose
- C. Pack the nose with soft, clean tissue
- D. Tilt the head forward and pinch the nostrils
Correct Answer: D
Rationale: Tilting the head forward and pinching the nostrils prevents blood from entering the airway and controls bleeding.
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.
The nurse has an order to administer 100 units of regular insulin in 500 mL of 0.9% NS to infuse at 12 units per hour. The nurse should program the IV pump to deliver how many mLs per hour?
Correct Answer: 60
Rationale: Concentration: 100 units/500 mL = 0.2 units/mL. To deliver 12 units/hour: 12 ÷ 0.2 = 60 mL/hour.