Acute Test 2: Evolve Questions

A client is admitted to the hospital with suspected Goodpasture's syndrome. Which findings does the nurse expect to observe? A. Bradycardia B. Hemoptysis C. Increased urine output D. Weight gain

B. Hemoptysis Hemoptysis (bloody sputum) is a manifestation of Goodpasture's syndrome. Goodpasture's syndrome usually is not diagnosed until serious lung and kidney problems are present.Tachycardia and not bradycardia, decreased and not increased urine output, and weight loss and not weight gain are manifestations of Goodpasture's syndrome.

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What electrolyte imbalance would the nurse monitor for after the blood transfusion? A. Hyponatremia B. Hyperkalemia C. Hypercalcemia D. Hypomagnesemia

B. Hyperkalemia The electrolyte imbalance the nurse needs to monitor after transfusing 2 units of blood to a postoperative client is hyperkalemia. During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products.High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.

A client who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action does the nurse take next? A. Infuse normal saline at 200 mL/hr. B. Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously. C. Discontinue infusing the antibiotic. D. Give diphenhydramine (Benadryl) 100 mg IV.

C. Discontinue infusing the antibiotic. The nurse's first action should be to discontinue the antibiotic. The antibiotic is the most likely cause of the client's apparent anaphylactic reaction.Infusing normal saline and administering epinephrine and diphenhydramine may be indicated, but these are not the nurse's first action.

Which client is at greatest risk for developing an infection? A. A 54-year-old man with hypertension B. A 17-year-old girl with a fractured tibia in a cast C. A 65-year-old woman who had coronary bypass surgery 4 days ago D. A 71-year-old man in a nursing home

C. A 65-year-old woman who had coronary bypass surgery 4 days ago Older clients such as the 65-year-old people with decreased vascularity to the integumentary system (from the bypass surgery) and compromised skin (surgical incision) are at risk for infection.No coexisting conditions are present for the client with hypertension to be at risk for infection. The 71-year-old client in a nursing home is not at highest risk because no coexisting conditions make this client most vulnerable to infection.

When preparing a client for allergy testing, the nurse provides the client with which instruction? A. "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." B. "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." C. "Aspirin in a low dose may be taken before testing." D. "You can take antihistamine nasal sprays before testing."

A. "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." The nurse should tell the client that, "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." Systemic glucocorticoids and antihistamines are discontinued 2 weeks before the test for this reason.Nasal sprays like fluticasone propionate (Flonase) to reduce mucous membrane swelling are permitted, except for sprays that contain an antihistamine. Allergists recommend that aspirin be withheld before testing.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications? A. "I am here to receive the yearly pneumonia shot again." B. "I am here to get my yearly flu shot again." C. "I should avoid large gatherings during cold and flu season." D. "I should cough into my upper sleeve instead of my hand."

A. "I am here to receive the yearly pneumonia shot again." The statement by the client, "I am here to receive the yearly pneumonia shot again" indicates a need for further teaching. The CDC recommends that adults older than 65 years be vaccinated with two vaccines, first with Prevnar 13 followed by Pneumovax about 6 to 12 months later. Adults who have already received the Pneumovax would have Prevnar 13 about a year or more later, but not annually.Older clients are encouraged to receive a flu shot annually because the vaccine is formulated annually, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. Recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

The nurse is teaching a client with newly diagnosed anemia about conserving energy. Which instructions would the nurse give to the client? Select all that apply. A. "Provide yourself with four to six small, easy-to-eat meals daily." B. "Perform your care activities in groups to conserve your energy." C. "Stop activity when shortness of breath or palpitations is present." D. "Allow others to perform your care during periods of extreme fatigue." E. "Drink small quantities of protein shakes and nutritional supplements daily." F. "Perform a complete bath daily to reduce your chance of getting an infection."

A. "Provide yourself with four to six small, easy-to-eat meals daily." C. "Stop activity when shortness of breath or palpitations is present." D. "Allow others to perform your care during periods of extreme fatigue." E. "Drink small quantities of protein shakes and nutritional supplements daily." Having four to six small meals daily is preferred over three large meals. This practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical. It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status.A complete bath needs to be performed only every other day. On days in between, the client can be taught to take a "mini" sponge bath, which will conserve energy and still be safe in preventing the risks for infection. Care activities would be spaced every hour or so rather than in groups to conserve energy. Care activities need to be avoided just before and after meals.

Which client does the medical unit charge nurse assign to a licensed practical nurse (LPN)/licensed vocational nurse (LVN)? A. A client with chronic microcytic anemia associated with alcohol use B. A client scheduled for a bone marrow biopsy with conscious sedation C. A client with a history of a splenectomy and a temperature of 100.9°F (38.3°C) D. A client with atrial fibrillation and an international normalized ratio of 6.6

A. A client with chronic microcytic anemia associated with alcohol use The medical unit charge nurse assigns the LPN/LVN a client with chronic microcytic anemia related to alcohol use. Chronic microcytic anemia is not considered life-threatening and is within the skill level of an LPN/LVN.The client with a bone marrow biopsy with conscious sedation, a history of splenectomy and a temperature, and atrial fibrillation require more complex assessment or nursing care and would be assigned to RN staff members.

Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is correct? A. Antibiotics have been given to clients for conditions that do not require antibiotics. B. Microorganisms are more susceptible to antibiotics today than when they were given years ago. C. Additional precautions are taken, along with Standard Precautions, to prevent infection. D. Most antibiotics are effective for infection.

A. Antibiotics have been given to clients for conditions that do not require antibiotics. Antibiotics have often been prescribed for conditions that do not require them, or have been given at higher doses or for longer periods of time than needed. As a result, a number of microorganisms have become resistant to certain antibiotics.Microorganisms are more resistant to certain antibiotics. Strictly adhered-to Standard Precautions are adequate to prevent infection. Most antibiotics are not effective for every infection.

The community health nurse is planning treatment for multi-drug resistant tuberculosis for a client who is addicted to heroin. Which action will be most effective in ensuring that the client completes treatment? A. Arrange for a health care worker to observe the client take the medication. B. Give the client written instructions about how to take prescribed medications. C. Have the client repeat medication names and side effects. D. Instruct the client about the possible consequences of nonadherence.

A. Arrange for a health care worker to observe the client take the medication. The most effective action for the nurse to take to ensure that the client completes the treatment is to arrange for the client to be directly observed during therapy. The client is unlikely to adhere to long-term treatment unless closely supervised while taking medications.Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless and addicted to opiates would most likely be more concerned with obtaining drugs and shelter than with properly taking his or her medication.

The nurse is assessing a client with suspected serum sickness. Which symptoms are consistent with serum sickness? Select all that apply. A. Arthralgia B. Blurred vision C. Lymphadenopathy D. Malaise E. Ptosis

A. Arthralgia C. Lymphadenopathy D. Malaise Serum sickness is a group of symptoms that occur after receiving serum or certain drugs. Symptoms include arthralgia (achy joints), lymphadenopathy (enlarged lymph nodes), fever, rash, malaise, and possibly polyarthritis and nephritis.Blurred vision and ptosis are not symptoms of serum sickness.

A client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? A. Epinephrine (Adrenalin) B. Fexofenadine (Allegra) C. Cromolyn sodium (Nasalcrom) D. Zileuton (Zyflo)

A. Epinephrine (Adrenalin) The most appropriate drug for the nurse to give in this situation is epinephrine (Adrenalin). The client is experiencing an anaphylactic reaction, and epinephrine is a first-line sympathomimetic drug used to treat anaphylaxis.Fexofenadine (Allegra) is a nonsedating antihistamine and is not a first-line drug to treat anaphylaxis. Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug used to prevent symptoms of allergic rhinitis. It is not useful during an acute episode. Zileuton (Zyflo) is a leukotriene antagonist also used to prevent symptoms of allergic rhinitis, but is also not useful during an acute episode.

A client is prescribed prednisone for treatment of a type I hypersensitivity reaction. The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Fluid retention B. Gastric distress C. Hypotension D. Infection E. Osteoporosis

A. Fluid retention B. Gastric distress D. Infection E. Osteoporosis Prednisone is a corticosteroid that may cause fluid and sodium retention. It can cause gastric distress and irritation and usually is taken with food or an antacid. Prednisone decreases the immune response, increasing the susceptibility for infection. It can also cause osteoporosis.Hypertension (not hypotension) is an adverse effect of prednisone.

