EAQ 1

What is an example of a type I hypersensitivity reaction? a. Anaphylaxis b. Serum sickness c. Contact dermatitis d. Blood transfusion reaction

a. Anaphylaxis

Which statement indicates that a client understands the ways HIV is transmitted? Select all that apply. a. "I can contract HIV by participating in oral sex" b. "I can contract HIV by eating from used utensils" c. "HIV is contracted by using contaminated needles" d. "I can contract HIV by using the bathroom of a person who is HIV positive" e. "Babies can contract HIV because of contact with maternal blood during birth"

a. "I can contract HIV by participating in oral sex" c. "HIV is contracted by using contaminated needles" e. "Babies can contract HIV because of contact with maternal blood during birth"

The nurse is caring for a client with a history of atrial fibrillation and a diagnosis of dehydration. What does the nurse anticipate that the plan of care will include? a. A glass of water every hour until hydrated b. Small, frequent intake of juices, broth, or milk c. A short-term NG tube for replacement of fluids and nutrients d. A rapid IV infusion of electrolyte and glucose solution

b. Small, frequent intake of juices, broth, or milk

What actions should the nurse taken when a client develops an anaphylactic reaction? SATA. a. Apply oxygen at 90 to 100% b. Call the Rapid Response Team c. Elevate the head of the bed to 45º d. Assign a nursing assistant to stay with the client e. Ensure emergency airway equipment is at the bedside

a. Apply oxygen at 90 to 100% b. Call the Rapid Response Team c. Elevate the head of the bed to 45º e. Ensure emergency airway equipment is at the bedside

The nurse is reviewing the laboratory reports of four clients. Which client is in the third stage of human immune virus (HIV) disease? Client A: CD4+ is 180 cells Client B: CD4+ is 250 cells Client C: CD4+ is 380 dells Client D: CD4+ is 600 cells a. Client A b. Client B c. Client C d. Client D

a. Client A

Which drug can be administered via IM to treat anaphylaxis? a. Epinephrine b. Methdilazine c. Phenylepinephrine d. Mycophenolate mofetil

a. Epinephrine

A client is admitted to the hospital for surgery for rectosigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with rectosigmoid colon cancer does the nurse expect the client to report? SATA a. Feeling tired b. Rectal bleeding c. Inability to digest fat d. Change in the shape of stools e. Feeling of abdominal bloating

a. Feeling tired b. Rectal bleeding d. Change in the shape of stools e. Feeling of abdominal bloating

A client is seen in the clinic with sickle cell anemia. The primary HCP has prescribed an iron supplement to treat the client's anemia. What is the nurse's primary concern in regard to giving the supplement? a. Giving iron with this condition is contraindicated b. Finding a straw is necessary to prevent staining of teeth. c. When giving iron, OJ is needed to improve absorption d. Warning about stools changing to black will prevent undue stress.

a. Giving iron with this condition is contraindicated

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected. A test for the human immunodeficiency virus (HIV) is performed and acute retroviral syndrome is diagnosed. Which clinical responses are associated most commonly with this syndrome? Select all that apply. a. Malaise b. Confusion c. Constipation d. Swollen lymph glands e. Oropharyngeal candidiasis

a. Malaise d. Swollen lymph glands

The hemoglobin levels of a 30-year-old female client are measured at 8 mg/dL (80 g/L). Which integumentary findings can be noticed in this client? Select all that apply. a. Pallor b. Clubbing c. Cafe au lait spots d. Brittle nails e. Koilonychia

a. Pallor d. Brittle nails e. Koilonychia

The student nurse demonstrates correct understanding of anemia r/t chronic disease with which statement? a. Red blood cells appear normal in size and color; however, there is decreased amount produced. b. The RBCs have an increased life span with a decrease in normal functioning c. Administration of vitamins B12 and folate will help to treat this type of long-term anemia. d. This is the mildest form of anemia and is easily corrected through administration of blood products.

a. RBCs appear normal in size and color; however, there is a decreased amount produced.

The client's laboratory report shows localized vasodilation and transudation of fluid. The nurse interprets these findings as erythema and a wheal. Which condition may be present in the client? a. Urticaria b. Angioedema c. Allergic rhinitis d. Contact dermatitis

a. Urticaria

A client presents with sneezing; lacrimation; swelling with an airway obstruction; and pruritus around the eyes, nose, throat, and mouth. The nurse interprets these findings as a Type I hypersensitivity reaction. Which disease might have occurred in the client? a. Angioedema b. Allergic rhinitis c. Contact dermatitis d. Goodpasture syndrome

b. Allergic rhinitis

A postmenopausal woman who has cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she tells the nurse that she does not feel well. The nurse reviews the medical record and notices WBCs 2200/mm 3 (2.2 x 10 9/L), RBCs 4.0 million/mm 3 (4.7 x 10 12/L), hemoglobin 12.0 g/dL (120 mmol/L), hematocrit 38%, platelets 170,000/mm 3 (170 x 10 9/L). Vital signs are heart rate 97 beats/minute, respiration rate 25 breaths/minute, oral temperature 99.1 ºF (37.3 ºC), blood pressure 110/72. Based on this information, what does the nurse conclude is the client's priority need? a. Promoting rest b. Preventing infection c. Avoiding bodily harm d. Maintaining fluid balance

b. Preventing infection

A client presents with cutaneous lesions with swelling in the face, eyelids, and lips from dilation and engorgement of the capillaries. No welts or vesicles are observed. Which condition most likely has occurred in the client? a. Urticaria b. Angioedema c. Atopic dermatitis d. Systemic lupus erythematosus (SLE)

