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Questions 158

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Question 1 of 5

The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse expects to find the sputum to be:

Correct Answer: B

Rationale: Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiella pneumonia. Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. Green-colored sputum is more characteristic of Pseudomonas than of gram-positive bacterial pneumonia. Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.

Question 2 of 5

A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to "stick out his tongue," the nurse is assessing the function of which cranial nerve?

Correct Answer: D

Rationale: The hypoglossal nerve (XII) controls tongue movement. Sticking out the tongue assesses its function. Optic (II) affects vision, olfactory (I) affects smell, and vagus (X) affects visceral functions.

Question 3 of 5

A five-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:

Correct Answer: A

Rationale: Atopic dermatitis involves itchy, broken skin prone to infection. Preventing infection through skin care and hygiene is critical. Antipyretics, dry skin, or fluid limits are not primary concerns.

Question 4 of 5

A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is 'rule out hepatitis.' Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis. Which of the following represents a high-risk group for contracting this disease?

Correct Answer: B

Rationale: Oncology nurses are at high risk due to exposure to invasive procedures and potential sources of infection, unlike the other groups listed.

Question 5 of 5

A client with cancer who is receiving chemotherapeutic drugs has been given injections of pegfilgastrim (Neulasta). Which laboratory value reveals that the drug is producing the desired effect?

Correct Answer: B

Rationale: Pegfilgastrim stimulates neutrophil production, increasing white blood cell counts. A WBC of 6,000/mm (
B) indicates effectiveness. Hemoglobin (
A), platelets (
C), and hematocrit (
D) are not directly affected.

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