NSG 119 Exam 1

Eschar related to wound healing

Black or brown necrotic tissue

Briefly explain the following complications of wound healing:

Hemorrhage: a Bleeding from a. wound site that occurs after hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object. Hematoma: localized collection of blood underneath the tissue Wound Infection: second most common health-care associated infection ; prudent material drains from wound (yellow, green, brown, depending on the organism) Dehiscence: A partial or total separation of wound layers; risks are poor nutritional status, infection, or obesity Evisceration: total separation of wound layers with protrusion of visceral organs, through a wound opening requiring surgical repair

Mary Adelaide Nutting

Instrumental in moving nursing education into universities.

Certified Nurse-Midwife (CNM)

Involves the independent care for women in normal pregnancy, labor, and delivery and care of newborns.

Clinical Nurse Specialist (CNS)

Expert clinician in a specialized area of practice.

Which information communicated by a nurse handing-off a client from the intensive care unit (ICU) to a receiving nurse in the step-down unit is most relevant to continuity of care in this transition?

Explaining that the client's right ear is deaf Any client problem that interferes with his or her ability to comprehend or communicate successfully has the potential to affect safety..

Educator

Explains, demonstrates, reinforces, and evaluates the patient's progress in learning.

Mary Mahoney

First professionally trained African American nurse

Which actions will the nurse take when a client is placed on Droplet Precautions? Select all that apply.

21. C, D C. Using a mask when within 6 feet of the client D. Putting a mask on the client whenever transport is necessary Infections spread by droplet transmission are heavy and released when the client sneezes or coughs. These droplets travel short distances, usually only 3 feet or less, and do not remain in the air. Wearing a mask within 6 feet of the client and having the client wear a mask whenever he or she is out of the room is all that is needed. Visitors are permitted but must remain at least 3 feet away from the client or wear a mask. Soap and water for handwashing is sufficient and gowns are not needed.

Which expected outcomes are appropriate for a client with a pressure injury? Select all that apply.

18. B, C, E B. Client will remain free from local or systemic infections C. Client will re-establish skin tissue integrity and restore skin barrier function E. Client's wound will show granulation and decrease decrease in size The expected outcomes for a client with a pressure injury include that the client will: experience progress toward wound healing by second intention as evidenced by granulation, epithelialization, contraction, and reduction or resolution of wound size; re-establish skin tissue integrity and restore skin barrier function; and remain free from local or systemic infections.

Which change in a client's white blood cell differential does the nurse interpret as associated with a severe or prolonged bacterial infection?

19. A Increased immature neutrophils A bacterial infection is usually associated with an increased total white blood cell count and an increase in the mature neutrophils. When a bacterial infection is severe or prolonged, the bone marrow increases the release of immature neutrophils, a phenomenon known as a "left shift." This change indicates that the body can no longer keep pace with the infection and the client is at increased risk for sepsis. An elevated lymphocyte count is associated with viral infections. An elevated eosinophil count is associated with allergic reactions. An elevated monocyte count is associated with mononucleosis.

Which priority nursing interventions focus on increasing client comfort and preventing skin injury when the client has pruritus? Select all that apply.

19. A, B, D, E, F A. Administering prescribed antihistamines or topical drugs B. Keeping client's fingernails trimmed short D. Applying mittens or gloves to client's hands at night E. Maintaining daily fluid intake of 3000 mL unless contraindicated F. After bathing, patting skin dry rather than rubbing All of these interventions are appropriate except that a podiatrist should trim the client's toenails, not an AP or a family member.

19. Which prescription will the nurse question for a client who has an allergy to penicillin? A. Acetaminophen 650 mg every 4 hours for pain B. Angiotensin-converting enzyme inhibitor (ACEI) daily for hypertension C. Cephalosporin to treat a chronic sinus infection D. Decongestant as needed for rhinorrhea

19. C Cephalosporin to treat a chronic sinus infection Cephalosporins have the same basic chemical structure as penicillin. A client with a penicillin allergy is very likely to have cross-reactivity and also have an allergic reaction to a cephalosporin. None of the other drugs are cross-reactive with penicillin.

21. Which adult-onset disorders have an autoimmune component? Select all that apply. A. Asthma B. Cardiovascular disease C. Colorectal cancer D. Diabetes mellitus type 2 E. Pernicious anemia F. Psoriasis G. Rheumatoid arthritis H. Systemic lupus erythematosus

21. E, F, G, H E. Pernicious anemia F. Psoriasis G. Rheumatoid arthritis H. Systemic lupus erythematosus Pernicious anemia, psoriasis, rheumatoid arthritis, and systemic lupus erythematosus are all autoimmune disorders in which one or more tissues are attacked by autoantibodies and cytokines. Asthma, cardiovascular disease, colorectal cancer, and type 2 diabetes mellitus do not have autoimmunity as a basis for the pathophysiology of the disease although some have a strong genetic component and asthma has a major inflammatory component.

Which teaching strategies would the nurse include when instructing clients about how to prevent burn injuries? Select all that apply.

36. B, C, D, E, F B. Never add a flammable substance to an open flame. C. Use sunscreen and protective clothes to avoid sunburn. D. Avoid smoking when drinking alcohol or taking drugs that induce sleep. E. When space heaters are used, keep flammable objects away from them. F. If using home oxygen, do not smoke in the room where oxygen is in use. All of the options presented are appropriate teaching points for prevention of burn injuries except A. Water heaters should be set below 120°F (49°C).

What would be the nurse's best action when a client with a burn injury develops a brassy cough, increased difficulty swallowing, and progressive hoarseness?

37. C. Activate the Rapid Response Team. The nurse would monitor a client's respiratory efforts closely to recognize possible airway involvement. For a burn client in the resuscitation phase who is hoarse, has a brassy cough, drools, has difficulty swallowing, or produces an audible breath sound on exhalation, the nurse responds by immediately positioning the client upright, applying oxygen, and notifying the Rapid Response Team.

24. Which factor does the nurse consider most likely to be responsible for promoting infection development in an older adult client after an HIV exposure? A. Decline in the overall efficiency of the immune system B. Belief that HIV is not an issue for older people C. Reluctance to discuss sexual activity with a health care professional D. Mistaking signs/symptoms as normal part of aging

A. Decline in the overall efficiency of the immune system A major part of susceptibility for developing HIV infection after an exposure is the efficiency of the client's immunity. All immunity decreases with age, placing the older adult client more at risk for infection after any type of infectious exposure, including HIV.

First aid for wounds includes the following. Briefly explain each one.

Hemostasis: Control bleeding by applying direct pressure in the wound site with a sterile or clean dressing, usually after trauma, for 24- 48 hours. Cleansing: Appropriate cleaning solution and using a mechanical means of delivering the solution without causing injury to healing wound tissue. Normal saline is the preferred solution. Protection: Applying sterile of clean dressings and immobilizing the body part

Explain the following factors that place a patient at risk for a pressure injury development

Mobility: potential effects of impaired mobility, muscle tone and strength Nutritional Status: Malnutrition is major risk factor: a weight loss of 5% of usual weight, weight is less 90% of ideal body weight with, or decrease of 10 lbs in brief period Body Fluids: continuous exposure to bodily fluids especially gastric and pancreatic drainage, increases the risk for skin breakdown Pain: adequate pain control and patient comfort will increase mobility, which in turns reduces risk

Describe the physiological process involved with wound healing: Primary intention

Wound that is closed by epithelialization with minimal scar formation as long as infection and secondary breakdown are prevented

Slough related to wound healing

Stringy substance attached to wound bed that is soft, yellow or white tissue

Types of surgical wound closures are:

Surgical wounds are closed with staples, sutures, or wound closures. Look for irrigation around staple or suture sites and note whether the closures are intact

Explain how a nurse assess the following

Wound Appearance: Whether the wound edges are closed, the condition of tissue at the wound base; look for complications Character of Wound drainage: amount, color, odor, and consistency of drainage, which depends on the location and the extent of the wound

Describe the physiological process involved with wound healing: Secondary intention

Wound is left open until it become filled by scar tissue ; chance of infection is greater; healing takes longer

Dermis

inner layer of the skin that provides tensile strength and mechanical support

12. What would the nurse direct the home assistive personnel (AP) to do for an older client who wants to avoid dry skin?

12. A Assist with a complete bath or shower only every other day (wash face, axillae, perineum, and any soiled areas with soap daily). To assist an older adult in prevention of dry skin, the nurse would teach the AP to help the client take a complete bath or shower every other day (wash face, axillae, perineum, and any soiled areas with soap daily), using tepid water. See Patient and Family Education: Preparing for Self-Management — Prevention of Dry Skin in your text for additional interventions to prevent dry skin.

12. Which personal protective equipment does the nurse assemble for use when giving oral and parenteral drugs care to an HIV-positive client who has amoebic diarrhea? Select all that apply. A. Air-purifying respirator B. Eye goggles C. Gloves D. Gown E. Hair cover F. Surgical mask

12. C, D C. Gloves D. Gown When performing the action of giving either oral or parenteral drugs to any client with diarrhea including those who are HIV positive, only Contact Precautions are needed.

For which client care situation will the nurse teach assistive personnel to perform handwashing, rather than using alcohol-based hand rubs (ABHRs)?

12. C. After contact with a client who has had diarrhea for 3 days Handwashing is recommended instead of ABHRs when hands are visibly dirty or soiled or feel sticky and after toileting (including toileting clients). ABHRs are ineffective against spore-forming organisms such as Clostridium difficile, a common cause of health care-associated diarrhea, especially in older adults. A client with diarrhea may have spores in the fecal matter or on his or her body.

Identify three principles that are important when cleaning an incision

1. Cleanse in a direction from least contaminated area to the surrounding skin 2. use gentle friction when applying solutions locally to the skin 3. When irrigating, allow the solution to flow from the least to the most contaminated area

List the questions to ask if the identified outcomes were not met

1. Was the etiology of the skin addressed? 2. Was wound healing supported by providing the wound base with a moist, protected environment? 3. Were issues such as nutrition assessed and a plan of care developed?

13. A nurse who is HIV positive and is now a client on a surgical unit the day after abdominal surgery asks a nurse colleague to keep her HIV status from the rest of the nursing staff. What is the unit nurse's best response? A. "Of course, there is no need for anyone else here to know." B. "Unless you require a blood transfusion, this should not be a problem." C. "I will only inform the person who is assigned to change your dressing." D. "I cannot promise that because I have an ethical obligation to protect everyone who works here."

13. A. "Of course, there is no need for anyone else here to know. The consistent use of Standard Precautions is sufficient to prevent HIV transmission from an infected client to a health care worker. Standard Precautions are universally applied and, thus, the client's HIV status does not need to be disclosed regardless of whether a blood transfusion is needed or dressing changes are needed. Although the nurse does have an obligation to ensure safety for all personnel, there is no ethical, legal, or other reason to not comply with the client's wishes.

14. Which client symptoms that started after IV administration of a newly prescribed drug prompts the nurse to initiate the Rapid Response Team for possible anaphylaxis? Select all that apply. A. Facial flushing B. Bradycardia C. Oxygen saturation of 88% D. Wheezing on exhalation E. Increased deep tendon reflexes F. Hives at the IV site spreading upward

14. C, D, F C. Oxygen saturation of 88% D. Wheezing on exhalation F. Hives at the IV site spreading upward Wheezing on exhalation is an indication of bronchoconstriction, which occurs during anaphylaxis. The bronchoconstriction is severe enough to result in some degree of hypoxia. Hives are an indicator of an allergic reaction, especially if they are spreading. Bradycardia does not occur with anaphylaxis; clients become become tachycardic with a weak and thready pulse as a result of sympathetic nervous system compensation for shock. Skin becomes cyanotic, not flushed. Increased deep tendon reflexes are not associated with anaphylaxis.

17. Which nursing response is most likely to cause harm to a client who has anaphylaxis? A. Failing to inform the family about a change in the client's condition B. Using a nonrebreather mask to administer oxygen C. Delaying the administration of epinephrine D. Increasing the IV saline flow rate

17. C Delaying the administration of epinephrin According to the Centers for Disease Control and Prevention, the single most harmful action during anaphylaxis is delaying the administration administration of epinephrine. It is safer to give the drug when it is not needed than it is to not give it when it is needed. When oxygen is applied, the recommendation is to use a nonrebreather mask to increase oxygen delivery. Increasing the IV flow rate (when the IV is not the source of anaphylaxis) can help support circulation and blood pressure. Informing the family, although a good action, is not the priority action during management of anaphylaxis.

Which characteristics would the nurse expect to assess for a client with plaque psoriasis? Select all that apply.

23. A, C, E A. Raised, red patches covered with silvery white scales C. Affected areas usually include scalp, knees, elbows, lower back E. May be itchy, painful, or bleeding Plaque psoriasis is the most common form of psoriasis. It is described as: raised, red patches covered with silvery white scales; usually found on scalp, knees, elbows, lower back; and may be itchy, painful, or bleeding. White pustules surrounded by reddened skin occurs with pustular psoriasis which usually occurs on hands and feet. Guttate psoriasis usually occurs after a streptococcal infection.

23. Which factor for a client who has type 1 diabetes mellitus indicates to the nurse that the disorder most likely has an autoimmune origin rather than a lifestyle basis? A. Is a vegetarian whose diet is high in soy-based proteins B. Works in a large chemical manufacturing plant C. Has an identical twin with Graves disease D. Has a parent with a severe peanut allergy

23. C Has an identical twin with Graves disease Twin studies have confirmed a strong link between genetic inheritance and autoimmunity. For monozygotic twins (identical twins), when one twin is diagnosed with an autoimmune disease, development of an autoimmune disorder (but not necessarily the same disorder) in the other twin is about 50%. Susceptible tissue types, known as human leukocyte antigens (HLAs), include DR2, DR3, DRB, DQA, DQB, and Cw6.

