Med Surg Exam #2 FA Davis Questions

The nursing diagnosis Potential for Ineffective Airway Clearance is most relevant to a patient with which immune disorder?

T-cell deficiency

The nurse correlates the function of the thymus gland to which outcome?

T-cell development

The nurse monitors for which clinical manifestations in the patient diagnosed with X-linked agammaglobulinemia (XLA)?

Tachypnea

The nurse is planning care for a patient diagnosed with human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this patient. Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply.

Teaching proper food-handling techniques to the family. Assessing the health status of all visitors. Monitoring hand-washing techniques used by the family

The nurse provides care to a patient who is diagnosed with HIV. Which assessment finding necessitates immediate notification to the healthcare provider?

Temperature of 102.2 F

The nurse identifies the nursing diagnosis of Chronic Pain for a patient with fibromyalgia. Which manifestation supports this nursing diagnosis?

Tender points in the knees

The nurse is providing health education to a diverse group at a neighborhood community center. The nurse includes information about signs and symptoms of systemic lupus erythematosus (SLE) for which of the following reasons?

The audience is mainly females of Asian-American descent.

The nurse is providing care to a several patients in the hospital environment. Which patient requires the nurse to closely monitor respiratory status?

The patient diagnosed with Acinetobacter

The nurse is providing care to a several patients in the hospital environment. Which patient should the nurse include education regarding the need for increased fluid intake in the plan of care?

The patient diagnosed with Clostridium difficile

The nurse provides care to several patients with a history of hypersensitivity reactions. Which patient requires education regarding a type I reaction?

The patient with allergic rhinitis

In preparing a patient for a blood transfusion, the nurse recognizes that a patient with blood type B can receive which blood types? Select all that apply.

Type B Type O

The nurse correlates which type of hypersensitivity reaction to a patient with myasthenia gravis?

Type II

The nurse working on the maternal-child unit understands that erythroblastosis fetalis, which is due to Rh sensitization, is an example of which type of hypersensitivity reaction?

Type II hypersensitivity reaction

The nurse recognizes that the local reaction typical of a positive tuberculosis test, including a wheal and flare reaction, is observed in which type of hypersensitivity reaction?1.

Type IV

The nurse monitors for which clinical manifestation in the patient diagnosed with DiGeorge's syndrome?

shortness of breath

Which statement by the patient diagnosed with gout indicates the need for further teaching by the nurse related to dietary guidelines?

"I am not allowed to drink wine but can drink beer."

The nurse provides education to a patient with rheumatoid arthritis who is prescribed methotrexate by the healthcare provider. Which patient statement indicates to the nurse the need for further teaching?

"I can have a glass of wine each night with dinner."

The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which patient statement indicates an appropriate understanding of the plan of care?

"I do not need to be concerned with a fever or rash because these are expected with this disorder."

The nurse is caring for a patient who was diagnosed with rheumatoid arthritis (RA) last year who has a history of type 2 diabetes mellitus. The patient has recently been placed on prednisone for treatment. Which patient statement indicates that the medication teaching was successful?

"I do not need to monitor my blood sugar more frequently while on this medication because I take pills for my diabetes."

A nurse has been providing a patient with a history of hypersensitivity reactions. The nurse is preparing instructions on the correct methods for using an EpiPen. Which patient statement indicates understanding of the proper technique?

"I make sure the EpiPen has not expired"

The nurse provides education to an older adult patient regarding age-related immune system changes. Which patient statement indicates the need for further teaching?

"I may experience a decreased production of autoantibodies as I age"

The nurse provides education to the parents of a pediatric patient who is diagnosed with X-linked agammaglobulinemia (XLA). Which statement indicates a need for additional teaching?

"My other children can receive the live attenuated oral polio vaccine."

The nurse correlates an increased risk of osteoarthritis in which of the following patients?

55-year-old obese female with works as a machine operator

A home health nurse is conducting home visits for several patients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which patient would the nurse see first?

A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath

The nurse monitors for which clinical manifestations in the patient experiencing a histamine-mediated hypersensitivity reaction? Select all that apply.

A report of itching The presence of hives The presence of vomiting Wheezing on auscultation

The nurse is caring for a patient with a history of latex allergies. The patient develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this patient?

Administer prescribed epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders

The nurse is screening patients for the risk of developing HIV infection. The nurse considers which patient at greatest risk?

African American male with a history of sex with men

Which of the following medications prescribed for a patient with acute gout requires an intervention by the nurse?

