Exam 3 Immune/Respiratory questions

The nurse is teaching the client with a platelet disorder about signs of bleeding. What statement from the client indicates the client has understood the teaching?

"Ecchymoses are large, purple skin bruises."

Which statement indicates that the client with osteoarthritis understands the effects of capsaicin cream?

"I always wash my hands right after I apply the cream."

A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement?

"I will need to take an iron supplement even if my laboratory values are normal."

A nurse is teaching a client about how to recognize when treatment for hypothyroidism is effective. Which statement from the client would indicate that the nurse's teaching has been effective?

"I will start feeling more energetic."

A client with hypothyroidism is afraid of needles and doesn't want to have their blood drawn. What should the nurse say to help alleviate the client's concerns?

"I'll stay here with you while the technician draws your blood."

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again."

A client with the beta-thalassemia trait plans to marry a person of Italian ancestry who also has the trait. Which client statement indicates understanding of the teaching provided by the nurse?

"We'll need more genetic counseling in the future."

What information should a nurse plan to teach a client newly diagnosed with an infection who has acquired-immune deficiency syndrome (AIDS)?

"You are more susceptible to infection due to damage to your immune system."

A young adult has been bitten by a human, and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. What should the nurse tell the client about the anticipated treatment plan?

"You'll need an injection of tetanus toxoid."

What should be included in the plan of care for clients receiving intravenous immunoglobulin (IVIG)? Select all that apply.

(Multiple choice)all 3 are correct Assess vital signs before, during, and after treatment. Premedicate with acetaminophen and diphenhydramine 30 minutes before infusion. Stop the infusion at the first sign of a reaction.

A client is being discharged with a home oxygen delivery device. Which comments indicate that the client understands safety regarding home oxygen? Select all that apply.

(Multiple choice; all 3 correct) "No one can smoke within 10 feet (3 meters) of the oxygen." "I need to keep my oxygen away from electrical sources." "I should keep my oxygen away from direct heat."

A nurse is to give a client heparin 8,000 units subcutaneously. The available vial is 10,000 units/mL. How many milliliters should the nurse draw up into the syringe? Record your answer using one decimal place.

0.8

A nurse is caring for a client diagnosed with pneumonia, a urinary tract infection, dehydration, and temperature of 101.4°F;(38.6°C;). The health care provider orders 1,000 ml of D5W to infuse over 8 hours. The available drop factor is 20 gtt/ml. The nurse would regulate the intravenous flow rate to deliver how many drops per minute? Round your answer to the nearest whole number.

42

A nurse is caring for a client with a pulmonary infection secondary to acquired immunodeficiency syndrome (AIDS). Which intervention would be most effective to manage night sweats?

Administer an antipyretic medication prophylactically as needed before the client goes to sleep.

The daily white blood cell (WBC) count in a client with aplastic anemia drops overnight from 3,900 to 2,900/µl (3.9 to 2.9 X 109/L). Which is the appropriate nursing intervention?

Call the primary care provider, and request that the client be placed in reverse isolation.

A client with acute lymphocytic leukemia is receiving vincristine. Prior to infusing the drug, the nurse administers diphenhydramine. What should the nurse tell the client about the purpose of taking diphenhydramine?

Diphenhydramine decreases incidence of a reaction to the vincristine.

A client experiencing an acute panic attack develops respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6°F (37°C). Which action will the nurse implement first to help improve respiratory alkalosis?

Instruct the client to breathe into a paper bag.

A client with diabetes is being tested for glycosylated hemoglobin. How would the nurse explain the reason for this diagnostic test?

It determines the average blood glucose level in the previous 2-3 months.

Bone resorption is a possible complication of Cushing's disease. To help the client prevent this complication, what should the nurse recommend to the client?

Maintain a regular program of weight-bearing exercise.

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and reports having pain in the left thorax that worsens when coughing. After checking the PCA system, what should the nurse do next?

Obtain a more detailed assessment of the client's pain using a pain scale.

The nurse notes grapefruit juice on the breakfast tray of a client who is taking repaglinide. What should the nurse do next?

Remove the grapefruit juice from the client's tray and bring another juice of the client's preference.

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set

The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information about the client is most important to communicate to the health care provider?

a 3-kg weight gain over 2 days

When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which physiologic functions?

bleeding tendencies

After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which activity observed by the nurse indicates the need for additional teaching?

carrying a laundry basket with clinched fingers and fists

A client with aplastic anemia is instructed to eat foods rich in iron. The nurse should instruct the client to include which food in the diet to increase iron intake?

dark green leafy vegetables

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

developing a list of people with whom the client has had contact

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

dyspnea, tachycardia, and pallor

A client with thyrotoxicosis says to the nurse, "I'm so irritable. I'm having problems at work because I lose my temper very easily." Which response by the nurse would give the client the most accurate explanation of this behavior? "You are experiencing:

excess thyroid hormone in your system."

A client is being evaluated for hypothyroidism. To plan care, the nurse should ask the client about which sign or symptom?

fatigue

Interferon alfa-2b has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which common adverse effects?

flulike symptoms

A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use?

intermittent suction while withdrawing the catheter

A client with iron deficiency anemia is taking iron supplements. What nutrient should the nurse instruct the client to take the supplements with in order to increase the absorption of iron?

orange juice

The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of arterial blood gas values does the nurse expect for this client?

pH 7.25, PaCO2 48, HCO3 24

A young adult is admitted for elective nasal surgery for a deviated septum. Which sign would be an important indicator of bleeding even if the nasal drip pad remained dry and intact?

repeated swallowing

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

restricting fluids

A client with bacterial pneumonia is to be started on IV antibiotics. The nurse should verify that which diagnostic test has been completed before administering the antibiotic?

sputum culture

A client is returned to the hospital room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

tracheostomy set