Pop exam 4

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first?a. Client with a Glasgow Coma Scale score that was 10 and is now is 8b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

ANS: A A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client

ANS: A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a. Administer oxygen. b. Apply an oximetry probe. c. Give pain medication. d. Start an IV line.

ANS: A All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.

A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse report to the provider? a. Creatinine: 2.9 mg/dL b. Hematocrit: 30% c. Sodium: 147 mEq/L d. White blood cell count: 12,000/mm3

ANS: A An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count. A sodium level of 147 mEq/L, although slightly high, is not concerning.

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond?a. Most of these types of blood clots come from the heart.b. Some of the blood clots may have gone to your heart too. c. We need to see if your heart is strong enough for therapy. d. Your heart may have been damaged in the stroke too.

ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.

The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

ANS: A Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.

A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best? a. Assess client fears and coping mechanisms. b. Reassure the client this is a common test. c. Sedate the client prior to the procedure. d. Tell the client he or she will be asleep.

ANS: A Assessing the clients specific fears and coping mechanisms helps guide the nurse in providing holistic care that best meets the clients needs. Reassurance will be helpful but is not the best option. Sedation is usually used. The client may or may not be totally asleep during the procedure.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care?a. Ambulate only with a gait belt.b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

ANS: A Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringers solution

ANS: A Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringers solution are isotonic. D50 is hypertonic and not used for hydration.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?a. Increased pressure from the abscess can cause seizures.b. Preventing febrile seizures with an abscess is important. c. Seizures always occur in clients with brain abscesses. d. This drug is used to sedate the client with an abscess.

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the provider leave a prescription for a placebo. d. Tell the client it is too early to have more pain medication.

ANS: A Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the clients pain. Giving placebos is unethical.

The health care provider tells the nurse that a client is to be started on a platelet inhibitor. About what drug does the nurse plan to teach the client? a. Clopidogrel (Plavix) b. Enoxaparin (Lovenox) c. Reteplase (Retavase) d. Warfarin (Coumadin)

ANS: A Clopidogrel is a platelet inhibitor. Enoxaparin is an indirect thrombin inhibitor. Reteplase is a fibrinolytic agent. Warfarin is a vitamin K antagonist

A client with a stroke has damage to Brocas area. What intervention to promote communication is best for this client?a. Assess whether or not the client can write.b. Communicate using yes-or-no questions. c. Reinforce speech therapy exercises.d. Remind the client not to use neologisms.v

ANS: A Damage to Brocas area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. Yes-or-no questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up words often used by clients with sensory aphasia.

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met?a. Doing activities of daily living (ADLs) using rest periodsb. Helping plan a daily activity schedule c. Requesting a sleeping pill at nightd. Telling visitors to leave when fatigued

ANS: A Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke?a. A 27-year-old heavy cocaine userb. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.

A client has Crohns disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiencyb. Fanconis anemiac. Hemolytic anemia d. Vitamin B12 anemia

ANS: A Malabsorption syndromes such as Crohns disease leave a client prone to folic acid deficiency. Fanconis anemia, hemolytic anemia, and vitamin B12 anemia are not related to Crohns disease.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is intolerable. What action by the nurse is best?a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently.c. Refer the client and spouse to a head injury support group.d. Tell the spouse this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isnt useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouses concerns and feelings.

A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best? a. It inhibits thrombin. b. It inhibits fibrinogen. c. It thins your blood. d. It works against vitamin K.

ANS: A Rivaroxaban is a direct thrombin inhibitor. It does not work on fibrinogen or vitamin K. It is not a blood thinner, although many clients call anticoagulants by this name.

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the clients record. What action by the nurse is best?a. Ask the client how long ago the clip was placed.b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip.d. Reschedule the client for computed tomography.

ANS: A Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives.

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

ANS: A The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the clients sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.