Allopurinol

The nurse monitors for which of the following clinical manifestations in the patient diagnosed with systemic lupus erythematosus? Select all that apply.

Alopecia Fever Ulnar deviation

The nurse provides care to a patient diagnosed with HIV. Which clinical manifestations cause the nurse to ask the patient if sulfamethoxazole/trimethoprim (Bactrim) was prescribed prophylactically within the last 2 weeks? Select all that apply.

Anemia Skin rash

The infection prevention and control nurse is providing an in-service regarding multi-drug resistant (MDR) infection. Which is the most common site of MDR MRSA colonization the nurse should include in the presentation?

Anterior nares

The nurse is providing care to a patient who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of rheumatoid arthritis. When providing care to this patient, which actions by the nurse are appropriate? Select all that apply.

Assessing for an allergic reaction. Monitoring for signs of renal problems. Advising against abrupt discontinuation of drugs. Encouraging the patient to take NSAIDs with water, milk, or a small snack to help avoid stomach distress.

A nurse is caring for a patient with who is experiencing leukocytosis. When providing care to this patient, which action by the nurse is the most appropriate?

Assessing for the source of infection

The nurse is conducting a physical assessment for a patient with a compromised immune system. Which actions by the nurse are appropriate? Select all that apply.

Assessing general appearance. Checking joint range of motion (ROM), including that of the spine. Inspecting the mucous membranes of the nose and mouth for color and condition. Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness.

The nurse correlates which laboratory value as a complication in the patient diagnosed with DiGeorge's syndrome?

Calcium 6.5 mg/dL

Which type of leukocyte releases heparin as part of the inflammatory response?

Basophil

The nurse is planning care for several patients. Which is a risk factor for a patient developing community- acquired MRSA?

Being younger than 2 years of age

The nurse monitors for which of the following clinical manifestations in the patient diagnosed with osteoarthritis? Select all that apply.

Bouchard's nodes Crepitus Heberden's nodes

The nurse correlates which clinical manifestations to the diagnosis of rheumatoid arthritis? Select all that apply.

Boutonniere deformity Swan-neck deformity Ulnar deviation

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics?

Bradypnea Orthostatic hypotension Nausea

A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain?

Breakthrough pain

What is the priority nursing action to decrease the risk of a blood transfusion reaction from a patient receiving incompatible blood?

Checking the bag to ensure it is the correct blood type

In providing care to a patient who is being evaluated for a possible connective tissue disease, the nurse correlates which finding to the definitive diagnosis of gout?

Crystals in synovial fluid

The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient developing hospital-acquired MRSA?

Current intensive care unit stay

The nurse correlates an increased risk of infection in a patient receiving radiation therapy for lung cancer based on which of the following factors?

Damage to first line of defense

Which assessment data supports the nursing diagnosis of deficient fluid volume for a patient diagnosed with Clostridium difficile? Select all that apply.

Decreased skin turgor Dry mucous membranes Increased serum creatinine

Which is being studied when a nurse participates in the BUGG (benefits of universal gown and gloving) research initiative? Select all that apply.

Decreasing the length of the hospital stay Decreasing the frequency of adverse events Decreasing the risk for hospital-acquired infection Decreasing the risk for being diagnosed with a bacterial infection during hospitalization

The nurse is assessing a patient's immune system. Which findings increase the patient's risk for infection as a result of alterations in biochemical barriers? Select all that apply.

Dry mouth Clogged tear duct

The nurse is assessing a patient's immune system. Which findings increase the patient's risk for infection as a result of alterations in mechanical barriers? Select all that apply.

Dysphagia Urinary retention

The nurse monitors for which laboratory result in the patient with a history of chronic inflammation?

Elevated erythrocytes sedimentation rate (ESR)

Which should the nurse include in the plan of care for a patient who is diagnosed with a multi-drug resistant (MDR) pneumonia? Select all that apply.

Encourage ambulation. Administer prescribed oxygen. Implement chest physiotherapy.

What is the recommendation for HIV testing in HIV-negative individuals who are at high risk for HIV infection?

Every 12 months

The nurse assesses a patient with a surgical wound infection. Which clinical manifestation leads the nurse to conclude that the patient is experiencing a system response to inflammation?

Fever

Which clinical manifestations should the nurse anticipate when assessing any patient diagnosed with a multi- drug resistant (MDR) infection? Select all that apply.

