Exam 2
Post exposure prophylaxis (PEP) medications should be started within ______________ after exposure, but no longer than ____________, to offer any benefit. It must be taken for _______________. A. 1 hour; 72 hours; 4 weeks B. 4 days; 7 days; 2 weeks C. 1 week; 3 weeks; 3 months D. 1 month; 2 months; 6 months
1 hour; 72 hours; 4 weeks
Which of the following clients should the nurse remain alert for the possibility of sepsis and septic shock? A. 72 year old man with severe allergies who has completed radiation therapy and has early stage prostate cancer B. 53 year old women who had an open abdominal hysterectomy 3 days ago to remove several large fibroid tumors C. 67 year old women on chronic corticosteroids therapy who had several teeth extracted 2 days ago D. 41 year old man who sustained a closed depression fracture of the face when hit with a baseball
67 year old women on chronic corticosteroids therapy who had several teeth extracted 2 days ago
The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? (Select all that apply) A. The CD4 count is the major indicator of immune function and guides therapy B. Antiretroviral therapy targets different stages of the HIV life cycle C. the goal of antiretroviral therapy is to prevent opportunistic infections D. medication therapy is rarely effective
A. The CD4 count is the major indicator of immune function and guides therapy B. Antiretroviral therapy targets different stages of the HIV life cycle
A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? (Select all that Apply) A. current medication regimen B. identification of client's support system C. history of sexual practices D. immune system function E. genetic risk factors for HIV
A. current medication regimen B. identification of client's support system C. history of sexual practices D. immune system function
Which of the following are indications for cardiac monitoring of a patient? (Select all that Apply) A. diagnose heart conduction abnormalities B. patients at high risk dysrhythmias C. to demonstrate how well the heart is pumping D. monitor the effects of electrolyte disturbances
A. diagnose heart conduction abnormalities B. patients at high risk dysrhythmias D. monitor the effects of electrolyte disturbances
A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. Which signs would the nurse expect when assessing the client? (Select all that Apply) A. fever B. tachypnea C. hypertension D. abdominal rigidity E. increased bowel sounds
A. fever B. tachypnea D. abdominal rigidity
Which of the following is (are) true regarding the medication norepinephrine (Levophed)? (Select all that Apply) A. norepinephrine is the drug of choice for treating septic shock B. norepinephrine is used to increase cardiac output C. norepinephrine is used to treat hypotension D. norepinephrine is used to decrease heart rate in bradycardia E. norepinephrine is used primarily to decrease blood pressure in hypertensive crisis
A. norepinephrine is the drug of choice for treating septic shock B. norepinephrine is used to increase cardiac output C. norepinephrine is used to treat hypotension
Which assessment findings support that the patient currently has AIDS? (Select all that Apply) A. persistant generalized lymphadenopathy B. esophageal candidiasis C. recurrent infectious pneumonia D. HIV-positive status E. kaposi's sarcoma F. wasting syndrome
A. persistant generalized lymphadenopathy B. esophageal candidiasis C. recurrent infectious pneumonia D. HIV-positive status E. kaposi's sarcoma F. wasting syndrome
The five cardinal signs of inflammation are: (Select all that Apply) A. swelling (edema) B. loss of function C. redness D. pallor E. pain F. warmth (heat) G. purulent discharge
A. swelling (edema) B. loss of function C. redness E. pain F. warmth (heat)
A client is suspected of sepsis from a post-surgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that Apply A. temperature 102F B. heart rate of 120 beats/minute C. respiratory rate 24 breaths/minute D. paCO2 of 42 mmHg E. blood pressure of 120/80
A. temperature 102F B. heart rate of 120 beats/minute C. respiratory rate 24 breaths/minute
A nurse is preparing a presentation about HIV for a local community group. Which of the following would the nurse include in the presentation about HIV transmission? (Select all that Apply) A. the amount of HIV contained in body fluids on exposure is associated with the risk for infection B. The risk of acquiring HIV through the transfusion of blood products is nonexsist C. HIV transmission from mother-child occurs primarily during pregnancy while the fetus is in utero D. HIV can be found in seminal fluid, vaginal secretions and breast milk F. sharing of infected equipment used to inject drugs increase the risk for infection
A. the amount of HIV contained in body fluids on exposure is associated with the risk for infection B. The risk of acquiring HIV through the transfusion of blood products is nonexsist D. HIV can be found in seminal fluid, vaginal secretions and breast milk F. sharing of infected equipment used to inject drugs increase the risk for infection
A client is admitted for complications of right lower lobe pneumonia. Which assessment finding requires immediate intervention by the nurse? (Select all that Apply) A. unable to state current year B. crackles right base on auscultation C. plasma glucose 110 D. blood pressure 105/45 E. urine output 25mL/hr
A. unable to state current year E. urine output 25mL/hr
Which characteristics of a cardiac rhythm strip will help the nurse identify a normal sinus rhythm? (Select all that apply) A. uniform and regular QRS complex occurrences B. P waves before every QRS complex C. PR interval= 0.12-0.20 seconds D. QRS measures 0.24 seconds E. heart rate between 60-100 beats per minute
A. uniform and regular QRS complex occurrences B. P waves before every QRS complex C. PR interval= 0.12-0.20 seconds E. heart rate between 60-100 beats per minute
What is the medication used to treat SVT?