b. Angioedema

The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? a. Increase in blood pressure b. Decrease in erythropoietin c. Increase in serum phosphate levels d. Decrease in serum sodium concentration

b. Decrease in erythropoietin

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what client data or assessment finding? a. Skin condition b. Fluid and electrolyte balance c. Food intake d. Fluid intake and output

b. Fluid and electrolyte balance

What information from a client's history should the nurse identify as risk factors for the development of colon cancer? Select all that apply. a. Hemorrhoids b. Increased age c. High-fiber diet d. Ulcerative colitis e. Low Hgb level

b. Increased age d. Ulcerative colitis

What is the priority nursing action in the care of a young child with severe diarrhea? a. Measuring daily urine output b. Maintaining fluid and electrolyte balance c. Replacing the lost calories with high-fiber foods d. Promoting perianal skin integrity by bathing often

b. Maintaining fluid and electrolyte balance

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. Which locations on the client's body should the nurse assess? Select all that apply. a. Sclera b. Nail beds c. Conjunctivae d. Palms of hands e. Bony prominences

b. Nail beds c. Conjunctivae d. Palms of hands

What determines if a client will develop AIDS from an HIV infection? a. Level of IgM in the blood b. The number of CD4+ T cells available c. Presence of antigen-antibody complexes d. Speed with which the virus invades the RNA

b. The number of CD4+ T cells available

What symptoms are observed in a client with Sjogren's Syndrome? SATA a. Angioedema b. Tooth decay c. Corneal ulcers d. Vaginal dryness e. Pulmonary hemorrhage

b. Tooth decay c. Corneal ulcers d. Vaginal dryness

A nurse is reviewing the laboratory reports of four clients. Which client's laboratory report indicates acquired immunodeficiency syndrome (AIDS)? Client 1: CD4+ is 750 cells Client 2: CD4+ is 550 cells Client 3: CD4+ is 175 cells Client 4: CD4+ is 450 cells a. Client 1 b. Client 2 c. Client 3 d. Client 4

c. Client 3

After providing epinephrine to a client experiencing an anaphylactic reaction, which second-line drugs should the nurse prepare to provide? SATA. a. Dopamine b. Norepinephrine c. Dexamethasone d. Diphenhydramine hydrochloride e. Hydrocortisone sodium succinate

c. Dexamethasone d. Diphenhydramine hydrochloride e. Hydrocortisone sodium succinate

The client's laboratory report shows deposits of immunoglobulin G (IgG) along the basement membranes of the lungs. The primary healthcare provider interprets this finding as a sign of Goodpasture's syndrome. What would be the reason for this condition? a. Goodpasture's syndrome develops rapidly after exposure to allergens. b. Goodpasture's syndrome is caused by dilation and engorgement of the capillaries. c. Goodpasture's syndrome occurs when circulating antibodies combine with tissue antigens d. Goodpasture's syndrome is caused by exposure of the skin to substances that combine with epidermal proteins.

c. Goodpasture's syndrome occurs when circulating antibodies combine with tissue antigens

The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history? a. Acute gastritis b. Diabetes mellitus c. Partial gastrectomy d. Unhealthy dietary habits

c. Partial gastrectomy

A client who was admitted with severe abdominal pain and vomiting states, "I know I am very sick. Do you think I have cancer?" What is the best response by the nurse? a. "You must be upset to think that you have cancer." b. "Did you receive information about what therapy will be prescribed?" c. "Your primary HCP will need to talk with you about that." d. "What are your feelings about the diagnosis of cancer?"

d. "What are your feelings about the diagnosis of cancer?"

A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan? a. Cover the area with a sterile gauze bandage. b. Put warm compresses on the site once a day c. Limit lying on the back and unaffected side when sleeping. d. Avoid applying lotions and powders over the area

d. Avoid applying lotions and powders over the area.

A client comes to the clinic for a physical and asks to be tested for acquired immune deficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for human immunodeficiency virus (HIV)? a. CD4 T cell count b. Western blot test c. Polymerase chain reaction test d. Enzyme-linked immunosorbent assay (ELISA)

d. Enzyme-linked immunosorbent assay (ELISA)

The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level? a. Macrocytic red blood cells b. Thrombocytopenia c. Decreased folate levels d. Increased total iron-binding capacity (TIBC)

d. Increased total iron-binding capacity (TIBC)

A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery? a. Infection caused by the excretion of feces b. Injury caused by exposed intestinal mucosa c. Altered bowel elimination caused by the ostomy d. Limited water reabsorption caused by removal of intestine

d. Limited water reabsorption caused by removal of intestine

What does the nurse explain to the client that a positive diagnosis for HIV is based on? a. Performance of high-risk sexual behaviors b. Evidence of extreme weight loss and high fever c. Identification of an associated opportunistic infection d. Positive enzyme-linked immunosorbent assay (ELISA) and western blot tests

d. Positive enzyme-linked immunosorbent assay (ELISA) and western blot tests

A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30. PO2 60mmHg, PCO2 55mmHg, and HCO3 23 mEq/L. How should the nurse interpret these findings? a. Hypocapnia b. Hyperkalemia c. Generalized anemia d. Respiratory acidosis

d. Respiratory acidosis

A client is admitted to the hospital with a diagnosis of intestinal obstruction. The HCP prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client? a. Protein enzymes b. Energy carbohydrates c. Vitamins and minerals d. Water and electrolytes

d. Water and electrolytes