A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

ANS: A The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first?a. Client who had two bloody diarrhea stools this morningb. Client who has been premedicated for nausea prior to chemotherapy c. Client with a respiratory rate change from 18 to 22 breaths/mind. Client with an unchanged lesion to the lower right lateral malleolus

ANS: A The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first. The client with the change in respiratory rate may have an infection or worsening anemia and should be seen next. The other two clients are not a priority at this time.

A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.

ANS: A The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The clients mental status is deteriorating. What action by the nurse is most appropriate?a. Attempt to find the family to sign a consent.b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.

ANS: A The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority?a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration.c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

ANS: A These manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full- time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. I know I can take care of all these needs by myself.b. I need to seek counseling because I am very angry. c. Hopefully things will improve gradually over time. d. With respite care and support, I think I can do this.

ANS: A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word hopefully. Realizing the importance of respite care and support also is a realistic outlook.

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition?a. Bence-Jones protein in urineb. Epstein-Barr virus: positive c. Hemoglobin: 18 mg/dLd. Red blood cell count: 8.2/mm3

ANS: A This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL is slightly high for a male and somewhat high for a female; this can be caused by several conditions, and further information would be needed to correlate this value with a specific medical condition. A red blood cell count of 8.2/mm3 is also high, but again, more information would be needed to correlate this finding with a specific medical condition.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the clients score to be 36. How should the nurse plan care for this client?a. The client will need near-total care.b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home.

ANS: A This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the clients dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client.

1. The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

ANS: A This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.

A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best?a. Assess the client for support systems.b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

ANS: A This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.

A client has a subarachnoid bolt. What action by the nurse is most important? a. Balancing and recalibrating the deviceb. Documenting intracranial pressure readingsc. Handling the fiberoptic cable with care to avoid breakage d. Monitoring the clients phlebostatic axis

ANS: A This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the devices accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the devices accuracy is most important. The phlebostatic axis is not related to neurologic monitoring.

A nurse is assessing a dark-skinned client for pallor. What action is best? a. Assess the conjunctiva of the eye. b. Have the client open the hand widely. c. Look at the roof of the clients mouth. d. Palpate for areas of mild swelling.

ANS: A To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is not related to pallor, nor is palpating for mild swelling.

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.

ANS: A Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?a. Assist the client to make sick day plans for household responsibilities.b. Determine if there are family members or friends who can help the client. c. Help the client inform friends and family that they will have to help out.d. Refer the client to a social worker in order to investigate respite child care.

ANS: A While all options are reasonable choices, the best option is to help the client make sick day plans, as that is more comprehensive and inclusive than the other options, which focus on a single item.

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority?a. Calling the Rapid Response Teamb. Delegating taking a set of vital signs c. Instituting bleeding precautions d. Placing the client on bedrest

ANS: A With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or putting the client back into bed is important, but the critical action is to call for immediate medical attention.

A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 yeard. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipatione. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.

A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.)a. Assess vital signs more often.b. Hold other IV fluids running. c. Premedicate to prevent reactions. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours.

ANS: A, B The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion. The other options are not warranted.

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the clients care? (Select all that apply.)a. Assess tube placement per agency policy.b. Keep the head of the bed elevated at least 30 degrees.c. Listen to lung sounds at least every 4 hours.d. Run continuous feedings on a feeding pump.e. Use blue dye to determine proper placement.

ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

ANS: A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a. Applying a cool washcloth to the headb. Assisting the client to a position of comfort c. Keeping voices soft and soothingd. Maintaining low lighting in the room e. Providing antipyretics for fever

ANS: A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigmae. Unknown transmission routes

ANS: A, B, C, D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

ANS: A, B, D A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.)a. Hanging the blood product using normal saline and a filtered tubing setb. Taking a full set of vital signs prior to starting the blood transfusion c. Telling the client someone will remain at the bedside for the first 5 minutesd. Using gloves to start the clients IV if needed and to handle the blood producte. Verifying the clients identity, and checking blood compatibility and expiration time

ANS: A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the clients identity and blood compatibility.