An 82-year-old client with anemia is prescribed 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? Select all that apply. A. Hypotension B. Hypertension C. Decreased pallor D. Rapid, bounding pulse E. Flattened superficial veins F. Capillary refill less than 3 seconds

A. Hypotension B. Hypertension D. Rapid, bounding pulse The assessment findings that are unsafe for the nurse to continue the blood transfusion for the client are: hypotension, hypertension, and rapid, bounding pulse. In an older adult receiving a transfusion, low blood pressure is a sign of a transfusion reaction, hypertension is a sign of overload, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic.Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem.

The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow for administering this blood product? A. Infuse the transfusion over a 15- to 30-minute period. B. Set up the infusion with the standard transfusion Y tubing. C. Give intravenous corticosteroids before starting the transfusion. D. Allow the platelets to stabilize at the client's bedside for 30 minutes.

A. Infuse the transfusion over a 15- to 30-minute period. The procedure the nurse follows to administer platelets to a hematopoietic stem cell transplant is to infuse the transfusion over a 15-to-30-minute period. The volume of platelets—200 or 300 mL (standard amount)—needs to be infused rapidly over a 15- to 30-minute period.A special transfusion set with a smaller filter and shorter tubing is used to get the platelets into the client quickly and efficiently. Administering steroids is not standard practice in administering platelets. Platelets must be administered immediately after they are received because they are considered to be quite fragile.

The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention would the nurse implement first? A. Obtain prescribed blood cultures. B. Place the client on Bleeding Precautions. C. Initiate the administration of prescribed antibiotics. D. Give 1000 mL of IV normal saline to hydrate the client.

A. Obtain prescribed blood cultures. The intervention the nurse would first implement is to draw prescribed blood cultures. Obtaining blood cultures to identify the infectious agent correctly is the priority for this client.Placing the client on Bleeding Precautions is unnecessary. Administering antibiotics is important, but antibiotics must always be started after cultures are obtained. Hydrating the client is not the priority.

Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) working on a medical-surgical unit? A. Obtain vital signs on a client receiving a blood transfusion B. Assist a client with folic acid deficiency in making diet choices C. Administer erythropoietin to a client with myelodysplastic syndrome D. Assess skin integrity on an anemic client who fell during ambulation

A. Obtain vital signs on a client receiving a blood transfusion The appropriate task for the nurse to delegate to a UAP is obtaining vital signs on a client receiving a blood transfusion. This activity is within the scope of practice for UAPs.Assisting with prescribed diet choices, administering medication, and assessing clients are complex actions that must be done by licensed nurses.

The nurse is performing an assessment on a client with anemia. What are the typical clinical manifestations of anemia? Select all that apply. A. Pallor B. Fatigue C. Tachycardia D. Dyspnea on exertion E. Elevated temperature F. Decreased breath sounds

A. Pallor B. Fatigue C. Tachycardia D. Dyspnea on exertion The typical clinical manifestations of anemia are: pallor, fatigue, tachycardia, and dyspnea on exertion. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth. Fatigue is a classic symptom of anemia because lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body.Respiratory problems with anemia do not include changes in breath sounds. Skin is cool to the touch, and an intolerance to cold is noted. Elevated temperature would signify something additional, such as infection.

The nurse is caring for a client who is in sickle cell crisis. What action would the nurse perform first? A. Provide pain medications as needed. B. Apply cool compresses to the client's forehead. C. Increase food sources of iron in the client's diet. D. Encourage the client's use of two methods of birth control.

A. Provide pain medications as needed. The action the nurse would perform first for a client in sickle cell crisis is to provide pain medications as needed. Analgesics are needed to treat sickle cell pain.Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.

The nurse is assessing several clients who are receiving transfusions of blood components. Which assessment finding requires immediate action by the nurse? A. Respiratory rate of 36 breaths/min in a client receiving red blood cells B. Temperature of 99.1°F (37.3°C) for a client with a platelet transfusion C. Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication D. A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP)

A. Respiratory rate of 36 breaths/min in a client receiving red blood cells The assessment finding that requires immediate action by the nurse is a respiratory rate of 36 breaths/min in a client receiving red blood cells. An increased respiratory rate indicates a possible hemolytic transfusion reaction. The nurse must quickly stop the transfusion and assess the client further.Temperature elevations are not an indication of an allergic reaction to a platelet transfusion, although the nurse may administer acetaminophen (Tylenol) to decrease the fever. Sleepiness is expected when Benadryl is administered. Because FFP is not usually given until the PTT is 1.5 times above normal, a PTT that is 1.2 times normal indicates that the FFP has had the desired response.

A client recently admitted to the hospital with a UTI is to receive the first dose of an antibiotic intravenously. Before checking the five rights prior to administration, what is the nurse's first action? A. Review the clinical records and ask the client about any known allergies. B. Check with the pharmacy for any known allergies for this client. C. Check the client's identification band for any allergies. D. Ask the nurse who previously cared for the client about any known allergies.

A. Review the clinical records and ask the client about any known allergies. The nurse's first action is to check the client's clinical record for any known hypersensitivities as well as asking the client about any known allergies.The pharmacy is not responsible for obtaining information on all of the client's known allergies. Checking the client's identification band for allergies is part of the "five rights" process at the bedside before the medication is given. Asking the previous nurse is not an appropriate safety measure before medication administration.

A client who is receiving a blood transfusion suddenly tells the nurse, "I don't feel right!" What is the nurse's first action? A. Stop the transfusion. B. Call the Rapid Response Team. C. Slow the infusion rate of the transfusion. D. Obtain vital signs and continue to monitor.

A. Stop the transfusion. The nurse's first action when a client receiving a blood transfusion says, "I don't feel right," is to stop the transfusion. The client may be experiencing a transfusion reaction, so the nurse must stop the transfusion immediately.Calling the Rapid Response Team or obtaining vital signs is not the first thing that must be done. The nurse would not slow the infusion rate but would stop it altogether.

The nurse is providing education for a client who is taking isoniazid, rifampin, and ethambutol for tuberculosis. Which of these points does the nurse include in the plan of care? Select all that apply. A. Take a supplement containing B vitamins. B. Avoid alcohol containing beverages. C. Have kidney function tests monthly. D. Report changes in vision to the health care provider. E. Notify the health care provider for red-orange urine.

A. Take a supplement containing B vitamins. B. Avoid alcohol containing beverages. D. Report changes in vision to the health care provider. Teach the client to take a daily multiple vitamin that contains the B-complex vitamins while on this drug as deficiency may occur. These medications can cause liver damage, which is potentiated by alcohol. Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Contact lenses will also be stained and oral contraceptives will be less effective.Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless and expected. Both isoniazid and pyrazinamide may cause liver failure. Side effects of major concern include jaundice, bleeding, and abdominal pain.

Which information does the nurse include when teaching a client about antibiotic therapy for infection? A. Take all antibiotics as prescribed, unless side effects develop. B. Take antibiotics until symptoms subside, and then stop taking the drugs. C. Take antibiotics when symptoms of infection develop. D. Share antibiotics with family members who develop the same infection.

A. Take all antibiotics as prescribed, unless side effects develop. Antibiotics should be taken as prescribed until they are gone. Teach the client about possible side effects and allergic manifestations. The provider must be contacted immediately if any side effects develop.Antibiotics must be taken until they are gone, even if the client feels better or when symptoms of infection appear. They should be taken only by the person for whom they are prescribed and not shared with anyone else.

The nurse is mentoring a recent graduate registered nurse (RN) about administering blood and blood products. What action does the nurse perform before starting the transfusion? A. Verify with another RN all of the data on blood products. B. Use a 22-gauge needle to obtain venous access when starting the infusion. C. Remain with the client who is receiving the blood for the first 5 minutes of the infusion. D. Obtain the client's initial set of vital signs (VS) within the first 10 minutes of the infusion.

A. Verify with another RN all of the data on blood products. Before administering blood and blood products, the nurse must verify with another RN all of the data on blood products. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities when administering blood and blood products.A 20-gauge needle (or a central line catheter) is used. The 22-gauge needle is too small. Initial VS must be recorded before the start of infusion of blood, not after it has begun. The nurse remains with the client for the first 15 to 30 minutes (not 5) of the infusion. This is the period when any transfusion reactions are likely to happen.

