Exam #1 - Med. Sure 3
Following surgery, total parenteral nutrition is instituted via a central venous infusion. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. After contacting the primary health care provider, what is the next action the nurse should take? A. Check the serum glucose level. B. Obtain an oxygen saturation level. C. Administer a prescribed analgesic. D. Prepare the client for immediate surgery for possible bowel obstruction
A. Rapid administration can cause glucose overload, leading to osmotic diuresis and dehydration. There is no indication of hypoxia. Signs of bowel obstruction are not present. The client's headache should disappear with oral fluid replacement; analgesics are not indicated.
A client demonstrates signs and symptoms of a transfusion reaction. The nurse immediately stops the infusion; what should the nurse's next action be? A. Obtain blood pressure in both arms. B. Send a urine specimen to the laboratory. C. Hang a bag of normal saline with new tubing. D. Monitor the intake and output every 15 minutes.
C. The tubing must be replaced to avoid infusing the blood left in the original tubing; the normal saline infusion will maintain an open line for any further intravenous (IV) treatment. All vital signs should be taken eventually; blood pressure may be taken on either arm, not necessarily both. A urine sample is collected after the blood transfusion is stopped, the tubing replaced, and a bag of normal saline hung. The specimen will be analyzed to determine kidney function. Although the intake, and especially the output, should be monitored to assess kidney function, this is not the priority.
A nurse is teaching a client about human immunodeficiency virus (HIV). What are the various ways HIV is transmitted? Select all that apply. A. Mosquito bites B. Sharing syringe needles C. Breastfeeding a newborn D. Dry kissing the infected partner E. Anal intercourse
B., C., & E. Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites or dry kissing.
Which personal protective equipment will the nurse wear when providing central venous access device site care? A. Double sterile gloves B. Mask and sterile gloves C. Hair cap and sterile gloves D. Mask, gown, and double gloves
B. A mask will protect the catheter insertion site from droplet and airborne microorganisms emanating from the nurse, and sterile gloves will protect the insertion site from contact with microorganisms on the nurse's hands. Double gloves and a hair cap are not needed. Gown use is based upon facility protocol. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.
A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order. 1. Change the intravenous (IV) administration set. 2. Stop the transfusion. 3. Notify the primary healthcare provider and blood bank. 4. Run 0.9% normal saline at a rapid rate.
2., 1., 4., & 3. The priority is to stop the transfusion. Failure to do so will make the reaction worse. Changing the IV administration set will prevent infusing any blood product remaining in tubing. Running normal saline rapidly will help to decrease shock and hypotension. Notifying the primary healthcare provider and blood bank would be the last step because this would take longer than the first three choices.
Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? A. Oropharyngeal candidiasis B. Cryptosporidiosis C. Toxoplasmosis encephalitis D. Pneumocystis jiroveci pneumonia
A. Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is the more common in a client infected with AIDs. It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Which findings lead the nurse to suspect a transfusion reaction caused by incompatible blood? Select all that apply. A. Cyanosis B. Backache C. Shivering D. Bradycardia E. Hypertension
B. & C. Mismatched blood cells are attacked by antibodies, and the hemoglobin released from ruptured erythrocytes plugs the kidney tubules; this kidney involvement results in backache. Shivering occurs as part of the inflammatory response associated with a transfusion reaction. Cyanosis is not commonly associated with a transfusion reaction. Tachycardia, not bradycardia, is associated with a transfusion reaction. Hypotension, not hypertension, is associated with a transfusion reaction.
A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Select all that apply. A. Goggles B. Surgical mask C. Shoe covers D. Gown E. Gloves F. N95 hepa mask
B., D., & E. A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would only be important if the client was on mechanical ventilation to avoid contact with sputum. An N95 hepa mask would be necessary if the client had tuberculosis, but not for Cryptococcal pneumonia alone. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving client care at the bedside.
Which medication class helps to prevent human immunodeficiency virus (HIV) incorporating its genetic material into the client's cell? A. Entry inhibitors B. Protease inhibitors C. Integrase inhibitors D. Reverse transcriptase inhibitors
C. Integrase inhibitors such as raltegravir and dolutegravir bind with integrase enzymes and prevent HIV from incorporating its genetic material into the host (client's) cell. Entry inhibitors prevent the binding of HIV. Protease inhibitors prevent the protease enzyme from cutting HIV proteins into the proper lengths needed to allow viable virions to assemble. Reverse transcriptase inhibitors inhibit the action of reverse transcriptase.
