Nursing SBU
Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (Select all that apply.)
"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party.
Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (Select all that apply.)
"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party.
A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.)
Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions
Ampicillin 250 mg by mouth every six hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin?
"The medicine should be taken one hour before or two hours after meals."
A client with tuberculosis asks the nurse about the communicability of the disease. Which is the best response by the nurse?
"Untreated active tuberculosis is communicable."
A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?
"Wash used dishes in hot, soapy water."
Which pain scale would the nurse use to measure the intensity of pain in toddlers? 1 FACES scale 2 Visual analog scale 3 Numerical rating scale 4 Verbal descriptor scale
1
Which education would the nurse provide the parents of an infant with pyloric stenosis?
1 It is unlikely that surgery will be necessary. Correct 2 This is a condition with an excellent prognosis. 3 This condition results from an error of metabolism. Incorrect 4 Special feedings will be needed for a few weeks after surgery. answer is 2
What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? 1. A low-phenylalanine diet is required. 2. Phenylalanine is not necessary for growth. 3. Phenylalanine can be administered to correct the deficiency. 4. A substitute for phenylalanine is an increased amount of other amino acids.
1.A low-phenylalanine diet is requiredReducing dietary phenylalanine helps prevent brain damage. The PKU diet is planned to maintain the serum phenylalanine level at 2 to 8 mg/100 mL. Phenylalanine is essential for growth and development of the brain. Administering phenylalanine is contraindicated. There are no substitute for phenylalanine, which is one of the essential amino acids.
A client is to receive an intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride to be administered over 20 minutes. At what rate should the nurse set the infusion pump? Record your answer using a whole number. __________ mL/hr
150 ml/hr
A client presents with chief complaints of unexplained weight gain and back pain from a compression fracture of the vertebrae. On assessment, there is truncal obesity with excessively thin extremities, a moon-shaped face, a buffalo hump, thin hair, and adult acne. The symptoms described are suggestive of which disease? Addison disease Cushing disease Multiple sclerosis Kaposi sarcoma
2
When providing postoperative teaching, which rationale would the nurse give to explain the purpose of administering an opioid analgesic via epidural catheter? 1 Facilitates oxygen use 21Relieves abdominal pain 3Decreases anxiety and restlessness 4 Dilates coronary and peripheral blood vessels
2
Which condition would the nurse document to describe a client presenting with the loss of the ability to taste after cancer treatment has affected the client's ability to eat food? 1 Mucositis 2 Dysgeusia 3 Dysphagia 4 Xerostomia
2
Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction? 1 Massage 2 Effleurage 3 Acupressure 4 Counterpressure
2
A nurse is counseling a client who has gonorrhea. What additional fact about gonorrhea, besides the fact that it is highly infectious, should the nurse teach this client?
It can produce sterility.
How would the nurse incorporate the quality of accuracy into client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each client's activity 3 By providing complete and appropriate information in each client's record Incorrect 4 By recording descriptive and objective information that he or she sees, hears, feels, and smells
2 By using exact measurements for each client's activity
A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood
3
On her first visit to the neonatal intensive care unit to see her preterm newborn, the mother's only comment to the nurse is, "My baby looks so fragile. Do you think my child will make it?" Which is the most appropriate response by the nurse? 1 "Many infants born as small as yours have done just fine." 2 "The staff is confident in your child's prognosis because preterm babies do look like this at first." 3 "Understandably, your baby looks fragile to you. What have you learned about the condition?" 4 "Your baby is not as fragile as it appears. Do you find it so frightening that you cannot touch your child?"
3 "It's understandable that your baby looks fragile to you. What have you learned about the condition?"
A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" Which is the nurse's most appropriate response? 1 "Do not tell your partner unless asked." 2 "This is a decision you alone can make." 3 "You are having difficulty deciding what to say." 4 "Tell your partner that you don't know how you became sick."
3 "You are having difficulty deciding what to say."
After surgery a client is to receive an antibiotic by intravenous (IV) piggyback in 50 mL of a diluent. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 15 gtts/mL. The nurse should set the piggyback to flow at how many gtts/min? Record your answer using a whole number. __________ gtts/min
38
After abdominal surgery, a client reports pain. Which action would the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.
