AH1 quizzes exam 2
A charge nurse is planning to admit several clients to the medical unit. Which of the following clients should the nurse assign to a private room? A. A client who is neutropenic B. A client who had a total hip arthroplasty C. A client who is HIV positive D. A client who has a fever of unknown origin
A
A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first? A. Assess the neurovascular status of the right leg. B. Notify the primary health care provider immediately. C. Document the findings in the patient's chart. D. Elevate the left leg on at least two pillows.
A
The nurse learns that which risk factors can affect immunity? (Select all that apply.) Age Ethnicity Drugs Nutritional status Environmental factors
A,C,D,E,F
The nurse understands that which type of immunity is the longest acting? A. Artificial active B. Natural active C. Natural passive D. Inflammatory
B
The nurse is assessing a client with a history of metastatic cancer when the client states, "I am having back pain and some numbness and tingling in my left foot." The nurse knows these symptoms are most often associated with what oncologic emergency: A. Syndrome of Inappropriate Antidiuretic Hormone B. Superior Vena Cava Syndrome C. Tumor Lysis Syndrome D. Spinal Cord Compression
D
A client has a metastatic bone tumor in the left leg. What action by the nurse is appropriate? A. Administer pain medication as prescribed. B. Elevate the extremity and apply moist heat. C. Teach the client about amputation care. D. Place the client on protective precautions.
A
A client has had several gouty attacks over the past year and despite preventative treatment, he is experiencing a gout flare. What medication would the nurse expect to be included in the client's plan of care? A. colchicine B. sulfinpyrazone C. probenecid D. allopurinol
A
A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? A. A dry, red rash across the bridge of the nose and on the cheeks. B. Subcutaneous nodules on the ulnar side of the arm. C. A grey colored, non-purpuric papular rash. D. Pitting edema of the hands and fingers.
A
A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV? A. A phlebotomist who collects blood from clients who have HIV B. An occupational therapist who works with a client who has HIV C. A personal trainer who works with a client who has HIV D. A nurse who works for an insurance company and collects urine samples from clients who have HIV
A
A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed? A. "I don't need to go to the hospital after using it." B. "I must carry two autoinjectors with me at all times." C. "I will write the expiration date on my calendar." D. "This can be injected right through my clothes."
A
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? A. Presence of peripheral edema. B. Client report of feelings of depression. C. Joint pain in hands and knees. D. Dry, raised rash on the face.
A
A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity (AMI). Which of the following information should the nurse confirm about AMI? A. AMI is mediated by antibodies produced by B-lymphocytes. B. Humoral immune response is mediated by T-lymphocytes. C. AMI involves phagocytic natural killer cells. D. AMI defends only against viral infections.
A
A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority? A. Administer antibiotics to the client. B. Increase the client's protein intake. C. Provide the client with antipyretic therapy. D. Teach relaxation breathing to reduce the client's pain.
A
A nurse is providing discharge teaching to a client following hip arthroplasty. Which of the following pieces of furniture should the nurse instruct the client to sit in at home? A. A straight-backed chair with an elevated seat B. A reclining chair with an ottoman C. A rocking chair with a curved back D. A couch with plush cushions
A
A nurse is providing teaching to a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates an understanding of the teaching? A "Low-impact aerobics can help reduce episodes of pain." B "I will take my duloxetine in the morning, so I have more energy to accomplish tasks." C "A course of chemotherapy treatment should provide a cure." D "I should increase my caffeine intake."
A
A nurse is teaching a client who has a new prescription of allopurinol for the treatment of gout. Which of the following instructions should the nurse include? A "Drink 2 liters of fluid each day while taking the medication." B "Take the medication on an empty stomach." C "Take a 650 milligram dose of aspirin for joint pain." D "Do not crush the medication before taking it."
A
Infection and sepsis prevention should be included as priority nursing care for patients undergoing chemotherapy. Which intervention should be included in the patient's plan of care: A. Strictly adhere to aseptic technique during dressing changes B. Restrict the client's fluid intake to 1 Liter per day C. Swab the client's mouth using non-alcohol based mouthwash. D. Apply a cooling cap to the client's head during chemotherapy administration
A
The nurse assesses a client after a total hip arthroplasty. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is appropriate? A. Assess neurovascular status in both legs. B. Prepare to administer pain medication. C. Elevate the surgical leg and apply ice. D. Try to place the surgical leg in abduction.