The primary healthcare provider prescribes two units of packed red blood cells for a client who is bleeding. Before blood administration, what is the nurse's priority? A. Obtaining the client's vital signs B. Letting the blood reach room temperature C. Monitoring the hemoglobin and hematocrit levels D. Determining proper typing and crossmatching of blood
D. Determining proper typing and crossmatching of blood is absolutely necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. Although important, obtaining the client's vital signs is not the highest priority. Blood must be kept cool until ready to use. If blood is at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within 4 hours. Monitoring the hemoglobin and hematocrit levels is not the highest priority; these laboratory results were part of the data used to determine the need for the blood. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.
A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first? A. Administer oxygen as prescribed. B. Notify the healthcare provider. C. Assist with insertion of chest tube. D. Continue to assess client's respiratory status.
A. The client most likely is experiencing a pneumothorax, which is a collection of air in the pleural space. This can be caused during the insertion of a central venous catheter. During insertion, the pleural covering of the lung can be punctured by the introducer on insertion of a direct subclavian approach. Signs and symptoms of a pneumothorax include chest pain, dyspnea, apprehension, cyanosis, decreased breath sounds on the affected side, and abnormal chest x-ray findings. The nurse should first think about the "ABC's" (airway, breathing, circulation) and therefore should administer oxygen as prescribed, then notify the healthcare provider, continue to assess the client's respiratory status, and then assist with chest tube insertion if indicated.
Which key feature would the nurse explain indicates malignancy in an acute immunodeficiency syndrome (AIDS) client? A. Dry skin B. Weight loss C. Kaposi sarcoma D. Opportunistic infections
C. Kaposi sarcoma is a key feature that indicates malignancy in an AIDS client. Dry skin is an integumentary manifestation in a client suffering from AIDS. Weight loss is a gastrointestinal manifestation in a client with AIDS. Opportunistic infection is an immunologic manifestation in a client with AIDS.
During the administration of total parenteral nutrition (TPN), an assessment of the client reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? A. Restart the client's infusion at another site. B. Slow the rate of the client's infusion of the TPN. C. Interrupt the client's infusion and notify the healthcare provider. D. Obtain the vital signs and continue monitoring the client's status
C. The client is experiencing pulmonary edema because of a fluid volume excess. The high concentration of TPN precipitates a fluid shift from the interstitial compartment into the intravascular compartment. Fluid will continue to be infused, which will continue to increase the intravascular volume.
A blood transfusion of packed cells has been prescribed for a client with leukemia. The nurse will complete the following steps in what order? 1. Ascertain that intravenous catheter size is 18 or 20 gauge. 2. Check primary healthcare provider's prescription. 3. Change main line solution to normal saline. 4. Obtain vital signs and history of transfusions. 5. Check client identification before hanging unit of blood.
2., 4., 1., 3., & 5. The nurse should first check the primary healthcare provider's prescription to notify the blood bank of what product will be needed. The next step is to obtain the client's baseline vital signs and ask whether the client has had previous transfusions and whether there were any untoward effects. Ascertaining the intravenous catheter size is at least 18 gauge will prevent hemolysis of red blood cells. The main line solution must be normal saline 0.9% to flush the line and use as a main line if the blood administration must occur because of a reaction. Other solutions can affect blood, causing it to clot. Checking the client identification and verification of blood product is necessary before proceeding.
A primary health care provider prescribes total parenteral nutrition for a client with cancer of the pancreas. A central venous access device is inserted. What does the nurse identify as the most important reason for using this type of access? A. Infection is uncommon. B. It permits free use of the hands. C. The chance of the infusion infiltrating is decreased. D. The amount of blood in a major vein helps to dilute the solution.
D. Unless diluted, the highly concentrated solution can cause vein irritation or occlusion. Although it permits free use of the hands, this is not the primary reason for a central line. Infection can occur at any invasive site and requires diligent care to avoid this complication. The chance of the infusion infiltration decreasing is not the primary reason, although the infusion at this site is more secure than a peripheral site and promotes free use of the hands.
A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. A. Obtain the client's vital signs. B. Monitor hemoglobin and hematocrit levels. C. Allow the blood to reach room temperature. D. Determine typing and crossmatching of blood. E. Use a Y-type infusion set to initiate 0.9% normal saline.
