Exam 4 Combined
The nurse's neighbor has a severe sunburn and cannot sleep. What is the best advice by the nurse?
"Apply a local anesthetic to the area that is sunburned."
The nursing instructor teaches the student nurses about the structure and function of the skin. What will the best teaching plan of the instructor include?
1. The outermost layer of the epidermis serves as the major waterproof barrier to the environment. 3. The amount of subcutaneous tissue varies and is determined by nutritional status and heredity. 3. The amount of subcutaneous tissue varies and is determined by nutritional status and heredity.
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care? a.Change the dressing every 6 hours. b.Assess the wound bed once a day. c.Change the dressing when it is saturated. d.Contact the provider when the dressing leaks.
ANS: A Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.
An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."
ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change.
A nurse cares for a client who has obstructive jaundice. The client asks, "Why is my skin so itchy?" How should the nurse respond? a. "Bile salts accumulate in the skin and cause the itching." b. "Toxins released from an inflamed gallbladder lead to itching." c. "Itching is caused by the release of calcium into the skin." d. "Itching is caused by a hypersensitivity reaction."
ANS: A In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.
A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the client's skin. How should the nurse document these lesions? a. Two 2-cm hyperpigmented patches b. Two 1-inch erythematous plaques c. Two 2-mm pigmented papules d. Two 1-inch moles
ANS: A Patches are larger flat areas of the skin. The information provided does not indicate a mole or the presence of erythema.
A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I should refrigerate the GoLYTELY before use." d. "I will buy a case of Gatorade before the prep."
ANS: A The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.
The nurse is working with a client who is recovering after a cervical biopsy. Which statement by the client indicates a need for further instruction? a. "I can resume vaginal intercourse after 6 weeks." b. "I should report heavy bleeding to the health care provider." c. "I must not lift heavy objects for about 2 weeks." d. "I will use the antiseptic rinse on a regular basis."
ANS: A The client should be instructed to keep the perineum clean and dry by using antiseptic solution rinses (as directed by her health care provider) and changing pads frequently. In addition, the client is instructed not to lift heavy objects for 2 weeks and to report excessive bleeding (more than like a normal period). She can resume intercourse in about 2 weeks, when the site has healed; she does not need to wait 6 weeks.
A nurse cares for an older adult client who has Salmonella food poisoning. The client's vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination.
ANS: B Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| hydration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "Drinking at least 2 liters of water each day is suggested." b. "I will decrease the amount of fatty foods in my diet." c. "Drinking fluids with my meals will increase bloating." d. "I will avoid concentrated sweets and simple carbohydrates."
ANS: B After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required.
A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the client's heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the client's abdomen
ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy.
The student nurse studying the gastrointestinal system understands that chyme refers to what? a. Hormones that reduce gastric acidity b. Liquefied food ready for digestion c. Nutrients after being absorbed d. Secretions that help digest food
ANS: B Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.
An older woman is asking the nurse about her husband's sexual functioning. Which statement by the nurse is most accurate? a. "Men his age tend to have a rapid decline in sexual abilities." b. "His testosterone levels will decrease only slightly until he is quite old." c. "Changes in testosterone levels do not affect sexual performance." d. "You are lucky your husband is healthy enough for sexual activity."
ANS: B Men experience a gradual but slight decrease in testosterone until they are in their 80s. Low testosterone levels do affect sexual performance. Stating that the woman is lucky does not give accurate information about sexual functioning.
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowler's position with the head of bed elevated.
ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.
ANS: B This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.
When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? a.Turn the mattress overlay to the opposite side. b.Do nothing because this is an expected occurrence. c.Apply a different pressure-relieving device. d.Reinforce the overlay with extra cushions.
ANS: C "Bottoming out," as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a.A 44-year-old prescribed IV antibiotics for pneumonia b.A 26-year-old who is bedridden with a fractured leg c.A 65-year-old with hemi-paralysis and incontinence d.A 78-year-old requiring assistance to ambulate with a walker
ANS: C Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphy's sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night
ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease. DIF: Applying/Application REF: 1182 KEY: Crohn's disease| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon.
ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client's respiratory rate is 8 breaths/min. What action by the nurse is best? a. Administer naloxone (Narcan). b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.
ANS: C For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.
After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client's understanding. Which statement indicates the client has a good understanding of this condition? a. "This rash is probably due to fluid overload." b. "I need to wash this daily with antibacterial soap." c. "I can use powder to keep this area dry." d. "I will schedule a mammogram as soon as I can."
ANS: C Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds.
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "The capsules can be opened and the powder sprinkled on applesauce if needed." b. "I will wipe my lips carefully after I drink the enzyme preparation." c. "The best time to take the enzymes is immediately after I have a meal or a snack." d. "I will not mix the enzyme powder with food or liquids that contain protein."
ANS: C The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.
A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.
ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? a. "Are you using lotion on your skin?" b. "Do you have a family history of this?" c. "Do your arms itch?" d. "What medications are you taking?"
ANS: D Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.
A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy
ANS: D Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the client's willingness and ability to follow the regimen. The other assessment findings are not as critical.
The client receives multiple antibiotics to treat a serious infection. What will the priority assessment of the client by the nurse include?
Assessing changes in stool, white patches in the mouth, and urogenital itching or rash
What is culture?
May be seen as a group's acceptance of a set of attitudes, ideologies, values, beliefs, and behaviors that influence the way the members of the group express themselves.
Contraindications of cyclosporine
The only contraindication is prior hypersensitivity to the drug
2. True or False: Anyone can learn to use an assertive communication style and develop assertiveness.
True
Normal flora contained in the colon aid digestion and produce which nutrients? Select all that apply. 1) Vitamin A 2) Vitamin B 3) Vitamin C 4) Vitamin K 5) Iron 6) Zinc
Vitamin B, Vitamin K
1. Select all of the following which interfere with the encoding of a message from a sender to a receiver. a. Convoluted message b. Clear speech c. Monotone voice d. Use of jargon e. Understanding the information f. Preoccupation
a. Convoluted message c. Monotone voice d. Use of jargon f. Preoccupation
3. Identify the most important factor in the initial negotiation of a contract. a. Discussion of the important issues b. Posturing and showmanship c. Resolution of key conflicts d. Lack of willingness to negotiate
a. Discussion of the important issues
A client presents at the clinic with intractable diarrhea for 2 weeks. The nurse would expect to administer what type of drug for the treatment of this condition? a. Opioids b. Laxatives c. Cathartics d. Bulk-forming agents
a. Opioids
When treating a patient experiencing nausea and vomiting with antiemetics, which is important for the nurse to consider? a. Patient safety is a concern, as drowsiness is a common side effect. b. Over-the-counter antiemetics are just as effective in relieving nausea. c. Sports drinks replace the essential ingredients lost by dehydration. d. The most effective antiemetic is determined by trial and error.
a. Patient safety is a concern, as drowsiness is a common side effect
A nurse is conducting a health history assessment of a patient and determines which findings as risk factors for development of peptic ulcer disease (PUD)? (Select all that apply.) a. Smoking cigarettes b. Having blood type A c. Drinking caffeinated beverages d. Using NSAIDs e. Having a family history of PUD
a. Smoking cigarettes c. Drinking caffeinated beverages d. Using NSAIDs e. Having a family history of PUD
A nurse is conducting a health history assessment of a client and determines that which factor places the client at risk for development of irritable bowel disease (IBD)? a. Stress b. Peptic ulcers c. GERD (gastroesophageal reflux disease) d. Helicobacter pylori
a. Stress
A patient is taking omeprazole (Prilosec) for the treatment of gastroesophageal reflux disease (GERD). Which information should the nurse emphasize when teaching about this medication? (Select all that apply.) a. The medication should not be taken with alcohol. b. This medication is for long-term therapy. c. The medication can affect kidney function. d. Although rare, blood disorders may occur. e. Common side effects include headache and diarrhea.
a. The medication should not be taken with alcohol d. Although rare, blood disorders may occur. e. Common side effects include headache and diarrhea.
which definition of immunodeficiency is accurate? A. disease/deficiency acquired as a result of viral infection, contact with toxin, or medical therapy B. deficient immune response as a result of imapired or missing immune components C. chronic infection wih immunodeficiency virus D. disease/deficiency pesent since birth
b
which statements are true about immunodeficiency? (Select all that apply) A. it causes a decrease in the patients risk for infection B. it may be acquired or congential C. it occurs when a persons body cannot recognize antigens D. it is the same as autoimmunity E. it may cause varied reactions from mild, localized health problems to total immune system failure
b, c, e
which statements about HIV are accurate? (Select all that apply) A. may be acquired or congenital B. it is retrovirus C. it always progresses to AIDS D. it is a virus that attacks the immune system E. it is a parasite that forces cells to make copies of itself
b, d, e
which immune function abnormalities are a result of HIV infection? (Select all that apply) A. lymphocytosis B. CD4+ depletion C. increased CD8+ activity D. long macrophage life span E. lymphocytopenia
b, e
1. Which of the following is an accurate statement about behavior changes when dealing with people who are displaying difficult behaviors? a. With consistent communication practices, co-workers are likely to change their behaviors. b. One of the important goals when dealing with patients with difficult behavior is to change their behavior. c. The nurse needs to be consistent and not change her behaviors in response to co-workers with difficult behavior. d. All behavior is a matter of perception.
b. One of the important goals when dealing with patients with difficult behavior is to change their behavior.
The nurse should be concerned with which aspect of the health history of a patient who is taking a magnesium-based antacid? a. Peptic ulcer disease b. Renal failure c. Hypertension d. Heart failure
b. Renal failure
A nurse is caring for a client receiving chemotherapy with high emetogenic potential. Which drugs should the nurse prepare to administer prior to chemotherapy administration? (Select all that apply.) a. Anticholinergics b. Serotonin (5-HT3) antagonists c. Corticosteroids d. Neurokinin receptor antagonists e. Phenothiazines
b. Serotonin (5-HT3) antagonists c. Corticosteroids d. Neurokinin receptor antagonists e. Phenothiazines
the HCP prescribes an integrase inhibitor for an HIV patient. the patient asks the nurse how this drug works. what is the nurses best response? A. it reduces how well HIV genetic material can be converted into human genetic material B. it reinforces the immune systems ability to fight off an infection C. it prevents viral DNA from integrating into hosts DNA D. prevent HIV infection from progressing to AIDS
c
A nurse is caring for a patient preparing to undergo a colonoscopy. The nurse should anticipate administering which drug? a. Laxative b. Diuretic c. Cathartic d. Antihypertensive
c. Cathartic
4. Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder? a. I want to cut my arms with a knife. b. My mind is racing and I can't control my thoughts c. I just got fired from my third job this month because the boss belongs to the CIA. d. Life has no meaning for me anymore and I just bought a gun from a street pusher.
c. I just got fired from my third job this month because the boss belongs to the CIA.
A patient has been using over-the-counter omeprazole (Prilosec) for relief of gastric upset. The nurse should provide which teaching regarding appropriate administration of this medication? a. Drink a full glass of water with administration. b. Do not take the medication with antacids. c. Never crush or chew the medication. d. Take medication 30 minutes after meals.
c. Never crush or chew the medication.
A nurse conducting a health history with a patient identifies that which health condition places the patient at risk for developing gastroesophageal reflux disease (GERD)? a. Cigarette smoking b. Type II diabetes mellitus c. Obesity d. Alcohol use
c. Obesity
5. What is the primary reason that a nurse use silence when communicating with a patient about his diagnosis? a. A period of silence makes the patient feel uncomfortable b. Several periods of silence makes the teaching session longer c. Silence periods allow the patient to gather their thoughts before speaking d. Silence periods allow the nurse to think of her next question for the patient
c. Silence periods allow the patient to gather their thoughts before speaking
4. A nurse is sitting by the bedside close to a patient to better hear him and letting him know that she has his full attention. What factor does the nurse need to keep in mind that may interfere with effective communication with this patient? a. The patient may not be hard of hearing b. The volume on the TV may be at a high setting c. The patient may have person space issues d. The nurse may need to sit closer to be most effective
c. The patient may have person space issues
3. In caring for a patient with third degree burns over 22 percent of his body, which of the following needs of Maslow have the highest priority? a. Love and belonging b. Psychological and social fulfillment c. Safety d. Physiological
d. Physiological
What is diversity?
differences between cultures
The client has scabies. The nurse has taught the client about safety in using topical scabicide medications and evaluates that teaching has been effective when the client makes which statement?
"I must avoid putting this lotion on my face."
The student nurse asks the nursing instructor for help with her microbiology class. The student is studying bacteria. What does the best instruction by the nursing instructor include?
3. E. coli are gram-negative bacteria. 4. Gram-staining is one way to identify bacteria. 5. Spherical-shaped bacteria are called cocci.
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion
ANS: A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion. DIF: Remembering/Knowledge REF: 1169 KEY: Inflammatory bowel disorder| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 liter of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."
ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
The nurse is preparing a teaching plan for a client who is scheduled to undergo mammography for the first time. What instruction by the nurse is accurate? a. "The test should be carried out even if you are pregnant." b. "Do not use deodorant on breasts or underarms before the test." c. "You will not experience any discomfort because this is just an x-ray." d. "The entire test should not take longer than 1 hour."
ANS: B The client should be reminded not to use creams, powders, or deodorant on breast or underarm areas before mammography because these products can show on the x-ray. The test should be rescheduled if any possibility exists that the client is pregnant. Women can experience discomfort as the breasts are compressed. The test is generally much less than an hour in duration.
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a.Draw blood for albumin, prealbumin, and total protein. b.Prepare for and assist with obtaining a wound culture. c.Place the client in bed and instruct the client to elevate the foot. d.Assess the right leg for pulses, skin color, and temperature.
ANS: D A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.
A patient is admitted to the hospital with severe diarrhea. The patient should be monitored for which complication associated with diarrhea? 1) Hypokalemia 2) Hypocalcemia 3) Hyperglycemia 4) Thrombocytopenia
Hypokalemia Diarrhea causes fluid loss and hypokalemia, not hypocalcemia, hyperglycemia, or thrombocytopenia.
What is the therapeutic class for Cyclosporine?