A
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? A. Correctly identifying the client prior to a blood transfusion Keeping the client free of the offending agent Administering steroids for a positive TB test Providing a latex-free environment for the client
A
The nurse is performing an assessment of a client with possible plantar fasciitis in the right foot. What assessment finding would the nurse expect in the right foot? A. Severe pain in the arch of the foot B. Redness and severe swelling C. Numbness and paresthesias D. Multiple toe deformities
A
The nurse is taking a history from an older client who reports having frequent falls. Which dietary habit could be contributing to the client's problem? A. Avoids dairy products. B. Limits fatty or greasy foods. C. Eats few concentrated sweets. D. Consumes high-protein foods.
A
The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? A. Regulator T-cells B. Natural killer cells C. CD4+ cells (Helper cells) D. Cytotoxic T-cells
A
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect? A. Pain B. Constipation C. Bradycardia D. High fever
A. Pain
The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.) A. Correct Draining sinus tracts B. Presence of foot ulcers C. Swelling and rednes D. High fevers E. Tenderness or pain
A, B
A nurse is visiting a client discharged home after a total hip arthroplasty. What safety precautions would the nurse recommend to the client and family? (Select all that apply.) Install grab bars in the shower and by the toilet. Remove all throw rugs throughout the house Buy and install an elevated toilet seat. Use a shower chair while taking a shower. Step into the bathtub with the affected leg first.
A, B, C, D
The nurse is performing a focused musculoskeletal assessment on an older female client. What assessment findings associated with aging would the nurse expect? (Select all that apply.) A. Kyphosis B. Osteoarthritis C. Decreased range of motion D. Muscle atrophy E. Scoliosis
A, B, C, D
The nurse is creating a care plan for his client undergoing chemotherapy. What specific nursing interventions related to mucositis should be included in his plan of care? (select all that apply) A. Encourage at least 2L of water daily. B. Assess oral mucosa including lips, and tongue every 4 hours for blisters, fissures, or lesions. C. Encourage fiber intake by providing fruits such as apples, oranges, and grapefruit. D. Apply water-based moisturizer to lips after mouth care.
A, B, D
A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.) A. Lubricate lips with water-soluble ointment. B. Use a straight edge razor to shave. C. Limit fruit consumption. D. Blow nose gently. E. Brush teeth with a soft toothbrush.
A, D, E
A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select all that apply.) A. Eosinophils increase during allergic reactions and parasitic invasion. B. Macrophages act to sound the alarm in the bone marrow and can participate in many episodes of phagocytosis. C. Basophils are only involved in the general inflammatory process. D. Monocytes turn into macrophages after they enter body tissues. E. Neutrophils can only take part in one episode of phagocytosis.
A,B,D,E
The nurse is caring for an older client who had a total knee arthroplasty. Prior to surgery, the client lived alone independently. With which interprofessional health care team members will the nurse collaborate to ensure positive client outcomes? (Select all that apply.) A. Case manager B. Mental health counselor C. Physical therapist D. Speech-language pathologist E. Clergy/Spiritual leader
A,C
A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.) A. Change in bowel pattern B. Leg cramps C. Change in moles D. Nagging cough E. A nonhealing sore
A,C,D,E
The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low. What information does the nurse provide? (Select all that apply. A. Do not empty the kitty litter boxes. B. Clean your toothbrush in the dishwasher daily. C. Bathe daily using antimicrobial soap. D. Do not work in the garden or with houseplants. E. Make sure meat, fish, and eggs are cooked well. F. Avoid people who are sick and large crowds
A,C,D,E,F
For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) A. Inflammation B. White blood cells C. Cell-mediated immunity D. Red blood cells E. Antibody-mediated immunity
A,C,E
A nurse is caring for a client who is postoperative following a total hip arthroplasty. The nurse assists the client into a supine position. Which of the following actions is appropriate to prevent dislocation of the hip? A. Place a wedge pillow between the legs. B. Place a footboard on the bed. C. Elevate the head of the bed to a Fowler's position. D. Position the legs in alignment with the spine.
A.
A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? A. "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." B. "Relax, you'll be asleep for most of the procedure and you won't remember a thing." C. "I will call your doctor and tell him you still have questions about the procedure." D. "I can understand because you must be very worried about what the biopsy will show."
A. "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible."
A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching? A. Bottled water is an appropriate choice to increase fluid intake. B. The salad bar is a healthy choice when dining out. C. Soft-boiled eggs are an appropriate source of protein. D. Eating at a buffet is a good choice to increase caloric intake.
