Exam 1 Nurse 327

Which of the following is the most effective treatment for trichomoniasis?

Metronidazole (Flagyl) Explanation: The most effective treatment for trichomoniasis is metronidazole and tinidazole. Penicillin G benzathine is used for syphilis. Doxycycline and azithromycin are used in the treatment of Chlamydia.

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

Moisten sterile gauze with normal saline and place on the protruding organ. Explanation A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with sterile normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ.

A pregnant patient asks the nurse if it is all right for her take the varicella immunization for entrance into nursing school. What is the best response by the nurse?

"It is not recommended that pregnant women take the live virus. You should wait until after your child is born." Explanation Some live vaccines (e.g., varicella, MMR [against measles, mumps, and rubella], yellow fever) are contraindicated for people who are severely immunosuppressed or pregnant.

The nurse is providing education to a client who has been diagnosed with chlamydia. The client will begin treatment with azithromycin today. Which teaching point should the nurse reinforce with this client?

"Abstain from any sexual activity for 1 week after the antibiotic is complete." Explanation Client counseling includes abstinence for 1 week after treatment, in addition to the completion of the partner's treatment. Although handwashing is an important aspect of preventing the spread of infection, the nurse must emphasize prevention of chlamydia through the normal route of transmission of this infection, which is sexually. Coinfection with chlamydia often occurs in clients infected with gonorrhea. Chlamydia and gonorrhea are caused by bacteria that are transmitted during sexual relations. Both chlamydia and gonorrhea infections frequently do not cause symptoms in women and thus are often referred to as "silent" related to clinical presentation. It is important to retest women 3 months' posttreatment, due to the possibility of reinfection.

The nurse is seeing a client who came into the sexual health clinic after discovering condylomata along her labia. The client states, "This makes no sense, I don't even know who I got this from and I have been so careful!" What is the nurse's best response?

"It sounds like you are feeling angry. Let's talk more about human papillomavirus (HPV) and strategies to stay healthy while you are being treated. Explanation In many cases, clients are angry about having warts from HPV and do not know who infected them because the incubation period can be long and partners may have no symptoms. Acknowledging emotional distress that occurs when a sexually transmitted infection is diagnosed and providing support and facts are important nursing actions. The client in this case is clearly feeling angry and overwhelmed. The nurse should first provide empathy and help the client focus on information regarding treatment in a solution focused way. Discussing the number of sexual partners and risk factors is important in prevention; however, given the client's emotional state the alternative responses would not be helpful and supportive. In addition, to inform the client that if a condom was used the virus cannot be transmitted is incorrect. Transmission can also occur through skin-on-skin contact in areas not covered by condoms.

You are caring for a client with an impaired immune system. You are concerned about the client acquiring a nosocomial infection. What intervention would help nurses control nosocomial infections?

Apply principles of medical and surgical asepsis. Explanation: Nosocomial infections are acquired when receiving care in a healthcare facility. To help prevent and control nosocomial infections, nurses should apply principles of medical and surgical asepsis whenever they care for clients. Childhood immunizations control community-acquired infections. Maintaining a proper diet and exercise regimen and use of antibiotics do not help control nosocomial infections. (less)

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated Explanation Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.

A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease?

Azithromycin (Zithromax) Explanation Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure Explanation Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.

Which condition of generally requires the identification and treatment of sexual partners?

Chlamydia trachomatis infection Explanation Chlamydia is a common sexually transmitted disease (STD) requiring the treatment of all current sexual partners to prevent reinfection. Bartholinitis results from obstruction of a duct. Candidiasis is a yeast infection that commonly occurs as a result of antibiotic use. Sexual partners may become infected, although men can usually be treated with over-the-counter products. Endometriosis occurs when endometrial cells are seeded throughout the pelvis and isn't an STD.

The following outcome appears on the plan of care for a client with genital herpes: "Client demonstrates knowledge about measures to reduce the risk of transmission and recurrences." Which of the following, if reported by the client, would support achievement of this outcome?

