ADH 2 Exam one study set

Which client would the nurse monitor carefully when continuous negative-pressure wound therapy (NPWT) is used to facilitate healing?

Client receiving anticoagulation

Which finding indicating infection in a client would the nurse report to the health care provider immediately?

D Changes in quantity, color, or odor of exudate

Which response during sponging of a client with a high fever indicates to the nurse that cooling may be occurring too quickly?

D. Acute confusion

Which instruction would the nurse give the AP about how to perform skin care on a client at risk for pressure injury because of immobility and incontinence?

D. Clean the skin and moisturize with dimethazone, zinc oxide, lanolin, or petrolatum

Which action will the nurse use during client care to prevent infection by mechanically disrupting biofilms?

D. Helping the client to floss and to brush teeth

Which routes are the most common means of HIV transmission?

D. Parenteral E. Perinatal F. Sexual

Which terms would the nurse use to document a client's rash that is red, raised, and itching over most of their body?

D. erythematous, diffuse, pruritic

When caring for an older adult, what skin change would cause the nurse to keep the client's room warmer?

Decreased layer of subcutaneous fat

What diagnostic test does the nurse prepare a client for when the PCP prescribes a test to determine if the client has a fungal infection of the skin?

KOH test

Which change in laboratory immune indicators does the nurse expect to find in a client whose HIV disease is at stage-III (AIDS)

Lymphocytopenia

Which situation is an example of innate-native immunity?

Nurse has intact healthy skin on hands and healthy mucous membranes

How does the nurse determine which dressing is best for a client with a stage 3 pressure injury over the left trochanter area that has a thick exudate?

Obtain a prescription to consult with the certified wound care specialist

Nadir

Regarding chemotherapy, it typically describes the point at which blood cell counts are at their lowest after a chemotherapy treatment

Which is the best rationale for the nurse to use to encourage a client to seek treatment for dandruff?

Sever dandruff is caused by excessive oiliness and can cause hair loss

What is the most common route by which nurses and other health care workers or providers are exposed to the HIV virus when caring for HIV-positive patients?

Sharp injuries with contaminated needles

Which clinical symptom(s) will the nurse expect to find in a client who is experiencing the release of histamine and kinins by basophils??

Swelling and edema

Which information ill the nurse include when teaching a client about the swelling and pain resulting from a sever ankle sprain?

The amount of pain and swelling is directly related to the severity of the injury

Which client situation indicates self-tolerance to the nurse

C. Skin from the client's thigh is successfully grafted to a burn wound

A nurse who is HIV positive and is not a client on a surgical unity the day after abdominal surgery asks a nurse colleague to keep her HIV status from the rest of the nursing staff. What is the unit nurse's best response?

"Of course, there is no need for anyone here to know."

When would the nurse expect to culture a client's pressure injury wound?

C. When clinical or systemic signs of infection are present

Which precaution is most important for the nurse to teach a client prescribed to take oral delafloxacin to treat a skin lesion infected with MRSA?

C. Take this drug 2 hours before or 6 hours after taking this drug

Which medical-surgical concept would the nurse designate as the highest priority for a client with pressure injuries of both heels?

C. Tissue integrity

Which actions will the nurse take when a client is placed on Droplet Precautions? SATA

C. Using a mask when within 6 feet of the client D. Putting a mask on the client whenever transport is necessary

Which client conditions will the nurse recognize as factors that may reduce immune function? SATA

A. A severely limited diet for several weeks to quickly lose weight B. homelessness and use of large public shelters C. Daily use of corticosteroids and an NSAID E. Age >80 and living alone F. Well-controlled type 2 diabetes

Erythropoietin

:Epogen :Procrit :increases RBCS :RBC <3.0

Granulocyte colony-stimulating factor

:Neulasta :increases neutrophils :check WBC before administration WBC below 2.0

With which client will the nurse use extra precautions to prevent harm from infection development as a result of medical or surgical intervention? SATA

A. 36 yr-old being mechanically ventilated B. 27 yr-old taking antirejection drugs after receiving a kidney transplant C. 45 yr-old with an indwelling urinary catheter E. 60 yr-old who had an artificial aortic valve replacement 4 yrs ago F. 65 yr-old taking corticosteroids daily for COPD