Adenosine
A nurse works in an employee health department of a hospital. She was asked to treat a staff nurse who was exposed to blood from a patient with an HIV infection. The nurse practitioner insituited a PEP protocol that included which of the following actions? (Select all that Apply) A. start prophylaxis medications between 3-6 hours after exposure B. continue HIV medications for 4 weeks post-exposure C. practice safe sex for 2 weeks (time for HIV medications to reach a satisfactory blood level) D. initiate post-exposure testing after 4 weeks E. finish post-exposure testing at 6 months
B. continue HIV medications for 4 weeks post-exposure D. initiate post-exposure testing after 4 weeks E. finish post-exposure testing at 6 months
A client is admitted with an infection and a high fever. Which assessments by the nurse take priority? (Select all that Apply) A. skin integrity B. mental status C. bowel sounds D. blood pressure E. pulse quality F. respiratory status
B. mental status D. blood pressure E. pulse quality F. respiratory status
A client has just been diagnosed as HIV positive. what should the nurse include in the discharge plan to help this client understands how to prevent transmission of the virus? A. having unprotected sex with another HIV positive person is safe, but condoms must be used if the partner is HIV negative. B. the only way to prevent transmission of the HIV virus is to practice sexual abstinence C. HIV virus is transmitted by body fluids such as vaginal secretions, seminal fluid and blood D. it is recommended to refrain from any close personal contact for 6 months until the viral load is reduced with medications
B. the only way to prevent transmission of the HIV virus is to practice sexual abstinence C. HIV virus is transmitted by body fluids such as vaginal secretions, seminal fluid and blood
A client is suspected of sepsis from a post-surgical incision infection. What characteristic of sepsis would the nurse recognize? (Select all that Apply) A. paCO2-42 B. blood pressure 120/80 C. heart rate-120 D. temperature 102 degrees F E. respiratory reate-26
C. heart rate-120 D. temperature 102 degrees F E. respiratory reate-26
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.
Infuse normal saline 500 mL over 30 minutes.
What are the only two rhythms that get defibrillation?
Pulseless v-tach and v-fib
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3, and the client has been diagnoses with pneumocystis pneumonia. What does this indicate to the nurse? A. The client has converted from HIV infection to AIDS B. the client has advanced HIV infection C. the client's T4-cell count has decreased due to the pneumocystis pneumonia D. the client has another infection present that is causing a decrease in the T4-cell count
The client has converted from HIV infection to AIDS
The nurse is planning a patient education class on sepsis risk reduction. It is most important for which of the following patients to attend? A. a 55 year old man who had a laparoscope knee exam B. a 20 year old female who was recently treated outpatient for a UTI C. a 65 year old female with breast cancer who is on chemotherapy D. a 75 year old man who had a cholecystectomy two weeks ago
a 65 year old female with breast cancer who is on chemotherapy
A client is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of success therapy? A. addressing possible barriers to adherence B. promoting appropriate use of only complementary therapies C. educating the client about the pathophysiology of HIV D. teaching the client about the need for follow-up blood work
addressing possible barriers to adherence
A client in this rhythm presents to the Emergency Department with a blood pressure of 70/40. Which intervention by the nurse is a priority? A. begin chest compressions B. defibrillate at 200 joules C. administer Atropine IV push D. document as a normal finding
administer Atropine IV push
You are caring for a client considered to be at risk for the development of disseminated intravascular coagulation (DIC). Which intervention is appropriate for this client? A. maintain strict intake and output B. monitor white cell count daily C. maintain a clean environment D. administer antibiotics intravenously
administer antibiotics intravenously
The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? A. administer recombinat human activated protein C (rhAPC) as prescribed B. begin a continous IV infusion per protocol C. initiate eternal feedings as prescribed D. administer norepinephrine as prescribed
administer norepinephrine as prescribed
What is the medication used to treat V-tach?