Consistently uses condoms with sexual activity Explanation Consistent use of condoms for sexual activity indicates that the client has knowledge of the disorder and its transmission, thereby taking steps to reduce the risk of transmission. This action supports achievement of the outcome. Sexual activity even when lesions are not present can still lead to transmission of the infection. Lesions should be cleaned with mild soap and water and patted dry; occlusive ointments, powders, or dressings should be avoided because they do not allow the lesions to dry.

A client is diagnosed with scabies in a long-term care facility. Which type of client care precautions would the nurse institute?

Contact Explanation A client with scabies requires contact isolation because the disease is highly transmissible through close or direct contact. Scabies is not transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with scabies. Enteric isolation is inappropriate because scabies is not transmitted through direct or indirect contact with feces.

The nurse is caring for a client diagnoses with severe acute respiratory syndrome (SARS). A family member asks what causes SARS. Which response by the nurse is accurate?

Coronavirus Explanation SARS is a severe acute viral respiratory illness caused by the coronavirus, typically the symptoms include fever, coughing, difficulty breathing, and pneumonia.

A group of students are reviewing class material on sexually transmitted infections in preparation for a test. The students demonstrate understanding of the material when they identify which of the following as the cause of condylomata?

Human papilloma virus Explanation: Genital warts or condylomata are caused by the human papilloma virus (HPV). Herpes virus causes genital herpes. Treponema pallidum is the cause of syphilis. Haemophilus ducreyi bacillus is the cause of chancroid

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing Explanation Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing. The edges of a wound healing by second intention are not approximated. The wound may be cleaned using sterile saline, but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed, impairing healing.

Which is a classic sign of hypovolemic shock?

Pallor Explanation The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing

What intervention by the nurse is most effective for reducing hospital-acquired infections?

Proper hand-washing techniques Explanation Efforts to prevent wound infection are directed at reducing risks, such as thorough hand washing. (Preoperative and intraoperative risks and interventions are discussed in Chapters 17 and 18.) Postoperative care of the wound centers on assessing the wound, preventing contamination and infection before wound edges have sealed, and enhancing healing.

A client in the clinic is diagnosed with diarrhea caused by a Campylobacter species. Which instruction should the nurse provide to prevent further episodes?

Properly store and cook meat. Explanation Campylobacter infection is caused by consuming undercooked or raw meat. Proper storage and cooking of meat will prevent further episodes of Campylobacter infection. The client should also be told to prepare meat separately from other foods, including the use of utensils. Giardia lamblia diarrhea is caused by drinking contaminated water. Shigella infection is transmitted via the fecal-oral route, so handwashing after going to the bathroom would help prevent the illness. Salmonella infections are usually caused by consuming raw eggs; they also can be transmitted via produce.

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism Explanation Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing dressings or applying pressure if bleeding is frank Explanation The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

Reorient the client. Assess for hypoxia. Assess urine output Explanation The nurse should provide reassurance and reorient the client as needed. Hypoxia and urinary retention may cause acute confusion in the older adults postoperatively, so it would be appropriate for the nurse to assess for hypoxia and urine output. Opioid pain medications may cause further confusion; the physician should be consulted about the type and dosage of the pain medication. Ambulating the client may present safety concerns, especially if the client is bleeding or hypoxic.

A client reports nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes as pale and dry. The client has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which is the priority nursing intervention?

Request an order from the physician for IV rehydration therapy Explanation The client is demonstrating hemodynamic instability that could lead to shock; therefore IV rehydration therapy is indicated. Oral rehydration therapy can begin once the client becomes hemodynamically stable. Although it is appropriate for the nurse to take vital signs frequently, the client needs fluid replacement and that need should be addressed first. Stool specimens can be obtain once the client is hemodynamically stable.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

Second-intention healing Explanation When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

The client is displaying early signs of shock. Explanation The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. Explanation Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dos

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Wound dehiscence Explanation Risk factors for wound dehiscence include advanced age over 65 years, chronic disease such as diabetes, hypertension, obesity, history of radiation or chemotherapy, malnutrition, particularly insufficient protein and vitamin C, and hypoalbuminemia. This client is not at increased risk for hypotension, contractures, or phlebitis.

