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While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HBsAg. The nurse recognizes that the client:
- A. Has chronic hepatitis B
- B. Has recovered from hepatitis B infection
- C. Has immunity to infection with hepatitis C
- D. Has no chance of spreading the infection to others
Correct Answer: A
Rationale: Presence of HBsAg indicates active hepatitis B infection, either acute or chronic, and potential infectivity.
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An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
- A. An alternate method should be tried prior to applying a restraint.
- B. Confused clients are almost always safer in restraints.
- C. Restraints must be removed and the client reassessed at least every 2 hours.
- D. A written policy for application of restraints must be in place.
- E. The most restrictive restraint should be applied.
- F. The nurse does not need an order for a restraint if the client is in danger.
Correct Answer: A,C,D
Rationale: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:
- A. Decrease respiratory effort and mucous production
- B. Increase efficiency of the diaphragm and gas exchange
- C. Dilate the bronchioles and help remove secretions
- D. Stimulate coughing and oxygen consumption
Correct Answer: C
Rationale: These therapies aim to dilate airways (via aerosols) and mobilize thick mucus (via percussion and drainage) to improve breathing in cystic fibrosis.
The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such clients is:
- A. Setting realistic limits
- B. Encouraging the client to express remorse for behavior
- C. Minimizing interactions with other clients
- D. Encouraging the client to act out feelings of rage
Correct Answer: A
Rationale: Setting realistic limits helps manage the manipulative and impulsive behaviors common in antisocial personality disorder, promoting safety and structure.
The nurse is preparing to administer a dose of regular insulin to a client based on a sliding scale. The client’s blood glucose is 320 mg/dL. The sliding scale orders 6 units of regular insulin for a blood glucose of 301–350 mg/dL. Which of the following actions should the nurse take?
- A. Administer 6 units of regular insulin.
- B. Administer 8 units of regular insulin.
- C. Withhold the insulin and notify the physician.
- D. Recheck the blood glucose in 30 minutes.
Correct Answer: A
Rationale: the sliding scale indicates 6 units for a blood glucose of 320 mg/dL, so the dose is correct
A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion?
- A. Vomiting, heart rate 120, chest pain
- B. Nausea, mild headache, bradycardia
- C. Respirations 16, heart rate 62, diarrhea
- D. Temp 101°F, tachycardia, respirations 20
Correct Answer: A
Rationale: Disulfiram causes a severe reaction with alcohol, including vomiting, tachycardia (HR 120), and chest pain due to acetaldehyde accumulation, making these symptoms most indicative.