amiodarone
What is the priority intervention by the nurse based on this rhythm? A. begin chest compressions B. assess for an apical pulse C. administer lidocaine IV D. defibrillate at 200 joules
assess for an apical pulse
A client has been admitted with a left tibial fracture and extensive soft-tissue injuries, and there is concern for the development of disseminated intravascular clotting. What is the priority nursing action? A. administer packed red blood cells, increase fluid intake , and encourage mobilization B. administer whole blood as ordered and initiate IV fluids C. assess for any signs of bleeding in the gums and other mucous membranes D. administer antihypertensives, measure intake and output and redress the wounds
assess for any signs of bleeding in the gums and other mucous membranes
The nurse notes this rhythm on the telemetry monitor. Which of the following interventions should the nurse do first? A. Start CPR B. adminster lidocaine IV push C. assess the patient D. prepare for transcutaneous pacing
assess the patient
What is the medication used to treat sinus bradycardia?
atropine
The client with AIDS has chronic diarrhea. Which dietary change should the nurse suggest for this client? A. avoid fatty food intake B. take an antacid 30 minutes before meals C. restrict fluid intake to 1 liter per day D. increase fiber intake
avoid fatty food intake
The nurses observes a client in this rhythm on the telemetry monitor. Which action by the nurse is a priority? A. external pacing at 70 beats/min B. apply oxygen at 2L nasal cannula C. begin chest compressions D. document as a normal finding only
begin chest compressions
A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client? A. control the shivering B. place the client on a warming blanket C. keep the client dry and uncovered D. maintain client in supine position with legs elevated
control the shivering
What is the initial treatment of choice for this rhythm? A. atropine B. dopamine C. pacemaker D. defibrillation
defibrillation
Which intervention by the nurse is a priority based on this rhythm? A. document findings and reassess B. defibrillate at 200 joules C. begin chest compressions D. adminster lidocaine 1mg/kg IV push
document findings and reassess
The nurse is caring for a client with hemodynamically stable sepsis who complains of abdominal pain. Which of these primary health care provider prescriptions would the nurse do first? A. draw peripheral blood cultures from two different sites B. administer levoflaxin 500mg IV over 30 minutes C. administer 1L intravenous bolus of LR over 30 minutes D. take the client to xray for an abdominal computed tomography (CT) scan
draw peripheral blood cultures from two different sites
The nurse cares for a client 12 hours post abdominal surgery. Which assessment finding would cause the most concern? A. drowsiness B. pains at incision site C. hypoactive bowel sounds D. heart rate 110
drowsiness
A client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). He undergoes biopsies of facial lesions. The preliminary report indicates Kaposi's sarcoma. Which action by the nurse is most appropriate? A. tell the client that kaposi's sarcoma is common in people with AIDS B. pretend not to notice the lesions on the client's face C. inform the client of the biopsy results and support him emotionally D. explore the client's feelings about his facial disfigurement
explore the client's feelings about his facial disfigurement
A primigravida client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which agent should the nurse expect the health care provider (HCP) to prescribe? A. magnesium sulfate B. warfarin sodium C. fresh-frozen plasma D. meperidine hydrochloride
fresh-frozen plasma
The nurse is caring for a client admitted with trauma from a motor vehicle accident. Which of the following assessment information would indicate the client may have disseminated intravascular clotting? A. pain in the calf muscles and swelling of the lower legs, increased platelets, high c-reactive protein levels B. hematemesis, melena, increased prothrombin time, thrombocytopenia C. increased bleeding at the fracture site, neurovascular impairment in the adjacent tissue, and decrease in fibrin degradation products (d-dimer) D. hematuria, cytsis, bladder distention, decreased platelets, low prothrobmin time
hematemesis, melena, increased prothrombin time, thrombocytopenia
An older adult client has been diagnosed with urosepsis and has a temperature of 39.7 (103.4F). The nurse must anticipate that the oxygen demands of the client's body will change in which direction and why? A. increase due to an increase in metabolism B. decrease due to a decrease in metabolism C. increase due to a decrease in metabolism D. decrease due to a increase in metabolism
increase due to an increase in metabolism
What should the nurse include in a discharge plan for a client with the diagnosis of HIV/AIDS who has significant weight loss secondary to anorexia and chronic diarrhea? A. calories of any kind will maintain energy levels B. increased protein helps to replace lean body mass C. iron supplements will prevent further anemia D. fat should be limited to prevent vitamin loss
increased protein helps to replace lean body mass
A 37 year old male is admitted with a severely abscessed tooth, BP 90/42, HR 136, RR 28, Sp02 90% on room air, T 38C. The nurse suspects sepsis from the tooth. The priority intervention by the nurse would be to: A. administered prescribed antibiotics prior to blood cultures B. initiate IV fluid resuscitation C. obtain a complete chemistry for laboratory analysis D. insert an indwelling urinary cathether