A. Bottled water is an appropriate choice to increase fluid intake.
A nurse is caring for a client who is postoperative following hip arthroplasty. The nurse should anticipate which of the following prescriptions for this client? A. Enoxaparin B. Alteplase C. Clopidogrel D. Aspirin
A. Enoxaparin
A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor? A. Headache B. Dependent edema C. Polyuria D. Photosensitivity
A. Headache
A client with HIV-II has had a sudden decline in status with a large increase in viral load. What action would the nurse take first? A. Ask the client about travel to any foreign countries. B. Assess the client for adherence to the drug regimen. C. Request information about new living quarters or pets. D. Determine if the client has any new sexual partners.
B
A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? A. Has decreased oral discomfort. B. Has a weight gain of 2 lb (1 kg)/1 mo. C. Eats 90% of meals and snacks D. Chooses high-protein food.
B
A client has a bone density score of −2.8. What intervention would the nurse anticipate based on this assessment? A. Asking the client to complete a food diary B. Planning to teach about bisphosphonates C. Scheduling another scan in 2 years D. Scheduling another scan in 6 months
B
A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What intervention by the nurse is best? A. Offer to tell the family for the client. B. Assess the client for support systems. C. Explain legal requirements to tell sex partners. D. Determine if a clergy member would help.
B
A client who is in clinical stage 3 of an HIV infection has an absolute neutrophil count of 850 mm3. What risk for infection level does this place the client? A. Mild Risk B. Moderate Risk C. Severe Risk D. Patient ANC is normal and not at risk for infection.
B
A nurse is providing education for a client with cervical cancer that is about to begin brachytherapy. The nurse knows further teaching is necessary when the client states: A. "I will most likely need to stay in the hospital for the duration of my brachytherapy." B. "I will only be radioactive for the first 24 hours after implantation." C. "I should not allow my pregnant sister to visit me while I am being treated." D. "This radiation implant should help shrink the tumor."
B
A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³ with increased immature neutrophils (bands). Which of the following is the appropriate analysis of the results? A. A resolving inflammatory process B. An acute, overwhelming, infectious process. C. Neutropenia D. Allergic reaction
B
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions? A. Febrile B. Hemolytic C. Allergic D. Bacterial
B
The physician documents the following: laryngeal carcinoma T1, NO, MO. The nurse can use this information to: A. Assist in explaining the purpose of surgery to the family. B. Understand the stage of the person's cancer. C. Plan for a chemotherapeutic treatment plan. D. Notify the American Cancer Association.
B
True or False: The nurse knows that chemotherapy that is taking orally is significantly less toxic than chemotherapy that is administered intravenously. A. True B. False
B
Your patient who has begun chemotherapy and is at increased risk for infection. Which of the following interventions should the nurse include in the plan of care? Select all that apply A. Allow only the patient's children to visit B. Limit the number of health-care providers C. Monitor VS q 4 hours, including temperature D. Have client specific equipment remain in the room
B, C, D
A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (Select all that apply.) A. Increased platelet count B. Decreased leukocyte count C. Decreased platelet count D. Increased hemoglobin count E. Decreased erythrocyte count
B, C, E
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Bacteria B. Smoking C. Obesity D. Diuretics E. Aging
B, C, E
Which primary prevention strategies should the nurse include when educating clients concerned about development of cancer? Select all that apply A. Annual mammograms for women >40 years old. B. Vaccinating against HPV. C. Digital rectal exam for men >50 years old. D. Chemoprevention for high risk individuals
B, D
A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select all that apply.) A. Affects bilateral, symmetrical joints B. Affects weight-bearing joints C. Crepitus can occur in affected joints D. Causes joint stiffness E. Causes joint pain
B,C,D,E
A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Active lifestyle B. Secondhand smoke C. Anorexia D. Aging E. Caffeine intake
B,C,D,E
The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) A. Pulselessness B. Redness C. Warmth D. Pallor E. Edema F. Decreased function
B,C,E,F
A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching? A. "Monitor your child's temperature daily." B. "Offer fluids to your child multiple times every day." C. "Restrict outdoor play activity to 1 hour per day." D. "Apply cold compresses when your child expresses pain."
B. "Offer fluids to your child multiple times every day."
A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions? A. Lactated Ringer's solution B. 0.9% sodium chloride C. Dextrose 5% in water D. Dextrose 5% in 0.45% sodium chloride
B. 0.9% sodium chloride
A nurse is admitting a client who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate? A. Neutropenic B. Bleeding C. Contact D. Droplet
B. Bleeding
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? A. All visitors from entering the client's room B. Fresh flowers and potted plants in the room C. Oral fluid intake to between meals only D. Activities that could result in bleeding
B. Fresh flowers and potted plants in the room
A nurse is teaching a client who has mucositis. Which of the following instructions should the nurse include? A. Rinse with a commercial mouthwash. B. Give ice or ice water before, during, & after rapid infusions known to cause mucositis C. Cleanse the mouth with lemon-glycerine swabs. D. Brush teeth with a medium bristled toothbrush.
