Nokea
An HIV-positive infant to receive an oral polio immunization.
Which of the following nursing actions is MOST appropriate?
- A. Wear gloves and a gown when administering the immunization.
- B. Administer the immunization as the infant is being discharged.
- C. Call the physician and discuss the rationale for the immunization.
- D. Administer the medication in the same manner as you would to any other infant.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the identified problem of the compromised immune system (2) does not address the identified problem of the compromised immune system (3) correct-polio vaccine contains live virus and should not be given to children who are immunocompromised (4) does not address the identified problem of the compromised immune system
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The nurse is caring for a client with a history of tuberculosis.
- A. Which precaution is most appropriate for a client with active tuberculosis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: D
Rationale: Airborne precautions are required for active tuberculosis to prevent transmission via respiratory droplets. Standard, droplet, and contact precautions are insufficient.
A client after an electroconvulsive therapy (ECT) treatment.
The nurse should report which observation to the client's physician?
- A. Headache.
- B. Disruption in short- and long-term memory.
- C. Transient confusional state.
- D. Backache.
Correct Answer: D
Rationale: Strategy: You are looking for something unexpected. (1) expected effect (2) expected effect (3) expected effect (4) correct-client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician
An adult is being worked up for a possible duodenal ulcer. The nurse knows that which data, if present, would be most consistent with a duodenal ulcer?
- A. Two hours after his last meal, the client says, 'I need to feed my ulcer.'
- B. The client complains of epigastric pain a half hour after eating.
- C. The client has clay-colored stools.
- D. The client complains of pain beneath the right shoulder blade after eating.
Correct Answer: A
Rationale: Duodenal ulcers typically cause pain 2-3 hours after eating, relieved by food ('feeding the ulcer'), unlike pain immediately after eating (gastric ulcer), clay stools (biliary issues), or shoulder pain (gallbladder).
The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent future asthmatic attacks.
- A. Which statement by the mother indicates the nurse should be most concerned?
- B. My son plays the tuba in the grade school band.'
- C. My son loves to help his dad rake leaves.'
- D. My son participates in after-school activities three days a week.'
- E. My son walks one mile to school every day with his friends.'
Correct Answer: B
Rationale: Raking leaves exposes the child to inhaled allergens like pollen and dust, which are primary asthma triggers. Playing the tuba, participating in activities, and walking are unlikely to trigger asthma unless exercise-induced, which is not indicated.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Syndeham's chorea?
- A. Irregular movements of the arms and legs and facial grimacing
- B. Painless swellings over the surface of the joints
- C. Faint areas of red demarcation over the back
- D. Swelling and inflammation of the joints
Correct Answer: A
Rationale: Syndeham's chorea is characterized by irregular, involuntary movements and facial grimacing, so A is correct. Answers B, C, and D describe other rheumatic fever symptoms but not chorea.