Which response during sponging of a client with a high fever indicates to the nurse that cooling may be occurring too quickly?

23. D. Shivering Shivering during any form of external cooling usually indicates that the client is being cooled too quickly. A rising temperature indicates the cooling method is not effective. Neither acute confusion nor changing urine output indicate excessive or too rapid cooling.

What is the priority focus of prehospital care for a client with a chemical injury burn?

35. A. Decontamination Acids and alkalines are the most common chemical substances that can inflict burns. Decontamination is the focus for prehospital emergency responders. Contaminated clothing is removed and chemicals in powder form are brushed off.

25. Based on the concept of "Treatment as Prevention," which outcome statement indicates to the nurse that the goal of combination antiretroviral therapy for an HIV-positive client is being met? A. Client states understanding of the prescribed medication regimen. B. Client's disease stage is classified as unknown. C. Opportunistic infections are not present. D. Viral load is at an undetectable level.

25. D Viral load is at an undetectable level. Understanding the medication regimen is not sufficient. When it is followed and the client's viral load is undetectable, the goal of treatment as prevention has been met. An unknown disease stage is dangerous and does not help in prevention. Absence of opportunistic infection is a positive sign and may indicate the disease has not progressed, but does not indicate the goal of prevention has been met.

28. Which type of focused assessment is a priority for the nurse to perform for an HIV-positive client who has toxoplasmosis encephalitis? Select all that apply A. Performing a mental status examination B. Assessing heart rate and rhythm C. Asking about headache presence D. Palpating the abdomen for tenderness E. Listening for bowel sounds F. Assessing neck movement

28. A, C, A. Performing a mental status examination C. Asking about headache presence Infection with Toxoplasma gondii causes encephalitis with symptoms of headache and acute confusion. Neck stiffness is associated with meningitis, not encephalitis. Heart rhythm changes and GI disturbances are not part of the toxoplasmosis encephalitis.

Which finding when the nurse assesses a nevus on a client's back would be of concern and warrant further investigation?

44. D. Report of itching and bleeding Melanomas are pigmented cancers arising in the melanin-producing epidermal cells. Most often they start as the benign growth of a nevus (mole). Normal nevi have regular, well-defined borders and are uniform in color, ranging from light colors to dark brown. The lesion's surface may be rough or smooth. Those with irregular or spreading borders, and/or multiple colors, are abnormal. Other suspicious features include sudden changes in lesion size and reports of itching or bleeding.

Which client is most likely to be a candidate for Mohs surgery?

45. A. Client with squamous cell carcinoma on the nose Mohs surgery is a specialized form of excision usually for basal and squamous cell carcinomas when they occur on the face, nose, or other areas of thin skin that may affect the cosmetic outcome.

Which clients with pressure injuries would the nurse assess as at high risk for development of infection? Select all that apply.

9. B, C, E, F B. Older client with a low white blood cell (WBC) count C. Client with type 1 diabetes mellitus E. Client with chronic obstructive pulmonary disease (COPD) on steroids F. Older client with large abdominal incision who needs help with repositioning Clients with diabetes are slow to heal and the longer the incision is open the greater the risk for infection. Low WBC count leaves the client unable to fight infection. Steroid therapy interferes with the actions of the immune system. The client with the large abdominal incision is at risk because of difficulty with healing. The client awaiting surgery and the client with high cholesterol who walks daily are not at increased risk for infection from a pressure injury.

Which action does the nurse take to prevent indirect contact transmission of microorganisms to a susceptible client?

9. C. Cleaning the glucometer with disinfectant between testing clients Indirect contact transmission occurs when microorganisms are transmitted from a source to a host by passive transfer from a contaminated object. A commonly used object that can be contaminated is a glucose testing device such as a glucometer. Even if blood is not seen on the device, it should be disinfected appropriately between clients to prevent indirect contact transmission of infection. The use of Airborne Precautions, wearing of filter masks, and wearing gloves are examples of preventing direct transmission, not indirect transmission of infection.

9. Which actions does the nurse recommend for a night shift co-worker, who just experienced a sharps injury from a known HIV-positive source client, to take immediately? Select all that apply. A. Go to the emergency department immediately for a tetanus booster vaccination. B. Immediately use an alcohol-based handrub on the injured area. C. Notify employee health tomorrow morning when it opens. D. Ask your sex partner to have HIV testing as soon as possible. E. Wash the injured area immediately for at least 1 minute with soap and water. F. Make an appointment with the nursing department and request a transfer to an area where direct physical contact with a client is not expected.

9. E E. Wash the injured area immediately for at least 1 minute with soap and water The first step with a sharps injury from a known HIV-positive source is to wash the hands thoroughly with soap and water for at least 1 minute. Using an alcohol-based handrub is not sufficient for this purpose. Although the co-worker should go immediately to the emergency department, the purpose is to initiate postexposure prophylaxis and begin documentation, not to get a tetanus booster (irrelevant to this situation). Notifying employee health to continue documentation and prophylaxis is important but cannot be done immediately. The co-worker's sex partner should have HIV testing relatively soon, but not immediately, to determine his or her current status. There is no legal, ethical, or medical reason for the co-worker to avoid direct physical contact with clients.

The critical care nurse is providing care for a client who is intubated, and wants to prevent ventilator-associated pneumonia (VAP). What actions will the nurse take to facilitate the progression from clinical judgment (frequent oral care) to systematic change in this critical care unit? Select all that apply.

A, B, C, E A. Place a sign over the client's bed reminding other nurses about oral care. B. Provide a unit educational unit covering the research and the results. C. Make copies of the research and results available to the nurses on the unit. E. Remind the nurses taking responsibility of the client's care about oral care. To move from clinical judgment to systems thinking, nurses must move from focus on individual nursing actions to focus on nursing actions and relationships within a nursing unit or organization. The goal is to add enhanced methods to promote safety and increase quality of care. Suctioning does not help to prevent VAP but all strategies that encourage frequent oral care have the potential to decrease the incidence of VAP.

The Emergency Department nurse is admitting a 58-year-old client with atypical chest pain. Which actions would the nurse delegate to the experienced AP? Select all that apply.

A. Label and place the client's belongings in a plastic bag C. Check admission vital signs and record D. Complete a 12-lead ECG for the client F. Place the client on a continuous cardiac monitor G. Assist the client to use the bathroom H. Use pulse oximetry to check the client's oxygen saturation .

Which health behavior does the nurse teach a client who is immunocompromised to prevent infection from normal flora?

A. Wiping perineal area from front to back after toileting for females Although all behaviors are appropriate actions for the client to take to reduce infection risk, only the action of option A helps reduce the risk of infection caused by normal flora of the intestinal tract from improperly entering the urinary tract (which should be a sterile site).

1. Which statement best describes allergy or hypersensitivity? A. Excessive response to the presence of an antigen B. Excessive response against self cells and their products C. Failure of the immune system to recognize self cells as normal D. Failure of the immune system to recognize pathogenic organisms as non-self

1. A Excessive response to the presence of an antigen A hypersensitivity or allergy is an overactive immunity with excessive inflammation occurring in response to the presence of an antigen to which the patient usually has been previously exposed. Although inflammation and immunity are generally protective, they can cause uncomfortable and serious responses when excessive. With hypersensitivity reactions, the immune system very much recognizes self cells as normal. The responses are directed against nonself but are excessive.

List the factors for heat and cold intolerance

1. A person is better able to tolerate short exposure 2. More sensitive to temperature changes to which a large area of the body is exposed 3. A person has less tolerance to temperature changes which a large area of the body is exposed 4. The body responds to minor temperature changes 5. Tolerance to temperature changes with age. 6. Physical conditions that reduce the reception or perception of sensory stimuli 7. Uneven temperature distribution suggests that the equipment is functioning improperly

Which of the following is not a sub scale on the Braden Scale for predicting pressure ulcer risk? 1. Age 2. Activity 3. Moisture 4. Sensory perception

1. Age

Which circumstances are examples of colonization? Select all that apply.

1. B, F B. A nurse has a nasal swab that cultures out methicillin-resistant Staphylococcus aureus (MRSA) and remains asymptomatic. F. A 64-year-old woman's urine culture is positive for Escherichia coli although the urine is clear and no symptoms of cystitis are present. Colonization is the presence of microorganisms (often pathogenic) in the tissues of the host that do not cause symptomatic disease because of normal flora. Options B and F are consistent with this definition. Option A is incorrect because the client has disease symptoms although the organism remains unknown, and option E is incorrect because the client has infectious symptoms consistent with the organisms in the culture. In option C, the client is at increased risk for infection development but is not known to be harboring any pathogenic pathogenic organisms. For option D, the client has an actual known infection and the assistive personnel is not using the recommended precautions to prevent spread.

Which medical-surgical concept would the nurse designate as the highest priority for a client with pressure injuries of both heels?

1. C. Tissue integrity A pressure injury (PI) is a loss of tissue integrity. It is caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface. This results in reduced tissue perfusion and gas exchange, which eventually leads to cell death. Most frequently these injuries are found on the sacrum, hips, and heels.

List the guidelines to follow during a dressing change procedure

1. Know the type of dressing, the presence of underlying drains or tubing and type of supplies needed 2. Use medical aseptic technique 3. Teach the patient how to change dressings in preparation for home care

Identify the four methods for debridement

1. Mechanical 2. Autolyic : removal of dead tissue via lysis of necrotic tissue but eh WBCs and natural enzymes of the body 3. Chemical - topical enzyme preparation (Dakin's solution or sterile maggots) 4. Sharp or surgical

List and explain the factors that influence blood pressure, and describe how blood pressure is regulated.

1. Nutrition - any deficiencies in nutrition results in delayed or impaired healing 2. Tissue perfusion - the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing 3. Infection - prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and increases the production of proinflammatory cytokines 4. Age - increased age causes a decrease in functioning of the macrophages, which leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization 5. Psychological impact of wounds - stress on patient's adaptive mechanisms

Identify the pressure factors that contribute to pressure ulcer development. (3)

1. Pressure Intensity 2. Pressure duration 3. Tissue tolerance

List the principles to address to maintain a healthy wound environment:

1. Prevent and manage infection 2. Cleanse the wound 3. Remove nonviable tissue 4. Maintain the wound in moist environment 5. Eliminate dead space 6. Control odor 7. Eliminate or minimize pain 8. Protect the wound

List the advantages of a transparent film dressing

1. Promotes a moist environment 2. Ideal for small wounds 3. Serves as a barrier to external fluids, bacteria 4. Adheres to undamaged skin, does not need a second dressing 5. Permits viewing

List the potential or actual nursing diagnoses related to impaired skin integrity

1. Risk of Infection 2. Acute or Chronic Pain 3. Impaired Mobility 4. Impaired Tissue Perfusion

The Braden Scale was developed for assessing pressure ulcer risks. Identify the subscales of this tool. (6)

1. Sensory Perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction

Identify the three major areas of nursing interventions for preventing pressure ulcers

1. Skin care and management of incontinence 2. Mechanical loading and support devices 3. Education

List the advantages of the hydrogel dressing

1. Soothing and reduces pain 2. Provides a moist environment 3. Debrides the wound 4. Does not adhere to the wound base and is easy to remove

Which action will the nurse take first to prevent harm when an assistive personnel (AP) reports that an 88-year-old client has a temperature of 100.2°F (37.9°C)?

18. B. Assess the client for other indications of infection. Although the client's temperature is not greatly above normal, older adults usually do not have high fevers even when infection is present. The most appropriate action is for the nurse to assess the client for other indications of infection before notifying the primary health care provider. Because this low-grade fever could represent a serious infection in an older client, administering acetaminophen is not performed before assessment to prevent masking the infection. Rechecking the temperature in 4 hours is not the first or priority action. The nurse will report the temperature elevation to the primary health care provider after gathering other pertinent assessment data.

18. The rate of new HIV infection in North America is highest among which groups people? A. White homosexual men and women B. Older non-monogamous heterosexual men and women C. Asian women who have sex with men D. Black and Hispanic men and women

18. D Black and Hispanic men and women Although the prevalence of HIV infection in North America is highest among men who have sex with men, the incidence of new cases is highest among Black and Hispanic men and women. Another emerging population of HIV-positive individuals is transgender females.

Which clients would the nurse understand are at risk for pressure injuries? Select all that apply.

2. A, C, D, E A. A middle-aged quadriplegic client who is alert and conversant C. A very thin client who sits for long periods in a chair and refuses meals D. An obese client who must be assisted to move and turn in the bed E. An older adult who is bedridden and in late stage of Alzheimer's disease Factors that increase the risk for development of pressure injuries include lack of mobility, exposure exposure of skin to excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. Clients with cognitive decline or impairment are at risk if they are unable to fully participate in care. Individuals with peripheral vascular disease and/or diabetes mellitus are at risk, as they may experience impaired sensory perception as well as delayed wound healing. The client who is ambulatory with occasional urinary incontinence is not at increased risk, nor is the confused client who can use the bathroom with assistance as long as they receive the care necessary to use the bathroom and keep their skin clean and dry.

Mr. Perkins has a stage II ulcer of his right heel. What would be the most appropriate treatment for this ulcer? 1. Apply a heat lamp to the area for 20 minutes twice daily. 2. Apply a hydrocolloid dressing and change it as necessary. 3. Apply a calcium alginate dressing and change when strikethrough is noted. 4. Apply a thick layer of enzymatic ointment to the ulcer and the surrounding skin.

