Question

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

Answer 1

Correct Answers:

The client's meal tray includes ice cream with fresh fruit.

Rationale :

🟢 Fresh fruit can harbor bacteria, increasing infection risk in neutropenic and immunocompromised clients (such as those with HIV). 🟢 Neutropenic diets specifically restrict raw fruits and vegetables to reduce microbial exposure. 🟢 Immunosuppressed clients must avoid uncooked foods, which can introduce pathogens not killed by cooking. 🟢 Ice cream, if not pasteurized or stored properly, can also be a contamination source, but fresh fruit poses the most risk. 🟢 Preventing exposure to bacteria and fungi is critical in clients with low white blood cell counts.

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Answer 2

Correct Answers:

Thyroid stimulating hormone

Rationale :

💎 Levothyroxine therapy effectiveness is monitored via TSH, as it reflects thyroid hormone levels and pituitary feedback. 💎 TSH is the most sensitive test for adjusting thyroid hormone replacement and detecting under- or overtreatment. 💎 Monitoring TSH helps guide dose changes to achieve euthyroid status. 💎 Changes in TSH levels indicate if the medication is working or if the dose needs adjustment. 💎 Routine TSH checks ensure optimal therapeutic outcomes and safety.

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Answer 3

Correct Answers:

"Draw up the insulin lispro and insulin glargine in separate syringes.

Rationale :

✴️ Insulin glargine (long-acting) and insulin lispro (rapid-acting) cannot be mixed together; each requires its own syringe. ✴️ Mixing these insulins alters their pharmacokinetics and may affect blood glucose control. ✴️ This prevents dosage errors and ensures proper absorption and effectiveness. ✴️ Separate administration maintains the integrity of each insulin type. ✴️ Teaching correct technique avoids hypoglycemia or poor glycemic control.

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Answer 4

Correct Answers:

"Soiled dressings should be placed in a biohazard trash receptacle."

Rationale :

🟣 Proper disposal of soiled dressings in biohazard bags prevents infection spread and adheres to infection control protocols. 🟣 It protects housekeeping and healthcare staff from exposure to bloodborne pathogens. 🟣 Safe handling of contaminated waste is essential for public and occupational health. 🟣 Regulatory agencies mandate biohazard disposal for medical waste. 🟣 Reinforcing this with new staff maintains a culture of safety.

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Answer 5

Correct Answers:

Case manager

Rationale :

🔶 Case managers connect clients to community resources, such as financial assistance and WIC for formula needs. 🔶 They coordinate care across disciplines to address both medical and social determinants of health. 🔶 Early referral helps address barriers to infant nutrition and promotes positive health outcomes. 🔶 Case managers can assess eligibility and arrange necessary support services. 🔶 Nurses rely on the case manager for holistic care of postpartum clients facing socioeconomic challenges.

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Answer 6

Correct Answers:

Ensuring that creases in the stockings on the front of the client's legs

Rationale :

🟦 Creases in antiembolic stockings increase the risk of impaired circulation and skin breakdown. 🟦 Smooth, wrinkle-free application is necessary to ensure effective venous return and prevent pressure ulcers. 🟦 Nurses must intervene if stockings are applied incorrectly to avoid complications such as DVT or skin injury. 🟦 Supervision and correction help educate assistive personnel on proper techniques. 🟦 Incorrect application reduces the preventive benefit of antiembolic stockings.

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Answer 7

Correct Answers:

‘’I will give this medication to my child once daily in the evening."

Rationale :

💠 Montelukast is a leukotriene receptor antagonist prescribed as a once-daily evening dose for asthma maintenance. 💠 It is not used for acute relief but rather for long-term control of symptoms. 💠 Evening dosing optimizes effectiveness since asthma symptoms often worsen at night. 💠 Adhering to the schedule improves control and reduces exacerbations. 💠 Understanding administration time supports treatment success and reduces misuse.

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Answer 8

Correct Answers:

"I should decrease my salt intake to 2 grams per day."

Rationale :

⭐ Reducing sodium intake to 2 grams daily is a primary lifestyle modification for managing hypertension. ⭐ Lower sodium intake helps decrease fluid retention and blood pressure. ⭐ Diet modification is essential alongside medication for effective hypertension management. ⭐ This strategy helps prevent long-term cardiovascular complications. ⭐ Adherence to dietary recommendations is evidence-based best practice.

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Answer 9

Correct Answers:

"Let me give you some information about respite care for your mother."

Rationale :

🔵 Respite care offers temporary relief for caregivers, reducing burnout and supporting continued home care. 🔵 This response validates the son's feelings and offers a practical, compassionate solution. 🔵 Providing respite information encourages healthy coping strategies for family caregivers. 🔵 It demonstrates understanding and addresses the root concern—caregiver fatigue. 🔵 Referring to respite care supports long-term, safe care for the client with Alzheimer’s disease.

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Answer 10

Correct Answers:

Believes that his brother's death will be reversible

Rationale :

🟤 School-age children often exhibit magical thinking, believing death is temporary or reversible. 🟤 This developmental stage impacts their understanding and coping with terminal illness in the family. 🟤 Nurses should expect and address such beliefs through age-appropriate explanations. 🟤 Recognizing this response helps guide supportive interventions for siblings. 🟤 Developmentally appropriate guidance can facilitate healthier grieving.

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QLexNursing

1 :
A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

2 :
A nurse is caring for a client who has a prescription for levothyroxine. Which of the following laboratory tests should the nurse monitor?

3 :
A nurse is reinforcing teaching with client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which the following instructions should the nurse include in the teaching?

4 :
A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

5 :
A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

6 :
A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

7 :
A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

8 :
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

9 :
A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should nurse make?

10 :
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

QLexNursing

1 : A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

2 : A nurse is caring for a client who has a prescription for levothyroxine. Which of the following laboratory tests should the nurse monitor?

3 : A nurse is reinforcing teaching with client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which the following instructions should the nurse include in the teaching?

4 : A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

5 : A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

6 : A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

7 : A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

8 : A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

9 : A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should nurse make?

10 : A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

1 :
A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

2 :
A nurse is caring for a client who has a prescription for levothyroxine. Which of the following laboratory tests should the nurse monitor?

3 :
A nurse is reinforcing teaching with client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which the following instructions should the nurse include in the teaching?

4 :
A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

5 :
A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

6 :
A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

7 :
A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

8 :
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

9 :
A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should nurse make?

10 :
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?