Fever Tachypnea Tachycardia

According to the Centers for Disease Control and Prevention, which states in the United States have the highest incidence of HIV infections? Select all that apply.

Georgia Louisiana Nevada

The nurse develops the nursing diagnosis "Altered Comfort related to inflammation and pain secondary to urate crystals in the joints and tissues." For which disorder is this nursing diagnosis most relevant?

Gout

The nurse is caring for a patient who is experiencing anaphylactic shock after the administration of a medication. Which position is the most appropriate for the nurse to place the patient based on this data?

HIgh-Folwer's position

Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with DiGeorge's syndrome?

Hand hygiene

Which finding in the history of a patient prescribed to receive Truvada for pre-exposure prophylaxis (PrEP) requires the nurse to contact the provider who ordered the medication?

Hepatitis B

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 480 cells/uL. Which complication is this patient at risk for developing?

Herpes zoster virus

The nurse provides care for a patient who is admitted to the cardiac care unit for a coronary artery bypass graft (CABG). The patient has a history of osteoarthritis. Which medication does the nurse question if prescribed by the healthcare provider?

Ibuprofen (Advil)

The nurse is caring for a patient who has recently been diagnosed with fibromyalgia. The nurse correlates which prescriptions as part of the patient's treatment plan? Select all that apply.

Ibuprofen (Advil) Aerobic exercise Pregabalin (Lyrica) Cognitive behavioral therapy

The nurse is teaching a new mother the immune benefits of breastfeeding her newborn. The nurse bases this teaching on the understanding that which immunoglobulin (Ig) is passed from mother to newborn through breast milk?

IgA

The nurse correlates which type of immunoglobulin (Ig) as playing a role in an allergic reaction?

IgE

The nurse recognizes that which immunoglobulin (Ig) is a mediator in allergic responses?1.IgA

IgE

The nurse recognizes which immunoglobulin (Ig) as the mediator for a type I hypersensitivity reaction?

IgE

The nurse recognizes which type of immunity as an example of passive immunity?

Immunity acquired to a newborn through the placenta

The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA). Which information does the nurse include in the patient's plan of care?

Immunization with inactivated polio vaccine (IPV)

A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer?

Ketorolac

A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus (HIV). The patient states, "I don't plan on giving up sex just because I am HIV positive." Based on this data, which is the priority nursing diagnosis for this patient?

Knowledge Deficit

A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching does the nurse include in the patient's plan of care?

Maintain a clean, dust-free environment

The nurse correlates which comorbidities as impacting length of time from infection to death in patients who are not receiving treatment for human immunodeficiency virus (HIV) infection? Select all that apply.

Malaria Malnutrition Tuberculosis

Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) Clostridium difficile?

Metronidazole

In reviewing the laboratory results for a patient admitted with hepatic disease, the nurse correlates which results with an increased risk of infection?

Neutrophils 30 %

In administering antiretroviral therapy medications to patients with HIV infections, the nurse correlates the mechanism of action of preventing viral RNA from becoming viral DNA by impacting the enzyme reverse transcriptase to which classes of medication? Select all that apply.

Non-nucleoside reverse transcriptase inhibitor (NNRTI). Nucleoside reverse transcriptase inhibitors (NRTI)

Which clinical manifestations does the nurse assess for in the patient diagnosed with gout? Select all that apply.

Presence of tophi Reports of severe pain in the great toe Redness and swelling of great toe

The nurse is assessing a patient who is receiving intravenous (IV) antibiotics. Which item in the patient's health history increases the risk for experiencing a hypersensitivity reaction?

Previous antibiotic therapy

The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient developing VRE?

Prolonged rehabilitation unit stay

The nurse recognizes which nutritional deficiency as often impacting an older adult patient's ability to mount an immune response?

Proteins

The nurse is providing care to a patient diagnosed with a MRSA skin infection. Which clinical manifestations should the nurse anticipate during the patient assessment? Select all that apply.

Pus Edema Discomfort

Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) VRE?

Quinuprisin-dalfopristin

The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient developing Acinetobacter baumannii?

Recent surgical procedure

The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient developing Clostridium difficile?

Recent use of antibiotics

A nurse is caring for a patient with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). When providing care for this patient, the nurse monitors for which adverse effect associated with the prescribed medication?

Retinal toxicity

In planning care for a patient admitted for treatment of a connective tissue disorder, the nurse formulates the nursing diagnosis, "Self-care deficit related to decreased joint mobility secondary to an autoimmune response resulting in Boutonniere deformities" is most relevant for which disorder?

