Nursing Elites

1. The client is being taught about the use of Rifampin for prophylaxis following exposure to meningitis. What change in bodily functions should the client be informed about?

• A. The client's urine may turn blue.
• B. The client remains infectious to others for 48 hours.
• C. The client's contact lenses may be stained orange.
• D. The client's skin may take on a crimson glow.

Correct answer: C

Rationale: Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained. Clients should be taught about these side effects to avoid unnecessary concern. Option A is incorrect as Rifampin does not cause the urine to turn blue. Option B is incorrect as the client is not infectious to others due to taking Rifampin for prophylaxis. Option D is incorrect as Rifampin does not cause the skin to take on a crimson glow.

2. A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant?

• A. Suctioning a client who requires periodic suctioning
• B. Assessing a client who has undergone an arteriogram and requires close monitoring
• C. Performing colostomy irrigation on a client with an ostomy
• D. Assisting a client who needs frequent ambulation with a walker

Correct answer: D

Rationale: When delegating tasks, a nurse must consider the staff member's education and competency level. Noninvasive tasks like helping a client ambulate with a walker are usually suitable for nursing assistants. Suctioning a client and colostomy irrigation are invasive procedures that require a licensed nurse's skills. Assessing a client post-arteriogram for any complications or changes in condition also necessitates the expertise of a licensed nurse. Therefore, the most appropriate task to assign to a nursing assistant is assisting a client who needs frequent ambulation with a walker.

3. A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, "No woman will ever want to marry me now."? Which of the following responses by the nurse is most therapeutic?

• A. "Don't worry. Maybe you'll meet a paraplegic woman."?
• B. "There is someone for everyone in this world."?
• C. "You are still an attractive man, even though you can't walk."?
• D. "Tell me more about your feelings on this issue."?

Correct answer: D

Rationale: The correct response is 'Tell me more about your feelings on this issue.' This answer is the most therapeutic as it encourages the client to express his emotions and concerns, fostering a supportive and open dialogue between the client and the nurse. Option A may come across as dismissive and does not directly address the client's emotional state. Option B, while positive, oversimplifies the client's complex feelings. Option C focuses only on physical appearance, missing the opportunity to delve deeper into the client's emotional well-being. Therefore, the most therapeutic response is to encourage further discussion about the client's feelings.

4. A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action?

• A. Administer cardiopulmonary resuscitation (CPR)
• B. Call the client's health care provider
• C. Administer oxygen to the client and call the health care provider
• D. Contact the nursing supervisor for directions

Correct answer: A

Rationale: Administering cardiopulmonary resuscitation (CPR) is the appropriate action when a client is not breathing and does not have a do-not-resuscitate (DNR) order. CPR is considered an emergency treatment that can be provided without client consent in life-threatening situations. Calling the health care provider or nursing supervisor for directions, as well as administering oxygen without addressing the lack of breathing, would delay critical life-saving interventions. Therefore, administering CPR is the most urgent and necessary action to perform in this scenario.

5. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS?

• A. Nucleoside reverse transcriptase inhibitors
• B. Protease inhibitors
• C. HIV fusion inhibitors
• D. All of the above

Correct answer: D

Rationale: The correct answer is 'All of the above.' Nucleoside reverse transcriptase inhibitors inhibit the enzyme reverse transcriptase, protease inhibitors block the activity of the HIV-1 protease enzyme, and HIV fusion inhibitors prevent HIV from entering human cells. Therefore, all the choices provided are valid antiviral drug classes for managing HIV/AIDS. Nucleoside reverse transcriptase inhibitors, protease inhibitors, and HIV fusion inhibitors play crucial roles in combating the virus at different stages. Nucleoside reverse transcriptase inhibitors target an early stage, protease inhibitors act on a later stage, and HIV fusion inhibitors prevent viral entry. Thus, 'All of the above' is the correct and comprehensive answer encompassing different mechanisms of action in managing HIV/AIDS.

Similar Questions