Adult II Exam 4 ❌
Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner?
Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9,500 mm3 (9.5 × 109/L), segs (6.0 × 109/L), bands 1.0% (0.1 × 109/L), oxygen saturation of 93% on room air, and afebrile
A nurse is having difficulty arousing a client following an EGD. Which of the following is the priority action by the nurse?
Assess the client's airway
Which nursing activity can the nurse delegate to a home health aide?
Assisting with bathing for a client with chronic rejection of a liver transplant
A charge nurse is teaching a group of nurses about medication compatibility with TPN. Which of the following statements should the charge nurse make?
"Regular insulin can be added to the TPN solution"
A nurse is reviewing the laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following blood laboratory results should the nurse expect to be elevated?
ESR WBC
A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnosis?
Emesis > than 500 mL with fecal odor Report of spasmodic abdominal pain High-pitched bowel sounds
A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect?
Epigastric pain radiating to the left shoulder
Which factor relates most directly to a diagnosis of primary immune deficiency?
Full-term infant surfactant deficiency
A nurse is teaching a client who has a new diagnosis of dumping syndrome following gastric surgery. Which of the following information should the nurse include in the teaching?
Increase protein in the diet
A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
Increased blood glucose level
A nurse is teaching a client who will undergo a sigmoidoscopy. Which of the following information about the procedure should the nurse include?
Increased flatulence can occur following the procedure NPO status should be maintained preprocedure
A nurse is completing discharge teaching with a client who has IBS. Which of the following instructions should the nurse include?
Keep a food diary to identify triggers to exacerbation
A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching?
Limit physical activity Avoid alcohol Eat small frequent meals
A nurse is instructing a client on how to administer cyclic enteral feedings at home. Which of the following information should the nurse include?
"Set the feeding up before you go to bed" "Weight yourself daily"
A charge nurse is teaching a group of nurses about a client who has chronic gastritis and is scheduled for a selective vagotomy. Which of the following statements by a unit nurse indicates understanding of the purpose of this procedure?
"The client will have a reduction of gastric acid secretions"
A nurse is discussing the use of a low-profile gastrostomy device with the guardian of a child who is receiving an enteral feeding. Which of the following is an appropriate statement by the nurse?
"The device is usually comfortable for children"
A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching?
"Notify the provider if you experience a sore throat"
A nurse is teaching a client who has a hiatal hernia. Which of the following client statements indicates an understanding of the teaching?
"Peppermint tea will increase my indigestion"
Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse?
"The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client."
A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by the client indicates understanding?
"This is an easy way to screen for colon cancer"
The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions?
"Washing my hands and putting on a gown and gloves is what I must do before starting care."
A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse?
"With this treatment, I probably cannot spread this virus to others."
A nurse is completing preoperative teaching for a client who is scheduled for a lap chole. Which of the following should be included in the teaching?
"You might have shoulder pain after surgery"
A nurse is providing care to a client who is 1 day postoperative following a paracentesis. The nurse observed clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention?
Apply a dry, sterile dressing
A nurse is caring for a client who is receiving TPN through a central venous access device, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse?
Administer 20% dextrose in water IV until the next bag is available
Which statement best exemplifies a client's protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos?
Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1.
A complete blood count with differential is performed on a client with chronic sinusitis. Which finding does the nurse expect?
Basophils, 4%
A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client?
Bathe daily using an antimicrobial soap.
The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. Zafirlukast works by which mechanism?
Blocking the leukotriene receptor
Which factors are possible transmission routes for human immune deficiency virus (HIV)?
Breast-feeding Anal intercourse Oral sex
A nurse is teaching a client who has constipation about a high-fiber, low-fat diet. Which of the following food choices by the client indicates understanding of the teaching?
Brown rice
A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy?
Change in orientation Asterixis Fetor hepaticus
Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia?
Change the decorations in the home according to the season. Put the bed close to the window. Ask the client what time he or she prefers to shower or bathe. Mark off the days of the calendar, leaving open the current date.