Immunosuppressant
What should be closely monitored by the healthcare provider for a patient taking cyclosporine
Renal Function
What is primary diversity?
more obvious, such as nationality, race, color, gender, age, religious beliefs
Is culture a monolithic concept?
no
What is the primary adverse effect of cyclosporine
occurs in the kidneys, resulting in reduction of urine output
What is secondary diversity?
socioeconomic status, education, occupation, length of time away from the country or origin, gender issues, residential status, and sexual orientation
Replication of HIV
• HIV targets CD4 receptor on T4 lymphocyte - Using reverse transcriptase, makes viral DNA from RNA • Virions bud from host cell - Enzyme protease enables virion to infect other T4 lymphocytes - Result is gradual destruction of immune system • HIV called "retrovirus" because of reverse synthesis process
Therapy for Viral Infections
• Mature particles called virions • Most viruses are self-limiting; require no pharmacotherapy - Example: rhinovirus that causes common cold • Some viruses cause serious disease and require aggressive therapy • Examples: - HIV fatal if left untreated - Herpes viruses can cause significant pain and disability if left untreated
Characteristics of Viruses
• Nonliving agents that infect bacteria, plants, animals • Intracellular parasite - Must be in host cell to replicate and cause infection - Many viruses infect specific host cells
Structure of Viruses
• Surrounded by capsid (protein coat) • Contain a few dozen genes, either RNA or DNA • DNA contains information needed for replication • May have lipid envelope with protein "spikes" that trigger immune response
Challenges of Antiviral Therapy
• Viruses mutate rapidly, and drug becomes ineffective • Difficult for drug to find virus without injuring normal cells • Each antiviral drug specific to one particular virus
What is amoxicillin used for?
prescribed for sinus and upper reparatory and genitourinary tract infections
The primary function of the dermis is to
provide foundation for hair and nails.
Dermatitis is characterized by
pruritus.
Influenza and Relenza
reported to shorten the normal 7-day duration of influenza symptoms to 5 days
What are cultural values?
shared beliefs about desirable end states or modes of conduct in a given culture
Contraindications in live vaccines
some attenuated vaccines cause a mild or subclinical case of the disease
Time frames for Arlalen
start 2 weeks before travel and continuing 4-6 weeks following retun
Skin cells in the epidermis are replaced and supplied by the
stratum basale.
Treatment of tuberculosis usually involves
the use of two or more drugs at the same time. : Multidrug therapy for 6-12 months is the usual pharmacotherapy for tuberculosis. Surgery is not the treatment. It is not necessary to keep the client in the hospital. Use of a single drug is not usual.
What is the leading cause of miscommunication?
touching clients from different cultures that they may deem as inappropriate
Viral Hepatitis
• A, B, C types are primary • Cause inflammation, necrosis of liver cells
Pharmacotherapy of Influenza
• Best approach—vaccination for prevention • Antivirals to prevent, decrease severity of acute symptoms - Amantadine (Symmetrel) - Rimantadine (Flumadine)
Treatment Failures
• Common with antiretroviral therapy - Patient nontolerance of adverse effects - Patient nonadherence to complex regimen - Emergence of resistant strains - Genetic variability • Therapy always changing • Stay current with latest treatments
Pharmacotherapy of Herpesvirus Infections
• Family of DNA viruses; causes repeated blister-like lesions on the skin, genitals, and other mucosal surfaces • Antiviral drugs lower frequency of acute episodes and diminish intensity of acute disease - Relieve acute symptoms, prevent recurrences - Do not provide cure
Highly Active Antiretroviral Therapy (HAART)
• Five drug classes used in various combinations - Nucleotide reverse transcriptase inhibitor (NtRTI) - Nonnucleoside reverse transcriptase inhibitor (NNRTI) - Protease inhibitor (PI) - Entry inhibitors (includes fusion inhibitors and CCR5 antagonists) - Integrase inhibitors and other miscellaneous antivirals
Phases of HIV Therapy
• Latent phase—Virus lies dormant - People often unaware they have HIV • Once diagnosis confirmed, decision made about starting or delaying treatment • Current protocols: Defer treatment in asymptomatic adults who have CD4 counts above 350 cells/mcL • Therapy is initiated when CD4 is under 200 cells/mcL or symptoms appear
The client asks the nurse how skin cells are replaced. What is the best response by the nurse?
"The epidermis supplies new cells after older cells have been damaged or lost."
The client tells the nurse that the doctor told him his antibiotic did not kill his infection but just slowed its growth. The client is anxious. What is the best response by the nurse to decrease the client's anxiety?
"This is okay because your body will help kill the infection too."
A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. "Ambulating in the hallway twice a day will help." b. "I will apply a cold compress to the painful area on your back." c. "Drinking a warm beverage can relieve this referred pain." d. "You should cough and deep breathe every hour."
ANS: A The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.
After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will let my husband do all of the cooking for my family." b. "I'll take the ciprofloxacin until the diarrhea has resolved." c. "I should wash my hands with antibacterial soap before each meal." d. "I must place my dishes into the dishwasher after each meal."
ANS: B Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carriers for up to 1 year. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| medications| antibiotics| medication safety MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
The nurse is counseling a postmenopausal woman about her new stress incontinence. Which statement by the nurse is most important? a. "You can try a variety of briefs and undergarments." b. "It will be important to keep that area clean and dry." c. "I can refer you to a good incontinence clinic." d. "Unfortunately, incontinence is common in women your age."
ANS: B After menopause, the vagina becomes dry, thinner, and smoother. This atrophy places the vagina at risk for infection. The combination of this fact with the presence of urine places the woman at higher risk for infection. The nurse should teach the client good hygienic practices to reduce the likelihood of infection. Education about briefs/undergarments may be needed, and a referral to an incontinence clinic would be very helpful, but neither takes priority over preventing infection. Stating that incontinence is common is not a helpful strategy.
After teaching a client with diverticular disease, a nurse assesses the client's understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice
ANS: D Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet. DIF: Applying/Application REF: 1187 KEY: Diverticular disease| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
The client is recovering from a severe sunburn. What will the best teaching by the nurse include?
"Apply a sunscreen when you are going to be in the sun."
A client has lice infestation of the eyelids. What instruction should the nurse provide?
"Apply a thin coat of petroleum jelly to your eyelashes once a day for a week."
The physician orders cefepime (Maxipime) for a client. What is a priority question for the nurse to ask the client prior to administration of this drug?
"Are you allergic to penicillin?"
The physician orders penicillin for a female client who has a sinus infection. What is a priority question to ask the client prior to administering the medication?
"Are you taking birth control pills?"
The mother of a young child calls the clinic and tells the nurse that she has just discovered head lice in her daughter's hair. What is the best instruction by the nurse?
"Follow the package directions exactly on the permethrin lotion from the pharmacy."
A client has been prescribed 0.1% tacrolimus (Protopic) for treatment of severe atopic dermatitis. The nurse would evaluate that medication teaching is successful when the client makes which statement?
"I am at increased risk for skin cancer because I am using this drug."
The client is prescribed amoxicillin (Amoxil) for 10 days to treat strep throat. After 5 days, the client tells the nurse he plans to stop the medication because he feels better. What is the best response by the nurse?
"If you stop the medicine early, you have not effectively killed out the bacteria making you sick."
Lice and body mites have been discovered in an elementary school population. Which instructions should the school nurse send home to parents?
"Look for small bugs in your children's hair or small objects attached to the hair shaft." "If lice or mites are found, stuffed animals should be washed or sealed in an airtight bag for 2 weeks."
The client receives multiple drugs for treatment of tuberculosis. The nurse teaches the client the rationale for multiple drug treatment and evaluates learning as effective when the client makes which statement?
"Multiple drugs are necessary because the bacteria are likely to develop resistance to just one drug."
The mother of a client with head lice has completed the applications of topical medication. What is the best instruction by the nurse at this time?
"Remove all nits from the hair shaft with a nit comb or a fine-tooth comb."
A patient has been prescribed ultraviolet (UV) light therapy for a skin condition. The patient says, "This treatment is so expensive, I think I will go to the tanning salon instead." The nurse would provide which information?
"The light therapy you require should be closely monitored."
A client has psoriasis. Prior to beginning education, the nurse assesses the client. Which statement indicates the client has a correct knowledge base about his illness?
"Treatment can help lessen the discomfort of my psoriasis."
The client receives topical glucocorticoids for the treatment of dermatitis. The nurse has completed medication education and evaluates that learning has occurred when the client makes which statement?
"Use of this lotion is really a lot safer and more effective than a pill."
The client calls the clinic and is frantic that her two children have been sent home from school with head lice. She has treated their scalps but does not know what else to do. What will be the best teaching by the nurse?
"Wash the bed linens and clothing that have come into contact with the children."
List the adverse effects of Intron-A
- A fulike syndrome of fever, chills, dizziness, and fatigue occurs in 50% of patients - Headache, nausea, vomiting, diarrhea, and anorexia are relatively common - Depression and suicidal intention - With prolonged therapy, serious toxicity such as immunosuppression, hepatotoxicity, and neurotoxicity may be observed
Contraindications in Hep B vaccine
- Contraindicated in patients with hypersensitivity to yeast or HBV vaccine - Patients who demonstrated severe hypersensitivity to the first dose of the vaccine should not receive subsequent doses
Tetracycline side effects
- affects vaginal, oral, and intestinal flora and cause superinfections - nausea, vomiting, epigastric burning, diarrhea
Fluvicin education
- given by mouth that is indicated for mycoses of the hair, skin, and nails that have not responded to conventional topical preparations - Medication given orally, increased fluids interferes with renal function - take full course of meds
Fluvin (griseofluvin)
- if symptoms worsen or don't improve call the doctor - Given orally - increase fluids interferes with renal function - take full course
The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, "For 3 days prior to testing, I should avoid eating 1) beef. 2) milk. 3) eggs. 4) oatmeal.
1) beef. The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and certain raw fruits and vegetables for 3 days prior to fecal occult blood testing.
The nurse is providing community education regarding ways to reduce development of antibiotic resistance. Which information should be included?
1. The best way to prevent antibiotic resistance is to prevent infections from occurring. 2. Do not expect to receive an antibiotic prescription for colds and influenza. 3. Take the full amount of any prescribed medication. 5. Use good infection control measures.
A patient diagnosed with rosacea has been prescribed topical metronidazole (MetroGel). The nurse would teach which other management strategies?
1. "Avoid drinking alcohol." 3. "Avoid eating spicy foods." 4. "Drink your coffee at room temperature."
A patient has been prescribed ciprofloxacin (Cipro) for a severe sinus infection. The nurse evaluates that medication education has been effective when the patient makes which statements?
1. "I should avoid milk while taking this medication."(Dairy products can decrease the absorption of ciprofloxacin.) 2. "I should avoid coffee while taking this medication."(Ciprofloxacin can increase serum levels of caffeine. ) 4. "I may have some diarrhea while taking this medication." 5. "If my stomach gets upset, I should take this medication with food."
A client has been prescribed tretinoin (Avita) for treatment of acne. Which medication information should the nurse provide?
1. "It will take several weeks for you to see improvement in your skin." "Continue to take the tetracycline previously prescribed for your cystic acne."
A patient has been advised to use an over-the-counter acne product that contains benzoyl peroxide and salicylic acid. The nurse prioritizes which information in patient teaching?
1. "Test this product on a small area of skin for 3 days before applying to your face." 3. "Some serious allergic reactions have occurred when using this medication."
A young child has been diagnosed with atopic dermatitis. The nurse would review the patient's history for which findings?
1. Family history of asthma 2. Allergy to soaps and lotions
A 16-year-old patient is admitted to the emergency room after attempting to commit suicide by overdosing on the isoniazid (INH) prescribed for newly diagnosed tuberculosis. What information does the nurse provide to the family?
1. INH overdose is very serious. 3. Treatment will include infusion of vitamin B6. 4. Liver damage may occur.
A client's medical record reveals presence of an erythematous urticarial rash with pruritus. What assessment findings would the nurse expect?
1. The area of the rash is red. 2. The area has a raised, bumpy texture. 4. The area itches.
When did the transcultural movement begin?
1974
When did the ANA recommend that multicultural content be included in nursing curricula?
1976
The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowler's position 2) Left side-lying position 3) Supine, with the head of the bed lowered flat 4) Supine, with the head of bed raised to 30 degrees
2) Left side-lying position The nurse should position an immobile patient in a left side-lying position to irrigate his colostomy. Semi-Fowler's, supine with the bed lowered flat, and the supine position with the head of bed elevated to 30 degrees are not appropriate positions for colostomy irrigation.
A client has been prescribed trimethoprim-sulfamethoxazole (Septra) for treatment of a urinary tract infection. Which comments, made by the client, would the nurse discuss with the prescriber before allowing the client to leave the clinic?
2. "I forgot to take my potassium supplement today."(Potassium supplements should not be taken during therapy unless directed by the health care provider.) 3. "Is it okay to take this with my warfarin?" (Sulfa drugs may enhance the effects of oral anticoagulants.)
A patient has recurrent skin infections. The nurse anticipates administering an aminopenicillin such as which drug?
2. Ampicillin 4. Amoxicillin
The client is to receive an injection of penicillin G benzathine (Bicillin LA) in the outpatient clinic. What are the priority nursing actions prior to administering this injection?
2. Ask the client if she has ever had an allergy to penicillin before. 3. Inform the client that she will need to wait 30 minutes before leaving the clinic.
A client who has diabetes mellitus is diagnosed with tuberculosis and has been prescribed multiple-drug therapy. What instruction should the nurse provide to this client?
2. Test your blood glucose more frequently while on these medications.(These medications may cause hyperglycemia. The client should monitor blood glucose levels more closely.) 3. If your blood glucose levels elevate consistently, contact us.(Constant elevation of blood glucose levels may warrant alteration in medication therapy for diabetes.)
A client receiving chemotherapy has a very low white blood cell count. Antibiotic therapy is initiated. What rationales should the nurse provide for the addition of this drug?
2. We would like to prevent you from developing any infections.
A client has been diagnosed with multidrug-resistant tuberculosis, and drug therapy has been initiated. The nurse evaluates that medication education has been effective when the patient says, "I can expect to take this medication for up to _____ months."
24
Which is a key treatment intervention for the patient admitted with diverticulitis? 1) Antacid 2) Antidiarrheal agent 3) Antibiotic therapy 4) NSAIDs
3) Antibiotic therapy A key treatment for diverticulitis (an infected diverticulum) is antibiotic therapy; if antibiotic therapy is ineffective, surgery may be necessary. Antacids, antidiarrheal agents, and NSAIDs are not indicated for treatment of diverticulitis.
A teenager is taking isotretinoin (Accutane) for treatment of severe acne. The nurse has completed medication education with her mother and evaluates additional learning is required when the mother makes which statement?
3. "At least I do not need to worry about her self-concept now."
A client has been prescribed permethrin (Nix) for the treatment of body mites. What medication information should the nurse provide?
4. "You may feel some stinging or tingling while the lotion is being used." 5. "You should not use this medication if you are sensitive to chrysanthemums."
A client comes to the emergency department complaining of a sore throat. He has white patches on his tonsils, and he has swollen cervical lymph nodes. What will the best plan by the nurse include?
