Which of the following is the best indicator of the diagnosis of HIV?
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Solution
Answer C is correct. The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500 requires investigation. The ELISA test, answer B, is a screening exam. Answer D is not specific enough.
The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client?
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Solution
Answer A is correct. The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and symptoms include elevated temp-erature, headache, nausea, and the rash. Although answers B and D are important, the question asks which would be best. Answer C has no significance.
The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?
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Solution
Answer C is correct. The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse.
The client arrives in the emergency room with a hyphema. Which action by the nurse would be best?
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Solution
Answer A is correct. Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem.
The client has an order for FeSo4 liquid. Which method of administration would be best?
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Solution
Answer C is correct. FeSO4 or iron should be given with ascorbic acid (vitamin C). This helps with the absorption. It should not be given with meals or milk because this decreases the absorption; thus, answers A and B are incorrect. Giving it undiluted, as stated in answer D, is not good because it tastes bad.
The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
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Solution
Answer C is correct. The best protector for the client with an ileostomy to use is stomahesive. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileostomy. Neosporin, answer D, is not used to protect the skin because it is an antibiotic.
Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which of the following reasons?
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Solution
Answer D is correct. Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks vitamin K needed for clotting. Answer A is incorrect because vitamin K is not directly given to prevent dehydration, but will facilitate clotting.Answers B and C are incorrect because vitamin K does not prevent infection or replace electrolytes.
Before administering Methytrexate orally to the client with cancer, the nurse should check the:
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Solution
Answer D is correct. The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because it is not necessary to check the electrolytes or blood gasses.
The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:
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Solution
Answer C is correct. Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect.
The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect?
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Solution
Answer B is correct. Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect because the position of the uterus is not related to the use of Pitocin.