Med-Surg Exam #2 Practice Questions
A nurse is preparing to administer a varicella immunization to a client. Which of the following questions by the nurse is appropriate?
"Are you pregnant?"
A patient who is diagnosed with AIDS tells the nurse, I feel obsessed with thoughts about dying. Do you think I am just being morbid? Which response by the nurse is the best?
"Can you tell me more about the kind of thoughts you are having?"
A 26 year old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determine the cause of the patient's symptoms?
"Can you tell me more about the pain?"
A 55 year old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?
"Do you use over the counter drugs?"
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take?
Explain to the patient that this is an expected finding
Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?
Needle stick with a needle and syringe used to draw blood
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdominal is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?
Notify the primary health care provider (PHCP)
The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation?
Numbness and tingling
A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify that which of the following as a risk factor for cholecystitis?
Obesity
Opportunistic diseases in HIV infection
Occur in the presence of immunosuppression
A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take?
Offer a glass of water following medication administration
A nurse is caring for a client following a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure?
Temperature Elevation Fever is an indication of bowel perforation during a paracentesis
The primary health care provider has determined that a client has contracted hepatitis A based on the flu-like symptoms and jaundice. Which statement by the client supports this medical diagnosis?
"I ate shellfish about 2 weeks ago at a local restaurant."
The nurse recognizes that teaching a 44 year old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?
"I can remove the bandages on my incisions tomorrow and take a shower."
A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates and understanding of the teaching? Select all that apply
"I plan to eat small, frequent meals" "I will eat easy to digest foods with limited spice" "I will use skim milk when cooking"
A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?
"I will add high protein foods to my diet."
A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse and understanding of the teaching?
"I will cook vegetables before eating them."
The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?
"I'm glad I don't have to lie still for this procedure."
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?
"It is important to participate in a needle-exchange program."
A nurse is preparing to administer an IM injection of immune globulin to a client who has been exposed to hepatitis A. Which of the following statements by the nurse is appropriate?
"This medication provides you with an immune response more quickly than your body can produce it."
A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching?
"You might have shoulder pain after the surgery."
A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order would the nurse implement these prescribed actions? Discontinue the antibiotic infusion Give diphenhydramine IV Inject epinephrine IM or IV Prepare an infusion of dopamine Start 100% oxygen using a nonrebreather mask
1. Discontinue the antibiotic infusion 2. Start 100% oxygen using a nonrebreather mask 3. Inject epinephrine IM or IV 4. Give diphenhydramine IV 5. Prepare an infusion of dopamine
During change of shift report, the nurse learns about the following four patients. Which patient requires assessment first? -40 yo with chronic pancreatitis who has gnawing abdominal pain -58 yo who has compensated cirrhosis and is complaining of anorexia -55 yo with cirrhosis and ascites who has an oral temperature of 102 F -36 year old recovering from a laparoscopic cholecystectomy who has severe shoulder pain
55 year old with cirrhosis and ascites who has an oral temperature of 102 F
The reason newborns are protected for the first three months of life from bacterial infections is because of the maternal transmission of:
IgG
A diagnosis of AIDS is made when an HIV-infected patient has
A CD4+ count below 200/uL
The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant?
A patient who is recovering from an anaphylactic reaction to a bee sting
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?
A rigid, boardlike abdomen
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor?
Ammonia levels
Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62 year old female patent who has acute pancreatitis?
Amylase
Which statements about metabolic side effects of ART are true? Select all that apply
ART- related body changes Lipid problems include increases in triglycerides and decreases in high density cholesterol Insulin resistance and hyperlipidemia can be treated with drugs to control glucose and cholesterol
A 67 year old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?
Abdominal pain is decreased
In a person having an acute rejection of a transplanted kidney, which of the following would help the nurse understand the course of events (select all that apply):
Acute rejection can be treated with OKT3 Repeated episodes of acute rejection can lead to chronic rejection Acute rejection is common after a transplant and can be treated with drug therapy
A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first?
Administer epinephrine
A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?
Administer skin testing by the cutaneous scratch method
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply
Administer stool softeners as prescribed Encourage a high fiber diet to promote bowel movements without straining Apply cold packs to the anal rectal area over the dressing until the packing is removed
A serum potassium level of 3.2 mEq/L is reported for patient who has scheduled doses of spironolactone (Aldactone) and Furosemide (Lasix) due. Which action should the nurse take?
