Custom Quiz
A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? 1)Reduce gastric acidity 2)Reduce colonic irritation 3)Reduce intestinal absorption 4)Reduce bowel infection rate
2)Reduce colonic irritation A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is to allow the bowel to rest, not to reduce infection rates.
The healthcare provider prescribes 1 liter of intravenous (IV) fluid to infuse over 4 hours for a client admitted for a urinary tract infection and hyponatremia. The tubing drop factor is 10 drops/mL. At what rate will the nurse infuse the medications? 1)20 drops/minute 2)34 drops/minute 3)42 drops/minute 4)60 drops/minute
3)42 drops/minute
While teaching a parents' group about acute otitis media, the nurse includes the fact that among infants and children acute otitis media is an infection commonly caused by what? 1)A virus 2)Bacteria 3)A fungus 4)Rickettsia
2)Bacteria Otitis media, one of the most prevalent illnesses in toddlers, is caused by a bacterial infection. The causative agent is not a fungus, virus, or rickettsial organism.
A 2-year-old toddler has hearing loss caused by recurrent otitis media. What treatment does the nurse anticipate that the practitioner will recommend? 1)Ear drops 2)Myringotomy 3)Mastoidectomy 4)Steroid therapy
2)Myringotomy Myringotomy is a surgical opening into the eardrum to permit drainage of accumulated fluid associated with otitis media. Ear drops are not used because they will obscure the view of the tympanic membrane. Removal of the mastoid will not relieve pressure within inflamed ears. Antibiotics, not steroids, are used for an infectious process.
Steroid therapy is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client identifies which times for the medication schedule? 1)At bedtime with a snack 2)Three times a day with meals 3)In the early morning with food 4)One hour before or two hours after eating
3)In the early morning with food Taking the drug in the early morning mimics usual adrenal secretions; food helps reduce gastric irritation. Diurnal rhythms may be altered, and steroids are ulcerogenic; they should be taken with more than just a snack. Steroids cause gastric irritation and should be taken with food. Although food helps decrease gastric irritation, dividing the dose and taking it throughout the day may alter regular diurnal rhythms; it should be taken in the early morning with food.
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? 1)Pouring warm water over the perineum 2)Ensuring the patency of the catheter 3)Removing the catheter within 24 hours 4)Cleaning the catheter insertion site
3)Removing the catheter within 24 hours Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.
A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed healthcare worker tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? 1)"You need to try to be patient. The client is going through a lot right now." 2)"I'll talk with the client. Maybe I can figure out the best way for us to handle this." 3)"Just ignore it and get on with your work. I'll assign someone else to take a turn." 4)"The client's frightened and taking it out on the staff. Let's think of approaches we can take."
4)"The client's frightened and taking it out on the staff. Let's think of approaches we can take." The correct response interprets the client's behavior without belittling the unlicensed healthcare worker's feelings; it encourages the unlicensed healthcare worker to get involved with plans for future care. Telling the unlicensed healthcare worker to be patient recognizes the client's feelings, but it does not address the unlicensed healthcare worker's feelings or help the unlicensed healthcare worker cope with the client's behavior. The nurse should not assume the unlicensed healthcare worker has nothing to contribute and that only the nurse can deal with the problem. Saying "Just ignore it" does not help the unlicensed healthcare worker understand the client's behavior, nor does it demonstrate an understanding of the client's feelings.
A nurse is taking the health history of a client who is to have surgery in one week. The nurse identifies that the client is taking ibuprofen for discomfort associated with osteoarthritis and notifies the healthcare provider. Which drug does the nurse expect will most likely be prescribed instead of the ibuprofen? 1)Naproxen 2)Aspirin 3)Ketorolac 4)Acetaminophen
4)Acetaminophen Acetaminophen is a nonopioid analgesic that inhibits prostaglandins, which serve as mediators for pain; it does not affect platelet function. Naproxen, aspirin, and ketorolac are nonselective nonsteroidal antiinflammatory drugs ( NSAIDs) that are contraindicated for clients undergoing surgery; nonselective NSAIDs have an inhibitory effect on thromboxane, a strong aggregating agent, and can result in bleeding.
