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Which of the following clients, receiving normal saline via IV infusion, is at the highest risk for bloodstream infections?
- A. A client who has a midline IV catheter in the left antecubital fossa.
- B. A client with a peripherally inserted central catheter (PICC) line in the right upper arm.
- C. A client with an implanted port in the right subclavian vein.
- D. A client who has a non-tunneled central line in the left internal jugular vein.
Correct Answer: D
Rationale: Non-tunneled central lines, such as those in the internal jugular vein, carry the highest risk of bloodstream infections due to their direct access to central circulation and external exposure.
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The nurse is caring for a client with human immunodeficiency virus (HIV). Which of the following conditions, if present in the client, should make the nurse concerned about the client developing acquired immunodeficiency syndrome (AIDS)? Select all that apply.
- A. Chronic, progressive visual loss
- B. Kaposi's sarcoma
- C. Wilms sarcoma
- D. Pulmonary tuberculosis
- E. Peripheral neuropathy
- F. Toxoplasma gondii
Correct Answer: B,D,F
Rationale: Kaposi's sarcoma, pulmonary tuberculosis, and Toxoplasma gondii are AIDS-defining conditions indicating progression to AIDS.
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Note
Vital Signs
Client reports right elbow pain and swelling for three days. The client says that he scraped his elbow while rollerblading, and it has become painful and swollen for the past two days. He reports waking up with a fever of 101.3°F (38.5°C) and feeling lightheaded. On assessment, the client appeared lethargic and pale. The client has a full range of motion in the elbow but reports pain with movement. The client reports pain of '7' on a scale from 0-10. The elbow has erythema with a large red bump, swollen and hot to the touch. Clear lung fields bilaterally. S1/S2 heart tones. Normoactive bowel sounds. Denies nausea. History of asthma and seasonal
Allergies.
The nurse reports the assessment findings and vital signs to the primary healthcare provider (PHCP). Click to specify if the potential prescription is anticipated or contraindicated for this client.
- A. Obtain peripheral vascular access
- B. Administer albuterol via nebulizer
- C. Collect blood cultures
- D. Infuse hypertonic saline at 30 mL/kg
- E. Administer broad-spectrum antibiotics
- F. Collect serum lactic acid
Correct Answer: A: Anticipated, B: Contraindicated, C: Anticipated, D: Contraindicated, E: Anticipated, F: Anticipated
Rationale: A: Peripheral access is needed for diagnostics and treatment. B: Albuterol is not indicated without respiratory symptoms. C: Blood cultures identify the infection source. D: Hypertonic saline is inappropriate for this case. E: Broad-spectrum antibiotics treat suspected infection. F: Serum lactic acid assesses for sepsis.
The nurse is assessing a female client with syphilis. Which assessment finding would support this diagnosis?
- A. Dysuria
- B. Vaginal discharge
- C. Chancre lesion
- D. Dyspareunia
Correct Answer: C
Rationale: A chancre lesion is a hallmark sign of primary syphilis, appearing as a painless ulcer at the infection site.
The nurse has just completed a continuing education lecture regarding the human immunodeficiency virus (HIV). Which of the following statements by the nurse indicate correct understanding? Select all that apply.
- A. I will clean contaminated surfaces with soap and hot water.
- B. The goal of treatment is for the client's viral load to increase and CD4 cells to decrease.
- C. Pre-exposure prophylaxis (PREP) is available to those with risk factors for HIV.
- D. Vertical transmission (mother to fetus) may be reduced with the use of antiretrovirals.
- E. It is possible to spread the infection through contaminated water.
Correct Answer: C,D
Rationale: Pre-exposure prophylaxis (PrEP) is effective for high-risk individuals, and antiretrovirals reduce vertical transmission. HIV is not spread through water, and the treatment goal is to decrease viral load and increase CD4 cells.
The nurse is triaging a client who reports recent international travel. The primary healthcare provider (PHCP) suspects the client may have severe acute respiratory syndrome (SARS). The nurse should initially
- A. place the client on contact and airborne precautions.
- B. obtain blood, urine, and sputum for culture.
- C. prepare the client for a chest radiograph (x-ray).
- D. infuse 0.9 saline at 100mL/hr.
Correct Answer: A
Rationale: SARS requires contact and airborne precautions to prevent transmission due to its respiratory spread.