4. Plan to obtain a throat culture.
the patient with HIV/AIDS appears emaciated and has diarrhea, anorexia, mouth lesions, and peristent weight loss. what condition does the nurse suspect this patient is developing? a. AIDS dementia B. AIDS wasting syndrome C. AIDS GI opportunistic infection D. AIDS candidiasis opportunistic infection
b
what is the most important means of preventing HIV spread? A. engineering B. education C. isolation D. counseling
b
A nurse assesses a client who has a chronic wound. The client states, "I do not clean the wound and change the dressing every day because it costs too much for supplies." How should the nurse respond? a."You can use tap water instead of sterile saline to clean your wound." b."If you don't clean the wound properly, you could end up in the hospital." c."Sterile procedure is necessary to keep this wound from getting infected." d."Good hand hygiene is the only thing that really matters with wound care."
ANS: A For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.
A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a.Client admitted from a nursing home with furuncles and folliculitis b.Client with a leg cut and other trauma from a motorcycle crash c.Client with a rash noticed after participating in sporting events d.Client transferred from intensive care with an elevated white blood cell count
ANS: A The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs are visible at present. The rash following participation in a sporting event could be caused by several different things. A client with an elevated white blood cell count has the potential for infection but should be at lower risk for MRSA than the client admitted from the communal environment.
A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a.Place the client in a single room. b.Administer an antihistamine. c.Assess the client's airway. d.Apply gloves to minimize friction.
ANS: A The client's presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the client's infectious disorder.
A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a.Recent wound assessment, including size and appearance b.Insurance information for billing and coding purposes c.Complete health history and physical assessment findings d.Resources available to the client for wound care supplies
ANS: A The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.
A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond? a. "Let's discuss potential factors that increase your symptoms." b. "If you take the prescribed medications, you will no longer have diarrhea." c. "To decrease distress, do not eat anything before you go out." d. "You must retake control of your life. I will consult a therapist to help."
ANS: A Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response. DIF: Applying/Application REF: 1180 KEY: Ulcerative colitis| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity
A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Client's weight decreased by 3 pounds
ANS: A Fistulas place the client with Crohn's disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority. DIF: Applying/Application REF: 1184 KEY: Crohn's disease| electrolyte imbalance MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)
ANS: A Metronidazole is the drug of choice for a Giardia infection. Ciprofloxacin and ceftriaxone are antibiotics used for bacterial infections. Sulfasalazine is used for ulcerative colitis and Crohn's disease. DIF: Remembering/Knowledge REF: 1190 KEY: Parasitic infection| medication MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-smeared output
ANS: A The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood. DIF: Applying/Application REF: 1177 KEY: Ostomy care| postoperative nursing MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Loose and bloody stool d. Lower abdominal cramps
ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn's disease. DIF: Applying/Application REF: 1179 KEY: Crohn's disease| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. "Do you have a one- or two-story home?" b. "Can you check your own pulse rate?" c. "Do you have any alcohol in your home?" d. "Can you prepare your own meals?"
ANS: A A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this client's safety.
To promote comfort after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine
ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.
21. A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values: 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.
ANS: A All actions are appropriate for this client who has manifestations of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider? a. Drainage from a fistula b. Absent bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage
ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.
11. The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients
ANS: A Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.
A nurse assesses a client who has open lesions. Which action should the nurse take first? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the client's pain. d. Obtain vital signs.
ANS: A Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on.
A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a. Ask the client about shellfish allergies. b. Document this information on the chart. c. Ensure that the client has a ride home. d. Instruct the client on bowel preparation.
ANS: A PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC.
6. A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"
ANS: A Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information.
A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How should the nurse respond? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."
ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may diminish the client-nurse relationship.
A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the client's foods. d. Make the client NPO.
ANS: A The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.
A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition? a. "What do you do for a living?" b. "Are your nails professionally manicured?" c. "Do you have diabetes mellitus?" d. "Have you had a recent fungal infection?"
ANS: A The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.
15. A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.
ANS: A The nurse needs to obtain further information about the spouse's specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining isolation precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse it's safe to visit is demeaning of the spouse's feelings.
A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.
ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used.
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."
ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.
8. A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity
ANS: A The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.
When scheduling an annual pelvic examination and Pap test, the client asks if she should abstain from intercourse before the test. Which is the nurse's best response? a. "Yes. Avoid having intercourse for 24 hours before the test." b. "Yes. Avoid having intercourse for 2 hours before the test." c. "No. Intercourse does not interfere with this test." d. "No. Intercourse can actually enhance the test results."
ANS: A The woman should not douche, use vaginal medications or deodorants, or have sexual intercourse for at least 24 hours before the test. Such activities may prevent the accurate evaluation of smears, cultures, and cytologic data.
A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first? a. Assess the client's endotracheal tube with 40% FiO2. b. Insert an indwelling Foley catheter to gravity drainage. c. Place the client's nasogastric tube to low intermittent suction. d. Start lactated Ringer's solution through an intravenous catheter.
ANS: A Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted and the nasogastric tube can be set.
A client tells the nurse she is happy that she never had children because she has less risk of developing cancer. Which response by the nurse is best? a. "Actually, your risk of breast cancer is slightly higher." b. "You're right; your risk of all reproductive cancer is quite low." c. "In reality, smoking is the leading risk factor for all types of cancer." d. "Your risk of uterine cancer is higher because you had no children."
ANS: A Women who have never had children have a slightly higher risk of breast cancer than the general population. Smoking is a major risk factor for many, but not all, cancers. Uterine cancer is not influenced by pregnancy.
A client is in the clinic for an annual examination and questions the need for a pelvic examination and Pap smear because she had a hysterectomy many years ago. Which response by the nurse is most appropriate? a. "Do you still have your cervix?" b. "Are you sexually active?" c. "We can skip it if you like." d. "Let's see what the doctor says."
ANS: A Women who still have their cervix after hysterectomy still need a Pap smear according to the guidelines established for other women. Sexual activity is not relevant. Simply stating that it can be skipped does not help the woman protect her health. Asking the provider does not help the nurse further assess the client.
A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a."Wash your hands before touching the client." b."Wear gloves when bathing the client." c."Assess skin for breakdown during the bath." d."Apply lotion to lesions while the skin is wet." e."Use a damp cloth to scrub the lesions."
ANS: A, B All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the client's skin. The other statements are not appropriate for the care of open skin lesions.
A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Look for asymmetry of shape and irregular borders." b. "Assess for color variation within each lesion." c. "Examine the distribution of lesions over a section of the body." d. "Monitor for edema or swelling of tissues." e. "Focus your assessment on skin areas that itch."
ANS: A, B Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.
A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.) a. Contact the provider immediately. b. Lower the head of the bed. c. Decrease intravenous fluids. d. Ask the client to bear down. e. Administer prescribed opioids.
ANS: A, B Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the client's head, and contact the provider or Rapid Response Team for immediate assistance. Treatment for shock usually includes intravenous fluids; therefore, decreasing fluids would be an incorrect intervention. The client's tachycardia is a result of shock, not pain. Performing the vagal maneuver or administering opioids could knock out the client's compensation mechanism.
2. A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)
ANS: A, B, C Amoxicillin, ciprofloxacin, and doxycycline are all possible treatments for inhalation anthrax. Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tract infections and other common infections.
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.) a. Colon cancer b. Diverticulitis c. Inflammatory bowel disease d. Peptic ulcer disease e. Pernicious anemia
ANS: A, B, C, D In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.
4. A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours
ANS: A, B, C, D The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse should perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury.
The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.) a. Achlorhydria b. Chronic atrophic gastritis c. Helicobacter pylori infection d. Iron deficiency anemia e. Pernicious anemia
ANS: A, B, C, E Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.
The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
ANS: A, B, C, E Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress.
The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified
ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding - Erosion of the bowel wall b. Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer e. Fistula - Dilation and colonic ileus caused by paralysis of the colon
ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon. DIF: Understanding/Comprehension REF: 1181 KEY: Ulcerative colitis MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. c. Prime the IV tubing with dextrose in water. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.
ANS: A, B, D, E Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identity), primes the IV tubing with normal saline, takes and records a baseline set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.
The nurse is teaching high school girls about the female reproductive tract. Which statements by the nurse are accurate? (Select all that apply.) a. The vagina has an acidic environment. b. The cervix is where the Pap smear is taken from. c. The ovum is fertilized in the uterus. d. Ovaries produce sex steroid hormones. e. The breasts contain fat tissue.
ANS: A, B, D, E The acidic environment of the vagina helps protect against infection. The cervix is the site for Pap testing. The ovaries produce sex steroid hormones. The breasts contain fat, glandular, fibrous, and ductal tissue. Ova are fertilized in the fallopian tubes.
A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a.Use a lift sheet when moving the client in bed. b.Avoid tape when applying dressings. c.Avoid whirlpool therapy. d.Use loose dressing on all wounds. e.Implement pressure-relieving devices.
ANS: A, B, E Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin won't tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output
ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis. DIF: Remembering/Knowledge REF: 1170 KEY: Inflammatory bowel disorder| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea associated with defecation?"
ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the client's pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color.
After teaching a client with an anal fissure, a nurse assesses the client's understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.) a. Taking a warm sitz bath several times each day b. Utilizing a daily enema to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories e. Taking a laxative each morning
ANS: A, C, D Taking warm sitz baths each day, using bulk-producing agents, and administering anti-inflammatory suppositories are all appropriate actions for the client with an anal fissure. The client should not use enemas or laxatives to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). DIF: Applying/Application REF: 1189 KEY: Skin lesions/wounds| bowel care MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the client's plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results
ANS: A, C, D Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status should include a high-protein, high-calorie diet. To determine the client's nutritional status, the nurse should assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and obesity. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing.
A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked."
ANS: A, C, D, E Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure meat and eggs are cooked properly, and, because it can be transmitted by flies, keep flies off of food. DIF: Applying/Application REF: 1191 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
1. A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension
ANS: A, C, D, E Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.
A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Rotavirus is more common among infants and younger children." b. "Escherichia coli diarrhea is transmitted by contact with infected animals." c. "To prevent E. coli infection, don't drink water when swimming." d. "Clients who have botulism should be quarantined within their home." e. "Parasitic diseases may not show up for 1 to 2 weeks after infection."
ANS: A, C, E Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals. DIF: Applying/Application REF: 1172 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider
ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.
A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowler's position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the client's nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent
ANS: A, C, E The client's head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate.
A nurse teaches a community group ways to prevent Escherichia coli infection. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."
ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection. DIF: Applying/Application REF: 1172 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A young adult client is in the clinic for evaluation of amenorrhea lasting 3 months. She takes birth control pills but is on no other medications. Which actions by the nurse are most appropriate? (Select all that apply.) a. Instruct the client on collecting a urinalysis for a pregnancy test. b. Assess the client's urinary and bowel habits. c. Perform a physical assessment on the client's abdomen. d. Weigh the client and calculate the body mass index. e. Reassure the client that amenorrhea can occur with oral contraception.
ANS: A, D Amenorrhea can be caused by several things, but not by urinary or bowel problems. Pregnancy should always be considered, even if the woman is on birth control of any type. Too little body fat can lead to menstrual irregularities. Simply reassuring the client is not as helpful as conducting further assessment.
A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli
ANS: A, D Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.
A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a.Place a small pillow between bony surfaces. b.Elevate the head of the bed to 45 degrees. c.Limit fluids and proteins in the diet. d.Use a lift sheet to assist with re-positioning. e.Re-position the client who is in a chair every 2 hours. f.Keep the client's heels off the bed surfaces. g.Use a rubber ring to decrease sacral pressure when up in the chair.
ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.
A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this client's condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%
ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.
A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a."Do you have a bedpan at home?" b."How are you coping with providing this care?" c."What are you doing to prevent pediculosis?" d."Are you sharing a bed with your husband?"
ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wife's feelings and provide support for coping with changes. Asking about the client's toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregiver's support and coping mechanisms and ability to continue to care for her husband.
A nurse assesses a client who has psoriasis. Which action should the nurse take first? a.Don gloves and an isolation gown. b.Shake the client's hand and introduce self. c.Assess for signs and symptoms of infections. d.Ask the client if she might be pregnant.
ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse should first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy should be completed after establishing a report with the client.
After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? a."I can help him shift his position every hour when he sits in the chair." b."If his tailbone is red and tender in the morning, I will massage it with baby oil." c."Applying lotion to his arms and legs every evening will decrease dryness." d."Drinking a nutritional supplement between meals will help maintain his weight."
ANS: B Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.
After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a."At the next family reunion, I'm going to ask my relatives if they have psoriasis." b."I have to make sure I keep my lesions covered, so I do not spread this to others." c."I expect that these patches will get smaller when I lie out in the sun." d."I should continue to use the cortisone ointment as the patches shrink and dry out."
ANS: B Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division.
After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a.Low-fat diet with whole grains and cereals and vitamin supplements b.High-protein diet with vitamins and mineral supplements c.Vegetarian diet with nutritional supplements and fish oil capsules d.Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet
ANS: B The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein
An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client? a. Check with the pharmacist before taking other medications. b. Increase intake of calcium and vitamin D. c. Report any worsening of symptoms to the provider. d. Take the medication as prescribed by the provider.
ANS: B All of this advice is appropriate for any client taking this medication. However, long-term use is associated with osteoporosis and osteoporosis-related fractures. This client is already at higher risk for this problem and should be instructed to increase calcium and vitamin D intake. The other options are appropriate for any client taking any medication and are not specific to the use of esomeprazole.
A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a.Beige freckles on the backs of both hands b.Irregular blue mole with white specks on the lower leg c.Large cluster of pustules in the right axilla d.Thick, reddened papules covered by white scales
ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.
3. Which teaching point is most important for the client with bacterial pharyngitis? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.
ANS: B Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.
A nurse assesses a client who is hospitalized for botulism. The client's vital signs are temperature: 99.8° F (37.6° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take? a. Decrease stimulation and allow the client to rest. b. Stay with the client while another nurse calls the provider. c. Increase the client's intravenous fluid replacement rate. d. Check the client's blood glucose and administer orange juice.
ANS: B A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not require additional intravenous fluids. Allowing the client to rest or checking the client's blood glucose and administering orange juice are not appropriate actions. DIF: Applying/Application REF: 1191 KEY: Inflammatory bowel disorder| respiratory distress/failure MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with my breakfast each morning." c. "Nausea and vomiting are common side effects of this drug." d. "I must wash my hands after I play with my dog."
ANS: B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing. DIF: Applying/Application REF: 1183 KEY: Ulcerative colitis| medication safety MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids
ANS: B Protecting the client's skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn's disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids. DIF: Applying/Application REF: 1181 KEY: Crohn's disease| bowel care MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How should the nurse respond? a. "Your friends will be happy that you are alive." b. "Tell me more about your concerns." c. "A therapist can help you resolve your concerns." d. "With time you will accept your new body."
ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the client's concerns or provide false reassurance. DIF: Applying/Application REF: 1180 KEY: Ostomy care| coping| support MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity
After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"
ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client. DIF: Applying/Application REF: 1179 KEY: Ostomy care| psychosocial response| coping MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I'll rinse my rectal area with warm water after each stool and apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."
ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry. DIF: Applying/Application REF: 1179 KEY: Bowel care| inflammatory bowel disorder MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
An African-American client has a prostate-specific antigen (PSA) of 12 ng/mL. Which action by the nurse is best? a. Remind the client to repeat the test in 1 year. b. Prepare the client for further diagnostic testing. c. Ask if the client ejaculated within 48 hours of the test. d. Assess the client for alcohol and tobacco use.
ANS: B A normal PSA level is less than 4 ng/mL. Elevated PSA levels, particularly those over 10 ng/mL, are associated with cancer. African Americans tend to have higher PSA levels as they age, but this level is so high that the nurse must suspect cancer and prepare the client for further diagnostic testing. The client should not wait a year to repeat the test. The client should not ejaculate for 24 hours before having blood drawn. Alcohol and tobacco use does not cause an elevation in PSA.
A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs
ANS: B Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure.
The nurse is teaching a postmenopausal woman about nutrition. Which statement by the nurse is most appropriate? a. "Be sure to eat cereal fortified with folic acid and B vitamins." b. "Make sure you take a calcium supplement every day." c. "Vitamin C is important for the postmenopausal woman." d. "You can get all the iron you need in two daily meat servings."
ANS: B Calcium is important throughout life, but for the postmenopausal woman, it is vital to help prevent osteoporosis. Folic acid and B and C vitamins are very important for the woman taking oral contraceptives. Iron might be important for this client for other reasons but is especially important for women with heavy menstrual bleeding.
A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client? a. Colonoscopy b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B c. Ova and parasites d. Stool culture
ANS: B Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time.
A postmenopausal client says that she is experiencing difficulty with vaginal dryness during intercourse and wonders what might be causing this. Which is the nurse's best response? a. "The less frequently you have intercourse, the drier the vaginal tissues become." b. "Estrogen deficiency causes the vaginal tissues to become drier and thinner." c. "Drinking at least 3 liters of water each day will make all your tissues less dry." d. "Try using a water-soluble lubricant during intercourse."
ANS: B Estrogen deprivation, which occurs as a result of menopause, decreases the moisture-secreting capacity of vaginal cells, thereby making the area drier. The vaginal tissues also become thinner and the rugae become smoother. Reduced frequency of intercourse will not dry out the vaginal tissues. Drinking excess water will not make the tissues less dry. A water-soluble lubricant may make intercourse less difficult. However, the client is asking what causes the problem.
A young woman is not pregnant but has not had a menstrual period for 5 months. Which factors does the nurse explore as a possible cause of the amenorrhea? a. The client's mother having type 2 diabetes mellitus b. Running 10 to 15 miles/day c. Taking aspirin daily d. Having a diet high in protein
ANS: B Excessive exercise, with corresponding loss of body fat, is associated with insufficient estrogen levels for the maintenance of normal ovulatory and menstrual cycles. The other factors are noncontributory.
13. A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3
ANS: B INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.
7. An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."
ANS: B It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has manifestations of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.
19. A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. Ask the client what foods cause trouble swallowing. b. Assess the client for pain when swallowing. c. Determine if the client can swallow saliva. d. Palpate the client's jaw while swallowing.
ANS: B Odynophagia is painful swallowing. The nurse should assess the client for this either by asking or by having the client attempt to drink water. It is not related to specific foods and is not assessed by palpating the jaw. Being unable to swallow saliva is not odynophagia, but it would be a serious situation.
An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.
ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.
A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel
ANS: B Pallor conjunctivae signifies anemia. The nurse should assess the client's hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this client's potential anemia.
17. A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.
ANS: B Polymerase chain reaction testing is used to diagnose pertussis, which this client is showing manifestations of. Hospitalization may or may not be needed but is not the most important action. The client may or may not be able to produce sputum, but sputum cultures for this disease must be obtained via deep suctioning. Blood cultures will be negative.
5. The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Cohort the "clients" in the same area of the unit. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.
ANS: B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease. The other actions are not appropriate.
The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach
ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.
A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.
ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation.
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.
ANS: B The local anesthetic used during this procedure will depress the client's gag reflex. After the procedure, the nurse should ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them
A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate? a. "Do you have family or friends for support?" b. "I'd like to know what you are feeling now." c. "Well, we knew this would probably happen." d. "Would you like me to refer you to hospice?"
ANS: B The nurse assesses the client's emotional state with open-ended questions and statements and shows a willingness to listen to the client's concerns. Asking about support people is very limited in nature, and "yes-or-no" questions are not therapeutic. Stating that this was expected dismisses the client's concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.
A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, "When I wake up I am in pain." Which action should the nurse take? a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client
ANS: B The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump.
14. A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.
ANS: B This client has manifestations of early inhalation anthrax. For treatment, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days. Sputum cultures are not needed. Anthrax is not transmissible from person to person, so Standard Precautions are adequate. Directly observed therapy is often used for tuberculosis.
A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? a. Auscultate for bowel sounds. b. Notify the provider immediately. c. Order an abdominal flat-plate x-ray. d. Palpate the mass and measure its size.
ANS: B This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurse's priority action is to notify the provider
3. A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L 3 e. White blood cell (WBC) count: 72,000/mm
ANS: B, C Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this client's problem.
After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the client's understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.) a. "I'll have my housekeeper keep my toilet clean." b. "I must take a shower or bathe every day." c. "I should have my well water tested." d. "I will ask my sexual partner to have a stool test." e. "I must only eat raw vegetables from my own garden."
ANS: B, C, D Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. Parasites are transmitted via unclean water sources and sexual practices with rectal contact. The client should test his or her well water and ask sexual partners to have their stool examined for parasites. Raw vegetables are not associated with parasitic gastrointestinal infections. The client can eat vegetables from the store or a home garden as long as the water source is clean. DIF: Applying/Application REF: 1190 KEY: Parasitic infection| infection control MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. "Do not allow the client to eat between meals." b. "Make sure the client receives a protein shake." c. "Do not allow caffeine-containing beverages." d. "Make sure the foods are bland with little spice." e. "Do not allow high-carbohydrate food items."
ANS: B, C, D During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.
A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.) a. Dispose of dirty linen in a red "biohazard" bag. b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client. e. Initiate Transmission-Based Precautions.
ANS: B, C, D The client should be placed in a private room and dirty linens kept in the client's room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring that the apron always faces the client. The nurse should also bundle care to minimize exposure to the client. Transmission-Based Precautions will not protect the nurse from the implanted radioactive iodine seeds.
A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr
ANS: B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.
A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a.Prepare a room for reverse isolation. b.Assess staff for a history of or vaccination for chickenpox. c.Check the admission orders for analgesia. d.Choose a roommate who also is immune suppressed. e.Ensure that gloves are available in the room.
ANS: B, C, E Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this client in a private room. Herpes zoster is a disease of immune suppression, so no one who is immune-suppressed should be in the same room.
The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach
ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.
A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Take a 20-minute walk at least 5 days each week." b. "Attend local Alcoholics Anonymous (AA) meetings weekly." c. "Choose whole grains rather than foods with simple sugars." d. "Use cooking spray when you cook rather than margarine or butter." e. "Stay away from milk and dairy products that contain lactose." f. "We can talk to your doctor about a prescription for nicotine patches."
ANS: B, D, F The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.
A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a."Have you eaten a large amount of chocolate lately?" b."Have you been under a lot of stress lately?" c."Have you recently used a public shower?" d."Have you been out of the country recently?" e."Have you recently had any other health problems?" f."Have you changed any medications recently?"
ANS: B, E, F Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a.Client with blood cultures pending b.Client who has thin, serous wound drainage c.Client with a white blood cell count of 23,000/mm3 d.Client whose wound has decreased in size
ANS: C A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.
A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a."Do you spend a great deal of time in the sun?" b."Have you or any family members ever had skin cancer?" c."Which method of contraception are you using?" d."Do you drink alcoholic beverages?"
ANS: C Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin.
A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? a.Administer it over 30 minutes using an IV pump. b.Give the client diphenhydramine (Benadryl) before the drug. c.Assess the IV site at least every 2 hours for thrombophlebitis. d.Ensure that the client has increased oral intake during therapy.
ANS: C Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to "red man syndrome"), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy.
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen
ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm. DIF: Applying/Application REF: 1172 KEY: Ulcerative colitis| hydration MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, "I am having trouble swallowing this pill." Which action should the nurse take? a. Contact the clinical pharmacist and request the medication in suspension form. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Ask the health care provider to prescribe the medication as an enema instead. d. Crush the pill carefully and administer it in applesauce or pudding.
ANS: C Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a provider's order. DIF: Applying/Application REF: 1176 KEY: Ulcerative colitis| medication safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I'll ride my bike or take a long walk at least three times a week." b. "I must try to include at least 25 grams of fiber in my diet every day." c. "I will take a laxative nightly at bedtime to avoid becoming constipated." d. "I should use my legs rather than my back muscles when I lift heavy objects."
ANS: C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining. DIF: Applying/Application REF: 1187 KEY: Diverticulitis| medication MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance
A nurse cares for a teenage girl with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How should the nurse respond? a. "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." b. "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." c. "Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."
ANS: C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible. DIF: Applying/Application REF: 1180 KEY: Ostomy care| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors should the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed
ANS: C "Diffuse" is used to describe lesions that are widespread. "Serpiginous" describes lesions with wavy borders. "Clustered" describes lesions grouped together. "Linear" describes lesions occurring in a straight line. Annular lesions are ringlike with raised borders, circinate lesions are circular, and circumscribed lesions have well-defined sharp borders. "Coalesced" describes lesions that merge with one another and appear confluent.
A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure."
ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider.
A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate? a. Assess the client for iodine or shellfish allergies. b. Educate the client on the side effects of sedation. c. Inform the client a second scan may be needed. d. Teach the client about bowel preparation for the scan.
ANS: C A second scan may be performed in 1 to 2 days to see if interventions have worked. The nuclear medicine scan does not use iodine-containing contrast dye or sedation. There is no required bowel preparation.
The nurse is counseling a mother who wants her teenage daughter to have a Pap smear and pelvic examination. Which statement by the nurse is most accurate? a. "If your daughter is over 18, she needs a pelvic examination and Pap smear." b. "A teenager does not need this examination unless she is sexually active." c. "Teach her to have her first examination by the age of 21 at the latest." d. "It is not needed unless you are worried about sexually transmitted diseases."
ANS: C A woman needs to have her first pelvic examination with Pap smear by the age of 21, or within 3 years of becoming sexually active. The other statements are not accurate.
When performing an assessment of the external genitalia of an older man, the nurse observes the scrotum to have smooth skin and to be very pendulous. Which action by the nurse is most appropriate? a. Suggest to the client that he should wear an athletic supporter while awake. b. Ask the client if he has been treated for a sexually transmitted disease. c. Document the observation and continue the assessment. d. Notify the health care provider and facilitate a scrotal ultrasound.
ANS: C As the male client ages, the scrotum loses rugae and becomes increasingly pendulous. This is a normal assessment finding. No further action is needed.
A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the client's bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care provider's notes about the prognosis for the client.
ANS: C Before conducting an assessment about the client's feelings, the nurse should determine whether he or she is willing and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an alternative meeting space may be located. The nurse should be present for the client during this time, and pulling up a chair and sitting with the client indicates that presence. Because the nurse is assessing the client's response to a terminal diagnosis, it is not necessary to have detailed information about the projected prognosis; the nurse knows that the client is facing an end-of-life illness.
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating
ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.
A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."
ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.
A nurse cares for an older adult client who has a chronic skin disorder. The client states, "I have not been to church in several weeks because of the discoloration of my skin." How should the nurse respond? a. "I will consult the chaplain to provide you with spiritual support." b. "You do not need to go to church; God is everywhere." c. "Tell me more about your concerns related to your skin." d. "Religious people are nonjudgmental and will accept you."
ANS: C Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses should assess how the client's skin changes are affecting the client's body image and encourage the client to express his or her feelings about a change in appearance. The other responses are not appropriate.
The nurse is assessing a client with a history of irregular periods. Which condition does the nurse possibly correlate with this problem? a. Childhood mumps b. Past valve replacement surgery c. Diabetes mellitus d. Mild intermittent asthma
ANS: C Endocrine disorders can affect the hypothalamic-pituitary-gonadal function of both men and women. Mumps would be important to know if the client were male. Past valve replacement surgery would not be contributory. Mild intermittent asthma also would not contribute to this problem. However, a client with more severe asthma who takes steroids on a long-term basis may develop secondary diabetes.
1. A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)
ANS: C First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine.
12. A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. "I need to take extra vitamin C while on INH." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."
ANS: C INH needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin (Rifadin).
A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasis c. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity
ANS: C Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.
10. A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.
ANS: C Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients is important to detect the onset of possible pneumonia but do not prevent it.
A nurse cares for a client with acute pancreatitis. The client states, "I am hungry." How should the nurse reply? a. "Is your stomach rumbling or do you have bowel sounds?" b. "I need to check your gag reflex before you can eat." c. "Have you passed any flatus or moved your bowels?" d. "You will not be able to eat until the pain subsides."
ANS: C Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.
A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."
ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.
A client is scheduled for an ultrasound to evaluate for possible uterine fibroids. Which instruction by the nurse is most appropriate? a. "Do not eat or drink anything after midnight." b. "Take these laxatives the morning of the test." c. "Do not urinate an hour before the test; a full bladder will give best results." d. "Have a designated driver because you will be sleepy from the anesthesia."
ANS: C The scan is noninvasive and painless. The abdominal and pelvic organs are better visualized with the bladder full during the scan. The other statements are inaccurate
20. A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.
ANS: C This "allergy test" is actually a positive tuberculosis test. The client should be placed on Airborne Precautions immediately. The other options do not take priority over preventing the spread of the disease.
2. A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule you for a computed tomography scan this week."
ANS: C This client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.
During examination of the male client's external genitalia, the nurse observes a discharge from the urethra when compressing the glans. Which is the nurse's next action? a. Document the observation. b. Ask the client to turn his head and cough. c. Obtain a specimen for culture. d. Test the cremasteric reflex.
ANS: C Urethral discharge is not considered normal in a continent client and should be cultured. The other options would not help provide information about the nature of the discharge.
A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting
ANS: C, D Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.