Which drug is most appropriate for relieving a painful muscle spasm in the back of a client with osteoarthritis (OA)? 1)Tramadol 2)Hyaluronate 3)Diclofenac epolamine patch 4)Cyclobenzaprine hydrochloride
4)Cyclobenzaprine hydrochloride Cyclobenzaprine hydrochloride is a muscle relaxant administered to relieve painful muscle spasms, especially those resulting from OA of the vertebral column. While tramadol is a weak opioid drug that may also be given to relieve pain in clients with OA, it is not as effective against painful muscle spasms. Hyaluronate is a specific injection for knee and hip pain associated with OA. The diclofenac epolamine patch is used in clients with signs and symptoms of knee OA.
A client is diagnosed with a human immune deficiency-2 (HIV-2) infection and is on rilpivirine therapy. What drug does the nurse anticipate that the primary healthcare provider will prescribe to the client? 1)Etravirine 2)Efavirenz 3)Delavirdine 4)Emtricitabine
4)Emtricitabine Emtricitabine is a nucleoside reverse transcriptase inhibitor that mimics DNA nucleoside bases and tricks the HIV reverse transcriptase enzyme into using it. Therefore emtricitabine would be prescribed. Etravirine, efavirenz, and delavirdine are non-nucleoside reverse transcriptase inhibitors (NNRTIs). NNRTIs stop viral cell DNA and RNA replication by directly binding to the HIV-1 enzyme reverse transcriptase. NNRTIs such as rilpivirine are not effective in suppressing HIV-2 replication.
A nurse is eliciting a health history from a client with ulcerative colitis. Which factor does the nurse consider to be most likely associated with the client's colitis? 1)Food allergy 2)Infectious agent 3)Dietary components 4)Genetic predisposition
4)Genetic predisposition Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn disease, are familial, which suggests that they are hereditary. Although food allergy and infectious agent may be causative factors, they are not the most common factors. No specific dietary component has been identified.
A woman arrives at the women's health clinic complaining of frequency and burning pain when voiding. The diagnosis is a urinary tract infection. What is important for the nurse to encourage the client to do? 1)Void every 2 hours. 2)Record fluid intake and urinary output. 3)Pour warm water over the vulva after voiding. 4)Wash the hands thoroughly after urinating and defecating.
4)Wash the hands thoroughly after urinating and defecating. Hand washing is a medical aseptic technique and should limit the spread of microorganisms and help prevent future urinary tract infections if incorporated into the client's health practices. Voiding every 2 hours is unnecessary, but the client should be encouraged to void when the urge occurs. Intake and output need not be measured. Pouring warm water over the vulva after voiding is unnecessary for cystitis; it may be used as a part of perineal care for other problems.
After reviewing the urinalysis reports of a client with a renal disorder, the nurse concludes that the client may have a urinary tract infection. Which urinary laboratory findings enabled the nurse to make this conclusion? Select all that apply. 1 )pH: 8.5 2 )Specific gravity: 1.010 3 )Red blood cells: 3/hpf 4 )Osmolality: 1500 mOsm/kg (1500 mmol/kg) 5 )White blood cells: 6/hpf
1 )pH: 8.5 5 )White blood cells: 6/hpf The client may have a urinary tract infection, as the urinalysis reports show the presence of pH as 8.5 and white blood cells as 6/hpf in the urine. A pH above 8.0 indicates a urinary tract infection; client's is 8.5. The normal level of white blood cells (WBC) in urine should be less than 5/hpf; therefore, the WBC level of 6/hpf indicates urinary tract infection. The specific gravity of 1.010 indicates a normal finding. The normal level of red blood cells (RBC) is less than 4/hpf; therefore, the RBC levels of 3/hpf indicates normal finding. Osmolality of 1500 mOsm/kg (1500 mmol/kg) indicates tubular dysfunction.
A nurse manager in a surgical unit finds that many clients are developing urinary tract infections post-operatively and wants to discuss the measures to prevent it with the team. Which action of the nurse manager reflects good communication practice? 1)Calling the team for a brief meeting 2)Texting every team member about the problem 3)Sending a detailed email about preventive measures 4)Requesting the nursing supervisor for a seminar to address all the nursing staff
1)Calling the team for a brief meeting Communication is a very important aspect of any leader. Solving a client care-related issue such as increasing incidences of urinary tract infections may require discussion with team and input from the team members to arrive at any decision. Therefore a face-to-face meeting with the team would be the best communication practice. Texting or sending emails to the team members would not facilitate feedback. Addressing all the nursing staff of the facility would not be needed, as the issue is limited to the surgical unit.
