Question 1 of 180:
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate
action for the nurse to take?
Ensure the state health department has been notified.
Administer antitoxin.
Educate the family to avoid sharing personal belongings.
Assess for skin necrosis.
Correct Answer:
Ensure the state health department has been notified.
Explanation:
Lyme disease is a reportable communicable disease, and notification to public health authorities is
required for surveillance and appropriate preventive measures. This helps in monitoring and controlling
its spread.
,Question 2 of 180:
A nurse is caring for a client who has been admitted to the hospital.
Nurses' Notes:
0900:
,The client reports experiencing a loss of appetite and shortness of breath within the last month or so.
The client reports experiencing weakness, abdominal pain, severe itching, and mood changes. The client
has had alcohol use disorder for the past 10 years and sometimes drinks alcohol uncontrollably.
The client is alert but disoriented to time. Their abdomen is bloated, and they have redness of the palms
of the hands. Excoriated areas on the upper thorax and shoulders are present. Sclera are yellow.
1230:
Administered antacids, spironolactone, and colchicine per provider’s prescription.
Select the 5 actions the nurse should take.
Provide frequent rest periods for the client.
Restrict the client’s sodium intake.
Advise the client to avoid the use of soap and alcohol-based lotions.
Place the client on a low-carbohydrate diet.
Place the client under contact isolation.
Instruct the client to avoid blowing their nose forcefully.
Assess the client's level of orientation.
Correct Answers:
Restrict the client’s sodium intake.
Advise the client to avoid the use of soap and alcohol-based lotions.
Place the client on a low-carbohydrate diet.
Instruct the client to avoid blowing their nose forcefully.
Explanation:
The symptoms (e.g., bloating, yellow sclera) suggest liver dysfunction, possibly cirrhosis. Restricting
sodium helps manage fluid retention. Avoiding alcohol-based lotions is necessary for skin protection,
and a low-carb diet may benefit liver health. Preventing forceful nose blowing is crucial to avoid stress
on the circulatory system.
, Question 3 of 180:
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited.
Which of the following actions should the nurse perform first?
Administer an antiemetic medication.
Evaluate functioning of the suction device.
Provide oral hygiene care.
Replace the NG tube.
Correct Answer:
Evaluate functioning of the suction device.
Explanation:
The priority action is to assess whether the suction device is functioning properly to clear any vomit or
gastric contents. Ensuring the device works effectively is crucial to preventing further vomiting and
maintaining patient safety.
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate
action for the nurse to take?
Ensure the state health department has been notified.
Administer antitoxin.
Educate the family to avoid sharing personal belongings.
Assess for skin necrosis.
Correct Answer:
Ensure the state health department has been notified.
Explanation:
Lyme disease is a reportable communicable disease, and notification to public health authorities is
required for surveillance and appropriate preventive measures. This helps in monitoring and controlling
its spread.
,Question 2 of 180:
A nurse is caring for a client who has been admitted to the hospital.
Nurses' Notes:
0900:
,The client reports experiencing a loss of appetite and shortness of breath within the last month or so.
The client reports experiencing weakness, abdominal pain, severe itching, and mood changes. The client
has had alcohol use disorder for the past 10 years and sometimes drinks alcohol uncontrollably.
The client is alert but disoriented to time. Their abdomen is bloated, and they have redness of the palms
of the hands. Excoriated areas on the upper thorax and shoulders are present. Sclera are yellow.
1230:
Administered antacids, spironolactone, and colchicine per provider’s prescription.
Select the 5 actions the nurse should take.
Provide frequent rest periods for the client.
Restrict the client’s sodium intake.
Advise the client to avoid the use of soap and alcohol-based lotions.
Place the client on a low-carbohydrate diet.
Place the client under contact isolation.
Instruct the client to avoid blowing their nose forcefully.
Assess the client's level of orientation.
Correct Answers:
Restrict the client’s sodium intake.
Advise the client to avoid the use of soap and alcohol-based lotions.
Place the client on a low-carbohydrate diet.
Instruct the client to avoid blowing their nose forcefully.
Explanation:
The symptoms (e.g., bloating, yellow sclera) suggest liver dysfunction, possibly cirrhosis. Restricting
sodium helps manage fluid retention. Avoiding alcohol-based lotions is necessary for skin protection,
and a low-carb diet may benefit liver health. Preventing forceful nose blowing is crucial to avoid stress
on the circulatory system.
, Question 3 of 180:
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited.
Which of the following actions should the nurse perform first?
Administer an antiemetic medication.
Evaluate functioning of the suction device.
Provide oral hygiene care.
Replace the NG tube.
Correct Answer:
Evaluate functioning of the suction device.
Explanation:
The priority action is to assess whether the suction device is functioning properly to clear any vomit or
gastric contents. Ensuring the device works effectively is crucial to preventing further vomiting and
maintaining patient safety.
