Question 1 of 5

The nurse is caring for a client who recently experienced a massive stroke. Which of the following statements by the spouse indicates a need for further teaching by the nurse?

A. My spouse may not return to normal for some time.B. I plan on returning to work full time as soon as my spouse returns home.C. Home health care will help us once my spouse is discharged.D. You will provide me with support during this difficult time.

Correct Answer: B

Rationale: Returning to work full time immediately after discharge may not be feasible due to the care needs of a client post-massive stroke, indicating a need for further education about caregiving demands.

Question 2 of 5

A client has an open draining wound infected with MRSA and is on contact precautions. If the nurse is entering the room to care for the client, when are gloving and gowning necessary?

A. When the nurse has direct contact with the wound or drainage.B. When the nurse has direct contact with the client's body, wound, or drainage.C. When the nurse enters the room for any type of patient or environmental contact.D. When drainage is not contained by a dressing.

Correct Answer: C

Rationale: Contact precautions for MRSA require gloving and gowning upon entering the room (
C) for any patient or environmental contact to prevent transmission. Limited contact (A,
B) or uncontained drainage (
D) does not override the need for full precautions.

Question 3 of 5

Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?

A. Providing the client with a favorite meal for dinnerB. Asking if the client has allergies to shellfishC. Encouraging fluids the evening before the testD. Telling the client what to expect during the test

Correct Answer: B

Rationale: Asking about shellfish allergies is critical, as iodine-based contrast used in IVP can cause severe allergic reactions in those with shellfish or iodine allergies.

Question 4 of 5

The wife of a client with colorectal cancer (CRC) is talking to the nurse about prevention and screening of the disease. Which statement should the nurse make to the wife?

A. A diet low in fat and high in fiber can help lower the risk, along with eating more fruit such as oranges.B. When an adult turns 40 years of age, a colonoscopy should be done to screen for CRC, regardless of family history.C. Those with average risk at age 50 and up should have a colonoscopy and fecal occult blood test every five years.D. Those with average risk at age 50 and up should have a colonoscopy and fecal occult blood test every 10 years.

Correct Answer: A

Rationale: A low-fat, high-fiber diet with fruits reduces CRC risk. Screening begins at 45 for average risk, with colonoscopy every 10 years or fecal occult blood test annually.

Question 5 of 5

A woman comes to a community health clinic and expresses concern she may have been exposed to HIV. The community nurse draws blood for an ELISA test, which comes back as positive. The nurse should

A. ask the client to come into the clinic to tell her in person she is HIV positive.B. request the client come in and follow up with a Western blot test.C. explain to the client this shows she has been exposed to HIV, but does not have HIV.D. call and tell client that she is HIV positive.

Correct Answer: B

Rationale: A positive ELISA requires confirmation with a Western blot test to diagnose HIV, ensuring accuracy and reducing false positives.

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