A., D. & E. Obtaining the client's vital signs provides a baseline and should be done before the transfusion is initiated. Prior to beginning the transfusion, the nurse and another hospital-approved personnel should double-check client identification and blood product identification (blood unit number, blood type and crossmatch data like Rh factor along with expiration date) with another licensed nurse. Using a Y-type infusion set with 0.9% saline on one side of the Y is necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. A Y-type infusion set is specific for blood administration. It has a special blood filter, the drop factor is different, and it allows for quick shutoff and the administration of normal saline in the event of a transfusion reaction. The laboratory results for hemoglobin and hematocrit levels were part of the data used to determine the need for blood initially and do not need to be performed again until after the transfusion is completed. Blood must be kept cold until ready for use; if blood is kept at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within four hours. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.
The laboratory report of a client reveals the presence of 350 cells/mm3 (350 cells/uL) of CD4+ T-cell count. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
B. According to the CDC, human immunodeficiency disease is divided into four stages. A client with a CD4+ T-cell count between 200 and 499 cells/mm3 (499 cells/uL) is in the second stage of HIV disease. A client with a CD4+ T-cell count of greater than 500 cells/mm3 (500 cells/uL) is in the first stage of HIV disease. A client with a CD4+ T-cell count of less than 200 cells/mm3 (200 cells/uL) is in the third stage of HIV disease. The fourth stage of HIV disease indicates confirmed HIV infection with no information regarding CD4+ T-cell counts.
A primary health care provider prescribes 1000 mL total parenteral nutrition (TPN) to be infused over 12 hours via a central venous access device. What is most important for the nurse to obtain when preparing the equipment? A. An infusion pump B. A steady intravenous (IV) pole C. An infusion set delivering 60 gtts/mL D. A set of hemostats to be taped at the bedside
A. An infusion pump should be administered in a continuous and uniform infusion to prevent hyperosmolar diuresis. A steady IV pole is true for any intravenous infusion; this is not unique to total parenteral nutrition. Also, infusion pumps can be placed on the bedside table. The tubing set should be specific for the type of infusion pump. Hemostats (clamps) are not necessary when administering total parenteral nutrition; an infusion pump should be used.
A prescribed blood transfusion of packed red blood cells was started five minutes ago. Now the client is complaining of chest pain, flank pain, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 100.8° F (38.2° C), and the client seems less alert. What should the nurse suspect? A. Urticarial reaction B. Hemolytic reaction C. Circulatory overload D. Anaphylactic reaction
B. Chest and flank pain, nausea, difficulty breathing, and chills are early signs of hemolytic reaction, which occurs with incompatible blood. Symptoms of shock and loss of consciousness occur later. This type of reaction occurs within minutes of starting the infusion. Urticarial reactions are minor allergic reactions that typically cause hives. Circulatory overload typically would occur with rapid infusion and would raise the blood pressure. An anaphylactic reaction would cause respiratory or cardiac collapse.
After receiving 75 mL of packed red blood cells, the client complains of chills and low back pain. The nurse suspects a hemolytic transfusion reaction and stops the infusion. The blood bag and a urine specimen are sent to the laboratory. What will the urine specimen be tested for? A. Specific gravity B. Free hemoglobin C. Carboxyhemoglobin D. Disseminated intravascular coagulation (DIC)
B. Blood incompatibility causes lysis of red blood cells with the result that hemoglobin is freed into the circulation; if a sufficient (100 mL or more) amount of incompatible blood is transfused, permanent renal damage can occur. Chills and low back pain indicate kidney involvement. Specific gravity need not be determined. Carboxyhemoglobin need not be determined. DIC is an intravascular clotting disorder that does not occur with a transfusion reaction.
A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? A. Perform a finger stick glucose test and call the primary healthcare provider with the results. B. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. C. Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready. D. Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.
B. Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may perform a finger stick glucose test and notify the healthcare provider if the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at keep vein open (KVO) until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless there is a negative client outcome that results.
NURSES CHART: Client A: CD4+ T-Cell count is 180 cells/mm^3 Client B: CD4+ T-Cell count is 250 cells/mm^3 Client C: CD4+ T-Cell count is 380 cells/mm^3 Client D: CD4+ T-Cell count is 600 cells/mm^3 The nurse is reviewing the laboratory reports of four clients. Which client is in the third stage of human immune virus (HIV) disease? A. Client A B. Client B C. Client C D. Client D
A. According to HIV disease classification, a client with HIV disease is in the third stage of the disease if the CD4+ T-cell count is less than 200 cells/mm3. Therefore, client A is in third stage of HIV disease. A client is in second stage of HIV disease if the CD4+ T-cell count is between 200 and 499 cells/mm3. Therefore, client B and client C are in the second stage of HIV disease. A client is in the first stage of HIV disease if the CD4+ T-cell count is greater than 500 cells/mm3. Therefore, client D is in first stage of HIV disease. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, health history), physical assessment data, and assistant/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.
