Nokea
Which of the following is the best indicator of the diagnosis of HIV?
- A. White blood cell count
- B. ELISA
- C. Western Blot
- D. Complete blood count
Correct Answer: C
Rationale: The Western Blot is the most specific test for confirming HIV diagnosis after a positive ELISA.
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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 has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet?
- A. Cornflakes, whole milk, banana, and coffee
- B. Scrambled eggs, bacon, toast, and coffee
- C. Oatmeal, apple juice, dry toast, and coffee
- D. Pancakes, ham, tomato juice, and coffee
Correct Answer: C
Rationale: Oatmeal, apple juice, and dry toast are low in sodium and saturated fat, aligning with a DASH diet for hypertension management.
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
- A. Mydriatics to facilitate removal
- B. Miotic medications such as Timoptic
- C. A laser to smooth and reshape the lens
- D. Silicone oil injections into the eyeball
Correct Answer: A
Rationale: Mydriatics are used to dilate the pupil, facilitating lens removal during cataract surgery.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions by the nurse is correct?
- A. Administer the injection in the deltoid muscle.
- B. Massage the injection site after administration.
- C. Inject the medication into the abdomen, at least 2 inches from the umbilicus.
- D. Aspirate before injecting to check for blood return.
Correct Answer: C
Rationale: enoxaparin is administered subcutaneously in the abdomen, at least 2 inches from the umbilicus, without aspiration or massage
A nurse is working in the cardiac unit when a Code Pink (infant abduction) is called. Which action by the nurse is the best response to the code?
- A. nothing; she does not work in the pediatric area
- B. search in empty rooms or unlocked closets for the infant
- C. avoid taking the elevator down to the lab until the all clear is called
- D. stay alert for someone who matches the description of the person of interest
- E. tell the visitors that they must leave since a code was called for an infant abduction
Correct Answer: D
Rationale: Staying alert for a person of interest helps ensure hospital-wide vigilance during a Code Pink, regardless of the unit.