Administer the spironolactone
Nursing management of the patient with acute pancreatitis include (Select all that apply)
Administering pain medication Checking for signs of hypocalcemia Monitoring for infection, particularly respiratory tract infection
The nurse caring for a patient with suspected acute cholecystitis would anticipate (select all that apply)
Administration of IV fluids Monitoring of liver function tests Administration of antiemetics for patient with nausea
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient?
Administration of immunosuppressant medications
The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?
After a couple of years, it is likely that I will be able to stop taking the cyclosporine
Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis?
Albumin level
The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of?
Alcohol consumption
A 24 year old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal..
Anti-hepatitis A virus immunoglobulin M (Anti-HAV IgM)
A nurse is providing care to a client who is one day postoperative following a paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention?
Apply a dry, sterile dressing
Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first?
Apply a tourniquet above the injection site
A 27 year old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take?
Apply and ice pack to the right lower quadrant
A nurse is preparing to administer a scratch test to a client who has possible food and environmental allergies. Which of the following actions should the nurse perform prior to the procedure? Select all that apply
Ask the client about previous reactions to allergens Ask the client about medications taken over the past several days Inform the client to expect itching at one site Obtain emergency resuscitation equipment
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is a documentation of the presence of asterixis. How should the nurse assess for its procedure?
Ask the client to extend the arms
To prepare a 56-year-old male patient with ascites for paracentesis, the nurse will?
Ask the patient to empty the bladder
Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?
Ask the patient to extend both arms forward
A 71 year old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first?
Assess the patient about risk factors for constipation
A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurses priority action?
Assess the patient's airway
What is the most appropriate nursing intervention to help an HIV infected patient adhere to a treatment regimen?
Assess the patient's routines and find adherence cues that fit into the patient's life circumstances
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?
Assessing for the return of the gag reflex
Association between HLA antigens and diseases is most commonly found in what disease conditions?
Autoimmune disorders
Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?
Avoiding alcohol ingestion
The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item?
Bananas
A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by "passive immunity." Which example should the nurse use to explain this type of immunity?
Breast-feeding her infant
The function of monocytes in immunity is related to their ability to:
Capture antigens by phagocytosis and present them to lymphocytes
A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? Select all that apply
Change in orientation Asterixis Fetor hepaticus
The health care provider asks the nurse whether a patient's Angi-edema has responded to prescribed therapies. Which assessment should the nurse perform?
Check for swelling of the patient's lips and tongue
When taking the blood pressure on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?
Check the calcium level in the chart
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
Check the patient's class schedule to help decide when the drugs should be taken
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply
Coffee Chocolate Peppermint Fried chicken
An older adult patient who is having an annual check up tells the nurse, I feel fine, and I don't want to ay for all these unnecessary cancer screening tests. Which information should the nurse plan to teach this patient?
Consequences of aging on cell-mediated immunity
The nurse, who is reviewing a clinic patients medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate?
Consult with the heath care provider about giving a lower allergen dose
The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? -Continue taking antibiotics until all the medication is gone. -Antibiotics may sometimes be prescribed to prevent infection. -Unused antibiotics that are more than a year old should be discarded. -Antibiotics are effective in treating influenza associated with high fevers. -Hand washing is effective in preventing many viral and bacterial infections.
Continue taking antibiotics until all the medication is gone Antibiotics may sometimes be prescribed to prevent infection Hand washing is effective in preventing many viral and bacterial infections
A young adult female patient who is HIV positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?
Continue to use contraception while on this medication
A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in her treatment to:
Exchange her plasmas that contains antinuclear antibodies with a substitute fluid
HIV antiretroviral drugs are used to:
Decrease viral RNA levels
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient?
Discuss a change in antiretroviral therapy
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse to expect to administer to this client? Select all that apply
Diuretic Beta-blocking agent Lactulose
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green brown drainage since the surgery. Which nursing intervention is most appropriate?
Document the findings
While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate?
Document the patient's allergy history and fee alert for any clinical manifestations of a type I latex allergy
The most common cause of secondary immunodeficiencies is
Drugs
The nurse is altered to possible anaphylactic shock immediately after a patient has received IM penicillin by the development of:
Edema and itching at the injection site
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time?
Encourage adequate nutrition, exercise and sleep
A nurse is completing an admission assessment for a client who has pancreatitis. Which of the following findings should the nurse expect?
Epigastric pain radiating to the left shoulder
A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value?
