Medsurg test 2

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?

Consistent use of Standard Precautions

The nurse is assessing a client for signs and symptoms of systemic lupus erythematosus (SLE). Which of the following would be consistent with this disorder? (Select all thatapply.)

Discoid rash on skin exposed to sunlight Urinalysis positive for casts and protein Pain on inspiration Serum positive for antinuclear antibodies (ANA)

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes?

"I'll increase animal proteins like fish and meat."

A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information?

"If you leave work wearing your scrubs, go directly home and wash them right away."

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct?

"Those WBCs are abnormal and don't provide protection."

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best?

0.45% normal saline (hypotonic solution)

Tubing Set Up for Blood Transfusions

1. Clamp both saline side and blood side of tubing before you spike the bags to hang. Remember:CLAMPthe Saline tubing side after priming the tube.You do not want blood flowing into the saline bag. Not pretty. (Clamp the blood tubing while the saline is priming

During Transfusion

1. Provide patient education 2. Assess vital signs immediately before starting infusion 3. Begin transfusion slowly, stay with patient first 15 to 30 minutes 4. Ask patient to report unusual sensations (for example, chills, shortness of breath, hives, itching) 5. Administer blood product per protocol 6. Assess for hyperkalemia

A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What intervention by the nurse is best?

Assess the client for support systems.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client would the nurse assess first?

Client who reports shortness of breath

The nurse is teaching a client about medications for HIV-II treatment. What drugs are paired with the correct information? (Select all that apply.)

Abacavir: avoid fatty and fried foods. Efavirenz: take 1 hour before or 2 hours after antacids. All drugs: you must adhere to the drug schedule at least 90% of the time for effectiveness.

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions. Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.)

Acute confusion Dyspnea Hypertension Bounding pulse

A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important for the nurse's safety?

Adhering to Standard Precautions

A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the nurse is best?

Administer bowel cleansing as prescribed.

A client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority?

Administer oxygen.

A client is being admitted with suspected tuberculosis (TB). What actions by the nurseare best? (Select all that apply.)

Admit the client to a negative-airflow room. Obtain specialized respirators for caregiving.

A nurse asks the supervisor why older adults are more prone to infection than other adults. What reasons does the supervisor give? (Select all that apply.)

Age-related decrease in immune function Decreased cough and gag reflexes Diminished acidity of gastric secretions Thinning skin that is less protective Higher rates of chronic illness

The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest?

Anal intercourse

A nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.)

Antibodies produced are incomplete and do not function well. Macrophages stop functioning properly. Opportunistic infections and cancer are leading causes of death.

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?

Antihistamines do not help poison ivy.

The nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.)

Appropriate drug Proper route of administration Sufficient dose Sufficient length of treatment

A client with HIV-III is hospitalized with P. jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values would be most important for the nurse report to the primary health care provider? (Select all that apply.)

Aspartate transaminase, alanine transaminase: elevated Platelet count: 80,000/mm3 (80 109/L) Serum sodium: 120 mEq/L (120 mmol/L)

A client with HIV-II has had a sudden decline in status with a large increase in viral load. What action would the nurse take first?

Assess the client for adherence to the drug regimen

The family of a neutropenic client reports that the client "is not acting right." What action by the nurse is the priority?

Assess the client for infection.

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV). The test is negative and the client states "Whew! I was really worried about that result." What action by the nurse is most important?

Assess the client's sexual activity and patterns.

A nurse is preparing to administer a packed red blood cell transfusion to an older adult. Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.)

Assess vital signs at least every 15 minutes. Avoid giving other IV fluids. Assess the client for fluid overload.

A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most important with this condition?

Assessing mucous membranes

A client with HIV-III has oral thrush and difficulty eating. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

Assist the client with oral care every 2 hours. Offer the client frequent sips of cool drinks. Remind the client to use only a soft toothbrush. Offer the client soft foods like gelatin or pudding.

A client with HIV-III is in the hospital with severe diarrhea. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Assisting the client to get out of bed to prevent falls Obtaining a bedside commode if the client is weak Providing gentle perianal cleansing after stools Reporting any perianal abnormalities

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?

Auditing staff members' hand hygiene practices

A client has been newly diagnosed with systemic lupus erythematosus and isreviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material?

Baby powder is good for the constant sweating

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition?

Bence-Jones protein in urine

Which findings are AIDS-defining characteristics? (Select all thatapply.)