2. Apply a hydrocolloid dressing and change it as necessary.

20. Which conditions, all present in a female client, alert the nurse to the possibility of HIV infection? Select all that apply. A. Chronic vaginal candidiasis B. Pelvic inflammatory disease C. Spontaneous abortion D. Chronic sinus infection E. Mononucleosis F. Genital herpes

20. A, B, F A. Chronic vaginal candidiasis B. Pelvic inflammatory disease F. Genital herpes Although any one of these conditions may occur in any client, when chronic vaginal candidiasis occurs in a woman who has genital herpes

What would the nurse suspect when a client is admitted with a rash of white or red edematous papules or plaques that developed after the client ate seafood?

20. A. Urticaria Urticaria (hives) is a rash of white or red edematous papules or plaques of various sizes. This problem is usually caused by exposure to allergens, which releases histamine into the skin. Blood vessel dilation and plasma protein leakage lead to formation of lesions or wheals.

Which action performed during hand hygiene by an assistive personnel does the nurse need to correct?

20. B. Using hot water and a scrub brush Using hot water and scrub brushes can injure the skin surface and may cause open areas in which microorganisms can enter. Although friction is required for good hand hygiene, abrading the skin with a brush is not.

Which question would the nurse ask a client,who has nonspecific eczematous dermatitis, to determine if avoidance therapy is an appropriate intervention?

21. B "Have you used any new soaps, detergents, or personal care products?" Avoidance therapy is used to reverse the reaction and clear the rash when the initiating cause is known. For example, if a new soap for handwashing causes contact dermatitis of the hands, the client is taught to avoid that substance.

29. Which client laboratory test results will the nurse identify as supporting a diagnosis of systemic lupus erythematosus (SLE)? Select all that apply. A. Increased erythrocyte sedimentation rate (ESR) B. Decrease erythrocyte sedimentation rate (ESR) C. Increased complement C3 protein levels D. Increased basophils E. Decreased eosinophils F. Increased extractable nuclear protein antibodies

29. A, C, F A. Increased erythrocyte sedimentation rate (ESR) C. Increased complement C3 protein levels F. Increased extractable nuclear protein antibodies The erythrocyte sedimentation rate is increased because of attached inflammatory proteins and debris. Some complement levels, including C3, are increased as a result of the chronic inflammatory nature of the disease. Basophils and eosinophil levels are not affected by the pathophysiology of the disorder. Many of the autoantibodies present in a client with SLE are directed against parts of cellular nuclei, including extractable nuclear protein antibodies (anti-ENA).

Which situations are examples of an animate reservoir? Select all that Apply.

3. A, D A. Coronavirus (COVID-19) influenza was first transmitted to humans from infected bats and snakes. D. A 48-year-old man living in the tropics develops malaria after being extensively bitten by a swarm of mosquitoes. Animate reservoirs include people, animals, and insects. COVID-19 influenza and mosquito- borne malaria are the examples in this list that meet the criteria. Romaine lettuce, kitty litter, stethoscopes, and aspergillus mold are inanimate reservoirs. Aspergillus is a newly designated inanimate reservoir of mold spores that becomes environmental particulate matter when released into the atmosphere such as during extensive renovation of older buildings.

What collaborative action would the nurse take to promote wound healing for a thin, malnourished client who had emergency abdominal surgery?

3. B Consult with the registered dietitian nutritionist (RDN) about a high-protein diet. Malnutrition increases the risk for skin breakdown and delayed wound healing. The nurse collaborates with the registered dietitian nutritionist (RDN) to help the client eat a well-balanced diet, especially emphasizing protein.

3. When educating women clients about HIV prevention, which route does the nurse emphasize as the most common way women acquire the disease? A. Prenatal transmission during the birth process B. Sex with an infected female partner C. Sex with an infected male partner D. Injection drug use

3. C Sex with an infected male partner In North America and worldwide, the most common route of HIV transmission to women is by having sex with an infected male partner.

3. Which assessment findings does the nurse expect in a client who is having a localized reaction to an environmental allergen? A. Hypotension B. Blood clotting C. Persistent constipation D. Redness and swelling in contact areas

3. D Redness and swelling in contact areas Local reactions to an allergen involve only the tissues in direct contact with the specific allergen, such as redness and swelling in contacted areas. Hypotension blood clotting are systemic symptoms or manifestations. Allergic responses with inflammation in the GI tract to a swallowed allergen result in diarrhea, not constipation.

Which of these patients has a nutritional risk for pressure ulcer development? 1. Patient has an albumin level of 3.5 2. Patient B has a hemoglobin level within normal limits. 3. Patient C has protein intake of 0.5g/kg/day 4. Patient D has a body weight that is 5% greater than his ideal weight.

3. Patient C has protein intake of 0.5g/kg/day The recommended protein intake for adults is 0.8k/kg/day for healing.

30. Which items will the nurse tell family members living with a client who is HIV positive to avoid sharing to prevent the spread of HIV? Select all that apply. A. Safety razor B. Dishes C. Towels D. Toilet E. Shoes F. Toothbrushes

30. A, F A. Safety razor F. Toothbrushes Anyone living with a client who is HIV positive is taught to avoid sharing items that might have the client's blood on them, which include include safety razors and toothbrushes. Dishes and eating utensils do not pose an HIV transmission risk to the family (although family infections could be transmitted to the client). Sharing of towels, toilets, and shoes pose no HIV transmission risk to anyone living with an HIV-positive client.

Which is the best action for the nurse to take prior to changing the dressing of a client with a burn injury?

38. B. Give pain medication 30 minutes prior to dressing change. Because dressing changes can be uncomfortable, giving pain medication at least 30 minutes ahead of time can make the procedure less painful and more comfortable.

Which are priorities of care when providing care for a client with a burn injury during the emergent phase? Select all that apply.

39. A, C, D, E A. Securing the airway C. Supporting circulation and perfusion D. Maintaining body temperature E. Keeping client comfortable with analgesics The priorities of care during the emergent phase include (1) securing the airway, (2) supporting circulation and perfusion, (3) maintaining body temperature, (4) keeping the client comfortable with analgesics, and (5) providing emotional support.

Place the following steps in order for performing a wound irrigation. 1. Use slow continuous pressure to irrigate the wound 2. Attache 19-gauge angiocatheter to syringe 3. Fill syringe with irrigation fluid 4. Assess wound 5. Position angiocatheter over wound

4, 3, 2, 5, 1 4. Assess wound 3. Fill syringe with irrigation fluid 2. Attache 19-gauge angiocatheter to syringe 5. Position angiocatheter over wound 1. Use slow continuous pressure to irrigate the wound

4. What is the nurse's best response to a client considering pre-exposure prophylaxis who asks why HIV testing must be performed every 3 months while on this therapy? A. "If you should become HIV positive while taking this therapy, your disease may become drug resistant." B. "Continued monitoring of your HIV status allows us to calculate the lowest effective dose you need." C. "The protection prophylaxis provides is effective against HIV but not against other infections." D. "If you are not monogamous, you could transmit the disease to your other partners."

4. A. "If you should become HIV positive while taking this therapy, your disease may become drug resistant." If pre-exposure prophylaxis is used in clients who become infected with HIV-1, the risk for developing drug resistance greatly increases. Thus, clients on this therapy must adhere to an every-3-month HIV testing schedule. The best dose for this therapy is generally established and is not modified individually. It is true that the therapy does not protect against other sexually transmitted infections, but that is not the reason HIV status must be monitored, nor is the fact that if the client becomes HIV positive, he or she could transmit the disease to another person.

Which technique would the nurse use to check for tunneling when assessing a large pressure injury on a client's hip with a small opening in the skin draining purulent material?

4. A. Use a sterile cotton-tipped applicator to probe gently for the tunnel. If the nurse suspects that tunneling is present ("hidden" wounds that extend from the primary wound into surrounding tissues), he or she uses a cotton-tipped applicator to probe gently for a much larger tunnel or pocket of necrotic tissue beneath the opening, estimates the size and location of any tunneled areas, and documents the findings.

4. Which immunoglobulin elevation does the nurse expect to see in the laboratory report of a client who is having a type I hypersensitivity response? A. Immunoglobulin A (IgA) B. Immunoglobulin E (IgE) C. Immunoglobulin G (IgG) D. Immunoglobulin M (IgM)

4. B Immunoglobulin E (IgE) The immunoglobulin type associated with hypersensitivity reactions is excessive production of IgE. Acute inflammation occurs when IgE responds to an antigen, such as pollen, by binding to the membranes of basophils, eosinophils, and mast cells, causing the release of many proinflammatory vasoactive amines.

Which factors increase the risk of complications from a burn injury in an older adult client? Select all that apply.

40. A, B, E A. Slower healing time B. Thinner skin E. Medical conditions such as diabetes Thinner skin increases the depth of injury even when the exposure to the cause of injury is of shorter duration. Slower healing time leads to longer time with open areas, which results in a greater risk for infection. Pre-existing conditions such as diabetes can lead to slower healing time. Decreased (not increased) inflammatory and immune responses would increase risk for complications. Increased pulmonary compliance would not affect an older adult's risk for complications with burn injuries. See Patient-Centered Care: Older Adult Considerations Age-Related Changes Increasing Complications

Which client does the nurse consider to be at highest risk for development of skin cancer?

41. B Light-skinned female who works as a lifeguard every summer Overexposure to sunlight is the major cause of skin cancer. Because sun damage is an age-related skin finding, screening for suspicious lesions is an important part of physical assessment..

Which preventive strategies for skin cancer would the nurse teach to clients and families? Select all that apply.

42. A, B, D, E A. Avoiding sun exposure between 11 a.m. and 3 p.m. B. Wearing a hat, opaque clothing, and sunglasses when you are in the sun D. Taking pictures of lesions and comparing them month by month E. Keeping a "body map" of your skin spots, scars, and lesions All options are appropriate except C and F. Tanning bed should be completely avoided, and whenever a client's skin will be exposed to sunlight, a sunscreen should be used.

Which is the most important action for the nurse to teach visitors to avoid acquiring influenza when visiting a client with the disease?

7.B B. Remaining at least 6 feet away from the client Influenza is spread by droplets, which are heavy and do not travel far in the air. The CDC recommends prevention by remaining at least 6 feet away from the client, which is farther than the droplets travel when the client sneezes or coughs. Influenza is not spread from toilets. Keeping windows open would be helpful for airborne diseases but is of no value for preventing infections spread by droplets.

9. Which questions are most important for the nurse to ask first to prevent harm for a client who comes to the emergency department with signs of severe angioedema? Select all that apply. A. "Are you able to swallow?" B. "When did you last eat or drink?" C. "Do you have an allergy to cortisone?" D. "What drugs do you take on a daily basis"? E. "Is there any possibility that you may be pregnant?" F. "Do any members of your family also have allergies?"

9. A, D A. "Are you able to swallow? D. "What drugs do you take on a daily basis The client has severe angioedema that can progress rapidly to laryngeal edema and loss of the airway. The very first question should be to assess symptom severity. Asking whether the client can swallow provides an indication of severity. If the client can still swallow, an immediate intubation or tracheotomy is not needed. Asking what drugs he or she takes can help establish the diagnosis and the cause. It is not necessary to know when the last food or drink were taken. Also, regardless of whether the client is pregnant, interventions for angioedema must be started. It is not helpful during this emergency to know whether other family members also have allergies. This information can be obtained at a later time or from family members. Cortisone is used to treat allergies and does not cause them..

Which of these are examples of types of long-term care services? Select all that apply.

A, B, C, E, F, H A. Nursing care B. Rehabilitation care C. Mental health E. Dementia care F. Respite care H. End-of-life care . Long-term care is a complex system within a larger system of the U.S. health care delivery system. Care is highly individualized and well coordinated to help provide partial or total care, sometimes indefinitely. Hospice care and home health care are types of community-based care. The rest of the responses are types of long-term care.

Which of the following are cognitive skills of Clinical Judgment that are recognized by the National Council of State Boards of Nursing (NCSBN)? Select all that apply.

A, C, D, F, G, H A. Recognizes cues C. Analyzes cues D. Prioritizes hypotheses F. Generate solutions G. Take action H. Evaluate outcomes

The nurse admits a client with COPD to the medical care unit and during initial assessment discovers these findings. Which data are relevant and directly related to client outcomes or priority of care for this client? Select all that apply.

A, C, D, F, G, H When a nurse assesses a patient using clinical judgment, the first step of a six-step process is to recognize cues and determine which cues are relevant (directly related to the client outcomes or the priority of care) versus those which are irrelevant (unrelated to the client outcomes or priority of care). Removal of his gall bladder a year ago and his daughter's fourth pregnancy are not relevant at this time. The remaining responses are relevant. A. Client describes shortness of breath when climbing stairs C. Client's medications include an albuterol inhaler which he uses as needed D. Client states that his health care provider (HCP) may prescribe home oxygen F. Client's wife still smokes a pack of cigarettes every day G. Client's pulse oximetry reading is 89% H. Client has crackles and wheezes bilaterally in lungs

What are the American Nursing Association Standards of Practice?

ADPIE

Identify the following types of emergency setting wounds

Abrasion - is superficial with little bleeding and is considered a partial thickness- wound Laceration - sometimes bleed more profusely depending on depth and location Puncture - Bleeds in relation to depth and size, with a high risk of internal bleeding and infection

When using the Situation, Background, Assessment, Recommendation (SBAR) method of communicating a client's condition, the nurse would include which information in the background section?