While in the hospital, the client has developed a methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? A. Wear a gown and gloves to prevent contact with the client or client-contaminated items. B. Assign the client to a private room with a negative airflow. C. Wear a mask when working within 3 feet (91 cm) of the client. D. Have the client wear a surgical mask when being transported out of the room.

A. Wear a gown and gloves to prevent contact with the client or client-contaminated items. Caregivers should wear a gown and gloves to prevent contact with the client or contaminated items when caring for a client with this infection. This is the best way to prevent the spread of infection. Gloves should also be worn when entering the room.A private room is preferred for this client. If a private room is not available, the client may be cohorted with another client with the same active infection and with the same microorganisms if no other infection is present. The client does not require respiratory isolation and does not need to wear a surgical mask when being transported out of the room because the infection is not airborne. Use of a mask is not the best way to prevent the spread of this infection.

The nurse is educating a group of young women who have sickle cell disease (SCD). Which statement from a class member indicates further teaching is necessary? A. "The pneumonia vaccine is protection that I need." B. "Getting an annual 'flu shot' would be dangerous for me." C. "I must take my penicillin pills as prescribed, all the time." D. "Frequent handwashing is an important habit for me to develop."

B. "Getting an annual 'flu shot' would be dangerous for me." Further teaching is needed when a young women with sickle cell disease says, "Getting an annual 'flu shot' would be dangerous for me." The client with SCD can receive annual influenza and pneumonia vaccinations. This helps prevent the development of these infections, which could cause a sickle cell crisis.The pneumonia vaccine is also appropriate for the client with sickle cell disease to receive. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection.

The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question would the nurse ask the client? A. "Can you prepare your own meals every day?" B. "How is your energy level compared with last year?" C. "Has your weight changed by 5 pounds (2.3 kg) or more this year?" D. "What medications do you take daily, weekly, and monthly?"

B. "How is your energy level compared with last year?" The question the nurse needs to ask the client about endurance in performing ADLs is "How is your energy level compared with last year"? Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. It is most likely to provide data about the client's ability and endurance for ADLs.The client may never have been able to prepare his or her own meals, and the ability to prepare meals does not really address endurance. The question about weight change addresses nutrition and metabolic needs, rather than ADL performance. The question about how often the client takes medication addresses nutrition and metabolic needs and focuses on health maintenance through the use of drugs, not on the client's ability to perform ADLs.

The nurse is teaching a client who is preparing for discharge after a bone marrow aspiration. The nurse provides which discharge instructions to the client? A. "Inspect the site for bleeding every 4 to 6 hours." B. "Place an ice pack over the site to reduce the bruising." C. "Avoid contact sports or activity that may traumatize the site for 24 hours." D. "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."

B. "Place an ice pack over the site to reduce the bruising." Discharge instructions after a bone marrow include placing an ice pack over the site to reduce bruising. Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure.The client must carefully monitor the site every 2 hours for the first 24 hours after the procedure. Contact sports and traumatic activity must be excluded for 48 hours, or 2 days. A mild analgesic is appropriate, but it needs to be aspirin-free. Acetaminophen (Tylenol) would be a good choice.

An older client presents to the emergency department with a 2-day history of cough, pain, wheezing, and dyspnea. The medical record states the client has not received the pneumococcal vaccine. While collaborating with the interprofessional team, which one of these medications does the nurse anticipate the health care provider will recommend as the priority? A. Corticosteroid B. Beta agonist C. Pneumococcal vaccine D. Antibiotic

B. Beta agonist The priority medication the nurse would expect the HCP to order is a beta-2 agonist or bronchodilator to help decrease bronchospasm and wheezing. This medication allows for adequate oxygenation by relaxing bronchial smooth muscle in the airways, and acts quickly to maintain airway patency.A corticosteroid will decrease airway swelling but takes many hours to days to become effective. A diagnosis of pneumonia has not been validated. However, if documented, the client should receive pneumococcal vaccine as an inpatient The anti-infective medication may be ordered after the cause of the symptoms is determined, but restoring adequate airway patency and reducing dyspnea take priority.

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? A. "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." B. "The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." C. "It results in release of mediators, especially histamine, because of the reaction of immunoglobulin E (IgE) antibody on mast cells." D. "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."

B. "The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." The best statement by the student describing type IV hypersensitivity reaction is that the reaction of sensitized T cells with antigen and release of lymphokines is a delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity).A reaction of IgG with the host cell membrane or antigen describes a type II hypersensitivity reaction. A release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells describes a type I hypersensitivity reaction. An immune complex of antigen and antibodies deposited in the walls of blood vessels describes a type III hypersensitivity reaction.

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information would the nurse explain to the parents about the risk of a child having sickle cell disease? A. "Sickle cell disease will be inherited by your children." B. "The sickle cell trait will be inherited by your children." C. "Your children will have the disease, but your grandchildren will not." D. "Your children will not have the disease, but your grandchildren could."

B. "The sickle cell trait will be inherited by your children." The statement that explains to parents about the risk of a child having sickle cell disease is that the children of the client with sickle cell disease will inherit the sickle cell trait but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.The children of the client with sickle cell disease will inherit the sickle cell trait but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.

A client with thrombocytopenia is being discharged. Which instruction would the nurse include in a teaching plan for this client? A. "Avoid large crowds." B. "Use a soft-bristled toothbrush." C. "Drink at least 2 L of fluid per day." D. "Elevate your lower extremities when sitting."

B. "Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia.Avoiding large crowds reduces the risk for infection but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration but is not particularly relevant to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema but is not specific to the client with thrombocytopenia.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? A. "You will not spread the disease unless you stop taking your medication." B. "You will not pose an increased risk of disease to the people you have been living with." C. "You will have to take these medications for at least 1 year." D. "Your sputum may turn a rust color as your condition gets better."

B. "You will not pose an increased risk of disease to the people you have been living with." The nurse tells the client that he/she will not be contagious to the people he/she lives with. The people the client has been living with have already been exposed and need to be tested. They cannot become at higher risk simply because the diagnosis has now been confirmed.The client with active tuberculosis is contagious, even while taking medication. However, the risk for transmission is reduced after the infectious person has received proper drug therapy for 2 to 3 weeks, clinical improvement occurs, and acid-fast bacilli (AFB) in the sputum are reduced. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

The nurse is starting the shift by making rounds. Which client would the nurse assess first? A. A 52-year-old who just had a bone marrow aspiration and is requesting pain medication B. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism C. A 47-year-old who had a Rumpel-Leede test and asks the nurse to "look at the bruises on my arm" D. A 42-year-old with a diagnosis of anemia who reports shortness of breath when ambulating down the hallway

B. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism After rounds, the nurse would first assess the 59-year-old client who has a nosebleed and is getting heparin to treat a pulmonary embolism. The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and must be assessed first for the severity of the situation.The client waiting for pain medication would be next on the nurse's "to do" list. Making clients wait for pain medication is not desirable, but in this scenario, the client who is bleeding is the higher priority. The client who had a Rumpel-Leede test and the client with anemia are more stable and can be assessed later. The Rumpel-Leede test is a tourniquet test used to determine the presence of vitamin C deficiency or thrombocytopenia.

A client has a bone marrow biopsy performed. What is the priority postprocedure nursing action? A. Inspect the site for ecchymosis B. Apply pressure to the biopsy site C. Send the biopsy specimens to the laboratory D. Teach the client to avoid vigorous activity

B. Apply pressure to the biopsy site The priority postprocedure action after a bone marrow biopsy would be to stop bleeding by applying pressure to the site.Inspecting for ecchymosis, sending specimens to the laboratory and teaching the client about activity levels will be done after hemostasis has been achieved.

A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effect? A. Bradycardia B. Headache C. Infection D. Metabolic alkalosis

B. Headache A client complaint of a headache is an adverse effect of norepinephrine (Levophed). This drug is a vasopressor and can cause headache.Norepinephrine does not suppress the immune system. Tachycardia, not bradycardia, and metabolic acidosis, not alkalosis, are adverse effects of norepinephrine.