CD4+ cell count less than 200/mm3 (0.2 109/L) or less than14% Infection with P. jiroveci Presence of HIV wasting syndrome Confusion, dementia, or memory loss

A client has a platelet count of 9000/mm3 (9 109/L). The nurse finds the client confused and mumbling. What nursing action takes priority at this time?

Call the Rapid Response Team.

A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding the most common causes of death for these clients is which of the following? (Select all that apply.)

Cardiovascular impairment Chronic kidney disease

A nurse is caring for a client with HIV-III who was admitted with HAND. What sign or symptom would be most important for the nurse to report to the primary health care provider?

Change in pupil size

A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.)

Change the client's gown and linens when damp. Offer cool fluids to the client frequently. Sponging the client with tepid water.

Which risk factor(s) places a client at risk for leukemia? (Select all that apply.)

Chemical exposure Ionizing radiation exposure Viral infections

A nurse is caring for four clients with leukemia. After hand-off report, which client would the nurse assess first?

Client who had two bloody diarrhea stools this morning.

A client with HIV-II is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?

Consult with the pharmacy about drug interactions.

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?

Consult with the primary health care provider about obtaining stool cultures.

A client has been hospitalized with an opportunistic infection secondary to HIV-III. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best?

Contact the social worker to assist the client with advance directives.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?

Correctly identifying the client prior to a blood transfusion

The nurse is caring for a client diagnosed with HIV-II. The client's CD4+ cell count is 399/mm3 (0.399 109/L). What action by the nurse is best?

Counsel the client on safer sex practices/abstinence.

A nurse is providing education about HIV risks at a health fair. What groups would the nurse include as needing to be tested for HIV on an annual basis? (Select all that apply.)

Couples planning on getting married Those who are sexually active with multiple partners Injection drugs users Sex workers and their customers

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory test results. Which finding would the nurse report to the primary health care provider?

Creatinine: 2.9 mg/dL (256 mcmol/L)

A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients be taught to avoid? (Select all that apply.)

Dehydration Extreme stress High altitudes Pregnancy

The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are) expected for this client? (Select all that apply.)

Decreased hematocrit Abnormal white blood cell count Low platelet count Decreased hemoglobin

The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low. What information does the nurse provide? (Select all that apply.)

Do not work in the garden or with houseplants. Do not empty the kitty litter boxes. Bathe daily using antimicrobial soap. Avoid people who are sick and large crowds. Make sure meat, fish, and eggs are cooked well.

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug?

Does not reduce the need for safe sex practices.

The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage this problem has been met?

Doing activities of daily living (ADLs) using rest periods

Which statement(s) about blood transfusion compatibilities is (are) correct? (Select all that apply.)

Donor blood type A can donate to recipient blood type AB. Donor blood type O can donate to anyone

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?

Double-check the client and blood product identification.

The nurse is assessing a client who has probable lymphoma. What is the most common early assessment finding for clients with this disorder?

Enlarged painless lymph node(s)

A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below: What action by the nurse takes is most appropriate?

Ensure a patent airway while calling the Rapid ResponseTeam.

A nurse is preparing to administer a blood transfusion. What action is most important?

Ensure that informed consent is obtained.

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?

Ensure that the radiology department is aware of the Isolation Precautions.

A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests pain medication, what action by the nurse is best?

Give the client pain medication if it is time for anotherdose.

The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are) most appropriate? (Select all that apply.)

Hang the blood product using normal saline and a filtered tubing set. Take a full set of vital signs prior to starting the blood transfusion Use gloves to start the client's IV if needed and to handle the blood product.

A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem

Has a weight gain of 2 lb (1 kg)/1 mo.

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best?

Help the client find things to hope for each day of recovery.

The nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.)

Host Mode of transmission Portal of entry Reservoir

A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed?

I don't need to go to the hospital after using it.

A client has thrombocytopenia. What statement indicates that the client understands self-management of this condition?

I usually put ice on bumps or bruises.

Which statement by a client with leukemia indicates a need for further teaching by the nurse?

I will take a daily laxative to prevent constipation

A nurse has presented an educational program to a community group on Lyme disease. What statement by a participant indicates the need to review the material?

If Lyme disease is not treated successfully, it is usually fatal.

A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?

Initiate Protective Precautions.

An assistive personnel asks why brushing client s' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?

It mechanically removes biofilm on teeth.

The nurse caring for clients admitted for infectious diseases understands what information about emerging global diseases and bioterrorism?

Many infections are or could be spread by international travel.

A nurse plans care for a client who is at risk for infection. Which interventions will the nurse implement to prevent infection? (Select all that apply.)

