Exam 1
A client presents with an oral temperature of 101.7°F (38.7°C) and painful, swollen cervical lymph nodes. Laboratory results indicate neutrophilia with a shift to the left. Which diagnosis is most likely?
A severe bacterial infection
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract
The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominence's. Which intervention should be added to the plan of care?
Place the client on a pressure redistribution bed
A patient is scheduled for Mohs microscopic surgery for removal of a skin cancer lesion on his forehead. The nurse knows to prepare the patient by explaining that this type of surgery requires:
Removal of the tumor, layer by layer
The student nurse asks the nursing instructor to explain why stress can increase the risk of infection. The instructor explains
Stress causes the body to release cortisol, which can increase the risk of infection
The perinatal nurse recognizes that what vaccine can be safely given to a neonate?
The perinatal nurse recognizes that what vaccine can be safely given to a neonate?
Schistosomiasis invade tissue
True
Which of the following actions should a nurse perform to help reduce the accumulation of debris within the burn wound?
Use powder-free sterile gloves
When caring for a postoperative client, in order to promote wound healing, which of these nutrients does the nurse encourage the client to consume?
Vitamin C
The nurse caring for a child with a skin allergy recognizes that the highest priority in the treatment for skin allergies is aimed at:
reducing swelling and relieving itching.
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?
Pink to red and soft, noting that it bleeds easily
A nurse caring for an infant born with a cleft palate notices that the parents rarely interact with their child. The nurse overhears the mother telling her spouse that she "feels like crying" every time she looks at their infant. What would be the best response from the nurse?
"I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?"
Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care?
"Tell me who or what gives you strength."
A child who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond?
"Wear gloves when you're likely to come into contact with the child's blood or body fluids."
