A client who has been diagnosed with acquired immunodeficiency syndrome (AIDS) presents with the following signs/symptoms; vital signs are: temperature, 102.8°F; pulse, 88 beats per minute; respirations 26 breaths per minute; blood pressure, 144/76; and oxygen saturation of 85%. The client complains of difficulty breathing, shortness of breath, and a productive cough. The nurse notes crackles bilaterally. The client denies nausea, vomiting, and diarrhea. Based on these findings, the nurse would anticipate which of the following orders? Select all that apply.

prepare the client for chest x-ray

obtain a sputum culture

antibiotic therapy as prescribed

insert a Foley catheter

nasogastric tube to suction for decompression

apply O2 at 2L per nasal cannula as needed

Answer and Explanation

Correct Answer : A,B,C,F

A.   The client's signs and symptoms, including crackles on auscultation and difficulty breathing, warrant a chest x-ray to assess for possible pneumonia or other respiratory conditions.
B.   Obtaining a sputum culture can help identify the causative organism and guide antibiotic therapy for respiratory infection.
C.   Antibiotic therapy is indicated for the treatment of respiratory infection, especially if the sputum culture indicates bacterial involvement.
D.   There is no indication for inserting a Foley catheter based on the client's signs and symptoms.
E.   Nasogastric tube insertion for decompression is not indicated based on the client's respiratory symptoms.
F.   Oxygen therapy is indicated for the client's low oxygen saturation level and respiratory distress. Applying oxygen at 2L per nasal cannula can help improve oxygenation.

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Correct Answer is D

Explanation

A. While a repeat titer could be considered, if the initial result is negative, administration of the rubella vaccine is typically the next step.
B. Administration of immune globulin is not indicated in this scenario.

C. A negative rubella titer indicates lack of immunity, so further action is needed to protect the individual.
D. Administration of the rubella vaccine is indicated for individuals with a negative rubella titer to provide protection against rubella infection.

A. Sharing a cell phone B. Not wearing a mask C. Sharing eating utensils D. Sharing the O2 saturation equipment between clients E. Touching others skin without washing hands F. Opening doors using your foot when possible G. Turning off the water faucet with paper towel

Correct Answer is ["A","C","D","E"]

Explanation

A. Sharing personal items like a cell phone can transmit infectious agents through contact.
B. Not wearing a mask primarily affects the transmission of airborne or droplet infections, not those transmitted by contact.
C. Sharing eating utensils can transfer infectious agents through contact with saliva or oral secretions.
D. Sharing equipment like O2 saturation equipment without proper disinfection between uses can transmit infections through contact.
E. Touching others' skin without washing hands can transfer infectious agents through direct contact.
F. Opening doors using your foot does not directly affect the transmission of infections through contact.
G. Turning off the water faucet with a paper towel primarily reduces the risk of contact with germs on the faucet itself, not the transmission of infections through contact.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly hired nurse is completing their health evaluation and physical for their new employment. The laboratory technician draws a titer for rubella. The laboratory results are negative. What would be the next action?

Correct Answer is D

Explanation

A nurse is providing health teaching to a client about ways a communicable disease is transmitted by contact. Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is assessing the hands of a client and notes bony enlargements of the client's joints, as pictured here. The joints are hard, painless, and some of the fingers are deviated from the midline. The nurse suspects these findings are a result of which of the following?

The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.

The nurse is caring for several clients on a hospital's surgical unit. Which of the following clients are at greatest risk for developing an infection?

The nurse is caring for a client who was diagnosed with "gouty arthritis." Which laboratory test is most important to perform to confirm this diagnosis?

A client with leukopenia is being discharged home. Which of the following should the nurse include in the teaching plan for this client?

A nurse is preparing to administer 400 mL of 0.9% sodium chloride IV over 8 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtts/min? Label your answer.

A client has been diagnosed with mumps as a child, the nurse concluded the client has which type of immunity?