The registered nurse receives report on four clients on a medical-surgical unit. Which of these clients will the charge nurse assign to the LPN/LVN? A. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor B. Client with pulmonary tuberculosis who is receiving multiple medications C. Client with sinusitis who has just arrived after having endoscopic sinus surgery D. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

B. Client with pulmonary tuberculosis who is receiving multiple medications The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Each state designates which tasks may be safely delegated and assigned to nursing team members. Depending on the state's nurse practice act, licensed practical/vocational nurses (LPNs/LVNs) and technicians may be trained and undergo competency verification related to the skill of peripheral IV insertion and assistance with infusions. The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks (Infusion Nurses Society [INS], 2016; Weinstein & Hagle, 2014).Stridor, a harsh respiratory sound, is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful swallowing and respiratory assessment and monitoring by the RN.

The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia, typical to older adults, does the nurse assess? A. Bradycardia B. Confusion C. Eupnea D. Pale skin

B. Confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present.Symptoms of pneumonia include flushing, not pale skin, anxiety, chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, not bradycardia, dyspnea, tachypnea not eupnea, hemoptysis, and sputum production. Severe chest muscle weakness also may be present from sustained coughing. Crackles, wheezing may be heard over areas of fluid, decreased breath sounds are present and wheezing may be heard where the airways are narrowed by exudate.

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? A. Grains B. Dairy products C. Leafy vegetables D. Starchy vegetables

B. Dairy products The nurse encourages the client to eat dairy products such as milk, cheese, and eggs. These foods will provide the vitamin B12 that the client needs. Grains, leafy vegetables, and starchy vegetables are not a source of vitamin B12.

Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? A. Feeling tired and having a temperature that runs about 100° F (37.8° C) during the day B. Disfiguring and embarrassing rash C. Peripheral neuropathies and cranial nerve palsies D. High risk for renal inflammation

B. Disfiguring and embarrassing rash Skin lesions associated with disfiguring and embarrassing rash are common to SLE and DLE.

A client with aspiration pneumonia occurring after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? A. Administer levofloxacin (Levaquin) 500 mg IV. B. Draw aerobic and anaerobic blood cultures. C. Give lorazepam (Ativan) as needed for agitation. D. Refer to social worker for alcohol counseling.

B. Draw aerobic and anaerobic blood cultures. The nurse would first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed. Getting cultures to identify the causative organism before initiating an antibiotic could affect the results of the culture and the type of antibiotic used.Levofloxacin, an antibiotic, is a priority intervention, and would be done after cultures are drawn. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action. Other interventions to help control the agitation may be tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.

The community health nurse is collaborating with the local health department on containment of an anticipated pandemic influenza outbreak. The nurse advises the health department that the best method to prevent outbreaks of pandemic influenza is which of these? A. Avoiding public gatherings at all times B. Early recognition and quarantine of affected persons C. Vaccinating community members with pneumonia vaccine D. Widespread distribution of antiviral drugs

B. Early recognition and quarantine of affected persons Early recognition and quarantine of affected persons is the best way to prevent outbreaks of pandemic influenza. The recommended approach to disease prevention consists of quick recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus.Public gatherings need to be avoided only in the case of widespread outbreak of influenza in the community. A vaccine (Vepacel) is available in case of H5N1 outbreaks, but is stockpiled and not part of general influenza vaccination. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.

Which statement about handwashing is in accordance with recommendations by the Centers for Disease Control and Prevention? A. If gloves are worn between treatments for clients sharing a room, handwashing is not necessary until the nurse has finished assessing the second client. B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. C. Handwashing does not need to be done after resetting a client's IV pump. D. If the hands are not visibly soiled, washing the hands is not necessary.

B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. Microorganisms that can be transmitted to another client can be found on intact skin.Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, any equipment connected to the client, and contaminated items; immediately after removing gloves; and between client contacts.

Which actions aid in the prevention and early detection of infection in a client at risk? Select all that apply. A. Inspect the skin for coolness and pallor. B. Promote sufficient nutritional intake. C. Encourage fluid intake, as appropriate. D. Monitor the red blood cell (RBC) count. E. Obtain cultures as needed. F. Remove unnecessary medical devices.

B. Promote sufficient nutritional intake. E. Obtain cultures as needed. F. Remove unnecessary medical devices. Promoting sufficient nutritional intake helps prevent and detect early infection in at risk clients. Nutrition has a direct correlation to improvement of general health. Malnutrition, especially protein-calorie malnutrition, places clients at increased risk for infection. Blood cultures would be used to detect a possible systemic infection. Advocating for the removal of unnecessary medical devices (e.g., intravascular or urinary catheters, endotracheal tubes, synthetic implants) may also interfere with normal host defense mechanisms and may help prevent infection.Inspecting the skin does not prevent or detect systemic infections. Fluid intake is important but does not directly relate to prevention or detection of infection. Monitoring the RBC count does not prevent, nor would it detect, infection.

Which intervention is the most appropriate to address the priority problem of feelings of isolation when caring for a client who is placed on Transmission-Based Precautions? A. Encourage family and friends to call the client. B. Provide education on the mode of transmission of infection. C. Encourage the client to watch television. D. Ask a certified hospital chaplain to visit the client.

B. Provide education on the mode of transmission of infection. Education is the most appropriate and main intervention for addressing a client's feeling of isolation when placed on Transmission-Based Precautions. It is important to teach the client and family about the mode of transmission and mechanisms that prevent spread to others. The nurse needs to assess coping mechanisms that the client has used in the past.Encouraging phone calls and distraction activities like watching television may be effective interventions. Engaging a certified hospital chaplain to visit the client may help alleviate the client's stress, anxiety, or depression.

A client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? A. Taking the antibiotic before jogging 2 miles daily B. Taking the antibiotic most days C. Taking the antibiotic as prescribed D. Taking the antibiotic with a full glass of water

B. Taking the antibiotic most days Antibiotics not taken as prescribed can result in recurring symptoms, as well as the development of drug-resistant infections and other emerging infections.Taking the antibiotic before jogging is not a contributing factor to the client's relapse. The client who is taking antibiotics as prescribed is not likely to develop recurring symptoms. Taking antibiotics with a full glass of water is a positive action and neither hinders nor promotes antimicrobial therapy.

The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target? Select all that apply. A. Breast cancer survivors B. Those in the local prison C. Homeless adults D. Recent immigrants to the United States D. Those who have received bacille Calmette-Guérin (BCG) vaccine

B. Those in the local prison C. Homeless adults D. Recent immigrants to the United States The groups the nurse plans to educate include those adults who live in crowded areas such as prisons and homeless shelters, and those who are recent immigrants to the USA. Other groups at higher risk for tuberculosis include those who abuse injection drugs or alcohol and those groups of lower socioeconomic status.Breast cancer survivors who are no longer undergoing immunocomprising therapy have the same risk as the general population. Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.

The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that the client has an infection or an infection needs to be ruled out? A. Evidence of pus B. Wheezes or crackles C. Fever of 102°F (38.9°C) or higher D. Coughing and deep breathing

B. Wheezes or crackles The clinical manifestation that indicates the client with neutropenia has an infection or an infection that needs to be ruled out is wheezes or crackles. Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs.Coughing and deep breathing are not indications of infection but can help prevent it. The client with leukopenia, not neutropenia, may have a severe infection without pus or with only a low-grade fever.

The nurse is caring for a group of hospitalized clients. Which client is at highest risk for infection and sepsis? A. A client with hemolytic anemia B. A client with cirrhosis of the liver C. A client who had an emergency splenectomy D. A client with recently diagnosed sickle cell anemia

C. A client who had an emergency splenectomy The client who is at the highest risk for infection and sepsis is the client who had an emergency splenectomy. Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms and is at increased risk for infection.A low red blood cell count with hemolytic anemia can contribute to a client's risk for infection, but this client is more at risk for low oxygen levels and ensuing fatigue. The liver plays a role in blood coagulation, so this client is more at risk for coagulation problems than for infection. Sickle cell anemia causes pain and discomfort because of the changed cell morphology, so acute pain, especially at joints, is the greatest threat to this client.

A hematology unit is staffed by registered nurse's (RNs), licensed practical nurses (LPNs)/licensed vocational nurse (LVNs), and unlicensed assistive personnel (UAP). When the nurse manager is reviewing staff documentation, which entry indicates the need for staff education for his or her appropriate level of responsibility and client care? A. "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" B. "Ambulated in hallway for 40 feet (12 m) and denies shortness of breath at rest or with ambulation. T.Y., LPN" C. "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" D. "Vital signs 98.6°F (37.0°C), heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"

C. "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" The documentation entry that needs education is the one from the UAP that states that the "client reports increased shortness of breath and that oxygen was increased to 4 L by nasal cannula." Determination of the need for oxygen and administration of oxygen must be done by licensed nurses who have the education and scope of practice required to administer it.All other documentation entries reflect appropriate delegation and assignment of care.