Admission diagnosis is new-onset type 2 diabetes The only background information presented is the admission diagnosis.

Briefly describe how the wound vacuum-assisted closure (wound vac) device works

Applies localized negative pressure to draw the edges of a wound together by evacuating wound fluids and stimulating granulation tissue formation, reduces the bacterial burden of a wound, and maintain moist environment

Which nursing action reflects the use of clinical judgment to adapt client care based on a change in care environment?

B Teaching family members to use clean supplies instead of sterile supplies when changing a wound dressing at home. Care of a wound in the home does not require sterile supplies or technique because the home environment has fewer environmental pathogens than does an acute care setting or other health care setting. All the other actions focus on changing client conditions rather than changing environmental conditions.

Using clinical judgment, which actions will the nurse take for a client with COPD admitted to the medical care unit? Select all that apply.

B, C, D, E, G B. Monitoring for changes in respiratory status C. Applying oxygen as prescribed by the health care provider D. Elevating the head of the client's bed to a position of comfort E. Teaching the client to perform effective coughing to eliminate excess mucus G. Instructing the client how to use metered-dose inhalers The actions that the nurse takes are performed to address the highest priorities of care. Most patients do not need to have a tracheostomy. Around-the-clock acetaminophen is not usually prescribed. Suctioning is only performed as needed, not on a routine schedule. The other responses are appropriate actions for a client with COPD.

12. What is the nurse's best response when client recovering from drug-induced angioedema caused by an ACEI asks why it took 6 months before a reaction occurred? A. "As your blood pressure was reduced, less drug was needed and the excess triggered an allergic response." B. "Possibly when you took your most recent dose you held it in your mouth too long instead of swallowing it, causing a local response." C. "It takes time for the main body chemical causing the reaction to build-up enough to cause symptoms." D. "If you took this drug with grapefruit juice, the two substances together are much more likely to result in an allergic reaction."

C "It takes time for the main body chemical causing the reaction to build-up enough to cause symptoms." Bradykinin is the inflammatory mediator most responsible for ACEI-induced angioedema. This mediator is a strong vasodilator and promoter of deep-tissue inflammation. It is rapidly deactivated by angiotensin-converting enzyme (ACE). Drugs that inhibit ACE lead to increasing tissue accumulation of bradykinin over time, which is responsible for the delayed onset of ACEI-induced angioedema even though it is a type I hypersensitivity reaction. Angioedema is a systemic response, not a local one. Holding it in the mouth a little longer does not make angioedema occur. The drug does not become more likely to cause an allergic reaction if taken with grapefruit juice and the response does not appear to be dose-related.

Which nursing activity most closely demonstrates the concept of telenursing?

C. Using a cell phone camera to directly observe a client while he or she is actually taking prescribed medication for tuberculosis therapy

Which process best describes the nurse's actions when his or her assessment reveals an oral temperature of 102.2°F (39°C) and new crackles in all lobes of the lungs, and then notifies the health care provider of these findings?

Clinical reasoning Clinical reasoning is the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process. This nurse recognized the cues that the client's situation was getting worse and notified the HCP so that the plan of care could be modified to improve his or her condition.

Exudate related to wound healing

Describes the amount, color, consistency, and odor of wound drainage; excessive indicates an infection

Describe the term genomics.

Describes the study of all the genes in a person as well as interactions of those genes.

Which nursing action is the best example of patient-centered care?

Determining the family's thoughts and fears when asking them to consider a do-not-resuscitate option

Describe the physiological responses to the following: Cold Applications

Diminshes swelling and pain, prolonged results in reflex vasodilation

Which statement is specific to the role of nurse practitioners?

Emphasizes patient-centered care that involves promotion of health and wellness While A is true of nurse practitioners, it is also true of physicians and physician assistants and therefore not specific to nurse practitioners. Nurse practitioners are educated and practice according to a nursing model which emphasizes client-centered care including promotion of health and wellness, and quality of life across the lifespan.

Identify the ANA Standards of Professional Performance

Ethics Culturally Congruent Care Communication Collaboration Leadership Education Evidence-Based Practice and Research Quality of Practice Professional Practice Evaluation Resources Utilization Environmental Health

Clara Barton

Founded the American Red Cross

Manager

Has personnel, policy, and budgetary responsibility for a specific nursing unit.

Describe the physiological responses to the following: Heat Applications

Improves blood flow to an injured part, it applied for more than 1 hour, the body reduces blood flow by reflex of vasoconstriction to control heat loss from the area

pressure injury

Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear

Which nursing action supports patient-centered care for a fearful client about to have a colonoscopy who refuses to be sedated until the family pastor can pray with him before the procedure?

Moving the client's procedure time until after his pastor arrives

According to Benner, an expert nurse goes through five levels of proficiency. Identify them.

Novice Advanced Beginner Competent Proficient Expert

What are the external forces that have affected nursing practice in the 21st century?

Nurse's self-care Healthcare and reform costs Demographic changes of the population Human rights Increased number of medically underserved

Define Nursing according to the ANA.

Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.

Lillian Wald and Mary Brewster

Opened the Henry Street Settlement, focusing on the health needs of the poor

Nurse Practitioner

Provides comprehensive care, usually in a primary care setting, directly managing the medical care of patients who are healthy or who have chronic conditions.

Certified Registered Nurse Anesthetist (CRNA)

Provides surgical anesthesia

Explain the rationale for deriding a wound

Remove nonviable necrotic tissue to rid the ulcer of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing.

Which QSEN competency is best demonstrated when the nurse places a bed alarm on the bed of a client with mental status changes?

Safety

How did Florence Nightingale see the role of the nurse in the early 1800s?

She saw the role of nursing as being in charge of a patient's health, based on knowledge of how to put the body in such a state as to be free of disease or to recover from disease.

Staging systems for pressure ulcers are based on the depth of tissue destroyed. Briefly describe each stage.

Stage I: Intact skin with nonblanchable redness of a localized area over a bony prominence Stage II: Partial- thickness skin loss involving the epidermis, dermis, or both Stage III: Full thickness with tissue loss Stage IV: Full-thickness tissue loss with exposed bone, tendon or muscle

Describe ANA's Nursing Code of Ethics.

The nursing Code of Ethics is the philosophical ideals of the right and wrong that define the principles you will use to provide care to your patients.

Which response by a nurse to a client's fear that his wide bed with traction equipment might prevent him from being moved to safety if a fire occurred on the unit demonstrates the most respect for the client's concerns?

We would disconnect your traction, lift you to the floor with a sheet, and pull you to a safe area.

Explain the benefits of binders and bandages

a. Creating pressure over a body part b. Immobilizing a body part c. Supporting a wound d. Reducing or preventing edema e. Securing a splint f. Securing dressings

List possible goals to achieve wound improvement:

a. Higher percentage of granulation tissue in the wound base b. No further skin breakdown in any body location c. An increase in the caloric intake by 10%

List the purposes of dressings. (7)

a. Protects a wound from microorganism contamination b. Aids in hemostasis c. Promote healing by absorbing drainage and debriding a wound d. Support or splints the wound site e. Protects the patient from seeing the wound f. Promote thermal insulation of the wound surface g. Provides a moist environment

Identify the competencies of the QSEN initiative.

a. Teamwork and Collaboration b. Evidence-Based Practice c. Quality Improvement d. Safety e. Informatics

Nurse Researcher

conducts evidence-based practice and research to improve nursing care and further define and expand the scope of nursing practice

darkly pigmented skin

does not blanch

Communicator

is essential for all nursing roles and activities

Palpation of a wound includes:

lightly press the wound edges, detecting localized areas of tenderness or drainage collection

Nursing Administrator

manages patient care and the delivery of specific nursing services within a health care agency

Blanching

normal red tones of the light-skinned patient are absent

Advocate

protects patients' human and legal rights and provides assistance in asserting these rights

Nurse Educator

works primarily in schools of nursing, staff development departments of health care agencies, and patient education departments

Which nursing actions performed for a client are most consistent with the attributes of patient-centered care? Select all that apply.

Asking the health care provider to prescribe the daily vitamin C the client takes at home Ensuring the presence of a professional interpreter when providing discharge instructions to the client and family whose English is poor

Summarize the principles of packing a wound

Assess the size, depth, and shape of the wound; dressing (moist) needs to be flexible and in contact with all of the wound surface; do not pack tightly (overpacking causes pressure): do not overlap the wound edges (maceration of the tissue).

Which professional nursing concepts are exemplified in an interaction in which a nurse at a rehabilitation center is working with a client who is Muslim and a registered dietitian nutritionist to honor the client's request for a Halal-restricted diet?

Autonomy Patient-centered care Safety

The nurse is administering the client's 9 a.m. medications when the client, who was admitted at 4 a.m. and has asthma, asks why he is not receiving his inhaled corticosteroid. Which process would the nurse use to assure that the client receives the medications he was taking at home while he is hospitalized?

Medication reconciliation is a formal process in which a client's actual current medications are compared to his or her medications during a care transition such as facility admission, transfer, or discharge.

Granulation tissue related to healing

Red, moist, tissue composed of new blood vessels, which indicates wound healing

compassion fatigue

Term used to describe a state of burnout and secondary traumatic stress

A nurse's responsibility with assessing drains is:

observe the security of the drain and its location with respect to the wound and the character of the drainage; measure the amount

Autonomy

independent nursing interventions that the nurse initiates without medical orders

List the functions of hydrocolloid dressings

1. Absorbs drainage through the use of exudate absorbers 2. Maintains wound moisture 3. Slowly liquifies necrotic debris 4. Impermeable to bacteria 5. Self-adhesive and molds well 6. Acts as a preventive dressing for high-risk friction areas 7. May be left in place for 3-5 days, minimizing skin trauma and disruption of healing

Which precaution is most important for the nurse to teach a client prescribed to take oral delafloxacin to treat a skin lesion infected with methicillin-resistant Staphylococcus aureus (MRSA)?

15. C Take this drug 2 hours before or 6 hours after taking an antacid. The drug can combine with any metal or divalent cation such as magnesium, reducing its effectiveness. Because many antacids contain magnesium, clients are taught not to take an antacid with or close to when delafloxacin is taken. There are no fluid requirements or position restrictions associated with the drug. Delafloxacin does not increase the risk for urinary tract infection.

1. Which factors increase the efficiency of infection by the human immune deficiency virus (HIV)? A. Is activated by contact with antibodies B. Is activated by normal human enzymes C. Contains the enzyme reverse transcriptase D. Has DNA similar to human DNA as its genetic material

1. C. Contains the enzyme reverse transcriptas HIV is a type of retrovirus, which is a family of viruses that use RNA as their genetic material instead of DNA and have three special enzymes to ensure infection. These viruses can insert their RNA into a human cell's DNA with the enzyme reverse transcriptase to exert control over the human cell's actions. Thus, the HIV retrovirus is very efficient at infecting host cells.

You are taking care of a patient who is experiencing frequent fecal and urinary incontinence. What specific nursing interventions could you institute to help manage this patients?

1. Frequent perineal and sacral skin assessments 2. Use an incontinence cleanser, followed by a application of application of moisture barrier cream 3. Offering frequent ambulation to the toilet

Explain the four phases involved in the healing process of a full-thickness wound:

1. Hemostasis: Injured Blood vessels constrict, and platelets gather to stop bleeding; clots form fibrin matrix for cellular repair 2. Inflammatory Response: Damaged tissues and mast cells secrete histamine (vasodilates) with exudation of serum and WBC into damaged tissues 3. Proliferative Phase: With the appearance of new blood vessels as reconstruction processes, 3- 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization. 4. Maturation: the final stage, may take up to one year; the collagen scar continues to reorganize of the wound by epithelialization.

Identify and explain the risk factors that predispose a patient to pressure ulcers

1. Impaired Sensory Perception - unable to feel when a part of their body undergoes increased, prolonged pressure or pain 2. Impaired Mobility - unable to change their positions independently 3. Alteration in level of consciousness - unable to protect themselves 4. Shear - occurs when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of the friction of the bed 5. Fiction - skin is dragged across a care surface affecting the epidermis layer 6. Moisture - reduces the resistance of the skin to other physical factors (pressure, friction, or shearing)

Identify the 3 components involved in the healing process of partial thickness wound

1. Inflammatory Response - Causing redness and swelling to the area with moderate amount of serous exudate 2. Epithelial proliferation (reproduction) - cells begin to regenerate, providing new cells to replace lost cells 3. Migration with reestablishment of the epidermal layers

List the nursing responsibilities when applying a bandage or binder:

1. Inspecting the skin for abrasions, edema, discoloration, or exposed wound edges 2. Covering exposed wounds or open abrasions with a sterile dressing 3. Assessing the condition of underlying dressings and changing if soiled 4. Assessing the skin for underlying areas that will be distal to the bandage for signs of circulatory impairment

10. The client with HIV-III (AIDS) and pain is refusing to take the newly prescribed antidepressant amitriptyline, stating that depression is not a problem. What is the nurse's best response? A. "Depression is common in adults with AIDS and can make pain worse." B. "In addition to helping depression, this drug can reduce neuropathic pain." C. "Your primary health care provider knows all the latest drugs and would only have prescribed this one if it were needed." D. "I will notify your primary health care provider to check whether a drug with a similar sounding name is what should have been prescribed."

10. B "In addition to helping depression, this drug can reduce neuropathic pain." The client has the right to refuse any drug but should only do so when adequately informed about the reason the therapy was prescribed and all of its side effects. Although amitriptyline is an antidepressant, it is effective in reducing neuropathic pain for many clients.