A nurse is reviewing bowel prep using polyethylene glycol with a client scheduled for a colonoscopy. Which of the following instructions should the nurse include?
Check with the provider about taking current medications when consuming bowel prep
A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect?
Client reports a sensation of bloating Client states that pain occurs 30 minutes to 1 hour after a meal Client experiences pain upon palpation of the epigastric region
A nurse is assessing a client who has been taking prednisone following an exacerbation of IBD. The nurse should recognize which of the following findings as the priority?
Client reports having an elevated body temperature
A nurse is teaching a client who is recovering from pancreatitis about following a low-fat diet. Which of the following foods should the nurse recommend?
Oatmeal Canned peaches Pretzels
A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify that which of the following is a risk factor for cholecystitis?
Obesity
A nurse is planning care for a client who has a new prescription for TPN. Which of the following interventions should be included in the plan of care?
Obtain a capillary blood glucose 4x a day Monitor vitals 3x during the 12 hour shift Change the TPN IV tubing every 24 hours
A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first?
Obtain blood cultures from two sites.
A nurse is preparing to administer precrelipase to a client who has pancreatitis. which of the following actions should the nurse take first?
Offer a glass of water following medication administration
A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding?
Painful swallowing
Which home health nurse should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)?
RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency
A client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client's discharge teaching plan?
Remove cloth drapes, carpeting, and upholstered furniture.
A nurse is caring for a client who is receiving TPN solution. The current bag of solution was hung 24 hours ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take?
Remove the current bag and hang a new bag
A nurse is providing discharge teaching to a client who is postoperative following a lap chole. Which of the following instructions should the nurse include in the teaching?
Resume a diet of choice Cleanse puncture site using mild soap and water Report nausea and vomiting to the surgeon
The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority?
Transfuse ordered packed red blood cells.
A nurse is completing an admission assessment for a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider?
Urine specific gravity of 1.040 Blood potassium 3.0
A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care?
Provide a high-calorie, high-carb diet
A nurse is admitting a client who has bleeding esophageal varices. The nurse should expect a prescription for which of the following medications?
Vasopressin
A nurse is administering a bolus enteral feeding to a client who has malnutrition. Which of the following are appropriate nursing interventions?
Verify the presence of bowel sounds Flush the feeding tube with warm water Administer the feeding at room temperature
A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide. Which of the following information should the nurse include in the teaching?
Wait 1 hour before taking other oral medications
The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching?
"I must regularly monitor my blood sugar."
When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use?
"Always position the condom with a space at the tip of an erect penis."
A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response?
"Blood concentrations will be decreased, which will lead to increased viral replication."
A charge nurse is providing information about fat emulsion added to TPN to a group of nurses. Which of the following statements by the charge nurse are appropriate?
"Concentration of lipid emulsion can be up to 30%" "Adding lipid emulsion gives the solution a milky appearance" "Check for allergies to soybean oil" "Lipid emulsion prevents essential fatty acid deficiency"
In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors?
"Have you had sex with men or women or both?"
The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing?
"I am 78 years old, and I was treated and cured of syphilis many years ago." "Seven years ago, I was released from a penitentiary." "At 68, I am going to get married for the fourth time."
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?
"I am immune to bee stings now that I have had a reaction."
A nurse is collecting data from a client who has PUD. Which of the following findings should the nurse expect?
Anemia Tarry stools Epigastric pain
A nurse is caring for a client who has a new diagnosis of GERD. The nurse should expect prescriptions for which of the following medications?
Antacids H2 Receptor antagonists PPIs
The nurse is assigned to care for four clients. Which client does the nurse assess first?
Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature
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?
Communicate the need for avoidance therapy to the health care team.
A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding?
Direct bilirubin 2.1 mg/dL
A nurse is preparing to administer intermittent enteral feeding to a client. Which of the following are appropriate nursing interventions?
Discard feeding equipment after 24 hours Place any unused formula in open cans in the refrigerator Flush the feeding tube every 4 hours
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client?