After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? a."I'll apply cortisone cream to reduce the inflammation." b."I'll apply a clean dressing after squeezing out the pus." c."I'll keep my arm down at my side to prevent spread." d."I'll cleanse the area prior to applying antibiotic cream."
ANS: D Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.
A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a.Viral infection - Clindamycin (Cleocin) b.Bacterial infection - Acyclovir (Zovirax) c.Yeast infection - Linezolid (Zyvox) d.Fungal infection - Ketoconazole (Nizoral)
ANS: D Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.
A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first? a. Heart rate and rhythm b. Bowel sounds c. Urinary output d. Respiratory rate
ANS: D Severe infection with C. botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected C. botulinum infection. The other assessments may be completed after the respiratory system has been assessed. DIF: Applying/Application REF: 1191 KEY: Hydration| inflammatory bowel disorder MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
18. A client has the diagnosis of "valley fever" accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? a. Intravenous amphotericin B b. Long-term anti-inflammatories c. No specific treatment d. Oral fluconazole (Diflucan)
ANS: D "Valley fever," or coccidioidomycosis, is a fungal infection. Many people do not need treatment and the disease resolves on its own. However, the presence of joint and muscle pain indicates a moderate infection that needs treatment with antifungal medications. IV amphotericin is reserved for pregnant women and those with severe infection. Anti-inflammatory medications may be used to treat muscle aches and pain but are not used long term.
A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.
ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.
A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2
ANS: D An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.
The nurse is working with a client who is recovering after a laparoscopy. Which assessment finding is considered a priority by the nurse? a. Slight drainage from the incision site b. Grogginess after the anesthesia c. Discomfort from the catheter d. Reports of shoulder pain
ANS: D Clients should expect mild drainage or blood from the incision site. Grogginess from the anesthesia and discomfort from a catheter are also expected minor occurrences post-laparoscopy. The nurse would not be concerned about these but should intervene and treat the client with shoulder pain. Shoulder pain is referred pain from phrenic nerve irritation and can be expected.
After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice
ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.
A client who has had numerous children is having her annual examination. The nurse wishes to discuss contraception, but the client is not interested. Which action by the nurse is most appropriate? a. Provide education on the value of spacing children. b. Explain the many alternatives from which to choose. c. Ask the client how her husband feels about so many children. d. Assess the client's religious and cultural background.
ANS: D Cultural and religious backgrounds can have a great deal of influence on clients' attitudes toward sexuality and reproduction. Because the client does not seem interested in the topic, the nurse should gently assess for these background influences and respect them. Providing education that the client does not want is not helpful and is disrespectful. Asking about the husband's preferences diminishes the nurse-client relationship, which should be focused on the client.
16. A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy
ANS: D Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.
A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first. d. Palpate the RUQ last.
ANS: D If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.
9. A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. "Are any family members also ill?" b. "Have you traveled recently?" c. "How long have you been ill?" d. "What is your occupation?"
ANS: D Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.
A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer? a. A 26-year-old with a body mass index of 21 b. A 33-year-old who frequently eats sushi c. A 48-year-old who often drinks wine d. A 66-year-old who smokes cigarettes
ANS: D Risk factors for pancreatic cancer include obesity, older age, high intake of red meat, and cigarette smoking. Sushi and wine intake are not risk factors for pancreatic cancer.
4. A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.
ANS: D Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client should be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.
A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a. Ask the client about recent exposure to illness. b. Assess the client's stool for obvious food particles. c. Include the date and time on the specimen container. d. Put on gloves prior to collecting the sample.
ANS: D To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.
A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Increased presence of fungal toenails d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead
ANS: D, F The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the American Cancer Society's hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups.
________ is abroad spectrum aminopenicillin (penicillin)
Amoxicillin
Which laboratory tests will be performed to determine whether a specific bacterium is resistant to a specific drug?
Culture and sensitivity test
What lab tests correlate with cyclosporine
Cyclosporine may increase serum triglycerides and uric acid. It may decrease hepatic enzymes and urinary function test values
What is the first step in becoming a culturally competent nurse?
Developing cultural awareness
Discharge planning for the client prescribed tetracycline will include which instruction?
Do not take the medication with milk. Tetracycline effectiveness can be decreased by using milk products. Antacids can decrease the effectiveness of tetracycline. Iron can decrease the effectiveness of tetracycline. It is not necessary to decrease vitamins.
What are the food interactions with cyclosporine
Food decreases the absorption of the drug
The client has MRSA and receives vancomycin (Vancocin) intravenously (IV). The nurse assesses an upper body rash and decreased urine output. What is the nurse's priority action?
Hold the next dose of vancomycin (Vancocin) and notify the physician.
The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patient's abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds
Hypoactive bowel sounds Hypoactive bowel sounds are low pitched, infrequent, and quiet. An abdominal bruit is a hollow, blowing sound found over an artery, such as the iliac artery. Normal bowel sounds are high pitched, with approximately 5 to 35 gurgles occurring every minute. Hyperactive bowel sounds are very high pitched and more frequent than normal bowel sounds.
The drug that would most likely be used in the treatment of tuberculosis is
Isoniazid (INH).
The client receives gentamicin (Garamycin) intravenously (IV) in the clinical setting. What is a priority nursing action?
Monitor the client for hearing loss.
A client comes to the emergency department with a fever of 104°F. The nurse anticipates which actions to help identify the correct antibiotic?
Obtaining a sterile urine specimen.
The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice and bananas
Oranges, raisins, and strawberries Oranges, raisins, and strawberries are high in fiber. White bread, pasta, and white rice are carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orange juice, and bananas are sources of potassium.
A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take? a. Clamp the nasogastric tube. b. Place the client in semi-Fowler's position. c. Assess vital signs once every shift. d. Provide oral rehydration.
Postoperative care for a client recovering from an open Whipple procedure should include placing the client in a semi-Fowler's position to reduce tension on the suture line and anastomosis sites, setting the nasogastric tube to low suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.
Simethicone (Gas-X, Mylicon) may be added to some medications or given plain for what therapeutic effect? a. decrease the amount of gas associated with GI disorders b. increase the acid-fighting ability of some medications c. prevent constipation associated with gastrointestinal drugs d. prevent diarrhea associated with gastrointestinal drugs
a. decrease the amount of gas associated with GI disorders
For a patient with a newly fractured pelvis, not yet in a cast, which of the following actions is appropriate when placing the patient on a bedpan? 1) Place the patient in semi-Fowler's position to defecate. 2) Ask the patient to push up with his feet to lift his hips while you place the bedpan. 3) Place a fracture pan under the buttocks, small end toward the feet. 4) Raise the siderail on the opposite side from where you are working.
Raise the siderail on the opposite side from where you are working. The nurse should always raise the siderail on the opposite side from where he is working to protect the patient from falls. Placing the patient in semi-Fowler's position or asking the patient to push up with his feet would cause pain and possible dislocation of the fracture. A fracture pan should be used, but the small large end is pointed toward the feet.
Multiculturism
Rather than blending smoothly into the bigger pot as former immigrants have done, this modern immigrants maintain their own unique flavors and textures, much like the ingredients in a large tossed salad.
The physician orders lindane (Kwell) for nursing home clients who have contracted head lice. The nurse will collaborate with the physician when one of the clients has which medical diagnosis?
Seizures
Side effects of Cipro
Serious adverse effects are uncommon - nausea, vomiting, diarrhea - phototoxicity - headache, dizziness
A client's medical record reveals the diagnosis of tinea unguium. The nurse would assess which body part for this disorder?
The nails
When nurses work with non-english speaking patients how will they measure a client's understanding?
The nurse needs to develop alternative ways through nonverbal responses.
Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) milk and cheese. 2) bread and pasta. 3) fruits and vegetables. 4) lean meats.
The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.
The nurse will know that a client with head lice understands principles of pediculicides when she can discuss
The nurse will know that a client with head lice understands principles of pediculicides when she can discuss
What is the action of bactericidal drugs?
They will kill the bacteria.
9. True or False: By venting and then emotionally and/or physically withdrawing, chronic complainers are seeking to gain the sympathy of others and develop some type of connection, even if it is dysfunctional.
True
When is healthcare considered culturally competent?
When health care providers and institutions are able to provide care for clients that meet the clients cultural needs.
What is cultural synergy?
When healthcare providers make a commitment to learn about other cultures and to immerse themselves in these cultures
A patient with a colostomy complains to the nurse, "I am having really bad odors coming from my pouch." To help control odor, which foods should the nurse advise him to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4) Yogurt and parsley
Yogurt and parsley Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy.
a patient asks why it is essential that HAART meds be taken everyday at the same time. what is the nurses best response? a. missing or delaying doses of these drugs decreases blood conenctrations needed to inhibit viral replication b. missing or delayed doses of these drugs decreases the risk of developing infections c. missing or delaying doses of these drugs decreases the effectiveness missing or delaying doses can decrease the risk of developing HIV resistant mutations
a
a patient with PJP usually presents with which symptom? A. dyspnea, tachypnea, persistent dry cough, fever b. cough with copious thick sputum, fever, and dyspnea c. chest pain and difficulty swallowing D. fever, persistant cough and vomiting
a
an IV drug user who regularly shares needles is in the ER. what information does the nurse provide to decrease he patients risk of HIV through shared needles after each use? A. fill and flush syringe with clear water, fill with bleach and shake for 30-60 seconds and rinse with clear water B. fill and flush with water then soap and hot water, shake for 2 minutes and flush with cold water C. rinse needles with bleach and water solution and allow to air dry D. rinse needles after each use with rubbing alcohol and water, then rinse with water
a
which point are you sure to include when teaching a new RN to prevent HIV transmission from patients? A. wear gloves when in contact with patients mucous membrane or non-intact skin B. be sure to wear protective gear when providing any care to HIV positive patients C. always war a mask D. use PEP whether a patient is positive or not
a
31. The recommended medication for the treatment of chlamydia would be A doxycycline. B podofilox. C acyclovir. D penicillin.
a Doxycycline is effective for treating chlamydia but should be avoided if the woman is pregnant. Penicillin is not recommended for chlamydia; it is the preferred medication for syphilis. Podofilox is a recommended treatment for nonpregnant women diagnosed with human papillomavirus infection. Acyclovir is used to treat genital herpes simplex virus infection.
32. When teaching adolescents about sexually transmitted diseases, it is important to emphasize prompt treatment when symptoms first appear to prevent complications. One example that may be used is that untreated gonorrhea may be associated with A infertility. B skin eruptions. C paralysis. D psychosis.
a Gonorrhea is associated with pelvic inflammatory disease, which increases the risk of tubal scarring and can result in infertility. The other choices are associated with syphilis.
4. Which one of the following is correct concerning the performance of a Pap test? A The woman should not douche, use vaginal medications, or have intercourse for at least 48 hours before the test. B It should be performed once a year, beginning with the onset of puberty. C A lubricant such as petroleum jelly should be used to ease speculum insertion. D The specimen for the Pap test should be obtained after a specimen is collected to test for cervical infection.
a Pap tests are performed annually for sexually active women or by age 21, especially if risk factors for cervical cancer or reproductive tract infections are present. Pap tests may be performed every 3 years in low-risk women between the ages of 21 and 29. No lubricant other than warm water should be used because accuracy of the test can be affected. The cytologic specimen should be obtained first.
13. A 65-year-old woman calls the clinic for an appointment stating that she has developed weakness, fatigue, and nausea over the past 2 weeks. The nurse should A have her come in immediately or go to the local emergency department. B make an appointment for later in the day. C make an appointment within 1 week. D discuss with her the need for referral to a hematologist.
a Recognition of coronary artery disease in women is important because they are more likely to die from a myocardial infarction (MI) than men. MIs tend to present with atypical vague symptoms in women that can delay recognition and treatment. Women may report having some vague symptoms that signal an imminent acute MI, such as fatigue, for several weeks before seeking care. Other symptoms may include nausea, vomiting, sweating, and dizziness.
18. A woman with premenstrual syndrome (PMS) may benefit from which of the following management techniques? A Relaxation therapy B Increasing caffeine C High-protein diets D One alcoholic drink at night during the luteal phase
a Relaxation therapy has shown benefits for women with more severe PMS symptoms. Avoiding alcohol and caffeine can help, and carbohydrate-rich foods can also help relieve PMS symptoms.
23. The simple procedure a nurse in a gynecologic clinic can do to assist patients with early detection of osteoporosis is to A measure the height of the patient at each annual appointment. B assess the spinal column for changes at each annual appointment. C recommend that the patient have serum calcium levels checked twice a year. D recommend that the patient have a bone mineral analysis done once a year.
a The first noticeable evidence of bone mass loss is the loss of height. Later signs include the dowager's hump on the spinal column. Serum calcium levels will not assist in determining osteoporosis. A bone mineral analysis is done to diagnose osteoporosis.
17. An 18-year-old has been diagnosed with primary dysmenorrhea. Prostaglandin inhibitors have been prescribed. The nurse recognizes that teaching concerning the use of prostaglandin inhibitors has been effective when the woman states: A "I will take ibuprofen as soon as my period starts and will continue around the clock for about 2 or 3 days." B "I will take ibuprofen once a day starting 2 days before my period should begin." C "I will take naproxen once a day every day." D "I will take naproxen around the clock every day that I am bleeding."
a The most effective prostaglandin inhibitors are nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen and naproxen. To be effective, the NSAID should be taken around the clock for at least 48 to 72 hours, beginning when menstrual flow starts.
What is a disadvantage of the salad bowl tradition?
a type of cultural confusion can be created that may lead to increased tension and anxiety.