10. Which change in a client with angioedema indicates to the nurse that immediate action is needed to prevent harm? A. Systolic blood pressure decrease from 136 mm Hg to 120 mm Hg B. Presence of stridor on inhalation and exhalation C. Mouth breathing because of nasal swelling D. Inability to sip liquids through a straw

10. B Presence of stridor on inhalation and exhalation Stridor on inhalation and exhalation indicates a severe partial obstruction of the airway from edema. Steps must be taken to maintain the airway with either immediate endotracheal tube placement or performance of an emergency emergency tracheostomy to prevent death. The systolic blood pressure decrease is not associated with worsening of the angioedema. Facial and nasal swelling are expected and may be severe but, unless the airway is compromised, do not require additional immediate action.

Which physical factors does the nurse assess for in an older adult client that are likely to increase the risk for infection? Select all that apply.

10. B, C, E, F B. Thin, delicate skin C. Decreased gag reflex E. Decreased mobility F. Higher incidence of chronic disease Thin, delicate skin is easily injured, reducing the barrier function and increasing the risk for infection. A decreased gag reflex increases the risk for aspiration and respiratory infection. Decreased mobility contributes to infection risk in many ways including venous stasis and loss of skin integrity. Increased age is associated with many chronic illnesses such as diabetes, chronic obstructive pulmonary disease, and neurologic impairment that also increase infection risk. Increased antibody production reflects good immunity, which is not associated with aging. Increased intestinal motility also does not increase infection risk.

Which finding indicating infection in a client would the nurse report to the health care provider immediately?

10. D Changes in the quantity, color, or odor of exudate In the presence of a pressure injury, the following changes are reported to the primary health care provider: sudden deterioration of the ulcer, with an increase in the size or depth of the lesion; changes in the color or texture of the granulation tissue; and changes in the quantity,quantity, color, or odor of exudate.

11. Which precaution has the highest priority for the nurse to teach a client taking an angiotensin-converting enzyme inhibitor (ACEI) to prevent harm? A. Go to the emergency department or call 911 if you develop tongue and lip swelling or have difficulty breathing. B. Avoid touching this drug with your bare hands to prevent absorbing it through direct skin contact. C. Stop taking the drug immediately if you develop a runny nose, itchy eyes, or a persistent cough. D. Take this drug with food or milk at the same time every day.

11. A Go to the emergency department or call 911 if you develop tongue and lip swelling or have difficulty breathing. ACEIs are the most common cause of drug-induced angioedema, which can be life-threatening. Indications for emergency care include lip and tongue swelling and difficulty breathing. Other indicators are the sensation of a "lump in the throat" and itching of the oral mucous membranes. It does not matter if the client absorbs this drug through his or her skin, he or she is taking it. A persistent cough may occur as a side effect of any ACEI but is not an indicator of need for emergency care. Taking the drug with food is important as is taking it at the same time every day but does not have the highest priority to prevent harm.

For which infectious diseases will the nurse recommend immunizations for older adult clients? Select all that apply.

11. A, B, D, F A. Influenza B. Pneumonia D. Herpes zoster (shingles) F. Tetanus, diphtheria, and pertussis The recommended immunizations for older adults include the following: • Pneumococcal 13-valent conjugate vaccine (Prevnar 13) to prevent pneumonia • Pneumococcal vaccine polyvalent vaccine (Pneumovax) to prevent pneumonia • Yearly influenza vaccine (trivalent or quadrivalent) to prevent influenza (flu) • Zoster vaccine recombinant (Shingrix) to prevent shingles (herpes zoster) • Adult Tdap vaccine to prevent tetanus, diphtheria, and pertussis (whooping cough) (and Tdbooster every 10 years after Tdap) Immunization against the human papilloma virus or against the childhood disorders of measles, mumps, and rubella are not recommended.

11. Which factors or problems in an HIV-positive client does the nurse know increases the risk for HIV transmission? Select all that apply. A. Diarrhea B. High viral load C. Chronic confusion D. HIV positive partner E. Pneumocystis pneumonia F. Nonadherence to the drug regimen.

11. B, C, F B. High viral load C. Chronic confusion F. Nonadherence to the drug regimen The higher the viral load, the greater the risk for transmission. Chronic confusion often reduces the client's adherence to drug therapy, which may cause inadequate suppression of viral replication and a higher viral load. Also, a confused client may not use other transmission prevention techniques. Diarrhea does not increase the transmission of HIV. Pneumocystis pneumonia is an opportunistic infection and does not increase HIV transmission risk. Having an HIV-positive partner does not increase the client's risk for transmitting the disease to anyone else.

How does the nurse determine which dressing is best for a client with a stage 3 pressure injury over the left trochanter area that has a thick exudate?

11. B. Obtain a prescription to consult with the certified wound care specialist. Specific dressings, because there are so many and recommendations are so specialized based on the individual client's needs, are often recommended by the wound nurse. The unit nurse will collaborate closely with this member of the interprofessional team to determine the most appropriate dressing.

13. Which action does the nurse perform first to prevent harm when a client receiving IV penicillin reports difficulty breathing and feeling dizzy about 15 minutes after the infusion is started? A. Stop the infusion. B. Initiate the Rapid Response Team. C. Assess the client's blood pressure. D. Ask whether the client is allergic to penicillin.

13. A Stop the infusion. The client is exhibiting more than one indication of anaphylaxis and time is critical. Stop the infusion of the likely offending substance to limit the amount of allergen entering the client and maintain the IV access. Then initiate the Rapid Response Team. The client may not know the names of the drugs he or she is allergic to or may not have had a severe enough response to an earlier exposure to understand that an allergy exists. Blood pressure assessment would provide additional substantiation of the problem but does nothing to help prevent harm.

In addition to Standard Precautions, which type of transmission-based precautions will the nurse use to prevent infection transmission when caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA)?

13. B Contact Precautions MRSA is an organism that is spread by direct and indirect transmission, not by the airborne or droplet route. The most appropriate type of precautions in addition to Standard Precautions are Contact Precautions. Cutaneous Precautions are not a designated category for protection.

Which intervention would the nurse use to reduce shearing force for an obese client who is on bedrest for the next 3 days?

13. C. Place the client in a side-lying position at a 30-degree tilt. Shearing forces are generated when the skin itself is stationary and the tissues below the skin (e.g., fat, muscle) shift or move. The movement of the deeper tissue layers reduces the blood supply to the skin, leading to skin hypoxia, anoxia, ischemia, inflammation, and necrosis. To reduce pressure, the head of the bed is NOT elevated above 30 degrees to prevent shearing. When a client is positioned on his or her side, the position is kept at a 30-degree tilt (avoiding 90-degree positions).

Which finding, when assessing a client's wound for signs of healing or infection, indicates to the nurse that healing is progressing as expected?

14. B. Area appears pale pink, progressing to a spongy texture with a beefy red color Granulation tissue is a sign of healing tissue. It may be pale pink (early granulation) to beefy red; healthy tissue is moist and slightly spongy. Eschar is an indicator of necrotic tissue, increased exudate often indicates infection, and deep red, maroon, or purple indicates a suspected deep-tissue injury.

14. Which part of the HIV infection process is disrupted by the antiretroviral drug class of CCR5 antagonists? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus's gp120 protein to one of the CD4+ co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

14. B. Binding of the virus's gp120 protein to one of the CD4+ co-receptors CCR5 antagonists work by binding to and blocking the CCR5 receptors on CD4+ T-cells, the main target of HIV. In order to successfully enter and infect a host cell, the virus must have its gp120 protein attach to the CD4 receptor and have its gp41 bind to the CD4+ T-cell's CCR5 receptor. Viral binding to both receptors is required for infection. By blocking the HIV's attachment to the CCR5 receptor, infection is inhibited.

For which clients does the nurse ensure placement in a private room? Select all that apply.

14. C, D C. 48-year-old severely immunosuppressed client receiving cancer chemotherapy D. 59-year-old with active tuberculosis Although all types of infections that can be transmitted by the direct contact, droplet, or the airborne routes are recommended to be cared for in private rooms, those that require private rooms are those clients who have airborne airborne transmitted infections and those who are severely immunosuppressed and need a protected environment. HIV infection and hepatitis C are bloodborne infections and do not require separate private rooms to prevent transmission. Those clients who have infections spread by droplets, such as influenza, and those who have infections spread by contact (MRSA) can be cohorted with another client who has the same infection.

Which conditions will the nurse consider to be contributing factors for a client with chronic pressure injuries? Select all that apply.

15. A, B, C, D, F A. Malnutrition B. Peripheral vascular disease C. Incontinence D. Immobility F. Prolonged bedrest Contributing factors for chronic pressure injuries include: prolonged bedrest and/or immobility; incontinence; diabetes mellitus and/ or peripheral vascular disease; malnutrition; and decreased sensory perception or cognitive problems. A pressure relieving mattress would help prevent pressure injuries.

15. Which drug does the nurse expect to administer administer first to a client with anaphylaxis? A. Oral diphenhydramine B. Parenteral epinephrine C. Albuterol via high-flow nebulizer D. Intravenous corticosteroids

15. B Parenteral epinephrine Although all drugs listed have some utility in managing anaphylaxis, only parenteral epinephrine is an effective first-line therapy that can save the client's life. Although diphenhydramine is a second-line drug, it also would be administered parenterally to be most effective.

15. With which activities does the nurse teach assistive personnel (AP) caring for a client who is HIV positive to wear gloves to prevent disease transmission? Select all that apply. A. Applying lotion during a back rub B. Brushing the client's teeth C. Emptying a Foley catheter reservoir D. Feeding the client E. Filing the client's fingernails F. Providing perineal care

15. B, C, F B. Brushing the client's teeth C. Emptying a Foley catheter reservoir F. Providing perineal care Standard Precautions for preventing the spread of any type of infection including HIV requires wearing gloves when coming into contact with mucous membranes, including oral and perineal membranes, as well as secretions and excretions. Although saliva has a low concentration of HIV unless frank blood is present, gloves are used for this task because of potential contact with the moist mucous membranes of the mouth. Standard Precautions require that gloves be worn when contact with urine is possible, including during such tasks as emptying a Foley catheter reservoir. Perspiration is not considered a body fluid with risk for transmission and neither is contact with the client's intact skin. Feeding the client should not result in directStandard Precautions for preventing the spread of any type of infection including HIV requires contact with transmissible fluids, nor should clipping finger nails.

16. Which action is a priority for the nurse to perform before giving the first dose of any drug or therapeutic agent to a client? A. Ask the patient about allergies to drugs or other substances. B. Be aware of types of drugs that are likely to cause allergic reactions. C. Check the medication administration record for allergic response to drugs. D. Make sure that emergency medications are readily available.

16. A. Ask the patient about allergies to drugs or other substances. Although some drugs are more commonly associated with an allergic reaction, the response can occur to any drug. Therefore, always ask clients about any allergy or other problem they have ever had with any drug before giving the first dose of a newly prescribed drug. It is better to rely on the client's report of a drug allergy or adverse reaction than to depend on the client's chart or record. All nursing units where drugs are administered should have an emergency cart with appropriate drugs to manage an allergic or other adverse reaction.

Which actions will the nurse take to prevent disease transmission when caring for a client who has an infection with a multidrug resistant organism? Select all that apply.

16. B, D, E B. Showering as soon as reaching home after work D. Keeping work clothes separate from personal clothes E. Wearing scrubs and changing clothes before leaving work To help prevent the transmission of an MDRO, nurses are expected to wear scrubs and change clothes before leaving work. Keeping work clothes separate from personal clothes, as well as taking a shower on reaching home helps rid the body of any unwanted pathogens. Taking prophylactic antibiotics can contribute to the development of MDRO and is most definitely not recommended. Remaining 6 feet away from infected clients is not possible during client care. Wearing gloves during blood draws is part of Standard Precautions and does not specifically address infection prevention for MDROs.

When would the nurse expect to culture a client's pressure injury wound?

16. C When clinical or systemic signs of infection are present Wound culturing is not routinely performed, unless there is lack of healing and signs of persistent infection are present. If performed, a tissue culture is done. Clinical indicators of infection (e.g., cellulitis, exudate changes, increase in injury size or depth) and systemic signs of bacteremia (e.g., fever, elevated white blood cell [WBC] count) are used to diagnose an infection.

16. A client diagnosed with HIV-III (AIDS) who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? A. The client can reduce the dosages of the prescribed drugs. B. The virus is resistant to the current combination of drugs. C. The client no longer has AIDS. D. The drug therapy is effective.

16. D The drug therapy is effective. When a client diagnosed with HIV-III (AIDS) has a CD4+ T-cell count increase as a result of therapy, the diagnosis of AIDS remains. The fact that the T-cell count has risen indicates the combination of drugs used for therapy are effective; however, the dosages are not decreased.

Which client is the nurse most likely to recommend for directly observed therapy (DOT)?

17. B B. Homeless man with tuberculosis (TB) prescribed prescribed four anti-TB drugs daily Tuberculosis is a highly contagious pulmonary infection transmitted by the airborne route that most commonly requires at least 6 months of daily drug therapy with four drugs. Failure to adhere to the drug regimen can result in disease progression, development of resistant organisms, and transmission to others. A homeless person is less likely to be adherent to the regimen for many reasons and would benefit most from directly observed therapy.

17. A young male client who has just been diagnosed as HIV positive suspects that he contracted the virus from a sex worker several weeks ago and is worried because he had sex with his girlfriend several days ago. What is the nurse's best response? A. "The virus needs time to replicate, so your girlfriend is not at risk unless you have symptoms." B. "Even in the early phase, it is possible to transmit the HIV virus and your girlfriend should be told and tested." C. "HIV always progresses to AIDS. You and your girlfriend need to start antiviral medication right away." D. "This is a reportable disease and you need to contact the health department so that both women can be informed.".