How often should women diagnosed with human papillomavirus (HPV) have Pap smears?

Yearly Explanation: Women with HPV should have annual Pap smears because of the potential of HPV to cause dysplasia.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds. If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound

dehisced. Explanation Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding.

Which term refers to the protrusion of abdominal organs through the surgical incision?

evisceration Explanation Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

The patient is having a repair of a vaginal prolapse. What position does the nurse place the patient in?

lithotomy position

The nurse understands that the purpose of the "time out" is to:

maintain the safety of the client.

During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and "horse barn"-smelling diarrhea. It would be most important for the nurse to advise the physician to order:

stools for a Clostridium difficile test. Explanation Immunosuppressed clients — for example, clients receiving chemotherapy — are at risk for infection with C. difficile, which causes "horse barn"-smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus and isn't indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn"-smelling diarrhea.

An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking properly. When assessing the client for dehydration, the nurse would expect to find:

tachycardia. Explanation With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended jugular veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic hypotension may occur.

The nurse teaches the parent of a child with chickenpox that the child is no longer contagious to others when

the vesicles and pustules have crusted. Explanation: When the lesions have crusted, the patient is no longer contagious to others. The child remains contagious when the rash is present. The child remains contagious if the fever occurs as the rash is progressing. The child remains contagious when the rash is changing into vesicles and pustules.

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

"I can resume my usual activities as soon as I get home." Explanation By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.

A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply.

• Fosters client participation in care • Facilitates reduction of postoperative pulmonary complications Explanation PCA promotes client participation in care, eliminates delayed administration of analgesics, maintains a therapeutic drug level, and enables the client to move, turn, cough, and take deep breaths with less pain, thus reducing postoperative pulmonary complications.

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?

"Make sure your family has all their childhood immunizations." Explanation: To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular checkups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections either.

The nurse is caring for a client who asks, "I heard the nurse tell my doctor I have adnexal tenderness. What does that mean?" The client has also been experiencing fever and loss of appetite. How should the nurse respond?

"This means the internal body parts surrounding your uterus are also sore. Knowing this helps confirm that you have pelvic inflammatory disease and now you can be given the correct treatment." Explanation The minimal criteria for diagnosis of pelvic inflammatory disease and the prescribed treatment include one, or more, of the following: uterine tenderness, adnexal tenderness (adnexa are the "appendages" of the uterus, namely the ovaries, fallopian tubes, and ligaments that hold the uterus in place), and cervical motion tenderness. Other symptoms include fever, general malaise, anorexia, nausea, headache, and, possibly, vomiting. Adnexal tenderness is not related to the adrenal glands. The nurse would be incorrect in responding to the client with this explanation. When client's report the cardinal symptoms of pelvic inflammatory disease, it is important to conduct pregnancy testing and ectopic pregnancy can be one of the consequences of this infection; however, this is not the correct response to the client's question. It is also incorrect to inform the client that ectopic pregnancy leads to infertility. Although there is a correlation between the two, the nurse cannot make such a conclusive statement to the client. Adnexal tenderness is not a symptom of bacterial vaginosis.

In the immediate postoperative period, vital signs are taken at least every

15 minutes Explanation Pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.

A nurse is assessing the client's readiness for discharge from the postanesthesia care unit (PACU). The nurse can rouse the client by calling the client's name. The client can move all extremities and has a blood pressure of 134/82. Baseline preoperative blood pressure was 128/78. The most recent pulse oximetry reading was 94% on room air; the client's respirations are deep and easy at a rate of 12 breaths/minute. What is the calculated Aldrete score?

9 Explanation The Aldrete score is used to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the client's condition in the PACU. The client's total Aldrete score is 9 because the client is aroused when name is called (1), moves all extremities (2), is able to breath deeply and cough (2), exhibits circulation (blood pressure) 20% or more above the preanesthesia level (2), and is able to maintain a oxygen saturation level >92% on room air (2).