A client with osteoarthritis is admitted to the hospital for evaluation of a possible hip replacement. To prevent flexion contractures, the nurse recommends that, when in bed, the client should lie in the supine or prone position. The client voices hesitation, stating that these positions are uncomfortable for the knees and hips. What action should the nurse take? 1)Encourage the client to maintain extension for specific periods of time. 2)Allow the client to lie in whatever position is most comfortable. 3)Insert a pillow under the client's knees to relieve discomfort. 4)Place the client in the semi-Fowler position most of the time.
1)Encourage the client to maintain extension for specific periods of time. Flexion contractures of the hips and knees can develop unless some periods of full extension are maintained. The most comfortable position that usually is assumed is one of flexion, which leads to contractures and should be avoided. Placing a pillow under the knees can cause flexion contractures of the hips and knees. Remaining in the semi-Fowler's position can cause flexion contractures of the hips.
The mother of a 5-year-old girl child reports to a nurse that her daughter has a genital discharge and recurrent urinary tract infections. What should the nurse suspect from the mother's statement? 1)The child may be a victim of sexual abuse. 2)The child may be a victim of physical abuse. 3)The child may be a victim of physical neglect. 4)The child may be a victim of emotional neglect.
1)The child may be a victim of sexual abuse. Genital discharge and recurrent urinary tract infections are signs of sexual abuse. Bruises, burns, fractures, or dislocation may indicate physical abuse. Malnutrition and poor hygiene may indicate physical neglect. Enuresis and sleep disorders may indicate emotional neglect.
The nurse performs a skin test on a client who has a mosquito bite. The client shows wheal and flare reaction post-skin test. Which type of hypersensitivity reaction most likely has occurred? 1)Type 1 2)Type II 3)Type III 4)Type IV
1)Type 1 Type I is an IgE-mediated hypersensitivity reaction that causes wheal and flare response. This reaction is characterized by a pale wheal containing edematous fluid surrounded by a red flare from the hyperemia. Type II is a cytotoxic hypersensitivity reaction that involves IgG and IgM antibodies but does not show any wheal and flare response. Type III hypersensitivity reaction is an immune complex-mediated reaction that involves erythema and edema in 3 to 8 hours. Type IV is a delayed hypersensitivity reaction that involves erythema and edema in 24 to 48 hours.
A nurse is teaching a health class about human immunodeficiency virus (HIV). Which basic methods are used to reduce the incidence of HIV transmission? Select all that apply. 1) using condoms 2)Using separate toilets 3)Practicing sexual abstinence 4)Preventing direct casual contacts 5)Sterilizing the household utensils
1)Using condoms 3)Practicing sexual abstinence HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. Therefore a client should use condoms to prevent contact between the vaginal mucus membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils.
The nurse instructs a human immunodeficiency (HIV)-positive client about ways to prevent infections. During a follow-up visit, which statement made by the client indicates a need for more education? 1)"I reuse cups after washing them." 2) "I wash my hands with tap water after gardening." 3)"I rinse my toothbrush in liquid laundry bleach every week." 4)"I wash my armpits, groin, and genitals with antimicrobial soap twice a day."
2) "I wash my hands with tap water after gardening." An HIV-positive client should refrain from digging in soil and performing gardening activities. Soil contains several infectious microorganisms. In unavoidable circumstances, the client should wear gloves and wash hands thoroughly with antimicrobial soap after gardening. The client should refrain from reusing cups without washing them. Weekly rinsing of a toothbrush in liquid laundry bleach helps prevent infectious pathogens from accumulating on the brush. The armpits, groin, and genitals tend to house higher amounts of microorganisms and should be cleaned twice a day with antimicrobial soap.
The healthcare team is caring for a client who has undergone surgery for lung cancer. The client needs respiratory therapy. Which task can be safely delegated to a respiratory therapist paired with a registered nurse? 1) Placing a Foley catheter 2) Assessing the respirations 3) Placing an intravenous (IV) catheter 4) Administering patient-controlled analgesia
2) Assessing the respirations Respiratory therapy is needed in clients who undergo surgery for lung cancer. Assessing respiration can be safely delegated to the respiratory therapist. Placing a Foley catheter, an IV catheter, or administering patient-controlled analgesia is within the scope of a registered nurse's practice.