A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.)a. Argatroban (Argatroban)b. Bivalirudin (Angiomax) c. Clopidogrel (Plavix)d. Lepirudin (Refludan)e. Methylprednisolone (Solu-Medrol)

ANS: A, B, D The standard drugs used to treat HIT are argatroban, bivalirudin, and lepirudin. The other drugs are not used. Clopidogrel is an antiplatelet agent used to reduce the likelihood of stroke or myocardial infarction. Methylprednisolone is a steroid used to reduce inflammation.

A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)a. Client who exhibits extreme emotional labilityb. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limpd. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

ANS: A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.

A student nurse learns that the spleen has several functions. What functions do they include? (Select all that apply.) a. Breaks down hemoglobin b. Destroys old or defective red blood cells (RBCs) c. Forms vitamin K for clotting d. Stores extra iron in ferritin e. Stores platelets not circulating

ANS: A, B, E Functions of the spleen include breaking down hemoglobin released from RBCs, destroying old or defective RBCs, and storing the platelets that are not in circulation. Forming vitamin K for clotting and storing extra iron in ferritin are functions of the liver.

An older client asks the nurse why people my age have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.) a. Bone marrow produces fewer blood cells. b. You may have decreased levels of circulating platelets. c. You have lower levels of plasma proteins in the blood. d. Lymphocytes become more reactive to antigens. e. Spleen function declines after age 60.

ANS: A, C The aging adult has bone marrow that produces fewer cells and decreased blood volume with fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive, and spleen function stays the sam

A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall.b. An arteriovenous malformation is the usual cause of strokes.c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.

ANS: A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.)a. Admission can overwhelm the coping mechanisms for older clients.b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.

A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the clients mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the clients abdomen.

ANS: A, C, D Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)a. Alcohol intakeb. Diabetes c. High-fat diet d. Obesitye. Smoking

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a. Dehydrationb. Exercise c. Extreme stress d. High altitudes e. Pregnancy

ANS: A, C, D, E Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.)a. Chemical exposureb. Genetically modified foods c. Ionizing radiation exposure d. Vaccinationse. Viral infections

ANS: A, C, E Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.)a. Donor blood type A can donate to recipient blood type AB.b. Donor blood type B can donate to recipient blood type O. c. Donor blood type AB can donate to anyone.d. Donor blood type O can donate to anyone.e. Donor blood type A can donate to recipient blood type B.

ANS: A, D Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 weekd. Providing and charting stroke educatione. Preventing venous thromboembolism

ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.)a. A client with a moderate trauma may need hospitalization.b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI.d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms mild TBI and concussion have similar meanings.

ANS: A, D, E Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L

ANS: A, D, E The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is norma

A client is having a bone marrow biopsy today. What action by the nurse takes priority? a. Administer pain medication first. b. Ensure valid consent is on the chart. c. Have the client shower in the morning. d. Premedicate the client with sedatives.

ANS: B A bone marrow biopsy is an invasive procedure that requires informed consent. Pain medication and sedation are important components of care for this client but do not take priority. The client may or may not need or be able to shower.

A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

ANS: B Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.

A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings.b. Perform hand hygiene before client care.c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.

ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first?a. Client with a blood pressure of 180/98 mm Hgb. Client who reports shortness of breath c. Client who reports calf tenderness and swelling d. Client with a swollen and painful left great toe

ANS: B Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder.

A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examinatio

ANS: B Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer?a. Carbamazepine (Tegretol)b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)

ANS: B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics.b. Ensure that informed consent is on the chart.c. Perform a full neurologic assessment. d. Review the clients medication lists.

ANS: B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.

A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identifying client using two identifiersb. Ensuring informed consent is obtained if requiredc. Hanging the blood product with Ringers lactate d. Staying with the client for the entire transfusion

ANS: B If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringers lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?a. Client with a core temperature of 95 F (35 C) for 2 daysb. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admissio

ANS: B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.