Monitor white blood cell count and differential Screen all visitors for infections. Promote sufficient nutritional intake.

A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority?

Never stop prednisone abruptly.

A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shift to the left" on the white blood cell count. What action by the nurse is most important?

Notify the primary health care provider and requestantibiotics.

A client is being administered the first dose of belimumab for a systemic lupus erythematosus flare. What actions by the nurse are most appropriate? (Select all that apply.)

Observe the client for at least 2 hours afterward. Ensure emergency equipment is working and nearby.

A client is admitted with possible sepsis. Which action will the nurse perform first?

Obtain specified cultures.

A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort measures to a client with an infection. What action by the AP requires intervention by the nurse?

Ordering an oscillating fan for the client

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?

Pace activities, allowing for adequate rest.

The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect?

Pain

The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action would help prevent infection?

Performing frequent handwashing

A client with known HIV-II is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first?

Place the client under Airborne Precautions.

A client has received a bone marrow transplant and is waiting for engraftment. What action(s) by the nurse are most appropriate? (Select all that apply.)

Placing the client in protective precautions Teaching visitors appropriate hand hygiene Telling visitors not to bring live flowers or plants

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?

Prepare to administer vancomycin.

A nurse is preparing to administer a blood transfusion. Which action is mostimportant?

Put on a pair of gloves.

The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s) of treatment will the nurse assess? (Select all that apply.)

Severe nausea and vomiting Low platelet count Skin irritation at radiation site Low red blood cell count

A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best?

Show the family how to avoid spreading the disease.

The nurse learning about infection discovers that which factor is the best and most important barrier to infection?

Skin and mucous membranes

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority?

Sperm banking

Which assessment finding(s) may indicate that a client may be experiencing a blood transfusion reaction? (Select all that apply.)

Tachycardia Fever Bronchospasm Tachypnea Urticaria Hypotension

The nurse assesses a client's oral cavity as seen in the photo below: What action by the nurse is most appropriate?

Teach the client about cobalamin therapy.

A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?

The donor's cells are actually attacking the patient'scells."

A client with HIV-III asks the nurse why gabapentin is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best?

This drug helps treat the pain from nerve irritation

The nurse is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)

Type I—examples include hay fever and anaphylaxis. Type III—immune complex deposits in blood vessel walls. Type IV—examples are poison ivy and transplant rejection.

The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is (are) appropriate regarding infusion administration. (Select all that apply.)

Use a dedicated filtered blood administration set. Stay with the client for the first 15 to 20 minutes of the infusion. Monitor and document vital signs per agency policy. Infuse the transfusion with intravenous normal saline.

Which statements are true regarding Standard Precautions? (Select all thatapply.)

Use personal protective equipment as needed for client care. Wear gloves when touching clients' excretions or secretions.

A nurse begins a job at a Veterans Administration Hospital and asks why so much emphasis is on HIV testing for the veterans. What reasons is this nurse given? (Select all that apply.)

Veterans have a high prevalence of substance abuse. Many veterans may engage in high risk behaviors. Many older veterans may not know their risks. Everyone should know their HIV status. Belief that the VA has tested them and would notify them if positive.

A nurse cares for several clients on an inpatient unit. Which infection control measures will the nurse implement? (Select all that apply.)

Wear a gown when contact of clothing with body fluids is anticipated. Teach clients and visitors respiratory hygiene techniques. Disinfect frequently touched surfaces in client-care areas.

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client?

Zoledronic acid

Transfusion Responsibilities

a. Verify prescription with another RN b. Test donor's/recipient's blood for compatibility c. Verify patient's identity with another RN d. Examine blood bag label, attached tag, and requisition slip for ABO and Rh compatibility with the patient with another RN e. Check expiration date with another RN f. Inspect blood for discoloration, gas bubbles, cloudiness

Which is a better indicator of blood transfusions

• 3 x's rule • How to determine the % of hematocrit? • Multiply the hgb (hemoglobin x 3)=hematocrit%

Acute Transfusion Actions

• Febrile • Hemolytic • Allergic • Bacterial • Circulatory overload • Transfusion-associated graft-versus-host disease (TA-GVHD) • TRALI • TACO

What type of transfusions

• RBC transfusions - Given to replace cells lost from trauma or surgery • Platelet transfusions - Given for low platelet counts, active bleeding, scheduled for invasive procedure • Plasma transfusions (FFP) - Given to replace blood volume and clotting factors • Granulocyte (WBC) transfusions - Given (rarely) to neutropenic patients