220 Exam 2

When planning care for a client with hepatitis A, the nurse should review laboratory reports for which laboratory values? 1. prolonged prothrombin time 2. decreased blood glucose level 3. elevated serum potassium level 4. decreased serum calcium level

1. prolonged prothrombin time (prothrombin time may be prolonged because of decreased absorption of vitamin K and decreased production of prothrombin by the liver. the client should be assessed carefully for bleeding tendencies)

The nurse is talking to a group of teens about transmission of HIV, what bodily fluids does nurse informed them will transmit the virus? (select all that apply) 1. semen 2. urine 3. breast milk 4. blood 5. vaginal secretions

1. semen 3. breast milk 4. blood 5. vaginal secretions

A client who is sexually active asks the nurse about using pre-exposure prophylaxis (PrEP) for HIV. The nurse should tell the client the drug, a combination of 300 mg tenofovir disoproxil fumarate and 200mg emtricitabine (TDF/FTC) can be used for which group of people who are at risk for becoming infected with HIV? 1. Anyone who is in an ongoing sexual relationship with an HIV infected partner 2. People who do not use condoms with in a sexual relationship 3. A person who has a sexually transmitted disease that is not being treated 4. Someone who has a compromised immune system

1. Anyone who is in an ongoing Sexual relationship with an HIV infected partner

the nurse is teaching an adult recreational drug user about measures to avoid acquiring hepatitis A. What information should the nurse include in the instruction? (select all that apply) 1. observing proper hand washing technique 2. follow safe syringe disposal technique 3. obtaining a vaccination 4. wearing a mask when in crowds 5. using caution when eating fresh fruits and vegetables

1. observing proper hand washing technique 2. follow safe syringe disposal technique 3. obtaining a vaccination 5. using caution when eating fresh fruits and vegetables

A client newly diagnosed with tuberculosis as being admitted with the prescription for "isolation precautions for tuberculosis. "The nurse should assign the client to which type of room? 1. A room at the end of the hall for privacy 2. A private room to implement airborne precautions 3. A room near the nurses station to ensure confidentiality 4. A room with windows to allow sunlight

2. A private room to implement airborne precautions

A nurse is teaching a client who has been diagnosed with Herculo sis how to avoid spreading the disease to family members. Which statements indicate that the client has understood the nurses instructions? Select all that apply 1. I will need to dispose of my old clothing when I return home 2. I should always cover my mouth and nose when sneezing 3. It is important that I isolate myself from family when possible 4. I should use paper tissues to cough in and dispose of them promptly 5. I will avoid crowds

2. I should always cover my mouth and nose and sneezing 4. I should use paper tissues to cough in and dispose of them promptly

A client with tuberculosis is to be discharged home with nursing follow up. Which aspect of nursing care will have the highest priority? 1. Offering the client emotional support 2. Teaching a client about the disease and it's treatment 3. Coordinating various agency services 4. Assessing the clients environment for sanitation

2. Teaching a client about the disease and its treatment

A nurse is providing teaching for a client who has stage three HIV disease. Which of the following statements by the client should indicate to the nurse and understanding of the teaching? a. I will wear clothes when changing the pet litter box b. I will rinse raw Fruits with Water before eating them c. I will wear a mask when around family members who are ill d. I will cook vegetables before eating them

a, b, c, d

The nurse is providing follow-up care to a client with tuberculosis who does not regularly take the prescribed medication. Which of the following nursing actions would be the most appropriate for this client? a. Ask the client's spouse to supervise the daily administration of the medications b. Visit the client weekly to verify compliance with taking medication c. Notify the healthcare provider of the clients noncompliance and request a different prescription d. Remind the client that tuberculosis can be fatal if it is not treated promptly

a. Ask the client's spouse to supervise the daily administration of the medications (Directly observed therapy (DOT) Can be implemented with clients who are not compliant with drug therapy. Visiting the client, changing the prescription, or threatening the client will not ensure compliance if the client will not or cannot follow to prescribe treatment )

The nurse find a container with the client here in specimen sitting on the counter in the bathroom. The client states that the specimen has been sitting in the bathroom for at least two hours. What should the nurse do with urine specimen? a. Discard the urine and obtain a new specimen b. Send the urine to the laboratory as quickly as possible c. Add fresh urine to the collected specimen d. Refrigerate the urine specimen until it can be transported to the laboratory

a. Discard the urine and obtain a new specimen

The nurse is developing a teaching plan for a client with viral hepatitis. What information should the nurse include in the plan? a. Obtain adequate bedrest b. Increase fluid intake c. Take antibiotic therapy as prescribed d. Drink 8 ounces of an electrolyte solution every day

a. Obtain adequate bedrest (Treatment consists primarily of bed rest with bathroom privileges. Bedrest is maintained during acute phase to reduce metabolic demands on the liver, thus increasing blood supply and promoting liver cell regeneration. When activity is gradually resumed, the client should be taught to rest before becoming overly tired. Although adequate fluid intake is important, it is not necessary to force fluids to treat hepatitis. Antibiotics are not used to treat hepatitis. Electrolyte imbalances or not typical of hepatitis)

When a blood transfusion is terminated following a reaction, what actions must the nurse take? Select all that apply a. Send freshly collected urine samples to the laboratory b. Return the remainder of the blood component unit to the blood bank c. Return the IV administration set to the blood bank d. Alert risk management about the incident e. Report the incident to the infection control manager

a. Send freshly collected urine samples to the laboratory b. Return the remainder of the blood component unit to the blood bank c. Return the IV administration said to the blood bank

A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi medication regimen. Which of the following instructions should the nurse give the client related to Ethambutol? a. Your urine can change dark orange b. Watch for a change in the sclera of your eyes c. Watch for any changes in vision d. Take vitamin B daily

c. Watch for any changes in vision (The client who is receiving ethambutol will need to Watch for visual changes due to optic neuritis, which can result from taking this medication)