4
What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? (Select all that apply.)
Joint pain Facial rash Pericarditis
A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling?
45-year-old woman with breast cancer
The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find:
A decrease in CD4 T cells
Which patients are at risk of developing health care-associated infections (HAIs)? Select all that apply.
A patient with laryngeal cancer A patient with diabetes mellitus A patient with an indwelling urinary catheter
antivenin
A serum that counteracts the effect of venom from an animal or insect.
A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. A priority nursing intervention is to:
Administer the prescribed antipyretic and notify the charge nurse or primary health care provider
A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. The priority nursing care is:
Administering prescribed antibiotics
A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions?
Airborne precautions
A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care?
Keep skin lubricated with lotion
Nursing Process
Assessment Diagnosis Planning Implementation Evaluation
A client receiving chemotherapy takes a steroid daily. The client has a white blood cell count of 12,000/mm3 and a red blood cell count of 4.5 million/mm3. What is the priority instruction that the nurse should teach the client?
Avoid large crowds and persons with infections
A client has a Mantoux test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. The nurse concludes that this response indicates that the client has:
Been exposed to the tubercle bacillus
The health care provider prescribes peak and trough levels of an antibiotic for a client who is receiving the medication intravenous piggyback (IVPB). For peak levels the nurse should have the laboratory obtain a blood sample from the client:
Between 30 and 60 minutes after the IVPB
3 examples of objective data
Blood pressure Heart rate Respirations
A client in the emergency department states, "I was bitten by a raccoon while I was fixing a water pipe in the crawl space of my basement." Which is the most effective first-aid treatment for the nurse to use for this client?
Cleansing the wound with soap and water
The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? Tachycardia Hypotension Rigid abdomen Nausea and vomiting Back and shoulder pain
Correct1 Tachycardia Correct2 Hypotension Correct3 Rigid abdomen Correct4 Nausea and vomiting Correct5 Back and shoulder pain
Which medication is used in the treatment of a client with intervertebral disc disease?
Cyclobenzaprine
A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain one week later. What does the nurse identify as the cause of the post therapeutic neuralgia?
Damage to the nerves
When assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies areas of white plaque on the client's tongue and palate. What is the nurse's initial response?
Document the presence of the lesions, describing their size, location, and color
A client is diagnosed with gastroenteritis. What does the nurse determine is the basic intention underlying the unique dietary management for this client?
Eliminate chemical, mechanical, and thermal irritation.
A primary health care provider prescribes airborne precautions for a client with tuberculosis. After being taught about the details of airborne precautions, the client is seen walking down the hall to get a glass of juice from the kitchen. The most effective nursing intervention is to:
Explore what the precautions mean to the client
A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16-year-old adolescent. Which should be of most concern to the nurse?
Finding the client's contacts
The parents of a toddler who has been admitted to the pediatric unit for surgery to correct hypospadias ask the nurse when this defect happened. Which fetal development time period would the nurse respond? 1 First 12 weeks 2 Third trimester 3 Second 16 weeks 4 Implantation phase
First 12 Weeks
4 Agonal breaths
Gasping
A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug?
Give the medication an hour before milk products are ingested.
A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? (Select all that apply.)
Gloves Hand hygiene
A nurse is caring for a client with a diagnosis of acute salpingitis. Which condition most commonly causing inflammation of the fallopian tubes should the nurse include when planning a teaching program for this client?
Gonorrhea
A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client:
Has a CD4+ T lymphocyte level of less than 200 cells/µL
2 Tachycardia
Heart rate over a 100
A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? (Select all that apply.)
Hyperthermia Splenomegaly
Before the nurse can be an advocate for a client who is homosexual who has acquired immunodeficiency syndrome (AIDS), the nurse needs to do what?
Identify personal attitudes and feelings about homosexuality
A mother with the diagnosis of acquired immunodeficiency disease (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine?
If the baby is breastfeeding
During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement?
