Nokea
Which response by the nurse provides the best clarification about the disease process?
- A. If you're afraid of getting HIV, you'll be safer if you avoid having sex with past sex partners.
- B. An HIV-positive individual may not develop symptoms of AIDS for years.
- C. HIV can only be transmitted when symptoms of AIDS are present.
- D. The medication prescribed for AIDS also protects against HIV infection.
Correct Answer: B
Rationale: HIV can be asymptomatic for years, during which it is still transmissible, making this clarification critical for understanding the disease process and transmission risk.
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Which nursing interventions are essential to restore the child's fluid and electrolyte balance during the emergent phase of burn care and treatment? Select all that apply.
- A. Initiate the administration of I.V. fluids.
- B. Track the child's vital signs.
- C. Give the child sips of water.
- D. Encourage the child to consume protein-rich feedings.
- E. Monitor the child's urine output.
- F. Assemble equipment for a small-gauge venous catheter.
Correct Answer: A,B,E,F
Rationale: During the emergent phase, I.V. fluids restore fluid and electrolyte balance due to massive losses. Monitoring vital signs and urine output assesses fluid status, and preparing venous access ensures timely administration. Oral fluids and protein-rich feedings are inappropriate due to gastrointestinal dysfunction.
Which finding best indicates that a school-age child has acute glomerular nephritis?
- A. Periorbital edema
- B. Excessive urination
- C. Increased appetite
- D. Low blood pressure
Correct Answer: A
Rationale: Periorbital edema is a classic sign of acute glomerular nephritis due to fluid retention from impaired glomerular filtration, reflecting reduced sodium and water excretion.
The physician orders I.V. insulin, and the registered nurse (RN) prepares to give it. The licensed practical nurse (LPN) is assisting the RN with the unstable client. Which of the following types of insulin should the LPN anticipate that the physician will order?
- A. Regular insulin (Humulin R)
- B. Isophane insulin suspension (Humulin N)
- C. Insulin aspart (NovoLog)
- D. None of the above
Correct Answer: A
Rationale: Regular insulin (Humulin R) is used for I.V. administration in DKA because it has a rapid onset and can be titrated to manage hyperglycemia effectively. Other insulins, like NPH or aspart, are not suitable for I.V. use.
Which dietary recommendation should the nurse provide to the parents of a child with iron deficiency anemia?
- A. Increase intake of red meat and leafy greens.
- B. Offer more dairy products like milk and cheese.
- C. Provide high-sugar snacks to boost energy.
- D. Limit consumption of whole grains.
Correct Answer: A
Rationale: Red meat and leafy greens are rich in iron, which is essential for correcting iron deficiency anemia by boosting hemoglobin production.
The nurse is reviewing the following labor history of a postpartum mother: “Mother positive for group B streptococcal (GBS) infection at 37 weeks’ gestation. Membranes ruptured at home 14 hours before presentation to the hospital at 40 weeks’ gestation. Precipitous labor,no antibiotic given.” Considering this information the nurse should observe her 15-hour-old newborn closely for which finding?
- A. Temperature instability
- B. Pink stains in the diaper
- C. Meconium stools
- D. Presence of erythema toxicum
Correct Answer: A
Rationale: GBS infection risk increases with prolonged membrane rupture and no antibiotics with temperature instability as an early symptom. Pink stains meconium and erythema toxicum are normal.