Which clients would the nurse understand are at risk for pressure injuries? SATA

A. A middle-aged quadriplegic client who is alert and conversant C. A very thin client who sits for a long periods in a chair and refuses meals D. An obese client who must be assisted move and turn in the bed E. An older adult who is bedridden and in the late stage of Alzheimer's disease

Which priority nursing interventions focus on increasing client comfort and preventing skin injury when the client has pruritus? SATA

A. Administering prescribed antihistamines or topical drugs B. Keeping client's fingernails short C. Instructing AP to trim toenails D. Applying mittens or gloves to client's hands at night E. Maintaining daily fluid intake of 3000mL unless contraindicated F. After bathing, patting skin dry rather than rubbing

When the nurse takes a client's medication history after noting the presence of ecchymoses, which types of drugs are of concern?

A. Aspirin products C. Anticoagulants D. Long-term corticosteroids

Which adaptation in care will the nurse anticipate as specifically appropriate for an 85-year old client? SATA

A. Carefully assessing all open skin areas daily B. Encouraging annual flu shot F. Asking when the patient last received a tetanus shot

What is the most accurate method for the nurse to use when assessing cyanosis in a dark-skinned client admitted for pneumonia?

A. Check the conjunctivae and nail beds for a bluish tinge color

Which assessment techniques would the nurse use when checking a client with dark skin for inflammation? SATA

A. Compare affected area with nonaffected area for increased warmth C. Compare the skin color of affected area with the same area as the opposite side F. Examine the skin of the affected area to see if it is shiny, taut, or pits with pressure

Which situation are examples of an animate reservoir

A. Covid-19 influenza was first transmitted to humans from infected bats and snakes D. A 48 yr-old man living in the tropics develops malaria after being extensively bitten by a swarm of mosquitoes

Which client factors does the nurse identify as increasing the risk for infection? SATA

A. Drinking 4-5 alcoholic beverages daily B. Smoking two packs of cigarettes daily E. Serving a 5-year prison term

Which change in a client's white blood cell differential does the nurse interpret as associated with a severe or prolonged bacterial infection?

A. Increased immature neutrophils

For which infectious diseases will the nurse recommend immunizations for older adult clients? SATA

A. Influenza B. Pneumonia D. herpes zoster (shingles) F. Tetanus, diphtheria, pertussis

Which condition will the nurse consider to be contributing factors for a client with chronic pressure injuries? SATA (15)

A. Malnutrition B. PVD C. Incontinence D. Immobility F. Prolonged bedrest

Age-related changes in the integumentary system include decreases in which factors? SATA

A. Rate of nail growth B. Thickness of epidermis C. Dermal blood flow E. Vitamin D production

How will the nurse document assessment findings on a client's coccyx region that is reddened, is intact, and does not blanch when pressure is applied?

A. Stage 1 pressure injury

Which technique would the nurse use to check for tunneling when assessing a larger pressure injury on a client's hip with a small opening in the skin draining purulent material?

A. Use a sterile cotton-tipped applicator to probe gently for the tunnel

Which intervention would the nurse use to prevent harm from development of a pressure injury in a client with a prolonged coma? SATA

A. Use pillows or padding devices to keep the client's heels free from pressure B. When positioning a client on his or her side, position at a 30-degree tilt D. Turn and reposition the client at least every 2 hours during all shifts E. Place pillows or foam wedges between two bony surfaces or between bony surfaces and the bed

Which health behavior does the nurse teach a client who is immunocompromised to prevent infection from normal flora?

A. Wiping perineal area from front to back after toileting females

Which roles of a client's intact skin will the nurse consider most important? SATA

A: Body temperature regulation B: Protection against infection D Maintaining fluid and electrolyte E: Aid in elimination of excess CO2

Which action performed during hand hygiene by an assistive personnel does the nurse need to correct?

B. Using hot water and a scrub brush

Which physical factors does the nurses assess for in an older adult client that are likely to increase the risk for infection? SATA

B. thin, delicate skin C. decreased gag reflex E. decreased mobility F. higher incidence of chronic disease

Which part of the HIV infection process is disrupted by the antiretroviral drug class of CCR5 antagonists?