The nurse is counseling a client infected with human immunodeficiency virus (HIV) regarding prevention of HIV transmission. Which statement by the client indicates the nurse needs to follow up? 1)"I should abstain from sexual activity." 2)"I can safely have anal sex without any barriers." 3)"I should get HIV counseling if planning for pregnancy." 4)"I will use condoms while having sexual intercourse."
2)"I can safely have anal sex without any barriers." The client with HIV should use barrier protection when engaging in insertive sexual activity such as anal, oral, and vaginal. Therefore the nurse should follow up to provide the client with the correct information. All the other statements are correct and need no follow up. Abstaining from all sexual activity is a safe way to eliminate the risk of exposure to HIV in semen and vaginal secretions. The client should undergo HIV counseling and routinely offer access to voluntary HIV-antibody testing when planning for pregnancy. The most commonly used barrier is a condom, which allows for protected intercourse.
The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? 1)Ulnar drift 2)Heberden nodes 3)Swan-neck deformity 4)Boutonnière deformity
2)Heberden nodes Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis. Ulnar drift, swan-neck deformity, and boutonnière deformity occur with rheumatoid arthritis.
After many episodes of otitis media a 3-year-old child is to undergo myringotomy and have tubes implanted surgically. What should the nurse include in the discharge preparation for this family? 1)Keep the child at home for 1 week. 2)Insert earplugs during the child's bath. 3)Apply an ointment to the ear canal daily. 4)Use cotton swabs to clean the inner ears.
2)Insert earplugs during the child's bath. Water in the ears after myringotomy may be a source of infection. There is no reason that the child cannot be around other children, because there is no infectious process. Applying an ointment to the ear canal daily will clog the ear canal and serves no purpose. Cotton swabs may be used occasionally in the outer ear, but should not be inserted into the ear.
A client with an acute episode of ulcerative colitis is admitted to the hospital. When reviewing the client's laboratory results, the nurse identifies that the client's blood chloride level is decreased. What is the most efficient way this can be corrected? 1)Low-residue diet 2)Intravenous therapy 3)Oral electrolyte solution 4)Total parenteral nutrition (TPN)
2)Intravenous therapy Intravenous therapy ensures a rapid, well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed. Oral electrolyte solution is not a rapid or well-controlled method for correcting electrolyte deficiencies. TPN is not necessary at this time, although it may be used eventually.
After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis? 1)Nodules on the pinna 2)Redness of the eardrum 3)Lesions in the external canal 4)Excessive soft cerumen in the external canal
2)Redness of the eardrum Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity but not the manifestation of otitis media. Excessive soft cerumen in the external canal impacts the hearing acuity but not the manifestation of otitis media.
The registered nurse (RN) assigns an unlicensed assistive personnel (UAP) to obtain and record the body temperature of a client with a fever. After completing the task, the delegator evaluates the work and gets clear feedback from the delegatee related to the task. Which delegation right is followed in this situation? 1)Right person 2)Right supervision 3)Right circumstance 4)Right Communication
2)Right supervision Right supervision is followed by the delegator in this situation. After completing the task, the delegatee gives the feedback related to the task. Right person is the right followed when the specific task is given and the delegate has the knowledge to complete the task safely. Right circumstance is the right followed when the delegatee has the appropriate supervision to complete the task. Right communication is followed when the delegator and the delegatee understand the common working language.
The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections? 1)Immunologic differences between adults and young children 2)Structural differences between eustachian tubes of younger and older children 3)Functional differences between eustachian tubes of younger and older children 4)Circumference differences between middle ear cavity size of adults and young children
2)Structural differences between eustachian tubes of younger and older children The eustachian tube in young children is shorter and wider, allowing a reflux of nasopharyngeal secretions. Immunologic differences are not a factor in the development of otitis media. There is no difference in the function of the eustachian tube among age groups. The size of the middle ear does not play a role in the occurrence of otitis media in young children.