The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority?a. Ask the client about pain.b. Assess the client for infection. c. Delegate taking a set of vital signs. d. Look at todays laboratory results.

ANS: B Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse should assess for infection. The nurse should assess for pain but this is not the priority. The nurse should take the clients vital signs instead of delegating them since the client has had a change in status. Laboratory results may be inconclusive.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best?a. Have the student ask the client if it is desired or not.b. Inform the student that the docusate should be given.c. Tell the student to document the rationale.d. Tell the student to give it unless the client refuses.

ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse shouldinstruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best?a. Both you and the father are equally responsible for passing it on.b. I can see you are upset. I can stay here with you a while if you like. c. Its not your fault; there is no way to know who will have this disease. d. There are many good treatments for sickle cell disease these days.

ANS: B The best response is for the nurse to offer self, a therapeutic communication technique that uses presence. Attempting to assign blame to both parents will not help the client feel better. There is genetic testing available, so it is inaccurate to state there is no way to know who will have the disease. Stating that good treatments exist belittles the clients feelings.

A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client?a. Impending brain herniationb. Poor prognosis and cognitive function c. Probable complete recoveryd. Unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?a. Documenting the events in the clients medical recordb. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies

ANS: B This client had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items is not related.

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best?a. Encourage high-protein foods.b. Perform a Hemoccult test on the clients stools. c. Offer frequent oral care.d. Prepare to administer cobalamin (vitamin B12).

ANS: B This client has laboratory findings indicative of iron deficiency anemia. The most common cause of this disorder is blood loss, often from the GI tract. The nurse should perform a Hemoccult test on the clients stools. High-protein foods may help the condition, but dietary interventions take time to work. That still does not determine the cause. Frequent oral care is not related. Cobalamin injections are for pernicious anemia.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best?a. Assess the clients magnesium level.b. Assess the clients sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client?a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodiumd. Mannitol (Osmitrol)

ANS: B This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self- management by teaching what principle of medical management? a. Infusions will be scheduled every 3 to 4 weeks. b. Treatment is aimed at treating specific infections. c. Unfortunately, there is no effective treatment. d. You will need many immunoglobulin A infusions.

ANS: B Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.

A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the clients fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

ANS: B, C, D, E The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

A nursing student learns that many drugs can impair the immune system. Which drugs does this include? (Select all that apply.) a. Acetaminophen (Tylenol)b. Amphotericin B (Fungizone) c. Ibuprofen (Motrin)d. Metformin (Glucophage) e. Nitrofurantoin (Macrobid)

ANS: B, C, E Amphotericin B, ibuprofen, and nitrofurantoin all can disrupt the hematologic (immune) system. Acetaminophen and metformin do not.

A nurse works in a gerontology clinic. What age-related changes cause the nurse to alter standard assessment techniques from those used for younger adults? (Select all that apply.) a. Dentition deteriorates with more cavities. b. Nail beds may be thickened or discolored. c. Progressive loss of hair occurs with age. d. Sclerae begin to turn yellow or pale. e. Skin becomes dry as the client ages.

ANS: B, C, E Common findings in older adults include thickened or discolored nail beds, dry skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques. Having more dental caries and changes in the sclerae are not normal age-related changes.

A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.)a. Headachesb. Night sweatsc. Persistent feverd. Urinary frequency e. Weight loss

ANS: B, C, E In this stage, the disease is located in a single lymph node region or a single nonlymph node site. The client displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related.

A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

ANS: B, C, E The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.

A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.)a. Azacitidine (Vidaza)b. Darbepoetin alfa (Aranesp) c. Decitabine (Dacogen)d. Epoetin alfa (Epogen)e. Methylprednisolone (Solu-Medro

ANS: B, D Darbepoetin alfa and epoetin alfa are both red blood cell colony-stimulating factors that will help increase the production of red blood cells. Azacitidine and decitabine are used for myelodysplastic syndromes. Methylprednisolone is a steroid and would not be used for this problem.

