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Questions 164

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Extract:


Question 1 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 2 of 5

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Avoiding NSAIDs (ibuprofen), excess coffee/cola, smoking, and alcohol reduces ulcer irritation and promotes healing. Whole wheat foods are beneficial for digestion and not contraindicated.

Extract:

Vital signs
Temperature 99.2 F (37.3 C)
Blood pressure 134/89 mm Hg
Heart rate 98/min
Respirations 19/min
Oz saturation (SpO) 99%
Sedation Awake, alert


Question 3 of 5

A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive 'another pain pill.' The nurse reviews the medication administration record. Which intervention should the nurse implement?

Correct Answer: A

Rationale: Pain rated 7/10 warrants administration of the prescribed analgesic if within the dosing interval. No indications suggest overdose (naloxone) or need for a different medication. Reducing the dose may inadequately manage pain.

Extract:


Question 4 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 5 of 5

The nurse is caring for a client with type 1 diabetes mellitus who is reporting abdominal pain and weakness. The client has a fruity odor to the breath and rapid, deep respirations. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Symptoms suggest diabetic ketoacidosis (DK
A). Checking glucose confirms hyperglycemia, cardiac monitoring detects arrhythmias from electrolyte imbalances, IV insulin corrects hyperglycemia, and saline bolus addresses dehydration. Breathing into a paper bag is for hyperventilation from anxiety, not DKA.

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