Ignorance related to correct condom use
Which would the nurse discuss with new parents to assist them in preparing for infant care?
Learning specific behaviors involving states of wakefulness to promote positive interactions
A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to best prevent malaria?
Mosquito bites
A client scheduled for surgery has a history of methicillin-resistant Staphylococcus aureus (MRSA) since developing an infection in a surgical site nine months ago. The site is healed and the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present?
Obtain a prescription to culture the client's blood
Which important intervention would be included in the nursing care provided immediately after a sexual assault? 1. Obtaining the assault history from the client 2. Reporting the assault to the police before the client is examined 3 Having the client void a clean-catch urine specimen 4 Testing the client's urine for seminal alkaline phosphatase
Obtaining the assault history from the client
What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?
Occurred in conjunction with treatment for an illness
An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis. The client states that a roommate at the extended care facility where the client resides sleeps a lot, coughs a great deal, and sometimes spits up blood. The primary reason that the nurse pursues more information about the roommate is because:
Older adults with chronic illness are affected adversely by tuberculosis
A chronically ill, older client tells the home care nurse that the daughter with whom the client lives seems run-down and disinterested in her own health, as well as the health of her children, who are 5, 7, and 12 years old. The client tells the nurse that the daughter coughs a good deal and sleeps a lot. Why is it important that the nurse pursue the daughter's condition for potential case finding?
Older adults with chronic illness are more susceptible to tuberculosis
3 examples of subjective data
Pain, Dizziness, Exhaustion
A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client?
Penicillin therapy
PPE -
Personal Protective Equipment
Which actions contribute to the transmission of human immunodeficiency virus (HIV) infection from an infected to a healthy person? Select all that apply.
Receiving blood transfusions Having sexual intercourse
A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should:
Reschedule administration of the vaccine for the next month
RACE -
Rescue, Activate alarm, Confine the fire, Evacuate/Extinguish
A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.
Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions
A nurse observes that an unlicensed assistive personnel (UAP) did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. The nurse's best way to handle this situation is to:
Review transmission-based precautions with the UAP
SMART goals
Specific, Measurable, Attainable, Realistic, Timely
SOP
Standard Operating Procedure (defined in Queensland mining legislation)
The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? (Select all that apply.)
Tachypnea Increased pulse rate
What is the incubation period for an infectious disease?
The interval between entrance of pathogen into body and appearance of first symptoms
A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?
Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine
A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?
Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine.
A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan?
Two to six weeks
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?
Use standard precautions.
A client arrives at the clinic after being bitten by a raccoon in an area in the woods where rabies is endemic. When considering the client's needs, the nurse recalls that rabies is a:
Viral infection characterized by convulsions and difficulty swallowing
The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in:
Vitamins A, C, E, and selenium
A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?
Wash used dishes in hot, soapy water."
A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, the nurse anticipates a prescription for:
Water-soluble forms of vitamins A and E
A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do?
Wear a particulate respirator mask
Clinical judgment
a judgment based on experience in observing and treating patients
ABCS
airway, breathing, circulation
dysphagia
condition in which swallowing is difficult or painful
Dyspnea
difficult or labored breathing
dysgeusia
distortion of the sense of taste
antihypertensive
drug that lowers blood pressure
xerostomia
dryness of the mouth
Palliative care
hospice care; taking care of the whole person—body, mind, spirit, heart and soul—with the goal of giving patients with life-threatening illnesses the best quality of life they can have through the aggressive management of symptoms
glomerulonephritis
inflammation of the glomeruli of the kidney
Objective data
information that is seen, heard, felt, or smelled by an observer; signs
A female client is upset with her diagnosis of gonorrhea and asks the nurse, "What can I do to prevent getting another infection in the future?" The nurse evaluates that the teaching is understood when the client states, "My best protection is to:
insist that my partner use a condom."
pyloric stenosis.
narrowing of the opening of the stomach to the duodenum
mucositis
painful inflammation of oral mucous membranes
hematuria
presence of blood in the urine
Etiology
the study of the causes of diseases
Subjective data
things a person tells you about that you cannot observe through your senses; symptoms
Debillitated
weakened