The nurse is assessing a client for hematologic risks. Which health history question would the nurse ask to determine if the risk cannot be reduced or eliminated? A. "Where do you work?" B. "Tell me what you eat in a day." C. "Does anyone in your family bleed a lot?" D. "Do you seem to have excessive bleeding or bruising?"

C. "Does anyone in your family bleed a lot?" To determine if hematologic risks exist while obtaining a health history from a client, the nurse asks if anyone in the client's family bleeds a lot. An accurate family history is important because many disorders that affect blood and blood clotting are inherited. Genetics cannot be changed.Work habits can be a risk, such as working near radiation, but these are behaviors that can be changed. Diet can affect risk, but it is a health behavior that can be changed.Excessive bleeding or bruising is a symptom, not a risk.

Which client statement indicates in-home stem cell transplantation is not a viable option? A. "We live 5 miles from the hospital." B. "I will have lots of medicine to take." C. "I was a nurse, so I can take care of myself." D. "I don't feel strong enough, but my wife said she would help."

C. "I was a nurse, so I can take care of myself." The client statement that indicates that in-home stem cell transplantation is not a viable option is "I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting requires support, assistance, and coordination from others. The client cannot manage this type of care on his own.It is acceptable for the client's spouse to support the client undergoing this procedure. It is not unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance from the hospital, in case of emergency.

A client on anticoagulant therapy is being discharged. Which statement by the client indicates an understanding of the anticoagulants drug action? A. "It will thin my blood." B. "It is used to dissolve blood clots." C. "It should prevent my blood from clotting." D. "It might cause me to get injured more often."

C. "It should prevent my blood from clotting." The statement that shows the client understands anticoagulant drug action is, "it will prevent my blood from clotting." Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade. Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots.Anticoagulants do not cause any change in the thickness or viscosity of the blood.Anticoagulants do not dissolve clots, fibrinolytics do. Anticoagulants do not cause more injuries but may cause more bleeding and bruising when the client is injured.

A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" Which is the nurse's best response to the client? A. "Yes, they do." B. "No, they don't." C. "The number varies with gender, age, and general health." D. "You have fewer red blood cells because you have anemia."

C. "The number varies with gender, age, and general health." The nurse's best response to the client with anemia about most people having the same number of blood cells is, "The number varies with gender, age, and general health." This statement is the most educational and reasonable response to the client's question.Responding "yes, they do." and "no, they don't." are not educational statements. Although telling the client that people do not have the same number of RBCs is true, it is not informative, and there is a better answer. While it may be true that the client has fewer red blood cells because of anemia, it does not answer the client's general question.

The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A. "The doctor will place a small needle in your back and will withdraw some fluid." B. "You will be sedated during the procedure, so you will not be aware of anything." C. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." D. "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area."

C. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." When describing a bone marrow biopsy procedure to a client, it is accurate to describe a crunching sound or scraping sensation when the needle punctures the bone. Proper expectations minimize the client's fear during the procedure.A very large-bore needle is used for a bone marrow biopsy, not a small needle, and the puncture is made in the hip or in the sternum, not the back. A local anesthetic agent is injected into the skin around the site. The client may also receive a mild tranquilizer or a rapid-acting sedative (such as lorazepam [Ativan]) but will not be completely sedated. The nurse, or sometimes a family member, is available to the client for support during a bone marrow biopsy. The procedure is sterile at the site of the biopsy, but others can be present without contamination at the site.

After reviewing the laboratory test results, the nurse calls the primary care provider about which client? A. A 52-year-old who had a hemorrhage with a reticulocyte count of 0.8% B. A 49-year-old with hemophilia and a platelet count of 150,000/mm3 (150 × 109/L) C. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) D. A 44-year-old prescribed warfarin (Coumadin) with an international normalized ratio (INR) of 3.0

C. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) The nurse calls the PCP about a 46-year-old client with a fever and a WBC of 1500/mm3 (1.5 × 109/L). This client is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed.An elevated reticulocyte count in the 52-year-old is expected after hemorrhage. A platelet count of 150,000/mm3 (150 × 109/L) in the 49-year-old is normal. The INR of 3.0 in the 44-year-old indicates a therapeutic warfarin level.

Which nurse does the charge nurse assign to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A. An experienced LPN/LVN who has worked on the medical unit for 10 years B. An RN with experience in the operating room who transferred a month ago to the medical unit C. A float RN with 7 years of experience on the inpatient oncology unit D. An RN who has worked mostly on the same-day surgery unit since graduating a year ago

C. A float RN with 7 years of experience on the inpatient oncology unit The float RN with experience on the inpatient oncology unit would be familiar with complications and assessment for IV fluids and pneumonia.LPN/LVNs do not have the scope of practice to provide care to this client. The RN with experience in the operating room or the RN who has worked mostly on the same-day surgery unit does not have the experience needed to care for an unstable client on an unfamiliar unit.

The nurse is transfusing a unit of whole blood to a client when the primary health care provider prescribes "Furosemide (Lasix) 20 mg IV push." Which intervention would the nurse perform? A. Piggyback the furosemide into the infusing blood. B. Give furosemide to the client intramuscularly (IM). C. Administer the furosemide after completion of the transfusion. D. Add furosemide to the normal saline that is infusing with the blood.

C. Administer the furosemide after completion of the transfusion. Completing the transfusion before administering furosemide is the best course of action in this scenario.Drugs are not to be administered with infusing blood products, because they can interact with the blood, causing risks for the client. Changing the admission route is not a nursing decision. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision.

The nurse plans to assess a client with type I hypersensitivity for which clinical manifestation? A. Poison ivy B. Autoimmune hemolytic anemia C. Allergic asthma D. Rheumatoid arthritis

C. Allergic asthma Allergic asthma is a clinical manifestation of type I hypersensitivity.Poison ivy is a type IV delayed mechanism of hypersensitivity. Autoimmune hemolytic anemia is a type II cytotoxic mechanism of hypersensitivity. Rheumatoid arthritis is a type III immune complex-mediated mechanism of hypersensitivity.

The nurse assess the client with which hematologic condition first? A. A 32-year-old with pernicious anemia who needs a vitamin B12 injection B. A 67-year-old with acute myelocytic leukemia with petechiae on both legs C. An 81-year-old with thrombocytopenia and an increase in abdominal girth D. A 40-year-old with iron deficiency anemia who needs a Z-track iron injection

C. An 81-year-old with thrombocytopenia and an increase in abdominal girth The nurse needs to first assess the 81-year-old client with thrombocytopenia and an increase in abdominal girth. An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage, and warrants further assessment immediately.The 32-year-old with pernicious anemia, the 67-year-old with acute myelocytic leukemia, and the 40-year-old with iron deficiency anemia do not indicate any acute complications, so the nurse can assess them after assessing the client with thrombocytopenia.

The nurse performs an assessment on a newly admitted client with thrombocytopenia. Which assessment finding requires immediate intervention by the nurse? A. Reports of pain B. Increased temperature C. Bleeding from the nose D. Decreased urine output

C. Bleeding from the nose The assessment finding on a newly admitted client with thrombocytopenia that needs immediate intervention by the nurse is bleeding from the nose. The client with thrombocytopenia has a high risk for bleeding. The nosebleed would be attended to immediately.The client's report of pain, decreased urine output, and increased temperature are not the highest priority.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A. Client with bacterial pneumonia and a cough productive of green sputum B. Client with neutropenia and pneumonia caused by Candida albicans C. Client with possible H5N1 influenza who currently has epistaxis D. Client with right empyema who has a chest tube and a fever of 103.2° F (39.6°C)

C. Client with possible H5N1 influenza who currently has epistaxis A client with possible tuberculosis or H5N1 avian influenza would be admitted to the negative-airflow room to prevent airborne transmission of organisms from the client room to other clients/staff and areas of the hospital.A client with bacterial pneumonia does not require a negative-airflow room but should have airborne or Droplet Precautions in place. A client with neutropenia may be in a regular room with an emphasis on handwashing. The client with a right empyema who also has a chest tube and a fever would have Contact Precautions in place but does not require a negative-airflow room.

Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? A. Report the need for desensitization therapy. B. Convey the need for pharmacologic therapy to the health care provider. C. Communicate the need for avoidance therapy to the health care team. D. Discuss symptomatic therapy with the health care provider.

C. Communicate the need for avoidance therapy to the health care team. The best nursing action is to communicate the need for avoidance therapy to the health care team. Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins.Desensitization therapy is administered via allergy shots when allergens have been identified and cannot easily be avoided. Discussing the need for pharmacologic therapy might be indicated if signs of type I or type IV hypersensitivity exist, but this is not a preventive measure. Symptomatic therapy interventions such as an epinephrine pen, antihistamines, and corticosteroids are not preventive but are effective only after the hypersensitivity reaction has already occurred.

A 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A. Decreased mononuclear leukocyte count B. Decreased leukocyte count C. Decreased neutrophil count D. Elevated erythrocyte sedimentation rate

C. Decreased neutrophil count In a client with mononucleosis, a white blood cell count would show a decrease in neutrophils.An abnormally large not decreased number of mononuclear leukocytes would be seen with mononucleosis. In most active infections, especially those caused by bacteria, the total leukocyte count is elevated, not decreased. An elevated erythrocyte sedimentation rate indicates infection, but does not specifically indicate mononucleosis.

Which statement about the transmission of hepatitis C is correct? A. Feces are a likely body fluid by which to transmit the disease. B. Airborne Precautions are used for the prevention of hepatitis C. C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D. No precautions are necessary with the use of nail clippers or scissors.

C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. Hepatitis C is a bloodborne pathogen. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection.Feces are not a likely source of transmission of hepatitis C. The hepatitis C virus is not airborne, so Airborne Precautions are not necessary. Hepatitis C can be spread by contact with contaminated items, such as clippers or scissors, so these items should be disinfected regularly.

The nurse on a medical surgical unit is caring for an adult client who has type 2 diabetes and is now admitted for pneumonia. The nurse must ensure the Joint Commission's National Client Safety Goals for this client are met and therefore follows up on which of these? A. Hemoglobin A1C B. Culture and Sensitivity report C. Evaluating pneumonia vaccine status D. Ensuring education to cough into the upper sleeve

C. Evaluating pneumonia vaccine status The Joint Commission's National Client Safety Goals (NPSGs) and core measures are client-safety oriented and recommends that all inpatients need to have their pneumonia vaccination status evaluated and, if needed, be vaccinated during that admission.It is important to provide diabetes education and assist the client in understanding the role of A1C in diabetes management, but that is not a core measure related to this situation. A culture and sensitivity may be performed, but is not a requirement or core measure. Coughing into the upper sleeve is a technique the center for disease control (CDC) recommends to prevent transmission and reduce the spread of disease.

The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? A. Uses a prepared list and finds out the client's food preferences B. Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) C. Has the client write down everything he or she has eaten for the past week D. Determines who prepares the client's meals and plans an interview with him or her

C. Has the client write down everything he or she has eaten for the past week The best way for the nurse to assess an anemic client's diet is to have the client write down everything he/she has eaten in the last week. Having the client provide a list of items eaten in the past week is the most accurate way to find out what the client likes and dislikes, as well as what the client has been eating. It will provide information about "junk" food intake, as well as protein, vitamin, and mineral intake.Determining food preferences from a prepared list provides information about what the client enjoys eating, not necessarily what the client has been eating. For instance, the client may like steak but may be unable to afford it. Rating scales are good for subjective data collection about some conditions such as pain, but the subjectivity of a response such as this does not provide the nurse with specific data needed to assess a diet. Interviewing the food preparer is time-consuming and poses several problems, such as whether a number of people are preparing meals, or if the client goes "out" for meals.

A newly admitted client has an elevated reticulocyte count. Which condition does the nurse suspect in this client? A. Leukemia B. Aplastic anemia C. Hemolytic anemia D. Infectious process

C. Hemolytic anemia The nurse suspects that the client has hemolytic anemia. An elevated reticulocyte count in an anemic client indicates that the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass and is prematurely destroying RBCs. Therefore, more immature RBCs are in circulation.A low white blood cell count is expected in clients with leukemia. Aplastic anemia is associated with a low reticulocyte count. A high white blood cell count is expected in clients with infection.

A 32-year-oldclient is recovering from a sickle cell crisis. The client's discomfort is controlled with pain medications and discharge planning has been initiated. What medication will the nurse anticipate to be prescribed before discharge? A. Heparin (Heparin) B. Warfarin (Coumadin) C. Hydroxyurea (Droxia) D. Tissue plasminogen activator (t-PA)

C. Hydroxyurea (Droxia) The nurse anticipates Hydroxyurea to be prescribed for pain for a sickle cell disease client who is being discharge. Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD).Clients with SCD are not prescribed anticoagulants such as heparin or warfarin (Coumadin). t-PA is used as a "clot buster" in clients who have had ischemic strokes.

A client who has recently relocated to the United States from Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? A. Contact the health care provider for tuberculosis (TB) medications. B. Perform a TB skin test. C. Place a respiratory mask on the client. D. Test all family members for TB.

C. Place a respiratory mask on the client. The nurse's first action is to place a respiratory mask on the client. The concern is that this client has a high risk for TB having recently immigrated from overseas. Client with symptoms consistent with TB should be considered infectious until the disease is ruled out.Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. Tell the client that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.

The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased laboratory value would be of greatest concern to the nurse because it is not age-related? A. Hemoglobin level B. Red blood cell (RBC) count C. Platelet (thrombocyte) count D. White blood cell (WBC) response

C. Platelet (thrombocyte) count The decreased laboratory value of the greatest concern to the nurse is the 76-year-old client's platelet count. Platelet counts do not generally change with age.Hemoglobin levels in men and women fall after middle age. Iron-deficient diets may play a role in this reduction. Total RBC and WBC counts (especially lymphocyte counts) are lower in older adults. The WBC count does not rise as high in response to infection in older adults as it does in younger people.

The nurse manager for a long-term care facility is in charge of implementing a plan to decrease the spread of infection within the facility. Which part of the plan is most appropriate to delegate to nursing assistants working at the facility? A. Evaluating each other's handwashing technique B. Deciding which brand of handwashing soap to use C. Reinforcing the need for handwashing after caring for clients D. Determining which clients are most likely to infect other residents

C. Reinforcing the need for handwashing after caring for clients All caregivers have a responsibility to reinforce basic handwashing, including that provided for nursing assistants.A higher level of administration is required to evaluate the performance of another worker. Deciding which brand of handwashing soap to use is done at the facility level by the infection control department. Determining which clients are most likely to infect other residents requires a higher level of education for client management.

Which task does the nurse delegate to unlicensed assistive personnel (UAP)? A. Refer a client with a daily alcohol consumption of 12 beers for counseling B. Obtain a partial thromboplastin time from a saline lock on a client with a pulmonary embolism C. Report any bleeding noted when catheter care is given to a client with a history of hemophilia D. Perform a capillary fragility test to check vascular hemostatic function on a client with liver failure

C. Report any bleeding noted when catheter care is given to a client with a history of hemophilia The task the nurse delegates to the UAP is to report any bleeding when catheter care is given to a client with a history of hemophilia. Reporting findings during routine care is expected and required of unlicensed staff members.Referring a client for alcohol counseling, drawing a partial thromboplastin time, and performing a capillary fragility test are more complex and would be done by licensed nursing staff.

A client is scheduled for a bone marrow aspiration. What is the priority nursing action before this procedure is performed? A. Hold the client's hand and ask about concerns. B. Review the client's platelet (thrombocyte) count. C. Verify that the client has given informed consent. D. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine).

C. Verify that the client has given informed consent. The priority nursing action before a scheduled bone marrow aspiration is done is for the nurse to verify that the client has been given informed consent. A signed permit must be on the client's chart.Cleaning the biopsy site is done before the procedure, but this is not done until consent is verified. Cleaning the site will be done just before the procedure is performed. Holding the client's hand and offering verbal support may be done during the procedure, but the procedure cannot be completed until the consent is signed. Reviewing the client's platelet count is not imperative.

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information? A. "How much exercise do you get?" B. "What is your endurance level?" C. "Are your feet or hands cold, even when you are in bed?" D. "Do you feel more tired after you get up and go to the bathroom?"