B. Give ice or ice water before, during, & after rapid infusions known to cause mucositis
A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH? A. Osteoarthritis B. Lung cancer C. Liver cirrhosis D. Dyspepsia
B. Lung cancer
A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia B. hoarseness C. dyspnea D. weight loss
B. hoarseness
A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important for the nurse's safety? A. Disposing of soiled dressings properly B. Assessing tolerance to dressing changes C. Adhering to Standard Precautions D. Performing hand hygiene before and after care
C
A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs? A. Reinforce physical therapy to aid with ambulating normally. B. Explain that the surgery leads to a longer life expectancy. C. Assess the client's coping skills and support systems. D. Refer the client to the social worker or hospital chaplain.
C
A community health nurse is teaching a class of adults regarding regular cancer screening recommendations for cancer preventions. Which of the following should the nurse include? A. "All women should start getting yearly mammograms at age twenty-five." B. "You need a colonoscopy at 40-years-old, and then every 10 years after." C. "Fecal Occult Blood should be tested annually." D. "Every woman should undergo genetic screening for breast cancer, even if they do not have a family history of breast cancer."
C
A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? A. Administer epinephrine. B. Assess the client's level of consciousness. C. Auscultate for wheezing. D. Monitor for hypotension.
C
A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which of the following changes is an early manifestation of RA? A. Morning stiffness B. Temporomandibular joint pain C. Fatigue D. Baker's cysts
C
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform? A. Flex the right arm at the elbow. B. Hold the right arm straight. C. Hold the wrist at a 90-degree flexion. D. Extend the right arm upward.
C
A nurse is assessing a patient with a genetic history of cancer. What assessment finding requires immediate nursing intervention? A. Pain in lower back after gardening B. Nasal congestion for several days C. Nagging cough with hoarseness D. Feeling tired all the time
C
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? A. Scoliosis B. Lordosis C. Kyphosis D. Ankylosis
C
A nurse is caring for a client who received a diagnosis of systemic scleroderma 5 years ago. The nurse plans to assess the client to document the disease's progression. In addition to skin changes, which of the following findings should the nurse expect? A. Excessive salivation B. Periorbital edema C. Finger contractures D. Thinning of the skin
C
A nurse is talking with a young adult client who has a family history of osteoporosis. Which health promotion activity should the nurse recommend as a possible preventive measure? A. Increase sodium intake. B. Have a bone-density scan each year. C. Engage in weight-bearing exercise regularly. D. Drink a cup of coffee each morning.
C
A nurse is teaching a client who has chronic tophaceous gout about his new prescription for allopurinol. The nurse should explain that the purpose of this medication is to reduce blood levels of which of the following substances? A. Interleukin 1 B. Chloride C. Uric acid D. Potassium
C
A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make? A. Riding a bicycle B. High-impact aerobics C. Walking briskly D. Stretching exercises
C
After radiation treatment, the client that reports dryness, redness, and scaling of his skn within the designated treatment markings. The nurse knows that further education is needed when the client states: A. "I will cleanse with a low pH, gentle cleanser" B. "I will need to use a good moisturizer such as Aquafor." C. "I will apply moist heat to the area." D. "I will protect my skin from the sun during treatment and at least one year after."
C
Lab results on a client diagnosed with HIV infection is showing a CD4 T-cell count of 323 cells mm3. What Stage of HIV infection does this indicate? A. Stage 0 B. Stage 1 C. Stage 2 D. Stage 3 E. Stage Unknown
C
The home care nurse is caring for a client who had right total knee arthroplasty 3 days ago. During the assessment, the nurse notes that the client's right lower leg is twice the size of the left. What is the nurse's priority intervention? A. Apply antiembolism stockings. B. Elevate the client's right leg. C. Assess the client's respiratory status. D. Massage the right lower leg.
C
The nurse is caring for a client who has severe osteoarthritis. What primary joint problems will the nurse expect the client to report? A. Effusions B. Deformities C. Pain D. Crepitus
C
The nurse learns that the most important function of inflammation and immunity is which purpose? A. Regulating the process of self-tolerance B. Destroying bacteria before damage occurs C. Providing maximum protection against infection D. Preventing any entry of foreign material
C
A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following instructions should the nurse include? (Select all that apply.) A. Do not drink alcoholic beverages while taking this medication. B. Expect to feel the medication's effects immediately. C. Report unexplained bruising to the provider. D. Avoid people who have infections. E. Take NSAIDS to help minimize the adverse effects of the medication.
