A client with newly diagnosed acquired immunodeficiency syndrome (AIDS) asks the nurse if it’s necessary to tell co-workers about the diagnosis. The nurse’s response is based on which correct understanding?
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Solution
Answer A is correct. AIDS is transmitted by transfer of blood and bodily fluids, not by casual contact. Answers B, C, and D are incorrect statements about AIDS. Some states require sexual contact notification; otherwise, confidentially is maintained.
A 45-year-old client returned from a colon resection 2 hours ago. Which vital signs indicate possible hemorrhagic shock?
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Solution
Answer D is correct. Vital sign changes with hemorrhagic shock are decreasing blood pressure with an increased heart rate. Answer A is a normal BP and heart rate. Answers B and C are abnormal vital signs but do not correlate with hemorrhagic shock.
A client has just returned from a bronchoscopy. Which safety measure is most important for the nurse to implement?
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Solution
Answer C is correct. A loss of gag reflex can occur due to the anesthetizing agent used for the tube insertion. It is most important to ensure an intact reflex before administering food or fluids because of the danger of aspiration. The position in answer A would be contraindicated because of possible increased secretions. Answer B would be instituted at a later time. Answer D would be necessary for clients with abdominal surgery
The nurse is administering digoxin (Lanoxin) to a client with congestive heart failure. What is the expected therapeutic effect of this drug?
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Solution
Answer A is correct. Digoxin (Lanoxin) increases the force of the contraction of the heart, thus increasing the cardiac output. Answer D is incorrect because Lanoxin increases cardiac output. Lanoxin slows the heart rate, making answer B incorrect. Answer C could result in a myocardial infarction and is not the effect of the drug.
What does the nurse recognize as the primary reason that food and fluids are withheld from clients with pancreatitis?
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Solution
Answer B is correct. Pancreatic enzyme secretion is activated by food and fluid. Therefore, keeping the client NPO will prevent the pancreas from secreting, resulting in decreased pain and damage to the pancreas. Answers A and D would produce negative outcomes and would have no relationship to why food and fluids are withheld. Because pancreatic enzymes are decreased by withholding food and fluids, answer C is incorrect.
The nurse is preparing to administer insulin to a diabetic. Ten units regular and 35 units of NPH are ordered. Which of the following is the proper procedure for drawing up the medications?
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Solution
Answer D is correct. When mixing insulins, air should be injected into both vials before drawing up the dose, and clear (Regular) insulin should be drawn up before cloudy (NPH). Answer A would require two injections, which is not necessary. Answers B and C are incorrect procedures because regular insulin, not NPH, should be drawn up first.
The nurse should assess a client who has a peptic ulcer for signs of bleeding. Which symptom would best indicate this complication?
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Solution
Answer A is correct. Melena is blood in the stools, which would occur with bleeding in the gastrointestinal tract due to a peptic ulcer. Answers B, C, and D are not specific to the GI system so are incorrect. Hematuria (blood in the urine) is not indicative of a peptic ulcer, blood from the lungs can occur as hemoptysis but is not related to this problem, and ecchymosis indicates bruising.
Which medication would the nurse expect to be prescribed for a client exhibiting tetany after thyroid surgery?
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Solution
Answer A is correct. Tetany is caused by a decrease in calcium. Answers B, C, and D are not used in the treatment plan for clients with hypocalcemia.
The nurse caring for a client with hyperthyroidism would expect which group of clinical manifestations to be exhibited?
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Solution
Answer C is correct. A hyperactive thyroid causes hypermetabolism and increased sympathetic nervous system activity. Weight gain occurs with hypothyroidism, making answer A incorrect. Although tachycardia occurs with hyperthyroidism, diuresis and hypokalemia do not, so answer D is incorrect. Dyspnea can occur with this disorder, but clients exhibit increased libido, making answer B incorrect.
The nurse is in the process of administering PO medications. Which of the following drugs should not be administered at the same time?
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Solution
Answer A is correct. Administering Levofloxacin (Levaquin) and Mylanta at the same time will decrease the absorption of the fluoroquinolones. The drug combinations in answers B, C, and D are not contraindicated because the drugs in each combination do not affect one another.