Rheumatoid arthritis

The nurse correlates which disorders to type III systemic hypersensitivity reactions? Select all that apply.

Rheumatoid arthritis Serum sickness Systemic lupus erythematous (SLE)

What is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)?

Risk for infection

Which immune disorder does the nurse include in the plan of care for a patient who is receiving chemotherapeutic agents for the treatment of cancer?

Secondary immune deficiency

Which nursing actions are appropriate when collecting a stool sample to determine if a patient is experiencing a C. diff. infection? Select all that apply.

Sending the sample to the laboratory immediately. Preparing a requisition for a culture and sensitivity.

A nurse is working in a summer camp. One of the campers comes to the clinic with several bee stings. Which clinical manifestations would require administration of epinephrine (EpiPen)? Select all that apply.

Skin that is cold and clammy to the touch Wheezing Restlessness and confusion

Which locations does the nurse include when discussing the storage and production of lymphocytes during an education session for novice nurses? Select all that apply.

Spleen Thymus Lymph nodes Bone marrow

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 500 cells/uL. The nurse documents this as which stage of HIV infection?

Stage 1

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 300 cells/uL. The nurse documents this as which stage of HIV infection?

Stage 2

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of less than 200 cells/uL. The nurse documents this as which stage of HIV infection?

Stage 3

A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement when providing direct care?

Standard

Which clinical manifestation noted during the patient's assessment indicates the need to notify the healthcare provider?

Swelling and redness noted to ankle

The patient enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the patient and finds a butterfly rash over the bridge of nose and on the cheeks. Then nurse correlates this data with the clinical manifestations of which disorder?

Systemic lupus erythematosus

A nurse is caring for a patient with systemic lupus erythematosus (SLE). Which intervention does the nurse plan to teach this patient to minimize skin infections associated with SLE?

Use sunscreen with an SPF of 50 or greater

In providing care to patients with compromised immune function, it is important that the nurse understand types of immunity. Which of the following leads to acquired (adaptive) immunity? Select all that apply.

Vaccinations Infection Transfer of maternal barriers

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Because the patient's CD4+ count is greater than 500 cells/uL, the nurse monitors for which complication?

Vaginal candidiasis

Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) MRSA?

Vancomycin

The nurse is discharging a patient who was recently diagnosed with acquired immunodeficiency syndrome (AIDS). Because the patient has a young child at home, which immunization is contraindicated for the child at this time?

Varicella vaccine

Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care?

Washing the injury under running water

The nurse educates a patient who is malnourished to increase foods that are considered complete protein sources to decrease the risk for infection. Which food choices indicate to the nurse the need for further teaching? Select all that apply.

corn

The nurse is teaching a group of patients about first-line defense against infection. Which patient statement indicates the need for further education?

"A cut with pus is a mechanical first-line defense against infection."

The nurse is assessing a patient diagnosed with human immunodeficiency virus (HIV) who presents with a rash. Which assessment question is most important?

"Are you taking Bactrim?"

Which question does the nurse need to ask during a health history with an adolescent patient, accompanied by a parent, to determine immune status?

"Are your child's immunizations up-to-date?"

The nurse is conducting an in-service on the spread of infection in the hospital environment. Which statement should the nurse include regarding the most common mode of pathogen transmission?

"Contact transmission is the common mode"

The nurse is conducting a health history for a patient. In assessing immune function, which question is best to ask related to risk factors in the patient's social history?

"Do you smoke cigarettes?"

A nurse is performing an admission assessment on a patient with clinical manifestations that indicate human immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting HIV?

"Have you ever experimented with intravenous drugs?"

Which of the following statements from the patient related to a scheduled bone marrow aspiration indicates patient understanding of the procedure?

"I am glad this is not painful like a bone marrow biopsy"

Which statement by the patient with rheumatoid arthritis indicates the need for further teaching?

"I may have to take steroids if I have a rheumatoid arthritis (RA) flare."

The nurse provides care to a patient diagnosed with osteoarthritis who is prescribed daily acetaminophen. Which patient statement requires an intervention?

"I only drink a couple of beers when I get home from work."

A patient with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and corticosteroids. Which patient statement indicates the need for further teaching?

"I should avoid getting the flu shot."

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device?