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometerb. Is allergic to acetaminophen (Tylenol) c. Laughing, says Strenuous? Whats that?d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a. Assess neurologic status with the Glasgow Coma Scale.b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest.d. Elevate the head of the bed to 45 degrees to prevent aspiration.e. Position the client supine with the head in a neutral midline position.

ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

A nurse is caring for four clients. After reviewing todays laboratory results, which client should the nurse see first? a. Client with an international normalized ratio of 2.8 b. Client with a platelet count of 128,000/mm3 c. Client with a prothrombin time (PT) of 28 seconds d. Client with a red blood cell count of 5.1 million/L

ANS: C A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding. The other values are within normal limits.

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority?a. Genetic testingb. Infection prevention c. Sperm bankingd. Treatment options

ANS: C All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis.

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?a. Apply ice packs to the clients legs.b. Elevate the clients legs on pillows. c. Keep the lower extremities warm.d. Place elastic bandage wraps on the clients legs.

ANS: C During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the clients legs will be cool or cold. The UAP can attempt to keep the clients legs warm. Ice and elevation will further decrease perfusion. Elastic bandage wraps are not indicated and may constrict perfusion in the legs.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?a. Chooses preferred items from the menub. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

ANS: C Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug. c. This drug helps treat the pain from nerve irritation. d. You are at risk for seizures due to fungal infections.

ANS: C Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best?a. Arrange a visitation schedule among friends and family.b. Explain that this process is difficult but must be endured. c. Help the client find things to hope for each day of recovery. d. Provide plenty of diversionary activities for this time.

ANS: C Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.

4. A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

ANS: C Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first?a. Client who has been diagnosed with meningitis with a fever of 101 F (38.3 C)b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

ANS: C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?a. I brush and use dental floss every day. b. I chew hard candy for my dry mouth. c. I usually put ice on bumps or bruises. d. Nonslip socks are best when I walk.

ANS: C The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?a. Inability to communicateb. Nutritional deficitc. Risk for acquiring an infectiond. Risk for skin breakdown

ANS: C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the clients medication list to determine if the client is taking which drug?a. Enoxaparin (Lovenox) b. Salicylates (aspirin)c. Unfractionated heparin d. Warfarin (Coumadin)

ANS: C This client has manifestations of heparin-induced thrombocytopenia. Enoxaparin, salicylates, and warfarin do not cause this condition.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority?a. Administer pain medication.b. Assess the clients vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

ANS: C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.

The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client?a. Can ambulate independentlyb. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

ANS: C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.

. A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.)a. Not allowing any visitors until engraftmentb. Limiting the protein in the clients diet c. Placing the client in protective precautionsd. Teaching visitors appropriate hand hygienee. Telling visitors not to bring live flowers or plants

ANS: C, D, E The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms. Limiting protein is not a healthy option and will not promote engraftment.

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a. Assist with oral hygiene using a firm toothbrush.b. Give the client an enema if he or she is constipated. c. Help the client choose soft foods from the menu.d. Shave the male client with an electric razor.e. Use a lift sheet when needed to re-position the client.

ANS: C, D, E This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft- bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hgb. Client who has a Glasgow Coma Scale score of 12c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102 F (38.9 C)

ANS: D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

ANS: D All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client?a. Bortezomib (Velcade)b. Dexamethasone (Decadron) c. Thalidomide (Thalomid) d. Zoledronic acid (Zometa)

ANS: D All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid (Zometa), which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately?a. Hematocrit: 25%b. Hemoglobin: 9.2 mg/dL c. Potassium: 3.2 mEq/Ld. White blood cell count: 38,000/mm3

ANS: D Although individuals with SCD often have elevated white blood cell (WBC) counts, this extreme elevation could indicate leukemia, a complication of taking hydroxyurea. The nurse should report this finding immediately. Alternatively, it could indicate infection, a serious problem for clients with SCD. Hematocrit and hemoglobin levels are normally low in people with SCD. The potassium level, while slightly low, is not as worrisome as the WBCs.

