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Questions 164

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Question 1 of 5

The nurse is interacting with a client who has just been told she is HIV positive. The client asks the nurse when she will die. What should the nurse plan to include when replying?

Correct Answer: A

Rationale: HIV positivity indicates antibodies, not AIDS; with modern antiretroviral therapy, progression is slow, and many live for decades, unlike rapid progression or fixed timelines.

Question 2 of 5

The nurse is talking with the parent of a 14-month-old client who was exposed to measles 2 days ago. The client has not received the measles, mumps, and rubella (MMR) vaccine. Which of the following statements would be most appropriate for the nurse to make?

Correct Answer: A

Rationale: Post-exposure MMR vaccination within 72 hours can prevent measles in unvaccinated individuals. Monitoring temperature or assuming no symptoms means no infection is incorrect, as measles has an incubation period. Measles spreads via respiratory droplets, not just rash contact.

Question 3 of 5

A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?

Correct Answer: B

Rationale: Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.

Question 4 of 5

The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:

Correct Answer: D

Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.

Question 5 of 5

Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.

Correct Answer: A,C

Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.

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