A client who works manufacturing latex gloves presents with dryness, pruritus, fissuring, and cracking of the skin followed by redness and inflammation about 24 hours after contact. The nurse identifies it as an allergic reaction. Which condition most likely has occurred? 1)Type I allergic reaction 2)Type IV contact dermatitis reaction 3)Immune complex reaction 4)Cytotoxic hypersensitivity reaction
2)Type IV contact dermatitis reaction Type IV contact dermatitis is caused by the chemicals used in the manufacturing process of latex gloves. It is characterized by dryness, pruritus, fissuring, and cracking of the skin and occurs within 6 to 48 hours of contact. Type I allergic reaction is a response to the natural rubber latex proteins and occurs within minutes of contact with the proteins; skin redness, urticaria, rhinitis, and conjunctivitis are the clinical manifestations. Immune-complex reaction is a type III hypersensitivity. The kidneys, skin, joints, blood vessels and lungs are common sites for deposit. Cytotoxic hypersensitivity reactions involve the direct binding of IgG or IgM antibodies to an antigen on the cell surface and is a type II hypersensitivity.
An older adult male is discharged after treatment for urinary tract infection. The family members are instructed regarding age-related changes and care to be taken. In the follow-up visit, which statement made by the client's family indicates decreased risk of urinary retention in the client? 1)"I ensure he sips water just before bed." 2)"I respond immediately when he indicates a need to void." 3)"I provide privacy and assistance to him to void." 4)"I encourage him to use the urinal at least every 2 hours."
3)"I provide privacy and assistance to him to void." The family must help the client while voiding and provide privacy to encourage voiding without embarrassment. These measures will promote voiding and prevent urinary retention in the client. Giving the client water to drink just before bed can increase the risk of nocturia. Immediate response to the client when he needs to void reduces the risk of urinary incontinence. Encouraging the client to use the urinal at least every 2 hours helps the client empty the bladder. Therefore voiding at regular intervals reduces the risk of overflow urinary incontinence.
A nurse is educating a client with human immunodeficiency virus (HIV) about self-management. Which suggestion by the nurse benefits the client? 1)"Limit your daily fluid intake." 2)"Eat more roughage." 3)"Rinse your mouth with normal saline after every meal." 4)"Maintain a 4-to-5-hour gap in between meals."
3)"Rinse your mouth with normal saline after every meal." A client infected with HIV should maintain proper oral care to improve his or her appetite. The client should rinse his or her mouth with sterile water or normal saline several times a day, especially after meals, to maintain proper oral hygiene. The client should drink plenty of fluids to maintain proper body fluid balance. Roughage should be limited in a client's diet because it is not easily digestible and may lead to severe diarrhea and contains microorganisms that can lead to infection. The client should consume small, frequent meals to maintain adequate caloric intake.
A nurse is providing preoperative teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is what? 1) Viral 2)Fungal 3)Bacterial 4)Rickettsial
3)Bacterial Haemophilus influenzae and Streptococcus pneumoniae, both bacteria, are the most frequent causes of otitis media. If an ear infection develops, the parents should contact their healthcare provider immediately so an antibiotic may be prescribed. Otitis media is not caused by viral, fungal, or rickettsial organisms.
The registered nurse instructs the nursing student about caring for a hospitalized client with a human immunodeficiency (HIV) infection. Which action made by the nursing student indicates effective learning? 1)Keeping fresh flowers in the client's room 2)Encouraging the client to eat fresh fruits and vegetables 3)Keeping a dedicated disposable glove box in the client's room 4)Changing gauze-containing wound dressings every other day
3)Keeping a dedicated disposable glove box in the client's room A client with an HIV infection is at a high risk of contracting infections. Therefore the nurse should keep a dedicated disposable glove box in the client's room and avoid using supplies from a common area. The nurse should refrain from keeping potted plants and flowers in the client's room because they act as source of potentially infectious bacteria and fungi. A client with an HIV infection should be discouraged from consuming raw fruits and vegetables and should be given well-cooked food to reduce risk of food borne pathogens. In order to reduce the risk of infections, the nurse should change gauze-containing wound dressings every day.