Binding of the virus's gp120 protein to one of the CD4+ co-receptors

The rate of new HIV infection in North America is the highest among which groups?

Black and Hispanic men and women

For which clients does the nurse ensure placement in a private room? SATA

C. 48 yr-old severely immunosuppressed client receiving cancer chemo D. 59 yr-old with active tuberculosis

For which client care situation will the nurses teach assistive to perform handwashing rather than using alcohol-based rubs?

C. After contact with a client who has had diarrhea for 3 days

Which cells, action, or characteristics are components of nonspecific general immunity? SATA

C. Can be transferred from one person to another D. Intact mucous membranes E. Macrophages F. Microbiome G. Neutrophils J. Self-tolerance

Which action does the nurse take to prevent indirect contact transmission of microorganisms to a susceptible client? SATA

C. Cleaning the glucometer with disinfectant between testing clients

Which PPE does the nurse assemble for use when giving oral and parenteral drugs care to an HIV-positive client who has amoebic diarrhea

C. Gloves D. Gown

Which personal protective equipment does the nurse assemble for use when giving oral and parenteral drugs to a client who has diarrhea from Clostridium difficile overgrowth?

C. Gloves D. Gown

What would the nurse be sure to do before documenting a client's pressure injury changes with a series of photographs?

C. Obtain informed consent from the client

Which intervention would the nurse use to reduce shearing force for an obese client who is on bedrest for the next 3 days?

C. Place the client in a side-lying position at a 30-degree tilt

Which type of immunity is the only one hat can be transferred from one person to another?

Antibody-mediated immunity

Which finding, when assessing a client's wound for signs of healing or infection, indicates to the nurse that healing is progressing as expected?

Area appears pale pink, progressing to a spongy texture with a beefy red color

Which assessment will the nurse perform first wen a clients labs indicate a shift to the left?

Assess for indications of infection, such as purulent sputum or foul-smelling urine

What would the nurse direct the home AP to do for an older client who wants to avoid dry skin?

Assist with a bath every other day

When will the nurse draw blood from a client who has been ordered to have a serum trough level of the prescribed antibiotic measured?

B. 30 minutes before the next ordered dose

Which circumstances are examples of colonization? SATA

B. A nurse has a nasal swab that cultures out the MRSA and remains asymptomatic F. A 64-yr woman's urine culture is positive for E-coli although the urine is clear and no symptoms of cystitis are present

Which questions would the nurses ask to determine if a client with a rash is having a new allergic reaction? SATA

B. Are you taking any new medications? C. Have you been using any different soaps, cosmetics, or lotions? E. Have you been exposed to any new cleaning solutions? F. Have you had any recent changes in your diet?

Which action will the nurse take FIRST to prevent harm when an assistive personnel reports that an 88-yr old client has a temperature of 100.2F?

B. Assess the client for other indications of infection

Which white blood cell types are involved in the development of antibody-mediated immunity? SATA

B. B-lymphocytes D. Helper T-cells E. Macrophages

Which expected outcomes are appropriate for a client with a pressure injury?

B. Client will remain free from local or systemic infections C. Client will re-establish skin integrity and restore skin barrier E. Client's wound will show granulation and decrease in size

Which client health problems will the nurse identify as most commonly an infection process along with inflammation rather than inflammation alone?

B. Conjunctivitis EStretococcal pneumonia

What collaborative action would the nurse take to promote wound healing for a thin, malnourished client who had emergency abdominal surgery?

B. Consult with the registered dietician nutritionist about a high-protein diet

In addition to Standard Precautions, which type of transmission-based precautions will the nurse use to prevent infection transmission when caring for a client who has MRSA?

B. Contact precautions

Which client conditions experienced over the bast year indicates to the nurse that the client's HIV status may have progressed tp HIV-III (AIDS)

B. Diagnosed with invasive cervical cancer D. Had two episodes of bacterial pneumonia in the past year

Which factors or problems in an HIV-positive client does the nurse know increases the risk for HIV transmission?