17. B "Even in the early phase, it is possible to transmit the HIV virus and your girlfriend should be told and tested It is possible to transmit the disease even in the early stages of the disorder. Also, the client does not know for sure when he acquired the disorder. His girlfriend is at risk and should be told so that she has options for testing. HIV disease does not always progress to AIDS and only those who are found to be HIV positive should be taking life-long therapy. Although all states require that new cases of HIV-III (AIDS) be reported, not all states require reporting of HIV-positive status.

Which client would the nurse monitor carefully when continuous negative-pressure wound therapy (NPWT) is used to facilitate healing?

17. B Client receiving anticoagulation The nurse would recognize that continuous negative-pressure wound therapy (NPWT) is used with caution with clients on anticoagulant therapy because NPWT increases the risk for bleeding at the application site. He or she would respond by consulting with members of the interprofessional team, such as the primary health care provider and wound care nurse, to ensure that anticoagulant status was appropriately monitored.

18. While waiting for the Rapid Response Team to arrive and assist a client with anaphylaxis, which nursing actions will the nurse take to help manage the situation? Select all that apply. A. Obtain IV access. B. Apply oxygen. C. Place the client in Trendelenburg position. D. Stay with the client E. Ask the client whether he or she has a specific drug allergy. F. Ask the client whether other family members have ever had an allergic reaction. G. Arrange for arterial blood to be drawn for blood gas evaluation. H. Elevate the head of the bed.

18. A, B, D, H A. Obtain IV access. B. Apply oxygen. D. Stay with the client H. Elevate the head of the bed. Actions that would be immediately helpful to promote perfusion and gas exchange are to apply oxygen, obtain IV access, and elevate the head of the bed. It is also important to stay with the client. Trendelenburg position is NOT recommended and could impinge on ventilation. Asking the client questions at this time is not helpful. Arterial blood gas values are not needed to identify and manage anaphylaxis.

19. Which findings would the nurse expect when assessing a client with HIV disease at HIV-I classification? Select all that apply. A. Multiple Kaposi's sarcoma lesions B. One or more opportunistic infections C. Emaciation from AIDS wasting syndrome D. No indications of an AIDS-defining illness E. HIV antibody negative and undetectable viral load F. CD4+ T-cell count of greater than 500 cells/mm3 (0.5 × 109/L)

19. D, F D. No indications of an AIDS-defining illnes F. CD4+ T-cell count of greater than 500 cells/mm3 (0.5 × 109/L) HIV-I classification is applied to clients who are HIV antibody positive, have no AIDS-defining illnesses, and have an immune profile in which the CD4+ T-cell count is greater than 500 cells/mm3 (0.5 × 109/L). Their viral load may be undetectable but their antibody test is positive. The immune function is sufficient to prevent any opportunistic infection or AIDS-defining illness.

2. Which change in laboratory immune indicators does the nurse expect to find in a client whose HIV disease is at stage HIV-III (AIDS)? A. Leukocytosis B. Lymphocytopenia C. High plasma macrophage count D. Increased functional antibody production

2. B Lymphocytopenia At stage HIV-III, the immune system is profoundly profoundly suppressed with decreased numbers of all immune system cell types, especially lymphocytes. Leukocytosis is an increase in the total white blood cell count, not a decrease. Macrophages do not circulate in the blood. Although antibody production may be increased, the antibodies produced are incomplete and nonfunctional.

20. Which statement(s) about autoimmunity is/are accurate? Select all that apply. A. The basic pathophysiologic changes result in immunosuppression. B. Autoimmune disorders are most common among men over 60 years of age. C. With early and appropriate management, autoimmune disorders are highly curable. D. Clients who have allergies as children usually develop autoimmune disorders as adults. E. Autoimmune disorders are caused by excessive or overactive immune and inflammatory responses. F. Clients who are most susceptible to developing autoimmune disorders are those who have human leukocyte antigen types DR2, DR3, DRB, DQA, DQB, and Cw6.

20. E, F E. Autoimmune disorders are caused by excessive or overactive immune and inflammatory responses. F. Clients who are most susceptible to developing autoimmune disorders are those who have human leukocyte antigen types DR2, DR3, DRB, DQA, DQB, and Cw6. Autoimmune disorders represent a failure of the immune system to tolerate self cells and make antibodies directed against normal cells. These antibodies then initiate excessive inflammatory responses that damage and sometimes destroy normal tissues. Women are 5 to 20 times more likely to develop an autoimmune disease. Autoimmunity is much more common among adults who have the human lymphocyte antigen subtypes of DR2, DR3, DRB, DQA, DQB, and Cw6. The basis of autoimmunity is immune system excess, not immunosuppression. At the current time, autoimmune disorders are chronic, progressive, and not curable. The presence of childhood allergies does not appear to increase the risk for development of autoimmunity.

21. Which HIV-positive client does the nurse expect will progress to HIV-III (AIDS) the most quickly? A. Adult female who has one-time sex with an HIV-positive partner B. Older male who has vaginal sex with an HIV-positive female C. Adult male who is transfused with HIV-contaminated blood D. Older nurse who is stuck with an HIV-contaminated needle at work

21. C Adult male who is transfused with HIV-contaminated blood The development of HIV disease and its course of progression depends on transmission route and degree of viremia. A client who receives HIV-contaminated blood has a much higher risk for development of HIV disease and more rapid progression to HIV-III than the other listed exposures. Even having sex once with an HIV-positive partner has only a 10% to 20% risk to result in infection. An uninfected male having sex with an infected female has a lower risk for successful infection. Even being stuck with an HIV-contaminated needle once is less likely to result in HIV disease than is receiving a blood transfusion with HIV-contaminated blood.Adult male who is transfused with HIV-contaminated blood

22. What role do T-regulatory lymphocytes (Tregs) have in the development of autoimmune disease? A. Reduced numbers of Tregs lead to loss of self-tolerance. B. The presence of Tregs inhibit secretion of tumor necrosis factor (TNF). C. Tregs secrete autoantibodies directed against one or more types of normal self cells. D. Increased numbers of Tregs stimulate excessive amounts of cytokines that damage normal healthy tissues.

22. A Reduced numbers of Tregs lead to loss of self-tolerance. During infancy and childhood, Tregs are able to remove the clones of lymphocytes that are prone to attack self cells. An individual with reduced numbers of Tregs develops greater numbers of immune system cells that cannot distinguish between normal healthy cells and non-self cells. Thus, self-tolerance is lost or reduced, which allows immune cells and their products to inappropriately attack normal body cells and tissues.

When will the nurse draw blood from a client who has been ordered to have a serum trough level of the prescribed antibiotic measured?

22. B 30 minutes before the next ordered dose Peak and trough levels may be measured to determine the consistent blood levels of a prescribed antibiotic. A specimen for a trough level (lowest serum drug concentration) is drawn about 30 minutes before the next scheduled dose. Specimens for peak levels are drawn about 60 minutes after a dose is given.

Which essential teaching would the nurse provide for a client who is prescribed diphenhydramine to treat urticaria (hives)?

22. C. Avoid alcohol consumption, which can potentiate the sedative effects of this drug. Antihistamines provide some relief from itching but may not keep the client totally comfortable. comfortable. The sedative effects of these drugs may be better tolerated if most of the daily dose is taken near bedtime. The client is taught about possible side effects like drowsiness, and reminded to avoid driving, use of machinery, concurrent use of alcohol or other drugs, and making decisions that require clarity of thought.

22. Which routes are the most common means of HIV transmission? Select all that apply. A. Airborne B. Enteral C. Oral D. Parenteral E. Perinatal F. Sexual

22. D, E, F D. Parenteral E. Perinatal F. Sexual Infected body fluids with highest HIV concentrations are semen, blood, breast milk, and vaginal secretions. HIV is transmitted most often by these routes: 1) sexual (genital, anal, or oral sexual contact with exposure of mucous membranes to infected semen or vaginal secretions), secretions), 2) parenteral (sharing of needles or equipment contaminated with infected blood or receiving contaminated blood products), and 3) perinatal (across the placenta, from contact with maternal blood and body fluids during birth, or through breast milk from an infected mother to child).

23. What is the most common route by which nurses and other health care workers or providers are exposed to the HIV virus when caring for HIV-positive clients? A. Getting blood on exposed skin of hands or arms B. Touching infected body fluids with bare hands C. Having urine splashed on mucous membranes D. Sharps injuries with contaminated needles

23. D Sharps injuries with contaminated needles Needlestick sharps injuries remain common in health care settings even though new equipment and action rules (i.e., do not recap needles) have reduced their incidence.

24. Which client assessment finding indicates to the nurse the possibility of systemic lupus erythematosus (SLE)? A. Use of penicillin prophylactically before dental examinations and procedures B. Intermittent fever and fatigue with no other symptom of infection C. Joint and muscle pain without swelling after exercise D. Oily skin and increased facial acne

24. B Intermittent fever and fatigue with no other symptom of infection The most common recurrent symptoms presenting in clients with SLE are unexplained intermittent fever and fatigue (often with swollen, painful joints) with no other indicators of infection. These occur even when other members of the household do not have these symptoms. Penicillin is not a drug that causes manifestations of SLE. Joint and muscle pain after exercise usually just results from the exercise, especially when joint swelling is not present, not SLE. Although skin lesions may be present on the face and elsewhere on the body, the skin is not oily and the lesions are not acne.

What is the priority action for the nurse to take for a client who has just been diagnosed with scabies?

24. B Place the client on Contact Precautions Scabies is an infectious mite infestation of the skin that can be transmitted by both direct and indirect contact. This infection is not oral and does not cause fever. In addition, it has no deleterious effect on kidney function.

Which essential teaching would the nurse provide for a younger female client with psoriasis who is prescribed tazarotene?

24. D. Tazarotene can cause birth defects even when applied topically. Tazarotene is a teratogenic substance (e.g., can cause birth defects). Women who are pregnant, or who plan to become pregnant, are instructed to avoid use of this drug, and to use effective contraception even if pregnancy is desired while using this drug. Corticosteroids provide anti-inflammatory effects. Anthralin is a hydrocarbon with action similar to tar which can help relieve chronic psoriasis. It should be applied to each lesion for a short period of time.

25. Which client statement indicates to the nurse that more teaching about systemic lupus erythematosus is needed? A. "During flares, I may need higher doses of my corticosteroid." B. "I will take walks and stretch my muscles daily even when my joints hurt." C. "If I do not have a flare in over a year, I can stop taking my anti-inflammatory drugs." D. "If my urine becomes bloody or foamy, I will call my rheumatology health care provider immediately."

25. "If I do not have a flare in over a year, I can stop taking my anti-inflammatory drugs." C Although the disorder is intermittent and flares may be avoided for a relatively long period, anti-inflammatories are needed to slow disease progression and permanent damage. There is no cure. Higher doses of all anti-inflammatories, including corticosteroids, may be needed during a flare. Low-impact exercises are needed on a regular basis, despite joint pain, to maintain muscle strength, joint function, and reduce the risk for cardiovascular problems associated with a sedentary lifestyle. Bloody or foamy urine can indicate kidney involvement and must be treated as early as possible to prevent chronic kidney disease.

Which assessment findings would the emergency department (ED) nurse expect when a client has a smoke-related inhalation injury? Select all that apply.

34. A, B, C, D, F A. Soot around the nose or mouth B. Singed nasal hairs C. Hoarseness of speech D. Shortness of breath F. Cough With a suspected inhalation injury, the nurse would assess the mouth, throat, and nose for signs of soot. He or she would also listen for coughing, shortness of breath, or hoarseness of the voice which may indicate smoke inhalation. Cherry red skin is a sign of carbon monoxide poisoning, not inhalation injury.

In addition to topical drugs for psoriasis, which therapies would the nurse teach a client to reduce symptoms? Select all that apply.

25. A, C, E, F A. Ultraviolet (UV) irradiation C. Photochemotherapy with psoralen E. Excimer lasers F. Systemic therapy Ultraviolet (UV) irradiation has been shown to be beneficial in controlling psoriatic lesions. Photochemotherapy can be given by administration of psoralen, a photosensitizer, taken either orally or within a bath, followed by ultraviolet A (UVA) radiation. Excimer lasers emit UVB light and can be used for localized lesion treatment. Whether administered in a continuous or pulsed exposure, this modality allows for better focus on the lesions and reduces exposure to the surrounding normal skin. Oral systemic agents are often prescribed for clients with more than 5% body surface area affected by psoriasis (e.g., methotrexate, folic acid, and systemic retinoids). Oral antibiotics and surgical excision are not interventions of choice for this problem.

Which actions would the nurse teach a client and family to use to stop the spread of methicillin-resistant Staphylococcus aureus (MRSA)?

26. A, B, C, D, E, F A. Wash your hands with soap and warm water before and after touching the infected area or handling the bandages. B. Shower (rather than bathe) daily, using an antibacterial soap. C. Sleep in a separate bed from others until the infection is cleared. D. Do not share clothing, washcloths, towels, athletic equipment, shavers or razors, or any other personal items. E. Avoid close contact with others, including participation in contact sports, until the infection has cleared. F. Wash all soiled clothing and linens with hot water and laundry detergent. Dry clothing either either in a hot dryer or outside on a clothesline in the sun. Preventing skin infection, especially bacterial and fungal infections, involves avoiding the offending organism and practicing good hygiene to remove the organism before infection can occur. Handwashing and not sharing personal items with others are the best ways to avoid contact with these organisms, including MRSA. In your text, see Patient and Family Education: Preparing for Self-Management: Preventing the Spread of MRSA for a list of strategies to teach clients and family members to prevent infection spread to other body areas and to other people.