The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement? A. Chest x-ray B. Flushing the line with heparin C. Withdrawing blood to ensure patency D. Chest fluoroscopy
A. The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.
Which is the first medication approved to reduce the risk of human immunodeficiency virus (HIV) infection in unaffected individuals? A. Truvada B. Abacavir C. Cromolyn D. Methdilazine
A. Truvada is the first medication approved to reduce the risk of HIV infection in unaffected individuals who are at a high risk of HIV infection. Abacavir is administered to treat HIV infection and is a reverse transcriptase inhibitor. Cromolyn is administered in the management of allergic rhinitis and asthma. Methdilazine, an antihistamine, is administered to treat the skin and provide relief from itching.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse would monitor the client for which complications? Select all that apply. A. Hyperglycemia B. Infection C. Hepatitis D. Anorexia E. Dysrhythmias
A. & B. Hyperglycemia related to the high concentration of dextrose in TPN is a common complication of this therapy and must be monitored for by the nurse. Another common complication is related to the central venous access that is needed for infusion of TPN. Catheter-related infection is frequently seen and must be monitored for by the nurse. Hepatitis is usually not associated with total parenteral nutrition. Anorexia often is present before the medical decision is made to begin total parenteral nutrition. Dysrhythmias are not related to total parenteral nutrition, but may be a sign of hyperkalemia or hypokalemia.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should assess for which complications? Select all that apply. A. Infection B. Hyperglycemia C. ABO incompatibility D. Electrolyte imbalance E. Cardiac dysrhythmias
A. B. & D. The concentration of glucose in the solution is an excellent culture medium that promotes the growth of microorganisms. Hyperglycemia is a common complication with TPN because of the high-glucose formulas used; blood glucose levels need to be monitored carefully during therapy. TPN formulas may need to be adjusted daily based on the client's daily electrolyte levels. ABO incompatibility is not associated with TPN. Cardiac dysrhythmias are not related to TPN.
The nurse is monitoring a client who is having a third transfusion of packed red blood cells. Which of these may be evident if the client is experiencing a febrile transfusion reaction? Select all that apply. A. Chills B. Urticaria C. Hypotension D. Tachycardia E. Bronchospasm F. Sense of impending doom
A. C. & D. Febrile transfusion reactions occur most often in clients who have had multiple transfusions. Symptoms include chills, hypotension, tachycardia, tachypnea, and fever. Urticaria and bronchospasm occur with allergic transfusion reactions. Feeling a sense of impending doom occurs with hemolytic transfusion reactions.
Which dietary changes does the nurse suggest for a client who has diarrhea associated with human immunodeficiency virus (HIV disease)? Select all that apply. A. "Eat more fatty food." B. "Eat much less roughage." C. "Drink two cups of coffee daily." D. "Eat more spicy and sweet food." E. "Drink plenty of fluids between meals."
B. & E. Clients infected with the HIV virus often suffer from diarrhea. Roughage should be limited in the diet of a client who has diarrhea associated with HIV disease, as it is not easy digestible. Drinking plenty of fluids helps to compensate for the fluid loss. Fatty foods are avoided as they alter the process of digestion. Coffee is avoided as it stimulates the gastrointestinal tract and leads to diarrhea. Spicy and sweet foods are avoided as they trigger the gastrointestinal tract and acidify the stomach contents that lead to diarrhea.
A client is diagnosed with acquired immunodeficiency syndrome (AIDS). When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? A. Cytomegalovirus B. Histoplasmosis C. Candida albicans D. Human papillomavirus
C. White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeastlike fungal infection. This condition is also known as "thrush." Cytomegalovirus may cause a serious viral infection in persons with human immunodeficiency virus (HIV), resulting in retinal, gastrointestinal, and pulmonary manifestations. Histoplasmosis is an infection caused by inhalation of spores of the fungus Histoplasma capsulatum and is characterized by fever, malaise, cough, and lymphadenopathy. Human papillomavirus typically manifests as warts on the hands and feet, as well as mucous membrane lesions of the oral, anal, and genital cavities. It may be transmitted without the presence of warts through body fluids, with some forms associated with cancerous and precancerous conditions. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.
A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? A. Septic shock B. Cardiogenic shock C. Neurogenic shock D. Anaphylactic shock
D. Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.
