AH EXAM II SG

The healthcare provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? Select one: a. Assess the patient's extremities for urticaria b. Observe for swelling of the patient's lips and tongue c. Question the patient about any clear nasal discharge d. Obtain patient's blood pressure and heart rate

Not D.

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. Clean drug injection equipment before each use b. Avoid sexual intercourse when using injectable drugs c. Consider participating in a needle-exchange program d. Ask those who share equipment to be tested for HIV

NOT A.

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency virus (HIV). Which medication is most important to administer at the scheduled time? a. Oral acyclovir (Zovirax) b. Aerosolized pentamidine (NubuPent) c. Oral saquinavir (Invirase) d. Nystatin tablet

NOT A.

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? Select one: a. The UAP stands by the patient's bed for 45 minutes talking to the patient b. The UAP places the patient's bedding in the laundry container in the hallway c. The UAP flushes the toilet once after emptying the patient's bedpan d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care

NOT B.

The nurse would immediately collaborate with the health care provider if a patient experiences a "shift to the left" in laboratory values. What is the rationale for this collaboration? Select one: a. This shift is an indicator of risk for a severe infection. b. This shift is an indicator of a potential bleeding problem. c. This shift is an indicator of electrolyte imbalance. d. This shift is an indicator of disruption of hemostasis.

NOT B.

A patient's laboratory values indicate a "shift to the left." The nurse would expect changes in which cell count? Select one: a. Absolute neutrophil count (ANC) b. Platelets c. White blood cell count d. Erythrocytes

NOT B. Select one: a. Teach the client about the cardiovascular medications b. Keep fresh flowers and raw vegetables out of the client's room c. Encourage the client to perform AROM d. Have the unlicensed assistive personnel (UAP) assist with ADLS

A patient in the healthcare office for intradermal skin testing develops itching, redness, and swelling at the skin site. Which action should the nurse take first? a. Ask the patient about the use of new skin products b. Administer a dose of oral Benadryl c. Monitor the patient's swelling at the site d. Administer a dose of epinephrine

NOT C.

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which action is most likely to detect early signs of infection in this patient? Select one: a. Ask about increased feelings of fatigue and malaise b. Measure temperature every 2 hours c. Monitor white blood cell count d. Check the skin for areas of redness

NOT C.

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Blueberry yogurt b. Fresh strawberries c. Bagel d. Lime sherbet

NOT C.

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake? Select one: a. Offer the patient frequent small snacks between meals b. Provide teaching about the importance of nutritional intake c. Assist the patient to choose favorite foods from the menu d. Apply prescribed anesthetic gel to oral lesions before meals

NOT d.

Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) MRSA? a. Metronidazole PO b. Quinupristin-dalfopristin IV c. Ampicillin-sulbactam IV d. Vancomycin IV

Vancomycin IV

Which patient would the nurse prioritize as needing information about lifestyle modifications to prevent cancer? Select one: a. A 44-year-old African American woman whose mother had breast cancer at age 50 and who is overweight, smokes one or two cigarettes a week, and drinks three cups of coffee daily b. A 47-year-old Hispanic female whose mother and father have a history of type 2 diabetes and who is overweight by 30 lbs., walks three times weekly, and is a nonsmoker c. A 35-year-old Caucasian male who is overweight, has a family history of heart disease, and is a vegetarian d. A 65-year-old woman whose body weight is within the normal range and who exercises twice a week, eats a variety of vegetables and fruits, eats red meat three times a week, and does not smoke

a. A 44-year-old African American woman whose mother had breast cancer at age 50 and who is overweight, smokes one or two cigarettes a week, and drinks three cups of coffee daily

A client just diagnosed with a benign neoplasm asks the nurse if he is going to die. On which of the following items of information will the nurse base the response? Select one: a. Benign neoplasms are localized, encapsulated growths that are easily removed and rarely cause death b. Benign neoplasms are rapidly growing tumors that metastasize to other areas of the body c. The client is experiencing an unusually high level of anxiety d. Benign neoplasms are associated with a high mortality rate

a. Benign neoplasms are localized, encapsulated growths that are easily removed and rarely cause death