D. "Do you feel more tired after you get up and go to the bathroom?" Asking about feeling tired after using the bathroom is the best question to ask to assess a client's endurance level. This question is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provides needed answers.The hospitalized client typically does not get much exercise. This would be a difficult assessment for a client in long-term care facility to make. Asking the client about his or her endurance level is too vague. The client may not know how to answer this question. Asking about cold feet or hands does not address the client's endurance.

The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? A. "I must wear a medical alert bracelet stating that I am allergic to bee stings." B. "I need to carry epinephrine with me." C. "My spouse must learn how to give me an injection." D. "I am immune to bee stings now that I have had a reaction."

D. "I am immune to bee stings now that I have had a reaction." More teaching is needed if the client states, "I am immune to bee stings now that I have had a reaction." No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe.The client should carry epinephrine (EpiPen) at all times and always wear a medical alert bracelet that states all allergies. Someone (spouse, neighbor, or family member) must learn how to give the client an injection in case the client is unable to self-administer the injection.

A client with a low platelet count asks the nurse, "Why are platelets important?" Which statement is the nurse's best response? A. "Platelets will make your blood clot." B. "Your platelets finish the clotting process." C. "Blood clotting is prevented by your platelets." D. "The clotting process begins with your platelets."

D. "The clotting process begins with your platelets." The nurse's best response to why platelets are important is that, "The clotting process begins with your platelets." Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis.Platelets do not clot blood but are a part of the clotting process or cascade of coagulation. Platelets do not prevent the blood from clotting. Rather they function to help blood form clots. Platelets do not finish the clotting process, they begin it.

The clinic nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? A. "Handwashing is the best way to prevent transmission." B. "I should avoid kissing and shaking hands." C. "It is best to cough and sneeze into my upper sleeve." D. "The intranasal vaccine can be given to everybody in the family."

D. "The intranasal vaccine can be given to everybody in the family." Further teaching is needed when the client states that the intranasal vaccine can be given to everybody in the family. The intranasal flu vaccine is approved for adult clients up to age 49 who are not pregnant.Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand.

A client with anemia asks the nurse, "Why am I feeling tired all the time?" What is the nurse's best response? A. "You are not getting enough iron." B. "When you are sick you need to rest more." C. "How many hours are you sleeping at night?" D. "Your cells are delivering less oxygen than you need."

D. "Your cells are delivering less oxygen than you need." The nurse's best response to the client complaining about feeling tired all the time is "Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.While it may be true that the client isn't getting enough iron, it does not relate to the client's fatigue. The statement about the client needing rest because of being sick is simply not true. Although assessment of sleep and rest is good, it does not address the cause related to the diagnosis.

Which client does the nurse assign as a roommate for a client with aplastic anemia? A. A 34-year-old with idiopathic thrombocytopenia who is taking steroids B. A 23-year-old with sickle cell disease who has two draining leg ulcers C. A 30-year-old with leukemia who is receiving induction chemotherapy D. A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol)

D. A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) The nurse assigns as a roommate to the client with aplastic anemia a 28-year-old with glucose-6-pgisphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol. Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia would be free from infection or infection risk.The client with sickle cell disease has two draining leg ulcer infections that would threaten the diminished immune system of the client with aplastic anemia. The client with leukemia who is receiving induction chemotherapy and the client with idiopathic thrombocytopenia who is taking steroids are at risk for development of infection, which places the client with aplastic anemia at risk, too.

Which client is at greatest risk for experiencing a hemolytic transfusion reaction? A. A 42-year-old client with allergies B. A 78-year-old client with arthritis C. A 58-year-old immune-suppressed client D. A 34-year-old client with type O blood

D. A 34-year-old client with type O blood The client at greatest risk for experiencing a hemolytic transfusion reaction is the 34-year-old client with type O blood. Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient.The client with allergies would be most susceptible to an allergic transfusion reaction. The older adult client with arthritis would be most susceptible to circulatory overload. The immune-suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease.

A pediatric nurse is floated to a medical-surgical unit. Which client is assigned to the float nurse? A. A 60-year-old with newly diagnosed polycythemia vera who needs teaching about the disease B. A 50-year-old with pancytopenia needing assessment of risk factors for aplastic anemia C. A 55-year-old with folic acid deficiency anemia caused by alcohol abuse who needs counseling D. A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells

D. A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells The client who is assigned to the pediatric float nurse is the 42-year-old sickle cell disease client receiving a transfusion of packed blood cells. Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion. Therefore, he or she would be assigned to the client with sickle cell disease.Polycythemia vera, aplastic anemia, and folic acid deficiency are problems more commonly seen in adult clients who would be cared for by nurses who are more experienced in caring for adults.

An alert, middle-aged client is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the "ABCs" for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? A. Raise the lower extremities. B. Start intravenous (IV) administration of normal saline. C. Reassure the client that appropriate interventions are being instituted. D. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.

D. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%. The most immediate priority is for the nurse to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Assessing respiratory status is the most important assessment priority.Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.

The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. Zafirlukast works by which mechanism? A. Blocking histamine from binding to receptors B. Preventing synthesis of mediators C. Preventing mast cell membranes from opening D. Blocking the leukotriene receptor

D. Blocking the leukotriene receptor Zafirlukast is a leukotriene antagonist that works by preventing the occurrence of allergic rhinitis by blocking the leukotriene receptor.Zafirlukast is not an antihistamine. Antihistamines such as diphenhydramine (Benadryl) block histamines from binding to receptors. Zafirlukast is not a corticosteroid. Corticosteroids prevent synthesis of mediators. Mast cell-stabilizing drugs such as cromolyn sodium (Nasalcrom) prevent mast cell membranes from opening when an allergen binds to immunoglobulin E; zafirlukast is not a mast cell-stabilizing drug.

Which task does the nurse delegate to unlicensed assistive personnel (UAP) who is assisting with the care of a female client with anemia? A. Monitor the oral mucosa for pallor, bleeding, or ulceration B. Ask about the amount of blood loss with each menstrual period C. Check for sternal tenderness while applying fingertip pressure D. Count the respiratory rate before and after ambulating 20 feet (6 m)

D. Count the respiratory rate before and after ambulating 20 feet (6 m) Counting the respiratory rate before and after ambulation is within the scope of practice for a UAP. The UAP will report this information to the RN.Monitoring oral mucosa requires skilled assessment techniques and knowledge of normal parameters, asking the client about the amount of blood loss with each menstrual period, and checking for sternal tenderness would be done by the RN.

Which nursing intervention most effectively protects a client with thrombocytopenia? A. Take rectal temperatures B. Avoid the use of dentures C. Apply warm compresses on trauma sites D. Encourage the use of an electric shaver

D. Encourage the use of an electric shaver The most effective nursing intervention that protects a client with thrombocytopenia is encouraging the client to use an electric shaver. This client must be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time.To prevent rectal trauma, rectal thermometers would not be used. Oral or tympanic temperatures would be taken. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. Ice (not heat) would be applied to areas of trauma.

Which is a common clinical manifestation of infectious disease? A. Dry and pink skin B. Hypothermia C. Decreased respiratory rate D. Fever

D. Fever Fever (generally a temperature above 101°F [38.3°C]) is a common clinical manifestation of infection.Skin tends to be warm and moist, not dry and pink, when an infectious disease is present. Clients typically have hyperthermia (fever), not hypothermia, when an infectious disease is present, although some clients can have infection without fever. Respiratory rate typically increases, as does the heart rate, with infectious disease.

The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client's health care provider if the client has which condition? A. Cataracts B. Crohn's disease C. Diabetes mellitus D. Hypertension

D. Hypertension The health care professional should be notified if the client has hypertension because decongestants have actions similar to adrenergic drugs, causing vasoconstriction and increasing blood pressure.Decongestants are not contraindicated in clients with cataracts, Crohn's disease, or diabetes mellitus.

A priority problem of hyperthermia is identified by the long-term-care RN who is caring for a client with a urinary tract infection. Which intervention is most appropriate to delegate to a nursing assistant? A. Monitor for improvement after antibiotic therapy is initiated. B. Teach the client the reason for taking antibiotics as prescribed. C. Administer acetaminophen (Tylenol) 650 mg orally for elevated temperature. D. Increase fluid intake by assisting the client to choose approved and preferred beverages.