What is personal space?
a zone that individuals maintain around themselves in most casual social situations
which conditions cause severe pain in HIV and AIDS (Select all that apply) a. enlarged organs b. peripheral neuropathy c. tumors d. high fever e. dry skin
a, b, c
an HIV positive women who is pregnant asks if her baby is at risk for HIV. which points must the nurse be sure to include when teaching? (Select all that apply) A. HIV can cross the placenta B. infant can contract HIV with exposure to blood and vaginal secretions during birth C. once your baby is born, you should be able to breastfeed D. there is a risk for perinatal transmission of HIV from you to your child. because you are on drug therapy, that risk is about 8% E. consider oral contraceptives o protect yourself from other STDs
a, b, d
what methods or agents are used to treat kaposi's sarcoma (Select all that apply) a. radiotherapy b. chemo c. antibiotics d. cryotherapy e. surgery
a, b, d
which actions are useful in helping orient a patient (Select all that apply) a. repeating person, place, time b. using clocks and calendars c. using MMSE screening test d. having familiar items present e. providing uninterrupted time
a, b, d
which descriptions are characteristic of a non progressor? (Select all that apply) A. has been infected for 10 years B. is asymptomatic C. has no CD4+ or t-lymphocytes D. is immunocompetent E. are functional antibodies
a, b, d
the nurse assesses a patient diagnosed with advanced AIDS for malnutirition. which findings does the nurse most likely assess (Select all that apply) a. pain b. anorexia c. urinary incontinence d. diarrhea e. vomiting
a, b, d, e
which methods or items are means of transmitting HIV (Select all that apply) a. sex b. household utensils c. breast milk d. toilet facilities e. mosquitoes
a, c
corticosteroids perform which actions (Select all that apply) a. block movement of neutrophils and monoctyes through cell membrane b. increase cell production in the bone marrow c. reduce number of circulating t cells, resulting in suppressed cell mediated immunity d. decrease ICP e. contrict blood vessels
a, c, d
where in the body can cytomegalovirus present with symptoms? (Select all that apply) a. eyes, causing visual impairment b. kidneys as glomerulonephritis c. respiratory tract causing pneumonia d. GI tract, causing diarrhea e. heart as cardiomyopathy
a, c, d
which actions can the nurse delegate to the UAP who will be giving mouth care to a patient with HIV/AIDS (Select all that apply) a. offer mouth rinses with sodium bicarb and sterile water several times a day b. assess mouth for increased presence of lesions c. encourage the patient to drink plenty of fluids d. provide a soft bristled toothbrush e. administer oral analgesic gel
a, c, d
which conditions may be the first signs of HIV in women? (Select all that apply) A. vaginal candidiasis B. bladder infections C. cervical caner D. PID E. mononucleosis
a, c, d
which lab resluts will the nurse expect to decrease (Select all that apply) a. cd4+ b. cd8+ c. WBC d. lymphocytes e. HIV antibodies
a, c, d
a patient presenting with toxicoplasmosis may have with s/s? (Select all that apply) A. speech difficulty B. Shortness of breath C. visual changes D. impaired gait E. mental status changes
a, c, d, e
which opportunistic infections can be observed in AIDS (Select all that apply) A. toxicoplasmosis B. gastroenteritis C. TB D. candidiasis E. cytomegalovirus
a, c, d, e
which practices are recommended to prevent transmission of HIV? (Select all that apply) A. latex condoms for genital and anal intercourse B. natural membrane condoms for genital and anal intercourse C. topical contraceptives D. antiviral meds E. latex barrier for genital and anal intercourse
a, e
38. Which measures provide comfort and prevent secondary infections when a sexually transmitted disease has been diagnosed? (Select all that apply.) A Keep the vulva clean but avoid strong soaps, creams, and ointments unless prescribed by the health care provider. B Keep the vulva dry. C Take analgesics (aspirin or acetaminophen) as directed by the health care provider. D Hot sitz baths may provide relief from itching. E Wipe the vulva from back to front after urination or defecation
a,b,c To provide comfort and prevent secondary infections, keep the vulva clean but avoid strong soaps, creams, and ointments unless prescribed by the health care provider, keep the vulva dry; using a hair dryer on low heat is helpful, wear absorbent cotton underwear and avoid pantyhose and tight pants as much as possible, take analgesics (aspirin or acetaminophen) as directed by the health care provider, cool or tepid sitz baths may provide relief from itching, wipe vulva from front to back after urination or defecation, and then carefully wash hands.
36. Which risk factors would necessitate performing a bone density scan on a woman younger than 65 years? (Select all that apply.) A Family history of osteoporosis B Fall history C Active life style D Chronic steroid use E Normal levels of estrogen F Overweight
a,b,d A bone density scan should be performed on a woman younger than 65 years when there is a family history of osteoporosis, history of falls, underweight, estrogen deficiency, or chronic steroid use.
37. A 55-year-old woman has a body mass index of 35. She is at high risk for which one(s) of the following? (Select all that apply.) A Diabetes mellitus B Pulmonary disease C Hypertension D Neurologic disorders E Coronary artery disease F Some cancers of the breast
a,c,e,f A 55-year-old woman with a body mass index of 35 is at high risk for diabetes mellitus, hypertension, coronary artery disease, and some cancers of the breast and reproductive organs.
7. What is usually considered to be an unfair labor practice? a. Being fired because a physician does not like a nurse's attitude b. Being passed over for promotion with an explanation of the rationale c. Being assigned to work five weekends in a row when the policy states that nurses will be required to work as needed d. Only being allowed 2 weeks of vacation during the first year of work.
a. Being fired because a physician does not like a nurse's attitude
Which drug should the nurse prepare to administer to prevent constipation in a client who had a surgical procedure? a. Docusate sodium (Colace) b. Prochlorperazine (Compazine) c. Loperamide (Imodium) d. Promethazine (Phenergan)
a. Docusate sodium (Colace)
A patient asks the nurse why the healthcare provider had advised against use of calcium carbonate as an antacid. What is the nurse's best response? a. Its use may result in kidney stones. b. It causes decreased gastric acid production. c. It often causes severe diarrhea. d. It may result in fluid retention and edema.
a. Its use may result in kidney stones.
7. What is the primary reason that a patient will attempt to bargain with the nurse during the course of their grief process? a. The patient is attempting to avoid anticipated bad things that may happen. b. The nurse can provide security when accepting the bargaining process. c. The patient is trying to pay the nurse for future favors and special treatment. d. Patients will only bargain with the nurse when they are angry.
a. The patient is attempting to avoid anticipated bad things that may happen.
10. What is the primary role of the Federal Mediation and Conciliation Service? a. To bring both sides together to work out a settlement b. To prevent nurses and other health-care groups from going on strike c. To develop a solution to the conflict that is binding on both sides d. To force management into accepting the employee demands
a. To bring both sides together to work out a settlement
8. Select all the actions that are correct for a co-worker who is using the wet-blanket behavior approach on the nursing unit. a. Uses complaints to dampen other peoples' attitudes. b. Likes to tear down the ideas of other in the group. c. Seek help with problems they are having from the group. d. Presents strong and useful ideas for solving problems. e. Likes to sow seeds of disappointment and failure. f. Places responsibility for problems on others in the group.
a. Uses complaints to dampen other peoples' attitudes. b. Likes to tear down the ideas of other in the group. e. Likes to sow seeds of disappointment and failure.
the nurse is assisting the older adult diagnosed with a gastric ulcer to schedule her medication administration. what would be the most appropriate time for this patient to take her lansoprazole (Prevacid)? a. about 30 minutes before her morning meal b. at night before bed c. after fasting at least 2 hours d. 30 minutes after each meal
a. about 30 minutes before her morning meal
the nurse is caring for a patient with gastroesophageal reflux disease and would question an order for which of the following? a. amoxicillin (Amoxil) b. Rantidine (Zantac) c. Pantoprazole (Protonix) d. calcium carbonate (Tums)
a. amoxicillin (Amoxil)
pancrelipase (Pancreaze) granules are ordered for a patient. which of the following will the nurse complete before administering the drug? SATA a. sprinkle the granules on a nonacidic food b. give the granules with or just before a meal c. mix the granules with orange or grapefruit juice d. ask the patient about an allergy to pork or pork products e. administer the granules followed by an antacid
a. sprinkle the granules on a nonacidic food b. give the granules with or just before a meal d. ask the patient about an allergy to pork or pork products
Discharge instructions for patient on antibiotics
advise patients to take anti-infectives for the full length of therapy
What is an advantage of the salad bowl tradition?
allowing individuals in the dominant culture to gain an appreciation of others cultures for their unique contributions to society.
HAART causes what effects? A. reversal of a patients antibody status B. decrease of the viral load C. increase of the viral load D. moe delectable HIV
b
What type of precautions should the nurse take for a patient suspected of having TB as a result of HIV? A. universal b. airborne c. enteric d. protective isolation
b
the nurse is teaching a patient about preventing infection through sex. which statement indicates effective teaching? a. latex condom with spermicide proves the best protection b. mutually monogamous sex with a non infected partner will best prevent HIV c. contraceptive methods like implants and injections are recommended to prevent HIV transmission d. if my partner and i are both HIV positive, unprotected sex is permitted
b
7. A 49-year-old woman has come to the nurse practitioner for an examination, stating, "I haven't been for a physical examination since my last child was born 20 years ago and thought I should one since I have gone through menopause." When taking the health history from this woman, it is important to include questions concerning A problems that may have occurred with her labor and birth. B family history of heart disease. C history of childhood immunizations. D history of infertility or problems conceiving.
b A family history of heart disease is especially important when the woman is postmenopausal because estrogen, which provides some protection against coronary artery disease, decreases after menopause and obesity may increase. If there is a family history of heart disease, or other signs of heart disease, the woman needs further screening.
A 48-year-old woman has just been diagnosed with breast cancer in her right breast, and a simple mastectomy has been recommended. The nurse assesses the patient teaching on the surgery to be effective when the woman states: A "They are going to take only the tumor out and a couple of the lymph nodes." B "They will remove my entire right breast." C "They are going to take the right breast, some nodes, and even some chest muscle out." D "They will be removing only some lymph nodes."
b A simple mastectomy involves the removal of the entire breast. Axillary dissection is omitted. A lumpectomy is the removal of only the tumor. A modified radical mastectomy involves the removal of the breast tissue, axillary nodes, and some chest muscles. A sentinel lymph node biopsy is a technique to remove a few key lymph nodes to evaluate the spread of the cancer.
20. Women who are past menopause are at higher risk for cardiovascular disease. One of the physiologic changes that occurs with menopause that might lead to cardiovascular disease is A atrophy of the heart. B a rise in the low-density lipoproteins. C a rise in the high-density lipoproteins. D spasms of the vascular system.
b Absence of estrogen is associated with an adverse change in serum lipid levels. Serum levels of low-density lipoproteins increase. Levels of high-density lipoproteins decrease.
35. When providing care to a young single woman just diagnosed with acute pelvic inflammatory disease (PID), the nurse should A point out that inappropriate sexual behavior caused the infection. B prepare the woman for the need of IV antibiotics for the next 48 hours. C explain to the woman that infertility is a likely outcome of this type of infection. D tell her that antibiotics need to be taken until the pelvic pain is relieved.
b Acute PID is often treated with IV administration of broad-spectrum antibiotics. The IV antibiotics can be changed to oral treatment after 48 hours; total duration of antibiotic therapy should be 14 days. Although sexual behavior may well have contributed to the infection, the nurse must discuss these practices in a nonjudgmental manner and provide information about prevention measures. Until treatment is complete and healing has occurred, the outcome is unknown and should not be suggested.
28. A woman is trying to decrease her urinary incontinence without medication or surgery. The nurse can recommend that the woman A decrease fluid intake at night. B decrease alcohol and caffeine intake. C decrease 10% of her average weight. D increase fluid intake in the morning and decrease the intake in the afternoon.
b Alcohol and caffeine can irritate the bladder and worsen incontinence. Obesity is associated with urinary incontinence, and the woman should attempt to be at her ideal weight range. Decreased fluid intake can lead to concentrated urine, which can irritate the bladder's mucous membranes and increase the urge to void.
21. A woman who has had a hysterectomy has been prescribed hormone replacement therapy. The nurse can anticipate which type of hormones that will be prescribed to this woman? A Combination of estrogen and progesterone B Estrogen therapy alone C Hormone therapy is not recommended for women after hysterectomies. D Progesterone therapy alone
b Estrogen therapy alone can be given to women who have had a hysterectomy because uterine hyperplasia is not a risk. Estrogen and progesterone are given to women with a uterus to prevent hyperplasia.
9. A 22-year-old woman has come to the clinic complaining of a "mass in my breast." The nurse practitioner notes two firm, freely mobile nodules in the upper outer quadrant of the right breast. The nurse is aware that the nurse practitioner will A refer the patient for a needle biopsy. B have the patient return during her menstrual period to reevaluate the masses. C schedule the woman for a mammography. D do nothing. Masses at this age are always benign.
b Fibroadenomas are benign tumors of the breast and are most common during the teenage years and the 20s. Fibroadenomas are firm, freely mobile nodules that may or may not be tender when palpated. Fibroadenomas do not change during the menstrual cycle. They are generally located in the upper outer quadrant of the breast, and more than one is often present. Treatment may involve careful observation for a few months to determine if the mass is stable. If the mass enlarges, a biopsy is done.
3. When scheduling times for women to have a pelvic examination and Papanicolaou (Pap) test, what question is important to ask the woman? A When was her last examination? B On what date will her next menstrual period start? C Does she have insurance coverage of the examination? D Does she use any type of birth control?
b Pelvic examinations should be scheduled between menstrual periods.
15. A 25-year-old woman comes to the clinic for her regular annual gynecologic examination. When taking the history, the woman tells the nurse that she has been dieting for the past year and has lost 150 lb (from 250 to 100 lb). Her menstruation stopped 6 months ago. A chart review indicates that prior to this visit her menses had been regular every 28 days. The nurse can classify this woman with A primary amenorrhea. B secondary amenorrhea. C amenorrhea of unknown origin. D possible pregnancy.
b Secondary amenorrhea is the cessation of menstruation for at least 6 months in a woman who has established a pattern of menstruation. Poor nutrition is one reason for secondary amenorrhea.
22. Which one of the following women is at greatest risk for osteoporosis? A African-American, weight 165 lb, height 5?2'3?3?; does not smoke cigarettes or drink alcohol B Asian, weight 105 lb, height 4?2'14?3?; smokes two packs of cigarettes a day C White, weight 145 lb, height 5?2'8?3?; had a hysterectomy with removal of ovaries at age 45 D Native American, weight 165 lb, height 5?2'7?3?; alcoholic for 15 years, has been without a drink for the past 2 years
b Small-boned, fair-skinned, White, and Asian women are at greatest risk for osteoporosis. Other risk factors include early menopause, smoking, and alcohol intake. The more risk factors, the higher the risk for developing osteoporosis. The Asian woman is small-boned and smokes, which gives her three risk factors. All the other women had zero to two risk factors.
16. A 32-year-old woman complains of excessive bleeding with menses for the past 3 months. With a chart review, the nurse notes that the woman had a urinary tract infection 3 months ago that was treated with an antibiotic, has hypothyroidism, uses condoms with foam for contraception, and uses antidepressants. Which one of these is the most likely cause of the woman's excessive bleeding? A Urinary tract infections treated with an antibiotic B Hypothyroidism C Use of condoms with foam for contraception D Use of antidepressants
b Systemic disorders such as hypothyroidism may be a cause of dysfunctional bleeding.
34. A woman calls the clinic concerned that a neighbor has been diagnosed with herpes genitalis type 2. The woman is upset and tells the nurse that this neighbor "used my toilet last week, so what should I do?" The nurse's response should be based on knowledge that herpes genitalis type 2 is transmitted only through A sexual intercourse. B direct contact. C blood contamination. D blood or body fluid contamination.
b Transmission occurs only through direct contact with an infected person.