26. Which assessment is a priority for the nurse caring for a client with HIV-III (AIDS) who has an exacerbation of cryptosporidiosis? A Assess breath sounds and respiratory status. B. Assess neurologic status and presence of headache. C. Assess for signs of dehydration and electrolyte imbalance. D. Assess for difficulty in swallowing and pain behind the sternum.

26. C Assess for signs of dehydration and electrolyte imbalance Cryptosporidiosis is an intestinal infection caused by Cryptosporidium organisms with problems ranging from a mild diarrhea to a severe wasting with electrolyte imbalance and dehydration. Oral and esophageal candidiasis causes difficulty swallowing and pain behind the sternum. Severe headache and neurologic changes are associated with Toxoplasma gondii infection. Respiratory problems are associated with Pneumocystis jiroveci infection.

26. What precaution is most important for the nurse to teach the client with systemic lupus erythematosus (SLE) prescribed to take 40 mg of a corticosteroid daily for 2 weeks to manage an SLE flare? A. "Take this drug at bedtime to avoid nausea and vomiting." B. "Avoid crowds and anyone who is ill because this drug reduces your immunity." C. "Drink at least 3 liters of fluid per day because this drug can cause kidney damage." D. "If you are vomiting and cannot take the oral drug, contact your health care provider immediately."

26. D "If you are vomiting and cannot take the oral drug, contact your health care provider immediately." The prescribed dose is relatively high and use for 2 weeks could cause some degree of adrenal suppression. Therefore, it should not be stopped suddenly. If the client cannot take an oral dose because of nausea or vomiting, he or she should have the dose administered parenterally and not "skipped." The drug is most effective when taken either in the morning or when doses are divided with two-thirds in the morning and one-third later in the day. Corticosteroids are not associated with kidney damage although they do increase the reabsorption of sodium and water, raising blood pressure. Although the chronic use of corticosteroids decreases the inflammatory and immune responses, making the client more susceptible to infection, this drug is being prescribed on a short-term basis for a flare, not chronic use.

27. Which precautions (in addition to Standard Precautions) will the nurse initiate for the newly admitted client who has HIV-III and symptoms that include cough, dyspnea, chest pain, fever, chills, night sweats, weight loss, and anorexia? A. Airborne Precautions B. Enteric Precautions C. Contact Precautions D. Droplet Precautions

27. A Airborne Precaution The client's symptoms are consistent with tuberculosis (TB), which is common in HIV-III and can be difficult to diagnose because standard TB skin testing may not be accurate and also takes 48 to 72 hours, during which time the client is contagious. Airborne precautions are most appropriate for TB because the organism is suspended in the air for long periods of time and does not form heavy droplets.

27. Which actions will the nurse recommend to the client who has systemic lupus erythematosus (SLE) for relief of general joint and muscle pain? A. Warm, moist heat B. Medical marijuana C. Avoidance of all exercise D. Application of ice packs

27. A. Warm, moist heat For the general joint and muscle pain of SLE, most clients achieve relief with applications of warm, moist heat, including baths. Medical marijuana has not yet been approved for use with SLE. Avoiding exercise does not reduce pain and will contribute to more loss of joint function. Ice and cold applications are recommended only when sprains or strains are present and not for general joint and muscle pain.

For which client would the nurse notify the primary health care provider when a Zostavax vaccine for shingles is prescribed?

27. B. Client with immunosuppression Zostavax (zoster vaccine live) should not be given to clients with severe immunosuppression, those who are taking drugs that reduce immunity, individuals who are undergoing radiation or chemotherapy, or those with cancer affecting the bone marrow or lymphatic system.

28. Which precautions are most important for the nurse to teach a client newly diagnosed with systemic lupus erythematosus (SLE) to prevent harm? Select all that apply. A. Avoiding direct sunlight B. Monitoring urine output C. Keeping open lesions clean and covered D. Avoiding the use of make-up E. Wearing a medical alert bracelet F. Avoiding any form of aerobic exercise G. Being immunized yearly against influenza H. Avoiding the use of hair dyes and having permanents

28. A, B, E, G A. Avoiding direct sunlight B. Monitoring urine output E. Wearing a medical alert bracelet G. Being immunized yearly against influenza The UV light exposure exacerbates all aspects of SLE and must be avoided. A common cause of death for clients with SLE is chronic kidney disease, which can be managed if identified earlier. Monitoring urine output and urine characteristics helps identify kidney changes. Wearing a medical alert bracelet or other disease identifying objects is important in case the client is unable to communicate his or her disorder and therapies. Management of SLE reduces the immune response and increases the risk for infection. Obtaining an annual influenza vaccination reduces the risk for this contagious disease. Open lesions do not have to be covered. Make-up is not contraindicated and neither is the use of hair dyes or other hair products. Clients are urged to continue low-impact aerobic exercise to prevent complications.

Which information would the nurse teach a client about treatment of pediculosis pubis?

28. B. Abstain from sexual intercourse with any infected person. Pediculosis pubis causes intense itching of the vulvar or perirectal region. Pubic lice can be contracted from infested bed linens or during sexual intercourse with an infected individual, so it is essential to avoid infected individuals. Although these lice are usually found in the genital region, they can also infest the axillae, the eyelashes, and the chest. The treatment of pediculosis involves using chemicals to kill the parasites (e.g., topical sprays, creams, and shampoos). Topical agents include permethrin cream or malathion lotion. Oral agents such as ivermectin may also be used. Over-the-counter lindane, a topical drug, has been used in the past as a pediculocide. It is no longer recommended as the first line of treatment for pediculosis because of possible neurologic adverse effects.

29. What is the nurse's best response to an assistive personnel (AP) who is upset because "Some of the client's spit got on my arm when I was helping him with oral hygiene, and he is HIV positive?" A. "Don't worry about it. A little bit of saliva is no big deal." B. "Wash your arm; saliva is not infectious with HIV unless it is bloody." C. "Use alcohol-based handrub on your arm and go to employee health for HIV testing." D. "Next time, wear a gown and stand back during the swish and spit."

29. B. "Wash your arm; saliva is not infectious with HIV unless it is bloody." Intact skin is not a portal of entry for HIV even if contaminated blood is in contact with it. The correct procedure is just to wash the area with soap and water. HIV testing is not necessary. Helping the AP to calm down is a nursing responsibility and the nurse does not just dismiss the AP's concern. A gown would not be needed according to the information provided in this question.

Which condition would the nurse suspect when observing linear ridges on the inner aspects of the wrists and the client reports intense itching especially at night?

29. C Scabies Scabies is a contagious skin infection caused by mite infestations. It is transmitted by close contact with an infested person or infested bedding. Curved or linear ridges in the skin are characteristic of scabies. The itching is very intense, and clients often report that it becomes unbearable at night. The webs of the fingers and on the inner aspects of the wrists are where the linear ridges are most commonly found.

Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. Mr. Post is at risk for developing a pressure ulcer on his coccyx because of: 1. Friction 2. Maceration 3. Shearing force 4. Impaired peripheral circulation

3. Shearing The force exerted parallel to the skin assessments from both gravity pushing down on the patient and resistance between the patient and the surface.

Which is the nurse's best response when a client diagnosed with bedbug bites states he or she is embarrassed, showers every day, and lives in a clean environment?

30. A. "Have you been travelling or staying in a hotel?" Bedbug infestations are increasingly common as a result of travel and resistance to pesticides. Clients are taught to: examine hotel rooms and sleeping quarters, especially in crevices of box springs; place luggage on a rack away from the bed when traveling; place used/worn clothing into a sealed plastic bag when traveling; and carefully examine used items from garage sales before bringing them home. Bedbugs often live in mattresses and fabric upholstery, and in cracks and crevices of furniture. The most common mode of infestation is carrying the bug home from an infested environment such as a hotel room. Options B, C, and D do not respond to the client's concerns

30. Which client symptom appearing 2 weeks after an extended camping trip does the nurse associate with the possibility of Lyme disease? A. Acute confusion B. Sudden onset of difficulty swallowing C. Sudden onset of painful, swollen joints D. Persistent watery diarrhea and weight loss

30. C. Sudden onset of painful, swollen joints In the early and localized stage I, the client appears with flulike symptoms, erythema migrans (round or oval, flat or slightly raised rash often in a bull's eye pattern), and pain and stiffness in the muscles and joints. Symptoms begin within 3 to 30 days of the bite of an infected tick, but most present in 7 to 14 days. Gastrointestinal problems are not usually associated with Lyme disease. Acute confusion is not present in stage I but can be a part of stages II and III.

What type of healing does the nurse assess when a client's surgical wound edges are approximated, closed with sutures, and there is no inflammation?

31. C. 2 to 3 days A wound without tissue loss, such as a clean laceration or a surgical incision, can be closed with sutures, staples, or adhesives. The wound edges are brought together with the skin layers lined up in correct anatomic position (approximated) and held in place until healing is complete. This type of wound represents healing by first intention, in which the closed wound eliminates dead space and shortens the phases of tissue repair.

How long would the nurse expect a client's partial-thickness wound to heal by epithelialization?

32. D D. Fractured ribs Partial-thickness wounds are superficial with minimal loss of tissue integrity from damage to the epidermis and upper dermal layers. These wounds heal by re-epithelialization, the production of new skin cells by undamaged epidermal cells in the basal layer of the dermis, which also lines the hair follicles and sweat glands. In a healthy adult, healing of a partial-thickness wound takes about 5 to 7 days.

What priority complication would the nurse suspect when assessing a client with an electrical electrical burn that has an entrance wound on the right shoulder and an exit wound through the left side ribs?

33. B Cardiac dysrhythmias An electrical injury occurs when an electrical current enters the body. Tissue injury occurs when electrical energy converts to heat energy as it travels through the body. Once the current penetrates the skin causing the entry wound, it flows through the body damaging tissues in its path until leaving the body at the exit wound. The path of this client's electrical injury flows across the chest through the myocardium causing damage to the heart, which can lead to dysrhythmias.

Which client factors does the nurse identify as increasing the risk for infection? Select all that apply.

5. A, B, E A. Drinking four to five alcoholic beverages daily B. Smoking two packs of cigarettes daily E. Serving a 5-year prison term Client factors that increase infection risk include cigarette smoking and drinking substantial amounts of alcohol daily. Living in crowded conditions, especially in institutions, also increases the risk for infection transmission. Hormone-based contraceptives, eating a balanced balanced vegetarian diet, and regular participation in low-impact exercise do not increase a client's susceptibility to infection.

What would the help-line nurse advise a client who states that a skin lesion's color has changed, its size has increased, and its border is irregular?

43. A. "Contact your primary health care provider immediately." . It is essential that the client contact the primary health care provider if any of these findings are noted: a change in the color of a lesion, especially if it darkens or shows evidence of spreading; a change in the size of a lesion, especially rapid growth; a change in the shape of a lesion, such as a sharp border becoming irregular or a flat lesion becoming raised; redness or swelling of the skin around a lesion; a change in sensation, especially itching or increased tenderness of a lesion; or a change in the character of a lesion, such as oozing, crusting, bleeding, or scaling.

What is the priority action for the nurse and other interprofessional team members when caring for a client with Stevens-Johnson syndrome?.

46. D Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening cutaneous reactions most commonly triggered by drugs. Drugs most commonly associated with SJS/TEN include allopurinol, carbamazepine, lamotrigine, phenobarbital, phenytoin, and sulfasalazine. The response will continue and worsen if exposure to the drug continues.

Which interventions would the nurse use to prevent harm from development of a pressure injury in a client with a prolonged coma? Select all that apply.

5. A, B, D, E A. Use pillows or padding devices to keep the client's heels free from pressure. B. When positioning a client on his or her side, position at a 30-degree tilt. D. Turn and reposition the client at least every 2 hours during all shifts. E. Place pillows or foam wedges between two bony surfaces or between bony surfaces and the bed. See Best Practice for Patient Safety & Quality Care (QSEN) Prevents Pressure Injuries in your text book. All of the responses except two are appropriate interventions. Donut-shaped pillows are not used because these can damage capillary beds and increase tissue necrosis. Reddened areas are not massaged because this increases the risk for skin breakdown.

5. Which client conditions experienced over the past year indicates to the nurse that the client's HIV status may have progressed to HIV-III (AIDS)? Select all that apply. A. Had influenza 2 months ago B. Diagnosed with invasive cervical cancer C. Lost his long-term partner to heart disease 6 months ago D. Had two episodes of bacterial pneumonia in the past year E. Developed hepatitis A during a vacation to South America F. Had an abscessed tooth that required treatment by root canal

5. B, D B. Diagnosed with invasive cervical cancer D. Had two episodes of bacterial pneumonia in the past year Invasive cervical cancer and two or more episodes of bacterial pneumonia within a 12- month period are AIDS-defining illnesses. Anyone, even a person with a healthy immune system can get influenza, an abscessed tooth, or hepatitis A (when exposed to the virus). Having a partner who died from heart disease is not in itself an indicator that the partner had late-stage HIV disease.

5. Which vasoactive amine is most responsible for the initial symptoms of inflammation during an allergic response? A. Leukotriene B. Bradykinin C. Histamine D. Prostaglandins

5. C. Histamine The initial inflammatory response is triggered by histamine, often within 10 minutes of exposure to an allergen. It is also a very prevalent vasoactive amine. The other amines are secreted later, causing the secondary phase and prolonging the allergic reaction.