IgE
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply Fever Positive Cullen's sign Complaints of indigestion Palpable mass in the upper left quadrant Pain in the upper right quadrant after a fatty meal Vague lower right quadrant abdominal discomfort
Fever Complaints of indigestion Pain in the upper right quadrant after a fatty meal
Which finding indicates to the nurse that a patients transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
Fewer episodes of bleeding varices
In planning care for a patient with metastatic liver cancer, the nurse should include interventions that
Focus primarily on symptomatic and comfort measures
Interventions to prevent health care associated infections should include (Select all that apply)
Following hand washing procedure Decontaminating equipment used for patient care Appropriately using personal protective equipment
An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer?
Gamma globulin
According to the Centers for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium difficult (C. Diff)? Select all that apply -Mask -Gown -Gloves -Shoe covers -Eye protection
Gown Gloves
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply Diarrhea Black, tarry stools Hyperactive bowel sounds Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back
Gray-blue color of the flank Abdominal guarding Left upper quadrant pain with radiation to the back
A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis?
Gray-blue discoloration of the skin around the umbilicus
The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?
Hairdressers
The nurse cares for a patient affected with HIV who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care? Select all that apply -Hepatitis B vaccine -Pneumococcal vaccine -Influenza virus vaccine -Trimethoprim-sulfamethoxazole -Varicella zoster immune globulin
Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine
What accurately describes rejection after transplantation?
Hyperacute reaction can be avoided if crossmatching is done before transplantation
Which statement by a patient would alert the nurse to a possible immunodeficiency disorder?
I had my spleen removed many years after a car accident
A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching?
I will plan to take oral antihistamines daily before going to work
The nurse tells a friend who asks him to administer his allergy shots that:
Immunotherapy should only be administered in a setting where emergency equipment and drugs are available
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?
Increase intake of fluids, including juices
A nurse is reviewing the admission lab results of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
Increased blood glucose level
The nurse is caring for a client following a gastrojejunostomy. Which postoperative prescription should the nurse question and verify?
Irrigating the nasogastric tube
A patient with Hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that
Itching is a common problem with jaundice in this phase
Screening for HIV infection generally involves:
Laboratory analysis of blood to detect HIV antigen or antibody
A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response?
Large amounts of fluid should be taken to prevent impaction or bowel obstruction
A nurse is caring for a client who has a WBC count of 20,000/mm3. The nurse should conclude that the client has which of the following?
Leukocytosis
The nurse administering -interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for?
Leukopenia
A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? Select all that apply
Limit physical activity Avoid alcohol Eat small, frequent meals
A nurse is providing discharge instructions to a client following a gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome?
Limit the fluids taken with meals
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed for the client? Select all that apply
Maintain NPO Encourage coughing and deep breathing exercises Give hydromorphone intravenously as prescribed for pain
Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?
Maintain adequate nutrition
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following?
Malaise
An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching?
Many medications have interactions with antiretroviral drugs
The nurse will plan to teach the patient diagnosed with acute hepatitis B about?
Measures for improving the appetite
A 53 year old patient is being treated for bleeding esophageal varies with balloon tamponade. Which nursing action will be included in the plan of care?
Monitor the patient for shortness of breath
A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, I am very nervous about making my baby sick. Which information will the nurse include when teaching the patient?
Most infants born to HIV positive mothers are not infected with the virus
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?
Muscle twitching and finger numbness
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time? -Oral acyclovir (Zovirax) -Oral saquinavir (Invirase) -Nystatin (Mycostatin) tablet -Aerosolized pentamidine (NebuPent)
Oral saquinavir (Invirase)
Which assessment finding is of most concern for a 46 year old woman with acute pancreatitis?
Palpable abdominal mass
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is a 85 mcg/dL. Which dietary selection does the nurse suggest to the client?
Pasta with sauce
Which information would be most important to help the nurse determine if the patient needs HIV testing?
Patient age
Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first?
Patient who has had 10 liquid stools in the last 24 hours
Which patient should the nurse assess first after receiving change-of-shift report? -Patient with urticaria after receiving an IV antibiotic -Patient who has graft-versus-host disease and severe diarrhea -Patient who is sneezing after having subcutaneous immunotherapy -Patient with multiple chemical sensitivities who has muscle stiffness
Patient who is sneezing after having subcutaneous immunotherapy
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?
Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
A patient who is HIV infected has a CD4 cell count of 400/uL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
Patient's ability to comply with ART schedule
A 34 year old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration?
Pegylated a interferon (PEG-Intron, Pegasys) SQ daily
A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. The client reports having a cough along with nausea and diarrhea. Their temperature is 100.6 F orally. The client is concerned about the possibility of having HIV. Which of the following actions should the nurse take? Select all that apply
Perform a physical assessment Determine when manifestations began Obtain a sexual history
A nurse is assign a client for HIV. The nurse should identify that which of the following are risk factors associated with this virus? Select all that apply
Perinatal exposure Older adult women Occupational exposure
Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with Clostridium difficile?
Place the client in a private room on contact isolation
A 38 year old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?
Place the patient on a pressure-receiving mattress
Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies?
Plan to wait in the clinic for 20 to 30 minutes after the testing
The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan?
Plasmapheresis will remove antibody-antigen complexes from circulation
The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that
Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space
A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following lab findings should the nurse expect?
Positive EIA test
The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands the this has been confirmed by which finding?
Positive punch biopsy of the cutaneous lesions
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?
Prevention of HIV transmission between sexual partners
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as priority in the plan?
Protecting the client from infection
A nurse on a medical surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care?
Provide a high calorie, high carbohydrate diet
A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include
Recommending a heart healthy diet
Emerging and reemerging infections affect health care by (select all that apply)
Reevaluating vaccine practices Revealing antimicrobial resistance Challenging researchers to discover new antimicrobial therapies
In a type I hypersensitivity reaction the primary immunologic disorder appears to be:
Release of chemical mediators from IgE-bound mast cells and basophils
A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?
Remind the patient about the need to return for retesting to verify the results
A patient with pancreatic cancer is admitted to the hospital for evaluation of treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure:
Removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with the joining of of the pancreatic duct, the common bile duct and the stomach into the jejunum
Teaching in relation to home management after a laparoscopic cholecystectomy should include
Reporting any bile colored drainage or pus from any incision
A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon?
Results of the patient-donor cross matching are positive
A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching? Select all that apply
Resume a diet of choice Cleanse the puncture site using mild soap and water Report nausea and vomiting to the surgeon
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?
Review the patient's current medication list
A 36 year old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?
Schedule the patient for HCV genotype testing
The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient?
Screening for malignancy
The registered nurse (RN) is caring for an HIV positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?
Stock the patient's room with all the necessary personal protective equipment
A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective?
Stools test negative for occult blood
Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?
Temperature 100.8 F
A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient?
The EIA test will need to be repeated to verify the results
During HIV infection:
The immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices?
The medication will prevent irritation of the enlarged veins
An older patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time?
The patient has a glass of grapefruit juice every day for breakfast
A patient who has a positive test for HIV antibodies is admitted to the hospital with Pnemocystis jiroveci pneumonia (PCP) and a CD4 T cell count of less than 200 cells/uL. Based on diagnostic criteria established by the CDC, which statement by the nurse is correct?
The patient has developed acquired immunodeficiency syndrome (AIDS)
Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72- year-old man who has advanced cirrhosis?
The patient is alert and oriented
The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?
The patient states, "Sometimes I miss a dose of zidovudine (AZT)."
Which information given by a 70 year old patient during a health history indicates to the nurse that the patient should be screened for Hepatitis C?
The patient used IV drugs about 20 years ago
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?
The patient will maintain intact perineal skin
Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patients skin rash?
The patient's antibodies are rejecting the donor bone marrow
The nurse is caring for a 73 year old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
The patients hands flap back and forth when the arms are extended
A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider?
There is a 2-cm wheal at the site of the allergen injection
Transmission of HIV from an infected person to another most often occurs because of?
Unprotected vaginal or anal intercourse
A patient with acute hepatitis B is being discharged. The discharge teaching plan should include instructions to
Use a condom during sexual intercourse
Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply
Use non latex gloves Use medications from glass ampules Keep a latex safe supply cart available in the client's area Avoid the use of medication vials that have rubber stoppers
Which strategy can the nurse teach the patient to eliminate risk for HIV transmission?
Using sterile equipment to inject drugs
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?
Viral load testing
A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection? Select all that apply
Western blot Indirect immunofluorescence assay
The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase)?
With each meal
Administration of Hepatitis B vaccine to a healthy 18 year old patient has been effective when a specimen of the patient's blood reveals..
anti-HBs