A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best?a. Because of immunosuppression, the donor cells take over.b. Its like a transfusion reaction because no perfect matches exist. c. The clients cells are fighting donor cells for dominance.d. The donors cells are actually attacking the clients cells.

ANS: D Graft versus host disease is an autoimmune-type process in which the donor cells recognize the clients cells as foreign and begin attacking them. The other answers are not accurate.

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present.b. The client is in a blast crisis and has too many WBCs.c. There must be a mistake; the WBCs should be very low.d. Those WBCs are abnormal and dont provide protection.

ANS: D In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best? a. It is due to side effects of medications for bronchodilation. b. It is from overactive bone marrow in response to chronic disease. c. It combats the anemia caused by an increased metabolic rate. d. It compensates for tissue hypoxia caused by lung disease.

ANS: D In response to hypoxia, more red blood cells are made so more oxygen can be carried and delivered to tissues. This is a physiologic process in response to the disease; it is not a medication side effect, the result of overactive bone marrow, or a response to anemia.

A client is having a radioisotopic imaging scan. What action by the nurse is most important? a. Assess the client for shellfish allergies. b. Place the client on radiation precautions. c. Sedate the client before the scan. d. Teach the client about the procedure.

ANS: D The nurse should ensure that teaching is done and the client understands the procedure. Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be radioactive and does not need radiation precautions. Sedation is not used in this procedure.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?a. Loss of bladder controlb. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

ANS: D The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest.

ANS: D This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the clients activity.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?a. Ensure that informed consent is on the chart.b. Document these findings in the clients record. c. Give the prescribed preprocedure sedation.d. Notify the provider of the findings immediately.

ANS: D This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client?a. Assess for bladder retention and/or incontinence.b. Listen to the clients lungs after eating or drinking. c. Prop the clients right side up when sitting in a chair.d. Rotate the clients meal tray when the client stops eating.

ANS: D This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunkcontrol.

The nurse assesses a clients oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods.c. Place the client in protective precautions. d. Teach the client about cobalamin therapy.

ANS: D This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need high- fiber foods or protective precautions.

A nurse is preparing to hang a blood transfusion. Which action is most important? a. Documenting the transfusionb. Placing the client on NPO statusc. Placing the client in isolation d. Putting on a pair of gloves

ANS: D To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.

An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

ANS: D Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important?a. Preparing to administer a blood transfusion b. Reinforcing the dressing and documenting findings c. Removing the dressing and assessing the surgical site d. Taking a set of vital signs and notifying the surgeon

ANS: D While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately. The client may or may not need a transfusion. Reinforcing the dressing is an appropriate action, but the nurse needs to do more than document afterward. Removing the dressing increases the risk of infection; plus, it is not needed since the nurse knows where the bleeding is coming from.

A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best? a. Encourage high-protein foods. b. Institute neutropenic precautions. c. Limit visitors to healthy adults. d. Place the client on safety precautions.

ANS: D With a platelet count between 40,000 and 80,000/mm3, clients are at risk of prolonged bleeding even after minor trauma. The nurse should place the client on safety precautions. High-protein foods, while healthy, are not the priority. Neutropenic precautions are not needed as the clients white blood cell count is not low. Limiting visitors would also be more likely related to a low white blood cell count.

A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-Pa, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) ____ mL/hr

ANS:1.4 mL/hr The client weighs 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the clients dose is 90 mg.10% of the dose is given as a bolus IV over the first minute (9 mg). That leaves 81 mg to run in over 59minutes., which rounds to 1.4 mL/hr.

A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activator (t-PA) alteplase (Activase). The client weighs 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) _____ mg

ANS:60 mg The dose of t-PA is 0.9 mg/kg with a maximum dose of 90 mg. The client weighs 66.4 kg.0.9 mg 66.4 = 59.76 mg, which rounds to 60 mg.