6. Which symptoms reported by a client who has HIV-III (AIDS) indicates to the nurse possible infection with Pneumocystis jiroveci? A. Chronic diarrhea and weight loss B. Severe headache and neck stiffness C. Persistent dry cough and breathlessness D. Pain behind the sternum and difficulty swallowing

6. C Persistent dry cough and breathlessness Infection with Pneumocystis jiroveci causes a form of pneumonia resulting in persistent dry cough and breathlessness. Infection with Candida albicans causes pain behind the sternum and difficulty swallowing. Severe headache and neck stiffness is associated with Toxoplasma gondii infection. Chronic diarrhea and weight loss have many causes, some of which are infectious; however, Pneumocystis jiroveci does not cause these symptoms.

6. Which statement made by a client who is scheduled to undergo diagnostic testing with use of contrast dye requires the nurse to take action to prevent harm? A. "Both diabetes and high blood pressure run in my family." B. "My sister is allergic to the dye that they use for x-ray procedures." C. "I have a lot of seasonal allergies, and they make me pretty miserable." D. "Last year I had a test with dye and my face got so swollen I could not see."

6. D Last year I had a test with dye and my face got so swollen I could not see." The most important concern to prevent immediate harm is the potential hypersensitivity to contrast medium. The client has clearly had some type of adverse reaction during a test using "dye" previously and may be at great risk for a severe reaction to the contrast medium for the scheduled procedure. The nurse must notify the radiologist and primary health care provider to explore this potential risk immediately. Although the client also has seasonal allergies, these are not associated with hypersensitivity to contrast medium. The sister's allergies are not relevant to the client's condition, and education for lifestyle changes to reduce the risk for diabetes and high blood pressure, although important, should not be the immediate focus.

Which instruction would the nurse give the assistive personnel (AP) about how to perform skin care on a client at risk for pressure injury because of immobility and incontinence?

6. D. Clean the skin and moisturize with dimethazone, zinc oxide, lanolin, or petrolatum. The skin is cleaned as soon as possible after soiling occurs and at routine intervals, and is then moisturized with dimethazone, zinc oxide, lanolin, or petrolatum. Incontinence products are changedd frequently and the skin is inspected at least every 2 hours, especially under these products. Skin is washed, not scrubbed, with clean, warm water and mild soap, using only the amount of pressure needed to clean. Skin is patted dry, not rubbed.

Which action will the nurse use during client care to prevent infection by mechanically disrupting biofilms?

6. D. Helping the client to floss and to brush teeth A biofilm is a complex of microorganisms that group together and form a gel-like coating (glycocalyx) that supports continued growth of the microorganisms. Effective treatment or prevention starts with disruption of biofilm. Human biofilms include plaque on teeth and gums, a coating on and in the crypts of tonsils, and as a layer of exudate in wounds. They do not usually form

7. Which noninfection-related health promotion behavior is a priority for the nurse to teach a client with HIV disease at stage II? A. Exercise regularly and maintain a healthy weight. B. Avoid salt substitutes and foods high in potassium. C. Do not travel to countries outside of North America. D. Avoid using acetaminophen and any type of NSAID.

7. A. Exercise regularly and maintain a healthy weigh With appropriate antiviral therapy, HIV stage II can last decades. However, the disease itself and many of the drugs used for its management increase the risk for diabetes and coronary artery disease, which are common causes of death for an HIV-positive client. A healthy weight and regular exercise help reduce the risks for these problems. Unless kidney impairment is present, potassium is not restricted. Infection risk is not great at this stage and there are no specific travel restrictions related. to the client's health. There is no specific recommendation to avoid acetaminophen or NSAIDs during this stage of HIV disease.

How will the nurse document assessment findings on a client's coccyx region that is reddened, is intact, and does not blanch when pressure is applied?

7. A. Stage 1 pressure injury Stage 1 pressure injuries are non-blanchable erythema of intact skin. Characteristics include: intact skin with localized area of non-blanchable erythema (may appear differently in skin with darker pigmentation); may be preceded by changes in sensation, temperature or firmness; and color changes are not purple or maroon. See Key Features of Pressure Injuries in your text.

7. Which statement(s) regarding type II hypersensitivity (cytotoxic) reactions is/are true? Select all that apply. A. Responses always occur within minutes of exposure to the allergen. B. Hemolytic transfusion problems are an example of type II hypersensitivity. C. Type II responses are usually directed against self cells attached to non-self cells and the response destroys the self cells. D. Susceptibility for developing a type II hypersensitivity response follows an autosomal dominant pattern of inheritance. E. Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction. F. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. G. An effective management strategy may include plasma filtration to remove specific substances.

7. B, C, G B. Hemolytic transfusion problems are an example of type II hypersensitivity. C. Type II responses are usually directed against self cells attached to non-self cells and the response destroys the self cells. G. An effective management strategy may include plasma filtration to remove specific substance Type II cytotoxic reactions occur when the body makes autoantibodies directed against self cells that have some form of foreign protein attached to them. The autoantibody binds to the self cell and forms an immune complex and destroys the self cell along with the attached protein. Examples of this type of hypersensitivity reaction include hemolytic transfusion reactions, hemolytic anemias, immune thrombocytopenic purpura, and drug-induced hemolytic anemia. Poison ivy and T-cell-mediated responses are associated only with type IV hypersensitivities. No hypersensitivities follow an autosomal dominant pattern of inheritance because they are not inherited as single gene traits. Although hemolytic transfusions often occur within 15 minutes of exposure, most type II cytotoxic reactions occur many hours after exposure. An effective management strategy may include plasma filtration to remove specific substances, especially when the problem is identified early.

8. When taking the history of a client being treated for angioedema, which information does the nurse consider most relevant to the situation? Select all that apply. A. Has long time known allergy to penicillin B. African American C. Has severe hypertension D. Is 52 years old E. Has well-controlled type 2 diabetes mellitus F. Has taken an angiotensin-converting enzyme inhibitor for 8 months G. Takes a beta blocker daily H. Eats a vegan diet

8. B, F B. African American F. Has taken an angiotensin-converting enzyme inhibitor for 8 months Although, in theory, any drug can cause angioedema, the main risk factor for drug-induced angioedema is taking an angiotensin-converting enzyme inhibitor (ACEI). This response to ACEIs is more common among African Americans. Therefore, these two factors are most relevant to the situation. Age is not an issue nor is having type 2 diabetes mellitus. The fact that the client is hypertensive, although an indication for the drug, does not itself increase the risk for this reaction. Neither beta blockers nor penicillin are likely to cause this reaction. A vegan diet is also an unlikely cause of the reaction.

Which personal protective equipment (PPE) does the nurse assemble for use when giving oral and parenteral drugs to a client who has diarrhea from Clostridium difficile overgrowth? Select all that apply.

8. C, D C. Gloves D. Gown When performing the action of giving either oral or parenteral drugs to any client with diarrhea, including those who have Clostridium difficile, only Contact Precautions are needed.

8. Which assessment findings in a client who is HIV positive and has new-onset acute confusion will the nurse report immediately to the immunity health care provider? Select all that apply. A. Alopecia B. Substernal pain C. Unequal pupil size D. Reduced grip strength E. Numbness of the fingers and toes F. Dry mouth with sticky tongue coating

8. C, D C. Unequal pupil size D. Reduced grip streng New-onset acute confusion is associated with several serious central nervous system problems that can increase intracranial pressure (ICP). Increased ICP requires immediate intervention to prevent brain impairment. Indicators include unequal pupil size or reactivity and reduced grip strength. Numbness of the fingers and toes is a peripheral nerve problem, not a CNS problem and is not associated with increased ICP. Alopecia, substernal pain, and dry mouth are not CNS problems indicating possible increased ICP.

What would the nurse be sure to do before documenting a client's pressure injury changes with a series of photographs?

8. C. Obtain informed consent from the client. Serial photographs of the wound are very helpful in documenting changes in wound appearance and progress toward healing. Policies on photographic documentation vary between agencies but require informed consent from the client or durable power of attorney if the client is unable to provide consent.

With which clients will the nurse use extra precautions to prevent harm from infection development as a result of medical or surgical intervention? Select all that apply.

A, B, C, E, F A. 27-year-old taking antirejection drugs after receiving a kidney transplant B. 36-year-old being mechanically ventilated C. 45-year-old with an indwelling urinary catheter E. 60-year-old who had an artificial aortic valve replacement 4 years ago F. 65-year-old taking corticosteroids daily for chronic obstructive pulmonary disease (COPD) Drug therapies that cause any degree of immunosuppression, such as corticosteroids or antirejection drugs, increase the risk for infection. Artificial (synthetic) medical devices also increase the risk for infection as do devices that provide a direct access to the client's internal environment and bypass normal protections, such as indwelling urinary catheters and endotracheal/tracheal tubes. Although diabetes mellitus increases a client's infection risk, this is not a medical or surgical intervention. Advancing age also increases a client's infection risk but is not a medical or surgical intervention. Diuretics do not increase infection risk.

2. Which statement(s) regarding hypersensitivity reactions is/are accurate? Select all that apply. A. The predisposition to develop hypersensitivity is genetic. B. Allergies to specific antigens (allergens) are directly inherited. C. Hypersensitivity symptoms are triggered by excessive inflammation. D. Avoidance of an antigen (allergen) reduces an adult's existing sensitivity to it. E. A client may have more than one type of hypersensitivity reaction at the same time. F. A person can develop hypersensitivity to almost any substance at any time during the lifespan.

A, C, E, F A. The predisposition to develop hypersensitivity is genetic. C. Hypersensitivity symptoms are triggered by excessive inflammation. E. A client may have more than one type of hypersensitivity reaction at the same time. F. A person can develop hypersensitivity to almost any substance at any time during the lifespan. The predisposition to develop hypersensitivity is inherited as a polygenic trait although hypersensitivities to specific substances is not inherited, making option B incorrect. The symptoms associated with hypersensitivity are caused by excessive inflammation in response to degranulation of basophils,eosinophils, and mast cells with release of a variety of vasoactive amines. Once a hypersensitivity to a specific substance develops, avoiding that allergen can prevent an episode of responses but does not reduce the adult's sensitivity to the allergen. Allergies can develop to almost any substance across the lifespan and can trigger more than one type of hypersensitivity response at the same time.

Which actions by a nurse best exemplifies the use of systems thinking to prevent pressure injury on a medical-surgical nursing unit? Select all that apply.

B, C, E, F B. Performing an electronic literature search to explore techniques for pressure injury prevention C. Reviewing client records for the past 12 months to determine the rate of pressure injury injury development E. Using an evidence-based practice assessment tool to identify all admitted clients at increased potential risk for pressure injury F. Collaborating with unit registered nurses to develop a "turning team" to ensure regular repositioning of all clients at risk for pressure injury Systems thinking reflects the general care and well-being of all clients. The process begins with knowledge of problem prevention (option B), identifying whether a problem exists as a systemic issue beyond the care of one client

Which type of health factor is best described when a client tells the nurse that she believes health is important and that people should be willing to take steps to maintain their health such as getting annual flu shots?

Behavioral social determinants of health Behavioral and social determinants of health include what "health" means to the client within the context of his or her culture and what actions he or she is willing to take to achieve or maintain health. This client is taking responsibility for her health.

What is the goal of systems thinking for nursing when moving from clinical judgment to systems thinking?

C. To encourage the nurse to develop awareness of the interrelationships that exist between individual care and the context of health care safety and quality The goal of systems thinking is to encourage the nurse to develop awareness of the interrelationships that exist between individual care and the overall context of health care safety and quality. Nurses need to address quality and safety concerns.

Advanced Practice Registered Nurse (APRN)

Four core roles; certified nurse midwife, certified nurse practitioner, clinical nurse specialist, and certified registered nurse anesthetist.

Explain what a deep tissue pressure injury (DTPI) is

Intake or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.

Which principle of ethics is violated most when a nurse fails to readminister pain medication to a client with advanced cancer within the next hour as was promised?

Nearly all the ethical principles listed are violated to some degree when the nurse fails to follow-through with an action that was promised; however, fidelity is most violated in this situation. Fidelity is the ethical principle in which the nurse always follows through with their obligations to clients or their promises in order to ensure quality care that is patient-centered. It is related to veracity, which is the obligation to be truthful.

At an office visit for an annual check-up, the client tells the nurse and HCP about increased shortness of breath and occasional chest discomfort when performing yard work; the HCP makes a referral to a cardiologist. Which term best describes this situation?

Primary Health Care Primary health care is generally provided by a primary care provider. That person becomes a "gatekeeper" for the client's care. Primary care ranges from prevention to management of chronic health conditions.

The nurse is providing care for four clients. Which best provides an example of the clinical judgment term failure to rescue (FTR)?

The client with pneumonia develops a fever of 101.9oF (38.8oC) and the nurse does not notify the health care provider. FTR is the inability of a nurse or other health care team member to save a client's life in a timely manner when a health care issue or medical complication occurs. Clients often have changes in signs and symptoms that are subtle. Failure to recognize those changes or to accurately interpret them leads to actions which may improve the client's condition not being implemented (FTR).

Summarize the principles of wound irrigation:

Use of an irrigating syringe to flush the area with a constant low-pressure flow of solution of exudates and debris. Never occlude a wound opening with a syringe.

Caregiver

help patients maintain and regain health, manage disease and symptoms, and attain a maximal level of function and independence through the healing process

Epidermis

top layer of skin

Collagen

tough fibrous protein