A nurse explains to the mother of a 1-year-old with a history of frequent ear infections that the primary cause of otitis media in young children is what? 1)Sinusitis 2)Recurrent tonsillitis 3)An inflamed mastoid process 4) An obstructed eustachian tube
4) An obstructed eustachian tube A blocked eustachian tube impairs drainage and creates negative pressure; when the tube opens, bacteria are pulled into the middle ear. Sinusitis is not related to otitis media. Recurrent tonsillitis is not the direct cause of otitis media. Mastoiditis is a complication, not a cause, of otitis media.
ition. What is the best response by the nurse? 1)"Antiinflammatory medications are recommended for this condition." 2)"Typically antiviral medications are given to treat acute otitis media." 3)"Current practice is to wait 72 hours to see whether the condition resolves." 4)"Antibiotics are recommended for infants younger than 6 months with acute otitis media."
4)"Antibiotics are recommended for infants younger than 6 months with acute otitis media." All cases of acute otitis media (AOM) in infants younger than 6 months should be treated with antibiotics because of their immature immune systems and the potential for infection with bacteria. Current literature indicates that waiting up to 72 hours for spontaneous resolution is safe and appropriate management of AOM in healthy infants older than 6 months and children. However, the watchful waiting approach is not recommended for children younger than 2 years of age who have persistent acute symptoms of fever and severe ear pain. Antiviral or antiinflammatory medications would not be recommended in an acute case of otitis media.
While caring for a client with urinary tract infection, the nurse manager delegated the work of administering oral medications. Which delegatee would be appropriate for this task? Select all that apply. 1 )Registered nurse (RN) 2)Patient care associate (PCA) 3)Licensed practical nurse (LPN) 4)Licensed vocational nurse (LVN) 5)Unlicensed assistive personnel (UAP)
3)Licensed practical nurse (LPN) 4)Licensed vocational nurse (LVN) Medications can be administered by the licensed practical nurse (LPN) or licensed vocational nurse (LVN) if the task is not complicated. The registered nurse (RN) administers intravenous fluids and medications. Patient care associates (PCA) perform basic hygiene for the client. Unlicensed assistive personnel (UAP) can record vital signs under the supervision of the delegator.
A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? 1)Inclusion of transmural involvement of the small bowel wall 2)Higher occurrence of fistulas and abscesses from changes in the bowel wall 3)Pathology beginning proximally with intermittent plaques found along the colon 4)Involvement starting distally with rectal bleeding that spreads continuously up the colon
4)Involvement starting distally with rectal bleeding that spreads continuously up the colon Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.
Which instruction should the nurse give a client who is on oral extended-release ciprofloxacin therapy for urinary tract infection? 1)Chew the medication along with food 2)Take a walk in morning sunlight 3)Stop the drug after symptoms subside 4)Refrain from taking the tablet immediately after an antacid
4)Refrain from taking the tablet immediately after an antacid Ciprofloxacin is an antibiotic used in treating urinary tract infections. The nurse should instruct the client to refrain from consuming ciprofloxacin within 2 hours of taking an antacid. Most antacids contain aluminum or magnesium, which interferes with the absorption of ciprofloxacin. The client should be instructed to swallow the tablet and not chew it because chewing it negates the extended-release action of the drug. Clients on ciprofloxacin therapy should avoid sunlight because the medication increases sensitivity to sun and could result in sunburn. The prescribed drug regimen should be followed even if symptoms subside. Premature cessation of medication can lead to recurrence of infection or bacterial resistance.
A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply. 1)Hips 2)Knees 3 )Ankles 4 )Shoulders 5 )Metacarpals
1)Hips 2)Knees Osteoarthritis affects the weight-bearing joints (e.g., hips and knees) first, because they bear the most body weight. The resulting joint damage causes a series of physiologic responses (e.g., release of cytokines and proteolytic enzymes) that lead to more damage. Although the ankles are weight-bearing joints and eventually are affected, the motion in the ankles is not as great as in the hips and knees; thus there is less degeneration. Shoulder joints are not the most likely to be involved first, because these are not weight-bearing joints. Although the distal interphalangeal joints are commonly affected, the remaining interphalangeal joints and metacarpals are not
The nurse is reviewing the problems that may occur after frequent episodes of otitis media in infants. What complications may be precipitated by this infection? Select all that apply. 1)Mastoiditis 2)Heart failure 3)Hearing loss 4)Gastroenteritis 5)Bacterial meningitis
1)Mastoiditis 3)Hearing loss 5)Bacterial meningitis Mastoiditis is an inflammation of the mastoid gland; it may occur as a complication of otitis media because of the mastoid gland's proximity to the ear. Hearing loss is a common complication of otitis media; the child should be assessed frequently for this problem. The closeness of the infant's structures results in infections of surrounding organs; meningitis is a complication of otitis media. Heart failure and gastroenteritis are not complications of otitis media.