B. High viral load C. Chronic confusion F. nonadherence to the drug regimen

Which client is the nurse most likely to recommend for directly observed therapy?

B. Homeless man with TB prescribed four anti-TB drugs daily

Which clients with pressure injuries would the nurse assess as at high risk for development of an infection?

B. Older client with low WBC C. Client with type 1 diabetes E. Client with COPD on steroids F. Older client with a large abdominal incision who needs help with repositioning

What is the priority action for the nurses to take for a client who has just been diagnosed with scabies?

B. Place the client on contact precautions

What changes in color does the nurses expect when assessing a client with polycythemia vera? SATA

B. Reddish blue generalized skin color D. Dark red nail beds

Which is the most important action for the nurse to teach visitors to avoid acquiring influenza when visiting a client with the disease?

B. Remaining at least 6 ft away from the client

Which actions will the nurse take to prevent disease transmission when caring for a client who has an infection with a multidrug resistant organism? SATA

B. Showering as soon as reaching home after work D. Keeping work clothes separate form personal clothes E. Wearing scrubs and changing clothes before leaving work

Which factors are included in the ABCDE features associated with skin cancer? SATA

Evolving or changing of any feature Color variations with a lesion Asymmetry of shape

What is the best method for the nurse to complete a client's skin assessment while effectively using time management?

Examine the client's skin while bathing or assisting with hygiene

Which non infection-related health promotion behavior is a priority for the nurse to teach a client with HIV disease at stage II.

Exercise regularly and maintain a healthy weight.

What does the nurse suspect when a client has skin that is tight and shiny over the lower extremities?

Fluid retention and edema

What is the best site for the nurse to assess skin for dehydration in an older adult client?

Forehead

Which assessment technique would the nurse use to check the skin turgor of a client who is at risk for hypovolemia?

Gently pinch the skin on the back of the hand and observe for tenting

Which technique does the nurse use to assess "health of the nails of a client with very dark skin"?

Gently squeeze the end of the finger exerting downward pressure, then release it

Which question would the nurse ask when assessing a female client who reports an unusual increase in facial hair?

Have you noticed any deepening of your voice quality?

What is the nurse's best response to a client considering pre-exposure prophylaxis who asks why HIV testing must be performed every 3 months while on this therapy

If you should become HIV positive while taking this therapy your disease may become drug resistant

The client with HIV-III (AIDS) and pain is refusing to take the newly prescribed antidepressants amitriptyline, stating that depression is not a problem. What is the best response?

In addition to helping depression, this drug can reduce neuropathic pain

Which client lab response indicates to the nurse that the erythropoietin therapy is successful?

Increased RBCs

Which skin changes does the nurses expect to see in an older adult client as a result of a decreased number of active melanocytes?

Increased sensitivity of sun exposure

Which skin assessment finding in an older adult client is most important for the nurse to report to the primary health care provider to follow up?

Irregular light-brown macule (6.5 cm) on the right scapula

Which statement regarding a temporary reduction of a client's immunity response is true? Chapter 16

The client's health is at risk for the duration of the reduction

A client diagnosed with HIV-III (AIDS) who is receiving combination antiretroviral therapy (cART) now has a CD4+ T cell count of 525 cells/mm. How will the nurse interpret this result?

The drug therapy is effective

For a decrease in which integumentary factor would the nurse avoid taping the skin of an older adult client?

Thickness of epidermis

What is the priority medical concept when the nurse assesses a client and finds reddened scratch marks on the right forearm?

Tissue integrity

What would the nurses suspect when a client is admitted with a rash of white or red edematous papules or plaques that developed after the client ate seafood? (20.)

Urticaria / hives

Which action does the nurse recommend for a night shift co-worker, who just experienced a sharps injury from a known HIV-positive source client, to take immediately

Wash the injured area immediately for at least 1 minute with soap and water

What priority instruction would the nurse provide the AP who is to bathe a client with skin that is not intact and is draining?

Wear gloves and use standard precautions

What is an example of artificial passive immunity?

serum antibodies from another human/animal transferred to another human

What is an example of artificial active immunity?

vaccination

5 cardinal signals of inflammation

warmth redness swelling pain decreased fx