Diuretic Beta blocker Lactulose
A nurse is assessing a client who is postoperative from a gastric bypass and who just finished eating a meal. Which of the following findings are manifestations of dumping syndrome?
Dizziness Hypotension Diarrhea
A nurse is planning care for a client who has a small bowel obstruction and an NG tube in place. Which of the following interventions should the nurse include?
Document the NG drainage with the client's output Assess bowel sounds Provide oral hygiene every 2 hours Monitor NG tube for placement
A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching?
Drink canned protein supplements
The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery of his AIDS by his family?
"Is there somewhere private in the home where we can go and talk?"
The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan?
"Please report any increased redness, swelling, warmth, or pain to your health care provider."
A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching?
"I plan to eat small, frequent meals" "I will eat easy-to-digest foods with limited spice" "I will use skim milk when cooking"
The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address?
"I remember to take my antiretroviral drugs almost every day."
A nurse is completing discharge teaching with a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding of the teaching?
"I will elevate the head of my bed on blocks"
A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates an understanding of the teaching?
"I will plan to limit fiber in my diet"
A nurse is completing discharge teaching for a client who has an infection due to H. pylori. Which of the following statements by the client indicates understanding of the teaching?
"I will take a combination of medications for treatment"
A nurse is teaching a client who has a new prescription for famotidine. Which of the following statements by the client indicates understanding of the teaching?
"I will take my pill at bedtime"
A nurse in the ED is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect?
Rigid abdomen Tachycardia Rebound tenderness
A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client?
Self-tolerance
A nurse is teaching a client who is starting continuous feedings about the various types of enteral formulas. Which of the following should the nurse include in the teaching?
Standard formula contains whole protein
A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching?
Take the medication 1 hour before a meal Limit NSAIDs when taking this medication
A nurse is caring for a client following a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure?
Temperature elevation
A nurse is assessing a client in an extended care facility. The nurse should recognize which of the following findings is a manifestation of an obstruction of the large intestine due to a fecal impaction?
The client is having small, frequent liquid stools
Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)?
The dietary worker hands the disposable meal trays to the LPN assigned to the client.
Which statement accurately explains otitis media?
The inflammatory response is triggered by the invasion of foreign proteins.
A nurse is reviewing a new prescription for chenodiol with a client who has cholelithiasis. Which of the following information should the nurse include in the teaching?
The medication dissolves gallstones gradually over a period of up to 2 years
A nurse is completing discharge teaching with a client who is 3 days postoperative following a transverse colostomy. Which of the following should the nurse include in the teaching?
The stoma should be moist and pink
A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should the nurse include in the plan of care?
Evaluate I&O Monitor laboratory reports of electrolytes Observe stool characteristics
A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition/PPN. Which of the following actions should the nurse include in the plan of care?
Examine trends in weight loss Review prealbumin finding Add a micron filter to IV tubing Use an IV infusion pump
A nurse is teaching about pernicious anemia with a client who has chronic gastritis. Which of the following information should the nurse include in the teaching?
Expect a monthly injection of vitamin B12
A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client?
Fluconazole (Diflucan)
A nurse is reviewing the health record of a client who has a suspected tumor of the jejunum. The nurse should expect a prescription for which of the following tests?
GI X-ray with contrast Small bowel capsule endoscopy/M2A
A nurse is instructing a client who has celiac disease about foods to avoid. Which of the following foods should the nurse include in the teaching?
Graham crackers
Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection?
Grand multipara female with a history of subsequent blood transfusions
A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis?
Grey-blue discoloration of the skin around the umbilicus
An HIV positive client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider?
Improved CD4+ T-cell count and reduced viral load
A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following laboratory findings should the nurse expect?
Positive EIA test
In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority?
Potential for infection transmission related to recurring opportunistic infections
A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant?
Provide oral care to the client before meals to enhance appetite.
A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bag. Which of the following actions should the nurse take?
Return the bag to the pharmacy