D. Increase fluid intake by assisting the client to choose approved and preferred beverages. Nursing assistants can provide dietary choices to clients, and allowing clients to select the beverage of their choice will improve oral intake. In clients with hyperthermia (fever), fluid volume loss is increased from rapid evaporation of body fluids and increased perspiration. As body temperature increases, fluid volume loss increases, placing the client at risk of becoming dehydrated. Offering a choice of beverage may increase oral intake and help prevent/treat hyperthermia.Monitoring for improvement and teaching the client require advanced education and are within the scope of the RN. Administering acetaminophen (Tylenol) is within the scope of the licensed nurse, not a nursing assistant.

A recently admitted client who is in sickle cell crisis requests "something for pain." What medication would the nurse be prepared to administer? A. Oral ibuprofen (Motrin) B. Oral morphine sulfate (MS-Contin) C. Intramuscular (IM) morphine sulfate D. Intravenous (IV) hydromorphone (Dilaudid)

D. Intravenous (IV) hydromorphone (Dilaudid) The client with sickle cell disease needs IV pain relief, and it needs to be administered on a routine schedule (i.e., before the client has to request it).Nonsteroidal anti-inflammatory drugs may be used for clients with SCD for pain relief once their pain is under control. However, in a crisis, this choice of analgesic is not strong enough. Moderate pain may be treated with oral opioids, but this client is in a sickle cell crisis. IV analgesics would be used until his or her condition stabilizes. Morphine is not administered intramuscularly (IM) to clients with sickle cell disease (SCD). In fact, all IM injections are avoided because absorption is impaired by poor perfusion and sclerosed skin.

A client recovering from a sickle cell crisis is to be discharged. The nurse says to the client, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Cefaclor (Ceclor) B. Vancomycin (Vancocin) C. Gentamicin (Garamycin) D. Penicillin V (Pen-V K)

D. Penicillin V (Pen-V K) The nurse expects the PHCP to prescribe Penicillin V for a client recovering from sickle cell crisis who is at risk for infection. Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use. It is a standard protocol for long-term prophylactic use in clients with sickle cell disease.Cefaclor (Ceclor) and vancomycin (Vancocin) are antibiotics more specific for short-term use and would be inappropriate for this client. Gentamicin (Garamycin) is a drug that can cause liver and kidney damage with long-term use.

The nurse is caring for a client with sickle cell disease. Which nursing action is most effective in reducing the potential for sepsis in this client? A. Check vital signs every 4 hours B. Administer prophylactic drug therapy C. Monitor for abnormal laboratory values D. Perform frequent and thorough handwashing

D. Perform frequent and thorough handwashing The most effective nursing action to reduce the risk for sepsis in a client with sickle cell anemia is to perform frequent and thorough handwashing. Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance.Taking vital signs every 4 hours will help with early detection of infection but is not prevention. Drug therapy is a major defense against infections that develop in the client with sickle cell disease but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? A. Ensures that the client is wearing a mask B. Informs the visitor that the client cannot receive visitors at this time C. Provides a particulate air respirator to the visitor D. Provides the visitor with a surgical mask

D. Provides the visitor with a surgical mask Because the visitor is entering the client's isolation environment, the visitor must wear a mask.The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator which is typically used for TB, H5N1 influenza, or SARS.

Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? A. Plan the schedule for desensitization therapy for a client with allergies. B. Monitor the client who has just received skin testing for signs of anaphylaxis. C. Educate a client with a latex allergy about other substances with cross-sensitivity to latex. D. Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.

D. Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing. The most appropriate action for the allergy clinic nurse to delegate to a nursing assistant is to remind the client about safety policies. This is within the scope of practice of a nursing assistant.Planning care and assessing for complications require broader education and scope of practice and should be done by the registered nurse. Client education is a registered nursing responsibility, requiring broader education and scope of practice.

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? A. Ask the client's name B. Check the client's armband C. Verify the client's room number D. Review all information with another registered nurse (RN)

D. Review all information with another registered nurse (RN) With another registered nurse, all information must be reviewed. This process includes verifying the client by name and number, checking blood compatibility, and noting the expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses.Asking the client's name and checking the client's armband are not adequate for identifying the client before transfusion therapy. Using the room number to verify client identification is never appropriate.

An elderly client is admitted to the emergency department (ED) with symptoms of possible seasonal influenza accompanied by vomiting and high fever. Which of these actions is the nurse's first priority? A. Ensure that ED staff members receive oseltamivir (Tamiflu). B. Administer IM influenza vaccination. C. Place the client in a negative air pressure room. D. Start an IV line and begin intravenous hydration.

D. Start an IV line and begin intravenous hydration. The nurse's first priority is to start an IV line and begin intravenous hydration. Elderly clients with influenza symptoms can develop dehydration quickly because of fever, vomiting and possible diarrhea. Initiating intravenous rehydration is a priority to maintain tissue perfusion.The ED staff would have received annual seasonal influenza vaccine, however if not, they can be given antiviral agents. A negative airflow room is not required in the ED, however a mask would be worn. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority as it takes weeks for full immunity to develop.

A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? A. Anxiety B. Urticaria C. Pruritus D. Stridor

D. Stridor The symptom that requires the most immediate action by the nurse is stridor which indicates airway involvement and warrants immediate intervention, such as use of oxygen and administration of epinephrine. Maintaining the client's airway is the highest priority.Anxiety, urticaria, and pruritus may be symptoms of a reaction, but are not the nurse's highest priority when the client is in respiratory distress.

The home care nurse is caring for an elderly client with streptococcal pneumonia. Which of these findings indicate a positive outcome to treatment? Select all that apply. A. The client states she will complete the entire dose of antibiotic prescribed. B. The client reports fatigue and malaise. C. White blood cell count is 16, 000 cells/cubic mm (16 × 109/L). D. The client has been afebrile for 48 hours.

D. The client has been afebrile for 48 hours. A positive outcome been afebrile for 48 hours.Expected outcomes to treatment include negative blood and sputum cultures, normal WBC count and differential, and absence of fever.Fatigue may persist for several weeks. The normal WBC count is 5000-10,000 mm3 (5-10 × 109/L). A WBC count of 16,000 mm3 (16 × 109/L) indicates infection. The client stating compliance with treatment is positive, but is not an objective measurement of eradicating the infecting organism.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? A. Combination medication therapy is effective in eliminating cough and fever. B. Combination medication therapy improves adherence. C. Combination medication therapy has fewer side effects, particularly liver damage. D. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.

D. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms. The nurse tells the client that multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Combination drug therapy is the most effective method for treating TB and preventing transmission.As the disease responds to treatment, the symptoms will decrease, but they are not eliminated. Combination drug therapy does not improve adherence to drug therapy. Isoniazid, rifampin, and pyrazinamide may cause liver damage.

Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A. Carefully wash hands that are visibly soiled. B. Wear a mask and gloves when the client's body secretions or body fluids are likely to be handled. C. Wear a mask with eye protection and perform proper handwashing. D. Wear gloves when contact with body secretions or body fluids is expected.

D. Wear gloves when contact with body secretions or body fluids is expected. The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids. C. difficile infection requires contact precautions. Hands must be properly washed before and after any contact with the client with C. difficile infection. Alcohol-based hand rubs are not effective for hand hygiene in the care of clients with C. difficile.Hands must be washed even if not visibly soiled. It is not necessary to wear a mask when caring for clients with C. difficile infection. A mask and eye protection are not necessary to prevent transmission of C. difficile.

The nurse is caring for a client with severe acute respiratory syndrome (SARS). What is the most important infection control precaution that the nurse takes when preparing to suction this client? A. Keeping the door to the client room closed B. Performing oral care after suctioning the oropharynx C. Washing hands and donning gloves prior to the procedure D. Wearing a disposable particulate mask respirator

D. Wearing a disposable particulate mask respirator The most important infection control precaution the nurse must take before suctioning a client is to wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms.The door to the room needs to be closed during care of the client with SARS and other instances of airborne precautions. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.

The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed? A. Cromolyn sodium (Nasalcrom) B. Desloratadine (Clarinex) C. Fexofenadine (Allegra) D. Zafirlukast (Accolate)

D. Zafirlukast (Accolate) The nurse anticipates that zafirlukast (Accolate) will be prescribed. Zafirlukast is a leukotriene receptor antagonist; it works by blocking the leukotriene receptor and is used to prevent allergic rhinitis.Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug. Desloratadine (Clarinex) and fexofenadine (Allegra) are nonsedating antihistamines.