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Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (AIDS)?
- A. Fever, cough, and shortness of breath.
- B. Oral thrush, esophagitis, and vaginal candidiasis.
- C. Abdominal pain, diarrhea, and weight loss.
- D. Painless violet lesions on the face and tip of nose.
Correct Answer: A
Rationale: Fever, cough, and shortness of breath indicate Pneumocystis pneumonia, the most common AIDS opportunistic infection. Candidiasis, GI symptoms, and Kaposi’s sarcoma are less frequent.
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The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
- A. Discuss the Myasthenia Foundation with the client's wife.
- B. Refer the client to a local myasthenia gravis support group.
- C. Ask the client's wife if she would like to talk to a counselor.
- D. Sit down and allow the wife to ventilate her feelings to the nurse.
Correct Answer: D
Rationale: Allowing the wife to ventilate feelings is therapeutic, addressing immediate emotional distress. Foundation discussion, support groups, and counseling are secondary.
The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention?
- A. The client's BP is 94/60 and AP is 112.
- B. Negative Chvostek's and Trousseau's signs.
- C. The serum potassium level is 3.5 mEq/L.
- D. Ecchymosis at the vascular site access.
Correct Answer: A
Rationale: Hypotension (BP 94/60) and tachycardia (AP 112) during plasmapheresis suggest hypovolemia or reaction, requiring immediate intervention. Negative signs, normal potassium, and ecchymosis are less urgent.
The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves?
- A. Use only sterile, nonlatex gloves for any procedure requiring gloves.
- B. Do not use gloves when starting an IV or performing a procedure.
- C. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform.
- D. Wear white cotton gloves at all times to protect the hands.
Correct Answer: C
Rationale: Carrying nonsterile, nonlatex gloves ensures safe practice for a latex-allergic nurse. Sterile gloves are unnecessary, avoiding gloves risks infection, and cotton gloves are inadequate.
The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse?
- A. Administer methotrexate, an antineoplastic medication, IV.
- B. Assess the lung sounds of a client with RA who is coughing.
- C. Demonstrate how to use clothing equipped with Velcro fasteners.
- D. Discuss methods of birth control compatible with treatment medications.
Correct Answer: C
Rationale: Demonstrating Velcro clothing is within LPN scope. Methotrexate administration, lung assessment, and birth control discussion require RN judgment.
The client diagnosed with Multiple Organ Dysfunction Syndrome (MODS) is admitted to the intensive care department. Which assessment data are most important for the nurse to collect/monitor?
- A. Lung sounds, heart sounds, and blood pressure.
- B. The client's psychological response to the illness.
- C. The client's family's expectations of the hospitalization.
- D. Amount of emesis, bile secretions, and mouth ulcers.
Correct Answer: A
Rationale: Lung sounds, heart sounds, and BP monitor respiratory, cardiac, and hemodynamic status, critical in MODS. Psychological, family, and GI data are secondary.