C,D
The nurse is teaching assistant personnel (AP) about care of an older ambulatory adult who has osteopenia. Which statement by the AP indicates understanding of the teaching? A. "I will assist the client with activities of daily living as needed." B. "I will tell the client to change positions frequently to prevent pressure injury." C. "I will remind the client to take frequent walks to strengthen bones." D. "I will apply warm compresses to the joints to relieve pain."
C.
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? A. Leave the client 5 min after beginning the transfusion. B. Infuse the transfusion at a rate of 200 mL/hr. C. Check the client's vital signs every 15 minutes for the first hour during the transfusion. D. Flush the blood tubing with dextrose 5% in water.
C. Check the client's vital signs every 15 minutes for the first hour during the transfusion.
A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests? A. Sweat test B. Haptoglobin C. Schilling test D. Antinuclear antibodies
C. Schilling test
A 28 year old client presents to the clinic with night sweats, chills, shortness of breath, and muscle aches. He lives a lifestyle that makes him at risk for HIV. What diagnostic test would the nurse expect to be ordered for a diagnosis of HIV? A. RA Factor B. PPD C. ELISA D. Western Blot Test
D
A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate? A. "You should be seen in the clinic right away." B. "You will need to take some IV steroids." C. "There are different antihistamines to try." D. "Antihistamines do not help poison ivy."
D
A client has a leg wound that is in Stage II of the inflammatory response. For what sign or symptom does the nurse assess? A. Swelling and pain B. Warmth at the site C. Noticeable rubor D. Purulent drainage
D
A client is hospitalized with Pneumocystis pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? A. Administer sleeping medication. B. Perform most activities for the client. C. Increase the client's oxygen during activity. D. Pace activities, allowing for adequate rest.
D
A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? A. Bradycardia B. Hypothermia C. Numbness of toes on the affected foot D. Localized erythema
D
A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What response by the nurse is best? A. Conclude that an infection is not present. B. Document findings and continue to monitor. C. Request the primary health care provider order blood cultures. D. Assess the client for more specific signs.
D
A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations? A. Excessive mucus secretion B. Serum sickness C. Bronchospasm D. Tissue damage at the site
D
A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take? A. Teach the client which positions to avoid during PT. B. Perform the client's morning care. C. Encourage the client to use full weight bearing. D. Identify the client's pain level and medicate if needed.
D
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen? A. "I will take one aspirin every day." B. "I will limit my fluid intake to 1 liter per day." C. "I will closely follow a high-purine diet." D. "I will limit my alcohol intake."
D
A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome? A. Truck driver B. Nursing assistant C. Elementary school teacher D. Assembly line worker
D
A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client? A. Decreased stiffness B. Maintenance of joint function C. Suppression of the inflammatory process D. Reduced joint stress
D
A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations should the nurse include in the teaching? A. Use Echinacea to manage joint pain. B. Reduce the amount of purine in the diet. C. Apply ice to the joint before exercising. D. Maintain a recommended body weight.
D
A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching? A. "I will have my child rest." B. "I will elevate the affected part." C. "I will compress the site." D. "I will apply heat."
D
The nurse's top priority when caring for a client receiving chemotherapy is: A. Consulting a therapist to assist with coping skills B. Managing Xerostomia that commonly occurs C. Assessing for Peripheral Neuropathy D. Protecting the client from life-threatening side-effects
D
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take? A. Tell the client to expect dark stools following chemotherapy. B. Have the client floss 4 times daily. C. Have the client swish with commercial mouthwash before therapy. D. Administer an antiemetic prior to the procedure.
D. Administer an antiemetic prior to the procedure.
A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? A. Prolonged bleeding B. Fluid retention C. Impaired immunity D. Cellular hypoxia
D. Cellular hypoxia
The nurse is assessing a client with a history of metastatic cancer when the client states, "I am having back pain and some numbness and tingling in my left foot." The nurse knows these symptoms are most often associated with what oncologic emergency: A. Syndrome of Inappropriate Antidiuretic Hormone B. Superior Vena Cava Syndrome C. Tumor Lysis Syndrome D. Spinal Cord Compression
D. Spinal Cord Compression
A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be A. infertility B. diarrhea C. dyspnea D. dysphagia
D. dysphagia