The nurse visits the home of a client with tuberculosis. Which action should the nurse teach family members to take during the first 2 weeks of treatment to prevent the spread of infection to other family members? a. be compliant with the medication regimen b. ensure that housemates of the client are tested and receive prophylactic treatment if indicated c. use disposable tissues to contain respiratory secretions d. emphasize the importance of maintaining good general health through diet and exercise

c. use disposable tissues to contain respiratory secretions

which of the following family members exposed to TB would be at highest risk for contracting the disease? a. 45-year-old mother b. 17-year-old daughter c. 8-year-old son d. 76-year-old grandmother

d. 76-year-old grandmother

A nurse is providing teaching for a client who has stage two HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse and understanding of the teaching? a. I will choose a diet high in fat to help gain weight b. I will be sure to eat three large meals a day c. I will drink up to 1 L of liquid each day d. I will add high-protein foods to my diet

d. I will add high-protein foods to my diet (The client should be taught to add high protein high calorie foods to the diet daily as the best way to gain weight and maintain health)

The nurse is administering packed red blood cells to a client. What should the nurse do first? a. Discontinue the IV catheter if a blood transfusion reaction occurs b. Administer the PRBCs through a percutaneously inserted central catheter line with a 20 gauge needle c. Flush PRBCs with 5% dextrose and 0.45% normal saline solution d. Stay with client during the first 15 minutes of infusion

d. Stay with the client during the first 15 minutes of infusion

A client who is in a sexual relationship with a partner partner who has HIV has a prescription for PreExposure prophylaxis (PrEP) using TDF/FTC. What should the nurse teach the client about taking this drug? 1. Renew your prescription every year 2. Take the medication daily 3. It is not necessary to use condoms 4. The drug is 100% effective

2. take the medication daily

The nurse is caring for a client who was recently diagnosed with hepatitis C. In reviewing the clients history, what information will be most helpful as the nurse develops a teaching plan? 1. Has a history of exercise induced asthma 2. Is a scientist and is frequently exposed to multiple chemicals 3. Traveled to Central America recently and ate uncooked vegetables 4. Has a known history of sexually transmitted disease

4. Has a known history of sexually transmitted disease (Although primarily blood-borne, unprotected sex with multiple partners and a history of sexually transmitted disease are risk factors for transmission of hep C)

The nurse if preparing a community education program about preventing Hepatitis B infection. Which information should be incorporated in the teaching plan? 1. Hepatitis B is relatively uncommon among college students 2. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B 3. Good personal hygiene habits are most effective at preventing the spread of hepatitis B 4. The use of a condom is advised for sexual intercourse

4. The use of a condom is advised for sexual intercourse (Hepatitis B is spread through exposure to blood or blood products and through high-risk sexual sexual activities. Hepatitis B is considered to be a sexually transmitted disease)

When teaching a client about human immunodeficiency virus (HIV) The nurse should take into account the fact that which strategy is the most effective way to control the spread of HIV infection? 1. Premarital serologic screening 2. Prophylactic treatment of expose people 3. Laboratory screening of pregnant women 4. Ongoing sex education about preventive behaviors

4. ongoing sex education about prevented behaviors (Education to prevent behaviors that cause HIV transmission is The primary method of controlling HIV infection. Behaviors that plays people at risk for HIV infection include unprotected sexual intercourse and sharing of needles for IV drug injection. Educating clients about using condoms during sexual relations is a priority and controlling HIV transmission.)

The nurse is preparing teaching for a client newly diagnosed with tuberculosis. Which drug generally used in initial treatment should the nurse include in the session? (select all that apply) a. isoniazid b. amikacin c. pyrazinamide d. rifampin e. ethambutol

a. isoniazid c. pyrazinamide d. rifampin e. ethambutol

Which nursing action is essential before performing a chest x-ray? a. Make sure the client does not eat food b. Remove the clients metal necklace c. Have a client swallow contrast dye d. Administer a dose of pain medication

b. Remove the clients metal necklace

The client with tuberculosis is to be discharged home with nursing follow up. Which aspect of nursing care will have the highest priority? a. Offering the client emotional support b. Teaching the client about the disease and its treatment c. Coordinating various agency services d. Assessing the clients environment for sanitation

b. Teaching the client about the disease and its treatment (Ensuring the client as well educated about TB is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. The other interventions are less important than Education about the disease process and its treatment)

What signs and symptoms in your patient with HIV indicates a disease is worsening in the immune system is severely compromised? a. open, oozing lesions around the mouth b. White hair like spot on the side of the tongue c. Cheesy white film on the tonsils and inside cheeks d. vision changes

b. White hair like spots on the side of the tongue (Is known as oral hairy leukoplakia. It occurs when the immune system is extremely compromised like with HIV and the Epstein-Barr virus. It is a signal that HIV is getting worse.)

A nurse suspects that a client is at risk for tuberculosis. Which risk factor should the nurse assess in this client? (select all that apply) a. sharing clothes with an infected individual b. living in a poorly ventilated environment c. using injection drugs d. being an immigrant to the united states e. having a compromised immune system

b. living in a poorly ventilated environment c. using injection drugs d. being an immigrant to the united states e. having a compromised immune system

The infection control nurse is teaching the staff at a long-term care facility after a recent outbreak of tuberculosis. Which element of infection control should the nurse include in the teaching? (select all that apply) a. implementation of universal screening b. use of airborne precautions c. treatment of clients with suspected or confirmed disease d. administration of the bacilli Calmette-Guerin (BCG) vaccine to residents e. identification of infected individuals

b. use of airborne precautions c. treatment of clients with suspected or confirmed disease e. identification of infected individuals