2. A school nurse is teaching a group of high school seniors about gynecologic care. It is important to include instructions on A.scheduling a mammogram within the next 3 years. B vulvar self-examination. C use of contraceptives by the menopausal woman. D breast self-examination.
b Vulvar self-examinations should begin in women 18 years old and in women younger than 18 if they are sexually active. Mammograms are routinely started at the age of 45. Due to lack of evidence of clear benefit, breast self-examinations are no longer recommended. Adolescents will not benefit from information about contraceptive use by menopausal women.
6. A nurse teaching adolescents concerning care during menses should include that A only perineal pads should be used until the woman is at least 24 years old to allow closure of the cervical os. B perineal pads should be worn at night. C tampons can be used around the clock. D tampons should be replaced every 6 to 8 hours.
b When using tampons, they should be changed at least every 4 hours to prevent excessive bacterial growth. Perineal pads should be used at night during sleep, which usually exceeds 4 hours.
A woman is undergoing chemotherapy for breast cancer. During the discharge teaching, it is important that the nurse teach the woman to A not wash off the marks on her skin made by the technician. B avoid crowds and anyone who is sick. C take the medication before her menstrual period. D have her calcium levels checked every 2 months.
b Chemotherapeutics may kill off normal cells along with the cancer cells, especially rapidly dividing cells such as those in blood cells. Therefore the woman may be more susceptible to infection during the treatment.
which statement about the transmission of HIV is true? (Select all that apply) A. can only be transmitted during end stage B. those with recent HIV infection and high viral load are very infectious C. those with end stage HIV and no drug therapy are very infectious D. HIV is only transmitted with sexual contact E. all people infected with HIV will quickly progress to AIDS
b, c
how does HSV manifest itself in patients with HIV/AIDS (Select all that apply) a. maculopapular lesions that can spread b. chronic ulceration after vesicles rupture c. vesicles ocated in the perirectal, oral, and genital area d. numbness and tingling before vesicle forms e. itching localized to perianal area
b, c, d
where can candidiasis occur in the body (Select all that apply) a. nose b. esophagus c. vagina d. mouth e. ears
b, c, d
HIV is most commonly transmitted by which routes? (Select all that apply) A. oral B. sexual C. parenteral D. airborne E. perinatal
b, c, e
the nurse is preparing to administer chemotherapy to an oncology patient who also has an order for ondansetron (Zofran). when should the nurse administer ondansetron? a. every time the patient complains of nausea b. 30-60 minutes before starting chemo c. only if the patient complains of nausea d. when the patient begins to experience vomiting during chemo
b. 30-60 minutes before starting chemo
A patient on chemotherapy is receiving ondansetron (Zofran) for treatment of nausea. The nurse will instruct the patient to watch for which adverse effect from this drug? a. Hiccups b. Headache c. Dry mouth d. Blurred vision
b. Headache
6. Select all the statements the nurse should say to family members about a loved one who is in denial about his cancer diagnosis that would be the most effective communication techniques. a. Use the hard sell to reinforce the diagnosis b. Let him talk about his feelings without interrupting c. If he yells at you, you need to yell back to keep him oriented d. Allow for periods of salience so that he can organize his thoughts e. Try to understand that denial is a protective mechanism f. Do not reinforce his denial by agreeing with him
b. Let him talk about his feelings without interrupting d. Allow for periods of salience so that he can organize his thoughts e. Try to understand that denial is a protective mechanism f. Do not reinforce his denial by agreeing with him
9. What is the most important feature of the shared governance model? a. Nursing administration retains most of the power over nurses to better regulate practice. b. Power and authority are transferred to the nursing staff rather than being located primarily in nursing administration. c. Clients are billed for nursing care as a separate item similar to the way they are billed for physician services. d. The nursing staff hierarchy structure is similar to the medical staff structure.
b. Power and authority are transferred to the nursing staff rather than being located primarily in nursing administration.
A client presents to the emergency department with severe nausea and vomiting following a case of food poisoning. Which antiemetic drug should concern the nurse if the client is taking quinidine? a. Metoclopramide (Reglan) b. Prochlorperazine (Compazine) c. Scopolamine (Transderm-Scop) d. Dronabinol (Marinol)
b. Prochlorperazine (Compazine)
A client received a drug for treatment of nausea and vomiting and is now complaining of dry mouth, constipation, and a rapid heart rate. The nurse concludes that which drug was taken by the client? a. Loperamide (Imodium) b. Prochlorperazine (Compazine) c. Peppermint d. Diphenoxylate (Lomotil)
b. Prochlorperazine (Compazine)
8. Select a practice that is an indication of failure to bargain in good faith. a. Agreeing to meet at reasonable times b. Sending individuals to negotiate who cannot make binding decisions c. Unwillingness to negotiate on all issues d. Exchanging lists of demands by both sides
b. Sending individuals to negotiate who cannot make binding decisions
A client who will be traveling on a plane is prescribed dimenhydrinate (Dramamine) for management of motion sickness. Which instruction about administration of the drug should the nurse provide the client? a. Apply the patch behind the ear the day before travel. b. Take the medication by mouth 20-60 minutes prior to the trip. c. Take the medication by mouth at onset of motion sickness. d. Inject the medication on the thigh intramuscularly.
b. Take the medication by mouth 20-60 minutes prior to the trip.
When teaching a patient who is taking twice-daily dosages of an aluminum antacid along with other medications, which instruction should the nurse provide? a. The other medications can be taken with the antacid, as long as it is with meals. b. The antacid should be taken at least 2 hours before or after the other medications. c. The antacid should be taken at least 4-6 hours apart from the other medications. d. The patient will not be able to take the antacid therapy at this time.
b. The antacid should be taken at least 2 hours before or after the other medications.
the nurse has administered prochlorperazine (compazine) to a patient for postoperative nausea. Before administering this medication, it is essential that the nurse check which of the following? a. pain level b. blood pressure c. breath sounds d. temperature
b. blood pressure
a 35-year old male patient has been prescribed omeprazole (Prilosec) for the treatment of gastroesophageal reflux disease. which of the following assessment findings would assist the nurse to determine whether drug therapy has been effective? SATA. a. decreased "gnawing" upper abdominal pain on an empty stomach b. decreased belching c. decreased appetitie d. decreased nausea e. decrease dysphagia
b. decreased belching d. decreased nausea e. decrease dysphagia
a 24-year old patient has been taking sulfasalazine (Azulfidine) for IBS and complains to the nurse that he wants to stop taking the drug because of the nausea, headaches, and abdominal pain it causes. what would the nurses best recommendation be for this patient? a. the drug is absolutely necessary, even with the adverse effects b. talk to the HCP about dividing the doses throughout the day c. stop taking the drug and see if the symptoms of the IBS have resolved d. take an antidiarrheal drug such as loperamide (Imodium) along with the sulfasalazine
b. talk to the HCP about dividing the doses throughout the day
Why is amoxacillin considered a broad spectrum antibiotic?
because it is effective against a wide range of microorganisms
The HIV positive patient tells the nurse that his HIV negative partner will be using preexposure drugs (Truvada). which statement indicates the need for additional teaching? A. my partner will need to be tested q3m B. this drug will decrease the chances of my partner becoming positive C. once we start using Truvada I will no longer need a condom D. my partner will need to be monitored for any side effects on this drug
c
shingles results from VZV leaving the body by which route? a. mucous membrane b. pulmonary space c. body fluids and other tissues d. bone marrow
c
the patient with HIV/AIDS tells the nurse that food tastes funny and is difficult to swallow. what is the nurses priority action at this time? a. Check the patients gag reflex b. ask about blood cultures c. examine the patient's mouth and throat d. collaborate with the dietitian to provide a soft diet
c
24. A 57-year-old woman eats two servings of calcium-rich food a day, usually in the form of 8 oz of skim milk or yogurt. To meet her calcium needs, she would need to take a calcium supplement that contains how much calcium? A 400 mg B 500 mg C 600 mg D 800 mg
c 8 oz of skim milk or yogurt contain between 300 and 350 mg of calcium. Two servings would give this woman at least 600 mg. A woman older than 50 years needs 1200 mg of calcium daily, so she would need to take 600 mg in a supplement.
30. When assisting a woman into the lithotomy position for a pelvic examination, the nurse notes a frothy, malodorous, yellow-green vaginal discharge. The nurse should anticipate the need for a A culture and sensitivity test of the discharge. B serologic test. C wet mount preparation test. D biopsy.
c A frothy, malodorous, and yellow-green discharge is an indication of trichomoniasis. The diagnosis is made by identifying the organism in a wet mount preparation.
14. Which one of the following women is at highest risk for cardiovascular disease? A 55-year-old who is overweight and participates in no physical activity during the week B 65-year-old who has type 2 diabetes C 45-year-old with type 2 diabetes, hypertension, overweight, and smokes D 70-year-old in good health but with a family history of cardiovascular disease
c Age, being overweight, no physical activity, type 2 diabetes, hypertension, family history, and smoking are all risk factors for cardiovascular disease. The more risk factors a woman has, the higher her risk for developing cardiovascular disease. The 45-year-old is the youngest in the choices shown, but she has the most risk factors.
29. During an annual gynecologic examination, the physician notes an enlarged left ovary in a 28-year-old woman. The woman has no complaints of pain or tenderness. The nurse can anticipate A an appointment for an ultrasound. B scheduling the woman for a laparoscopy. C scheduling the woman for a follow-up examination after her next menses. D nothing. The finding is insignificant.
c Follicle ovarian cysts are usually asymptomatic and generally regress during the subsequent menstrual cycle. If the woman is in her childbearing years, when the risk of ovarian cancer is less, the physician may wait until after the next menstrual cycle and examine the woman again.
5. The nurse is reviewing laboratory reports from several patients who had Pap tests done 3 days ago. One result stated, "high-grade squamous intraepithelial lesion." The nurse is aware that this report indicates A negative results and no follow-up is required. B a negative result but a 3-month repeat Pap test should be done. C this result has a high likelihood of becoming cancerous, and a follow-up is necessary for treatment. D the results are inconclusive and the woman should have a repeat test done in 6 months.
c High-grade squamous intraepithelial lesion was previously categorized as carcinoma in situ. These cell changes are likely to become cancerous without definitive treatment. This woman requires immediate follow-up on the results.
27. After teaching a woman about Kegel exercises, the nurse assesses that the teaching has been effective when the woman states: A "Once I can contract the muscles for 10 seconds at a time I can stop the exercise." B "I will need to do these exercises until I get up to 45 daily repetitions." C "I will need to do these exercises for the rest of my life." D "If I can stop the stream of urine I don't need to do the exercises."
c Kegel exercises involve conscious contracting and relaxing of the pelvic muscles. To maintain pelvic muscle tone, the woman should continue Kegel exercises for the rest of her life.
1. A 25-year-old woman is in for her first gynecologic examination. She is in good health and has no family history of cancer or reproductive diseases. She asks the nurse if a mammogram will be performed. The nurse is aware that this woman will A need a mammogram this year, and it should be repeated every 2 years. B need a mammogram this year, and it should be repeated every 5 years. C not need a mammogram until she is 45 years old. D not need a mammogram until she is 30 years old.
c The American Cancer Society and American College of Obstetricians and Gynecologists recommends that mammograms start at the age of 45 unless the woman is at high risk for breast cancer.
26. A 65-year-old woman, gravida 6, para 6, is complaining of increasing stress incontinence and pelvic pressure and fullness. Pelvic examination reveals a bulging in the anterior vaginal wall. This woman is most likely experiencing A uterine prolapse. B rectocele. C cystocele. D vesicovaginal fistula.
c The classic clinical manifestations of cystocele are described in the question. Prolapse or downward displacement of the uterus could result in protrusion of the uterus through the vagina. Rectocele results in herniation of the rectal wall through the posterior vagina. Clinical manifestations relate to alterations in bowel elimination. A vesicovaginal fistula is an abnormal passage between the bladder and vagina, resulting in urinary incontinence and excoriation of the vaginal mucosa.
33. A woman confides in the nurse about a painless chancre that developed next to her vaginal opening about 8 weeks ago. The woman is not concerned because it has gone away. The nurse should teach this woman A that the use of condoms will decrease chances of this developing again. B to wash the perineum with mild soap and water after intercourse to prevent recurrences. C that a serologic test is indicated. D that a vaginal culture is indicated.
c The first sign of primary syphilis is a painless chancre that heals in about 6 weeks. About 2 months after the initial infection, serologic tests are generally positive for syphilis. The infection does not heal but moves into the secondary stage of syphilis.
25. A 50-year-old woman is trying to decrease her chances of developing osteoporosis. Which exercise can the nurse recommend that will be beneficial? A Swimming B Water aerobics C Walking D Yoga
c Weight-bearing and resistance exercise have been shown to be beneficial in slowing loss of bone mass to maintain bone density. Water-based exercises such as swimming do not help limit bone loss.
12. A woman who was diagnosed with breast cancer 1 month ago is making an appointment for a follow-up appointment with the physician. During the conversation with the nurse, the woman becomes angry and yells, "You never have any appointments available when I can come. I always have to rearrange my day to agree with your schedule." The best response by the nurse is: A "We have so many patients and there are few available times for an appointment. I am sorry it is inconvenient for you." B "Let's look to see if we have another time that is better for you." C "You seem to be upset today." D "I am doing the best job I can. Tell me when you can come and I will try and work you in at that time."
c During the stages of cancer, women think that they have lost control and that their lives have been taken over by cancer. The nurse should provide time and demonstrate genuine interest in the woman's concerns using communication techniques, such as reflecting feelings, and open-ended statements to encourage her to express her concerns.