The nurse plans a presentation for community members about how to decrease the risk of antibiotic resistant infections. Which information will the nurse include in the teaching plan? Select all that apply: a. Handwashing is effective in preventing many viral and bacterial infections b. Antibiotics are effective in treating influenza associated with high fevers c. Unused antibiotics should be discarded d. Continue taking antibiotics until all of the prescription is gone e. Antibiotics should be prescribed to prevent infection

a. Handwashing is effective in preventing many viral and bacterial infections d. Continue taking antibiotics until all of the prescription is gone

Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? Select one: a. IL-2 enhances the body's immunologic response to tumor cells b. IL-2 protects normal cells from harmful effects of chemotherapy c. IL-2 prevents bone marrow depression caused by chemotherapy d. IL-2 stimulates malignant cells in the resting phase to enter mitosis

a. IL-2 enhances the body's immunologic response to tumor cells

Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? Select one: a. Local joint pain b. Anemia c. Weight loss d. Osteoporosis

a. Local joint pain

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 lbs. the patient has not seen a healthcare provider for 20 years. She walks 5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk? Select all that apply Select one or more: a. Sunscreen use b. Mammography c. Colorectal screening d. Tobacco use e. Pap testing

a. Sunscreen use b. Mammography c. Colorectal screening e. Pap testing

The nurse is using a nonpharmacologic method to manage a patient's pain, and applies a unit that applies low-voltage electrical stimulation directly over the pain area. When documenting this intervention, which term is the most appropriate for the nurse to use? Select one: a. TENS unit b. Nerve block c. Functional restoration d. Cutaneous stimulation

a. TENS unit

A patient diagnosed with cancer has been receiving radiation treatments to shrink the tumor. After several weeks, the patient tells the nurse that she has not needed as much pain medication. What should the nurse consider when responding to this report? Select one: a. The radiation treatments have probably reduced the pressure of the tumor on adjacent tissues b. The patient may be developing tolerance to the pain c. The patient is probably continuing to have pain but is benefiting from the placebo effect of taking action against the tumor d. The tumor is secreting pain-control chemicals initiated by the radiation

a. The radiation treatments have probably reduced the pressure of the tumor on adjacent tissues

The nurse is educating a client who will likely experience alopecia as a result of the current chemotherapy treatment. Further instructions are necessary when the client states which of the following? Select one: a. "I will pat my hair dry and avoid the use of hair dryers." b. "I will wash my hair everyday." c. "I will choose a wig or hair piece before the loss of hair occurs." d. "My hair will likely begin to grow back after the chemotherapy."

b. "I will wash my hair everyday."

The concept of impaired immunity has been identified by the nurse as it applies to the client diagnosed with Acquired Immune Deficiency Syndrome (AIDS). Which intervention should the nurse implement? Select one: a. Teach the client about the cardiovascular medications b. Keep fresh flowers and raw vegetables out of the client's room c. Encourage the client to perform AROM d. Have the unlicensed assistive personnel (UAP) assist with ADLS

b. Keep fresh flowers and raw vegetables out of the client's room

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? Select one: a. Restrict all visitors b. Teach the client and family about the need for meticulous hand hygiene c. Restrict fluid intake d. Insert an indwelling urinary catheter to prevent skin breakdown

b. Teach the client and family about the need for meticulous hand hygiene

A patient's gynecologic examination reveals dysplasic changes of the cervix. Which historical information would the nurse interpret as indicating an increased risk that these changes are related to cervical cancer? Select one: a. The patient did not become sexually active until marriage at age 22 b. The patient was treated for human papillomavirus 2 years ago c. The patient reports eating fast food several times a week d. The patient reports "getting drunk" a few times a year

b. The patient was treated for human papillomavirus 2 years ago

The nurse is caring for a client receiving chemotherapy prior to a bone marrow transplant. The client is placed on thrombocytopenic precautions (bleeding precautions). Which of the following interventions would the nurse utilize for this client? Select all that apply: a. Mask worn by caregivers and visitors b. Use a soft-bristle toothbrush or water pick for mouth care c. Avoid shaving with a straight razor d. Place client in a negative pressure room e. Avoid intramuscular injections

b. Use a soft-bristle toothbrush or water pick for mouth care c. Avoid shaving with a straight razor e. Avoid intramuscular injections