"I should tell the nurse if the pain doesn't stop after I use this device"

A patient with rheumatoid arthritis (RA) is being seen in the outpatient clinic for a progress checkup. The nurse is reviewing the patient's plan of care and determines that the patient has met a goal of treatment when the patient makes which statement?

"I try not to be too active because of the pain."

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Which patient statement indicates the need for further education regarding HIV management?

"It important that I take my medications as scheduled at least 90% of the time."

The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of contact transmission?

"It occurs when I come in direct contact with a pathogen"

The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of airborne transmission?

"It occurs when I come into contact with pathogens by breathing"

The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of vector-borne transmission?

"It occurs when I get bit by tick or other insect"

The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of vehicle transmission?

"It occurs when I ingest food containing a disease-carrying organism"

The nurse educates a patient on first-line anatomic barriers to infection. Which patient statement indicates to the nurse the need for further teaching?

"My saliva is an anatomic barrier to infection"

A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if the disease is caused by ethnicity. Which response by the nurse is the most appropriate?

"RA affects females more often than males"

A nurse is caring for a patient who is newly diagnosed with rheumatoid arthritis (RA). The patient asks the nurse what the difference is between RA and osteoarthritis (OA). Which response by the nurse is most appropriate?

"The onset of OA is gradual, whereas the onset of RA may be rapid."

The nurse is providing education to a patient who is diagnosed with Clostridium difficile. Which patient statement indicates correct understanding regarding the cause of inflammation?

"Toxins released from the bacteria cause inflammation"

The nurse educates a patient who is diagnosed with therapy-induced immune dysfunction. Which patient statement indicates the need for additional teaching?

"We are planning to get our son an iguana for his birthday."

Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) Acinetobacter?

Ampicillin-sulbactam

A nurse working in the emergency department (ED) is providing care for a group of patients. Which patient demonstrates a decline in immune response that typically occurs with the aging process?

An 88-year-old with pneumonia who has a temperature of 99.5F

The nurse is caring for an HIV-positive patient who has been on prophylaxis to reduce the risk of opportunistic infections. In reviewing the patient's health record, the nurse correlates that prophylaxis can be stopped based on which data?

CD4+ count greater than 200 cells/uL for at least 3 months

In completing discharge teaching for a patient recently diagnosed with HIV infection, the nurse instructs the patient to have tuberculosis (TB) screening at what interval?

Every 6 months

A nurse is caring for a patient who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the patient is experiencing a type I hypersensitivity reaction?

Hypotension

Which nursing action is appropriate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) MRSA?

Implementing isolation precautions

In preparing an education program for staff about human immunodeficiency virus (HIV), the nurse includes which information? Select all that apply.

In HIV-infected patients who do not receive treatment, the time from infection and death is approximately 12 years. Malnutrition is a comorbidity of HIV infection. In adults, HIV is categorized into three different stages.

In evaluating an HIV-positive patient's response to antiviral therapy, which data indicates a positive response?

Increased CD4+ count

In providing care to an HIV-positive patient, the nurse correlates which finding to a therapeutic response to antiretroviral therapy (ART) medications?

Increased CD4+ count

The nurse correlates the increased risk of autoimmune disorders in the older adult to which age-related change of the immune system?

Increased autoantibodies production

The nurse correlates which factors to immunosenescence? Select all that apply.

Increased risk for infection Increased risk of cancer Increased risk of autoimmune disorders

Which immunization should the nurse encourage for a patient who is diagnosed with stage 2 HIV?

Influenza vaccine

The nurse is providing care for a patient diagnosed with agammaglobulinemia and correlates management of this disorder includes which medication? Which is the anticipated treatment for this patient?

Intravenous immunoglobulin (IVIG)

The nurse is preparing to assess a patient when one of the patient's family members begins showing symptoms of a mild latex sensitivity. Which action by the nurse is best?

Obtaining latex-free products for the patient's room

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include?

Pain is whatever the client says it is

Which is the priority nursing action to decrease the risk of spreading infection among patients diagnosed with Multidrug-Resistant Organisms?

Performing hand hygiene before and after care

The nurse is providing care to a patient who is being evaluated for an immune deficiency. Which information in the patient's health history supports this diagnosis? Select all that apply.

Persistent oral thrush Eight new infections in a 1-year period Two serious sinus infections in a 1-year period

The nurse correlates systemic hypotension to which hypersensitivity mediator?

Platelet-activating factor

Which laboratory value requires an intervention by the nurse for the patient scheduled for a positron emission tomography (PET) scan?

Serum glucose 250 mg/dL