In addition to the use of multiple antibiotics, the nurse should anticipate which medication to be included in the patient's treatment of PUD due to H. pylori infection? a. Antacids b. H2-receptor inhibitors c. Bismuth compounds d. Vitamin E compounds
c. Bismuth compounds
A patient tells the nurse that she has been taking sodium bicarbonate antacid 3-4 times a day for the past 3 weeks to relieve symptoms of GERD. For what should the nurse assess in this patient? a. Constipation b. Respiratory acidosis c. Metabolic alkalosis d. Hypokalemia
c. Metabolic alkalosis
10. Which of the following would be effective approaches to chronic complainers to help them recognize that their behaviors are inappropriate and that expressing their needs by complaining is harmful to themselves and the work environment? a. Reinforce their attitudes towards people and work b. Completely ameliorate the behavior c. Use active listening d. Use an aggressive confrontation to change their behavior
c. Use active listening
6. What communication technique will make patients less likely to perceive communication from the nurse, as a personal attack? a. Using a firm, confident tone of voice b. Using encouraging words such as "Okay," and "Tell me more." c. Using "I" rather than "you" statements d. Keeping the conversation light
c. Using "I" rather than "you" statements
a female patient reports using OTC aluminum hydroxide (alternaGEL) for the relief of gastric upset. she is on renal dialysis 3 times a week. what should the nurse teach this patient? a. continue using the antacids but if she needs to continue them beyond a few months, she should consult the health care provider about different therapies b. take the antacid no longer than for two weeks. if it has not worked by then, it will not be effective c. consult with the health care provider about the appropriate amount and type of antacid d. continue to take the antacid; it is OTC and safe
c. consult with the health care provider about the appropriate amount and type of antacid
a patient with severe diarrhea has an order for diphenoxylate with atropine (lomotil). when assessing for therapeutic effects, which of the following will the nurse expect to find? a. increased bowel sounds b. decreased belching and flatus c. decrease in loose, watery stool d. decreased abdominal cramping
c. decrease in loose, watery stool
Tetracycline contraindications
contraindicated in patients with hypersensitivity to drugs in this class - not to be used in the second half of pregnancy - not to be used n children 8 years or younger - not to be used in patients with severe renal or hepatic impairment
a patient with HIV is receiving meds to reduce viral load and improve cd4+ counts. which term accurately describes this HIV drug regimen a. interferon treatment b. antiviremia c. ELISA administration d. HAART
d
cryptosporidiosis is a form of intestinal infection in which diarrhea can amount to a loss of how many liters of fluid per day? A. 1-2 B. 3-5 c. 5-8 d. 15-20
d
which is the most common route for HCP to contract HIV: A. blood B. bodily fluids C. mucous membranes D. needle sticks
d
which malignancy is most common in patients with HIV/AIDS a. non-hodgkins B cell lymphoma b. anal cancer c. primary brain cancer d. kaposi's sarcoma
d
which statements regarding HIV/AIDS among older adults are true? A. the risk for HIV infection after exposure is minimal for older adults B. older men are more susceptible to HIV C. it is not necessary to assess an older adult for history of drug use D. older adults who participate in high-risk behaviors are susceptible to HIV
d
which treatments are intended to boost the immune system? a. protease inhibitors b. hematopoietic growth factors c. lymphocyte transfusion d. interleukin-2 infusion
d
8. The nurse should refer the patient for further testing if which one of the following is noted on inspection of the breasts of a 55-year-old woman? A Left breast slightly smaller than the right breast B Eversion (elevation) of both nipples C Bilateral symmetry of venous network that is faintly visible D Small dimple located in the upper outer quadrant of the right breasts
d Dimpling or retraction is often associated with an underlying mass or tumor. The other choices are all expected findings.
19. A woman who is 17 weeks pregnant because of incest asks the nurse about having a therapeutic abortion. The nurse's best response should be based on the knowledge that A therapeutic abortions are not available in this country for a woman more than 14 weeks pregnant. B mifepristone (RU486) can be used up to week 20 of pregnancy. C methotrexate (Folex, Mexate) can be used up to week 24 of pregnancy. D a dilation of the cervix with removal of the fetus and placenta can be performed during the 17th week of pregnancy.
d Medications such as mifepristone and methotrexate are used for early abortions. For second-trimester abortions, dilation with removal of the fetus and placenta is performed.
which groups are experiencing increased numbers of HIV infection? (Select all that apply) A. men having sex with other men B. IV drug users C. women having sex with men D. african americans E. hispanics
d, e
In taking a new client's history, the nurse notices that he has been taking omeprazole (Prilosec) consistently over the past 6 months for treatment of epigastric pain. Which recommendation would be the best for the nurse to give this client? a. try switching to a different form of the drug b. try a drug like cimetidine (Tagamet) or famotidine (Pepcid) c. try taking the drug after meals instead of before meals d. check with his health care provider about his continued discomfort
d. check with his health care provider about his continued discomfort
a patient with constipation is prescribed psyllium (metamucil) by his health care provider. what essential teaching will the nurse provide to the patient? a. take the drug with meals and at bedtime b. take the drug with minimal water so that it will not be diluted in the GI tract c. avoid caffeine and chocolate while taking this drug d. mix the product in a full glass of water and drink another full glass of water after taking the drug
d. mix the product in a full glass of water and drink another full glass of water after taking the drug
Following surgery, a client is placed on cefotaxime (Claforan). The assessment for possible adverse effects should include observing for
diarrhea.
Fluvicin side effects
granulocytopenia, cholestatic hepatitis, neurotropenia - if symptoms worsen or do not improve call doctor.
Hypersensitivity reaction with Fungizone
immunosuppression, renal impairment, and liver toxicity
Pathogenicity is different than virulence in that pathogenicity can
lead to the ability of organisms to cause infection.
What drug to drug interaction results in increase of cyclosporine levels
macrolide antibiotics
Lab results in Retrovir
mean corpuscular volume may be increased during zidovudine therapy. White blood cell and hemoglobin may decrease due to neutropenia and anemia, respectively
Diet education for Flagyl
must be taken on an empty stomach
superinfections
occur when miccroorganisms normally present in the body are destroyed
What is the most productive way to start the communication process?
open-ended language
The nurse is caring for a client receiving gentamicin IV. The nurse would observe for adverse effects of
ototoxicity.
HIV-AIDS—Nucleoside and Nucleotide Reverse Transcriptase Inhibitors Prototype drug: zidovudine (Retrovir, AZT)
• Mechanism of action: Virus mistakenly uses zidovudine as nucleoside, thus creating defective DNA strand • Primary use: with other antiretrovirals for symptomatic and asymptomatic HIV- infected patients - Also for post exposure prophylaxis (preventive health care) in HIV- exposed health care workers - To reduce transmission rate from HIV-positive mother to fetus • Adverse effects - Toxicity to blood cells at high doses - Anemia and neutropenia - Anorexia, nausea, diarrhea - Fatigue, generalized weakness
Agents for HIV-AIDS—Nonnucleoside Reverse Transcriptase Inhibitors Prototype drug #2: efavirenz (Sustiva)
• Mechanism of action: to bind directly to reverse transcriptase, disrupting enzyme's active site • Primary use: in combination with other antivirals in treatment using HAART • Adverse effects: CNS effects: sleep disorders, inability to concentrate, delusions, dizziness; rash
Agents for HIV-AIDS—Protease Inhibitors: Prototype drug: lopinavir with ritonavir (Kaletra)
• Mechanism of action: to inhibit HIV protease • Primary use: In combination with other antiretrovirals for HIV-infected patients, it is the preferred drug for initial treatment • Adverse effects: nausea, vomiting, dyspepsia, diarrhea, general fatigue, headache - Hyperglycemia has been reported, lipodystrophy syndrome occurs in many patients receiving long-term therapy, pancreatitis is rare but possible serious effect
Role of the nurse in general
• Monitor patient's condition • Provide patient education • Obtain medical, surgical, drug history • Assess lifestyle and dietary habits • Obtain description of symptomology and current therapies
HIV Pharmacotherapy
• No cure yet, but many new drugs developed • Some therapeutic successes - People live symptom-free longer - Rates of transmission from mother to newborn reduced - 70% decline in death rate in U.S. § Incidence of infections still very high in African nations
HIV-AIDS Antiretrovirals Classification
• Nucleotide reverse transcriptase inhibitors (NtRTIs) - Resemble natural building blocks of DNA • Nonnucleoside reverse transcriptase inhibitors (NNRTIs) - Target the enzyme needed for reverse transcriptase • Protease inhibitors (PIs) - Block the viral enzyme protease, inhibiting final assembly of HIV virions • Entry inhibitors - Block the entry of viral nucleic acid into the T4 lymphocyte • Integrase inhibitors/Miscellaneous antivirals - Integrase enzyme inserts its viral DNA strand into human chromosome
Role of the Nurse: NtRTI, NNRTI, and PI Therapy
• Nursing care similar for NtRTIs, NNRTIs, and PIs • Establish trusting, nonjudgmental relationship with patient • Assess patient's understanding of HIV disease process • Assess for symptoms of HIV and any opportunistic infections • Monitor plasma HIV RNA (viral load) assays, CD4 counts, complete blood count, liver and renal profiles, blood glucose levels • Assess for bone marrow suppression, liver toxicity, and Stevens-Johnson syndrome • Patients should not drive or perform hazardous activities until medication reactions are known • Be aware of conditions and drugs that are problematic with antiretroviral therapy • Teach patients how to practice blood and body fluid precautions
Initiation of Pharmacotherapy
• Pharmacotherapy may be initiated - In acute phase (symptomatic) - In chronic phase (asymptomatic)
Therapeutic Goals
• Reduce HIV RNA load in the blood - To undetectable level or less than 50 copies/mL • Increased lifespan • Higher quality of life • Decreased risk of transmission from mother to child
Role of the Nurse: Antiviral Therapy
• Use drugs with extreme caution with pre- existing renal or hepatic disease • Judicious use is warranted during pregnancy • Emphasize compliance with antiviral therapy • Some drugs cause digestive distress and should be taken with food
Pharmacotherapy of Viral Hepatitis
• Vaccination available for A and B, not C • Prophylaxis or post exposure treatment - Hepatitis A immunoglobulins (HAIg) - Hepatitis B immunoglobulins (HBIg) • Symptomatic treatment for chronic hepatitis • Hepatitis C - Interferon - Antiviral ribavirin
The nurse works in infection control and teaches a class to staff nurses about the ways that resistance to antibiotics can occur. The nurse evaluates that learning has occurred when the nurses make which statement?
"Resistance to antibiotics can occur by the common use of them for nosocomial infections."
The nurse has taught a client how to manage constipation. Which action by the client would provide evidence of learning? (Select all that apply.) The patient: 1) increases his intake of high-fiber foods. 2) drinks at least four 8-ounce glasses of water a day. 3) goes to the bathroom to evacuate after meals. 4) takes a daily laxative.
1) increases his intake of high-fiber foods. 3) goes to the bathroom to evacuate after meals. The urge to defecate typically comes after eating; the nurse can help manage the patient's constipation by assisting the patient to the bathroom after meals. The nurse should also encourage the patient to increase his intake of high-fiber food and drink at least eight glasses of water a day (not four). Laxatives should be administered or taken only when absolutely necessary.
The nurse plans to teach the client with acquired immune deficiency syndrome (AIDS) about bacterial infections. Which information should the nurse include in this teaching?
1. "If just a few bacteria make you sick, this is virulence." 4. "Pathogenicity means the bacteria can cause an infection." 5. "Actually, most bacteria will not harm us."
The client receives a topical medication for treatment of an acne-like skin disorder. The nurse completes medication education and evaluates learning has occurred when the client makes which statements?
2. "I will call my doctor if I notice a change in my symptoms." 3. "I will apply the medication only to the affected area."
A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"
ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.
While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action should the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the client's oxygen saturation. c. Auscultate the client's lung fields for adventitious sounds. d. Palpate the client's bilateral radial and pedal pulses.
ANS: B Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.
While assessing a client's lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? a. Ask about a family history of skin disorders. b. Palpate the client's pedal pulses bilaterally. c. Check for the presence of Homans' sign. d. Assess the client's skin for adequate skin turgor
ANS: B Localized, decreased skin temperature and pallor indicate interference with vascular flow to the region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency. Without adequate blood flow, the client's limb could be threatened. Asking about a family history of skin problems would not take priority over assessing blood flow. Homans' sign is a screening tool for deep vein thrombosis and is often inaccurate. Skin turgor gives information about hydration status. This assessment may be needed but certainly does not take priority over assessing for blood flow.
A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.
ANS: B Pyloric stenosis can lead to hypokalemia, which is manifested by muscle weakness. The nurse first obtains an ECG because potassium imbalances can lead to cardiac dysrhythmias. A potassium level is also warranted, as is placing the client on bedrest for safety. Documentation should be thorough, but none of these actions takes priority over the ECG.
A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? a. Administer ibuprofen (Motrin). b. Call the Rapid Response Team. c. Start a large-bore IV with normal saline. d. Tell the client to remain lying down.
ANS: C This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.
A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently
ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.
A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education? a."Use lots of moisturizer several times a day to minimize dryness." b."Take a cold shower instead of soaking in the bathtub." c."Use antimicrobial soap to avoid infection of cracked skin." d."After you bathe, put lotion on before your skin is totally dry."
ANS: D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.
The nurse is conducting a reproductive assessment of a postmenopausal woman. Which assessment finding reported by the client requires immediate intervention by the nurse? a. Urinary incontinence b. Vaginal dryness c. Painful intercourse d. Returning periods
ANS: D All client reports require some action by the nurse, but the priority would be to further investigate and report the "returning periods." In a postmenopausal woman, this can signal cancer.
5. Fill in the blank: If the nurse displaying dictator behavior is in a ____________ position such as a charge nurse this type of behavior is called ________ violence.
Superior, Vertical
When a patient with heartburn takes antacids, for which problem is he especially at risk? 1) Diarrhea 2) Constipation 3) Stomach ulceration 4) Flatulence
Constipation Antacids slow peristalsis, placing the patient at risk for constipation. Antibiotics increase the risk for diarrhea. Stomach ulceration is an adverse effect associated with NSAIDs. Iron supplementation may cause flatulence.
Which type of bowel diversion allows the patient to be free from an appliance? 1) Colostomy in the transverse colon 2) Double-barreled colostomy 3) Ileostomy 4) Kock pouch
Kock pouch A Kock pouch, also known as a continent ileostomy, creates an internal pouch to collect ileal drainage. To drain the pouch, the patient inserts a tube through the external stoma into a pouch several times a day. This allows the patient to be free from an appliance. A colostomy, double-barreled colostomy, and ileostomy all require an appliance.
2. Which of the following statements is most accurate concerning the personal happiness of the nurse when dealing with people with difficult behavior? a. The nurse must believe that she or he is 100 percent responsible for their own happiness. b. Difficult people can put the nurse in a persistent state of unhappiness. c. It is up to others to make the nurse happy or unhappy. d. Hanging out with unhappy people will allow the nurse to identify factors in her or his own life that causes unhappiness and counter act them.
a. The nurse must believe that she or he is 100 percent responsible for their own happiness.
A patient being treated for peptic ulcer disease (PUD) due to Helicobacter pylori asks the nurse why two or more antibiotics need to be taken. What is the nurse's best response? a. They lower the potential for bacterial resistance. b. They decrease the chances of development of duodenal ulcers. c. They completely eliminate redevelopment of gastric ulcers. d. They decrease the cost of future drug therapies.
a. They lower the potential for bacterial resistance.
What is Cyclosporine used for?
used to prevent rejection in organ transplants