A patient undergoing external radiation has developed dry skin in the treatment area. The nurse teaches the patient about the management of the skin. Which statement, if made by the patient, indicates that teaching was effective? Select one: a. "I can use ice packs to relieve the itching." b. "I will expose my skin to a sun lamp each day." c. "I can buy aloe vera gel to use on my skin." d. "I will scrub the area with hot water."

c. "I can buy aloe vera gel to use on my skin."

The nurse is making a home visit to a client receiving external radiation therapy on an outpatient basis. Further teaching is necessary when the nurse observes the client doing which of the following? Select one: a. Protecting the skin with soft, loose clothing b. Inspecting the skin for any damage c. Applying scented lotion to the irritated skin d. Washing the radiation site with plain water and patting skin dry

c. Applying scented lotion to the irritated skin

A patient has a wound infection. Which localized responses should the nurse expect to see? Select all that apply: a. Malaise b. Neutropenia c. Pain d. Erythema e. Edema

c. Pain d. Erythema e. Edema

A patient with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and corticosteroids. Which patient statement indicates the need for further education after teaching? Select one: a. "I should avoid getting the flu shot." b. "I will report any symptoms of infection immediately." c. "I will use contraception to avoid pregnancy." d. "I can go to events with large crowds."

d. "I can go to events with large crowds."

A patient presents to the emergency department after sustaining a minor laceration. The patient tells the staff that he may be HIV positive, "but I don't know for certain." Which information should the nurse provide? Select one: a. "You must go to the state health department to be tested." b. "No additional testing is necessary." c. "It will take at least 5 days for test results to return." d. "There is a test available that will quickly give us an idea of your HIV status."

d. "There is a test available that will quickly give us an idea of your HIV status."

The nurse is performing an assessment in a local clinic. Based on the history provided by the clients, which one of the following requires an immediate referral for screening and observation? Select one: a. Client who smokes 2 packs of cigarettes per day b. Client who consumes diet high in fats and low in fiber c. Client who reports history of long-term sun exposure d. Client who reports unintended weight loss of 25 lbs over the past 2 months

d. Client who reports unintended weight loss of 25 lbs over the past 2 months

Which of the following measures would be beneficial for the nurse to use in helping a client with a past history of anaphylaxis to develop a plan of care to manage possible allergic reactions? Select one: a. Have acetylsalicylic acid (ASA) readily available b. Have diphenhydramine (Benadryl) readily available c. Have acetaminophen (Tylenol) readily available d. Have an Epi-pen (epinephrine) readily available

d. Have an Epi-pen (epinephrine) readily available

The nurse is providing care to a several patients in the hospital environment. Which patient should the nurse include education regarding the need for increased fluid intake in the plan of care? Select one: a. The patient diagnosed with VRE b. The patient diagnosed with MRSA c. The patient diagnosed with Acinetobacter d. The patient diagnosed with Clostridium difficile

d. The patient diagnosed with Clostridium difficile

The nurse is evaluating the nutritional status of a client who is receiving chemotherapy as treatment for cancer. On assessment, which finding could potentially affect the client's nutritional intake? Select one: a. Ecchymotic areas on forearms b. Pale and moist mucus membranes c. Pale skin d. Ulcerations of oral mucosa

d. Ulcerations of oral mucosa

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observations by the nurse would indicate a need for further teaching? Select one: a. The patient uses soap and shampoo to shower every other day b. The patient ambulates around the room c. The patient's visitors bring in fresh peaches d. The patient cleans with a warm washcloth after having a stool

not a.