initiate IV fluid resuscitation
The nurse recognizes the importance of monitoring what parameter to assess progression of sepsis? A. potassium B. hematocrit C. creatinine D. lactic acid
lactic acid
The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? A. central venous pressure of 6 B. mean arterial pressure of 70 C. urine output of 0.2mL/kg/min D. ScvO2 of 60%
mean arterial pressure of 70
A nurse is caring for a client after a bone marrow transplant. What is the nurse's priority in caring for the client? A. monitor the client's toilet patterns B. monitor the client to prevent sepsis C. monitor the client's physical condition D. monitor the client's heart rate
monitor the client to prevent sepsis
How should the nurse correctly document this client's rhythm in the nurse's note? A. normal sinus rhythm with ventricular tachycardia B. normal sinus rhythm with unifocal premature ventricular contractions C. normal sinus rhythm with couplets D. normal sinus rhythm with multifocal premature ventricular contractions
normal sinus rhythm with unifocal premature ventricular contractions
The nurse initiates the admission database for a client who is HIV positive. Which nursing measures should ensure that the information about medications is thorough and accurate? A. obtain information about allergic reactions to previous or current medications B. gather information about medications previously used for opportunistic infections C. ask the client about all medications currently being taken and any side effects D. obtain information about previous and current medications, including herbal supplements
obtain information about previous and current medications, including herbal supplements
Which assessment findings should alert the nurse to systemic progression of the inflammatory response? A. urine outout 20mL/hr, HR 100, RR 24 B. HR 96, RR 16, O2 sat is 90 C. rectal temp 101, BP 90/60, WBC-10,000 D. oral temp-102F, HR 110, WBC-14000
oral temp-102F, HR 110, WBC-14000
The nurse assesses this rhythm in a client. Which additional assessment finding would prompt the nurse to notify the healthcare provider? A. oral temperature of 103.9F B. blood pressure 112/69 C. urine output of 45 mL/hr D. oxygen saturation of 96%
oral temperature of 103.9F
A client on telemetry demonstrates the following rhythm. Which medication should the nurse administer initially? A. oxygen B. epinephrine C. adenosine D. atropine
oxygen
While monitoring a client for the development of disseminated intravascular coagulation, the nurse should take note of which assessment parameters? A. d-dimer, red blood cell count and partial thromboplastin time B. platelet count, prothrombin time, and partial thromboplastin time C. platelet count, red blood cell count and hemoglobin D. thrombin time, fibrinogen and hemoglobin level
platelet count, prothrombin time, and partial thromboplastin time
What is the outcome of treatment for an individual with Kaposi's sarcoma? A. increase the CD4 cell count B. reduce the number of lesions C. decrease transmission to others D. increase the size of the lesions
reduce the number of lesions
Which of the following interventions is priority when managing care for the client with septic shock? A. reverse systemic vasoconstriction B. decrease vascular permeability C. prevent spread of infection D. restore intravascular volume
restore intravascular volume
Which statement reflects understanding of sepsis screening requirements by the nurse? A. blood cultures are required to diagnosis sepsis and begin sepsis protocol B. an oral temperature of 96.4 is not an indicator of sepsis C. a primary health care provider's prescription is required to screen for sepsis D. sepsis mortality is affected greatly by treatments preformed in the first 6 hours
sepsis mortality is affected greatly by treatments preformed in the first 6 hours
A nurse has infused 3500mL of 0.9% NS for a client with sepsis. The nurse should assess this client for what finding to determine effectiveness of treatment? A. respiratory rate 30 breaths per minute B. fine crackles in the lung base C. heart rate 110 beats per minute D. skin pink, warm and dry
skin pink, warm and dry
The best prevention of HIV positive transmission in the healthcare environment is: A. standard precaution B. airborne precautions C. giving only IV or oral medications D. avoid caring for HIV positive clients
standard precaution
A client presents to the Emergency Department in this rhythm. What condition is the client at risk for? A. stroke B. pneumonia C. renal stenosis D. diabetes insipidus
stroke
Which assessment data should warrant immediate intervention by the nurse for a client diagnosed with septic shock? A. abnormal chest xray B. a white blood cell count of 11,000 C. urinary output of 70 mL in the last 4 hours D. temp 101.5, RR 24, BP 100/60
urinary output of 70 mL in the last 4 hours
A client with sepsis is experiencing disseminated intravascular coagulation (DIC). The client is bleeding from mucous membranes, venipuncture sites, and the rectum. Blood is present in the urine. The nurse establishes the nursing diagnosis of risk for deficient fluid volume related to bleeding. The most appropriate and measurable outcome for this client is that the client exhibits: A. urine output greater than or equal to 30mL/hr B. decreased bleeding C. stable level of consciousness D. systolic blood pressure greater than 70mmHg
urine output greater than or equal to 30mL/hr
Which assessment finding is the most indicative of inadequate perfusion? A. systolic blood pressure of 100mm/Hg B. bilateral 2+ peripheral pulses C. crackles and tachypnea D. urine output of 450mL in 24 hours
urine output of 450mL in 24 hours