A nurse is teaching a client with an acute exacerbation of ulcerative colitis about the most appropriate diet. Which food selected by the client indicates that the dietary teaching is effective? 1)Orange juice 2)Scrambled eggs 3)Vanilla milkshake 4)Creamed potato soup
2)Scrambled eggs Low-fiber foods and lactose-free foods are recommended during acute exacerbations. Eggs are low residue and are less irritating to the colon than the other foods. Orange juice is high in fiber and contains cellulose, which is not absorbed and irritates the colon. Milk, found in the vanilla milkshake and creamed potato soup, contains lactose, which is irritating to the colon.
A nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching by the nurse is effective? Select all that apply. 1 )Orange juice 2 )Creamed soup 3 )Jelly sandwich 4)Lean roast beef 5 )Scrambled eggs
3 )Jelly sandwich 4)Lean roast beef 5 )Scrambled eggs A jelly sandwich is low in residue and therefore is less irritating to the colon than other foods. Lean roast beef is low in residue and therefore is less irritating to the colon than other foods. Eggs are low in residue and therefore are less irritating to the colon than other foods. Orange juice contains cellulose (fiber), which is not absorbed and irritates the colon. Milk in creamed soup contains lactose, which is irritating to the colon.
The nurse is assessing the body temperature of four febrile clients over 4 days. Which client is suffering from remittent fever? 1)Client A: 100 F, 100.4 F, 100.8 F, 100.6 F 2)Client B: 102F, 98.5F, 103F, 99F 3)Client C: 103F, 101F, 104F, 102 F 4)Client D: 102F, 98.5 F, 99.9F, 103F
3)Client C: 103F, 101F, 104F, 102 F In remittent fever, body temperature spikes and falls without a return to normal temperature levels. In client C, the temperature for 4 days is febrile with fluctuations, and the temperature does not return to normal. Client A has sustained fever, with a constant body temperature continuously above 38° C (100.4° F) that has little fluctuation. Client B has intermittent fever, in which the fever spikes interspersed with normal temperature levels. Client D has relapsing fever, which has periods of febrile episodes and periods with acceptable temperature values, often for longer than 24 hours.
Which type of hypersensitivity reaction is present in a client with a body temperature of 102 °F, severe joint pain, rashes on the extremities, and enlarged lymph nodes from serum sickness? 1)Delayed reaction 2)Cytotoxic reaction 3)Immediate reaction 4)Immune complex-mediated reaction
4)Immune complex-mediated reaction Serum sickness is a type III immune complex-mediated reaction. A delayed reaction is a type IV hypersensitivity reaction that may include poison ivy skin rashes, graft rejection, and sarcoidosis. A cytotoxic reaction is a type II hypersensitivity reaction that includes autoimmune hemolytic anemia, Goodpasture syndrome, and myasthenia gravis. An immediate reaction is a type I hypersensitive reaction that includes allergic asthma, hay fever, and anaphylaxis.
What functions of leukocytes are involved in inflammation? Select all that apply. 1 )Destruction of bacteria and cellular debris 2 )Selective attack and destruction of non-self cells 3 )Release of vasoactive amines during allergic reactions 4 )Secretion of immunoglobulins in response to a specific antigen 5 )Enhancement of immune activity through secretion of various factors, cytokines, and lymphokines
1 )Destruction of bacteria and cellular debris 3 )Release of vasoactive amines during allergic reactions Leukocytes such as monocytes and eosinophils are involved in inflammation. Their functions include the destruction of bacteria and cellular debris and the release of vasoactive amines during allergic reactions to limit these reactions. Helper/inducer T-cells and cytotoxic cells selectively attack and destroy non-self cells and secrete immunoglobulins in response to the presence of a specific antigen. B-lymphocytes, or plasma cells, secrete immunoglobulins in response to the presence of a specific antigen. Helper/inducer T-cells are involved in cell-mediated immunity, enhancing immune activity through the secretion of various factors, cytokines, and lymphokines.