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg Explanation A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

Which of the following medications are used to suppress viral load of the HSV-2 infection?

Acyclovir (Zovirax) Explanation: The antiviral agents acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) are recommended to suppress the viral load and decreases recurrence and shedding. Flagyl and Cleocin are not used for this action

You are a school nurse teaching a health class about the chain of infection in the transmission of sexually transmitted diseases (STDs). A student asks you which part of the chain of infection can be missing when transmission occurs. What would be your best answer?

All parts of the chain of infection have to be present for the disease to be passed to another human." Explanation All components in the chain of infection must be present for an infectious disease to be transmitted from one human or animal to a susceptible host. This makes options A, B, and C incorrect.

A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?

An induration of 12mm Explanation: The size of the induration, not including the surrounding area of erythema, is measured in millimeters. The measurement determines whether the reaction is significant. For example, a tuberculin skin test is test is considered positive if the induration is 10 mm or greater in persons with no known risk factors for TB; smaller measurements are significant in certain risk groups, such as immunocompromised clients. The other answers are not indicative of positive results. (less)

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

An isolation room three doors from the nurses' station Explanation A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.

The nurse is discussing childhood immunization recommendations with a pediatric patient's parent. Where would the nurse find the most current information on this topic?

CDC Explanation The standard recommended immunization schedules are revised by the CDC (2013a) as epidemiologic evidence warrants.

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?

Call the health care provider. Explanation The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.

A nurse would anticipate instituting contact precautions for a client with which of the following?

Clostridium difficile infection Explanation: Contact precautions would be appropriate for a client with an infection due to Clostridium difficile. Airborne precautions are appropriate for clients with measles or varicella. Droplet precautions are appropriate for clients with mumps.

Which of the following describes microorganisms present without host interference or interaction?

Colonization Explanation The term colonization is used to describe microorganisms present without host interference or interaction. Infection indicates a host interaction with an organism. Infectious disease is the state in which the infected host displays a decline in wellness due to the infection. Reservoir is the term used for any person, plant, animal, substance, or location that provides nourishment for microorganisms and enables further dispersal of the organisms.

A nursing measure for evisceration is to:

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. Explanation If evisceration occurs, the nurse aseptically covers the abdominal contents with moist saline dressings to prevent drying of the bowel, notifies the surgical team immediately, and assesses the patient's vital signs including oxygen saturation. The patient remains in bed with knees bent to reduce abdominal muscle tension.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention Explanation When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.

After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment?

Genital herpes Explanation: Besides AIDS, the five most common STIs are chlamydia, gonorrhea, syphilis, genital herpes, and genital warts. Of these, chlamydia, gonorrhea, and syphilis are easily cured with early and adequate treatment. Genital herpes recurs.

The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority?

Impaired Skin Integrity Explanation: The priority nursing diagnosis focuses on the Impaired Skin Integrity. Interventions would include nursing instruction on the care of the skin to prevent further infection to self and others. The nurse would also focus on the management of the disease. Because this is a reoccurrence, Knowledge Deficit is not a priority. Psychosocial nursing diagnoses are not a priority at this time unless other data suggests. (less)

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

Ineffective thermoregulation Explanation Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

Which term describes the time interval after primary infection when a microorganism lives within the host without producing clinical evidence?

Latency Explanation During a period of latency, the person who is infected has no signs or symptoms.. Virulence is the degree of pathogenicity of an organism. The incubation period is the time between contact and onset of sign and symptoms. Susceptibility is not possessing immunity to a particular pathogen.

he client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply.

Listening to music Watching television Changing position Explanation Nonpharmacological management of pain includes listening to music, watching television, and changing position. Pharmacological pain management strategies include epidural infusions and On-Q pumps. An epidural infusion delivers a local opioid with or without a local anesthetic agent directly into the epidural space of the spine. An On-Q pump delivers a local anesthetic agent subcutaneously to the incisional area.

Which intervention should a nurse perform after administering an injection of penicillin to a client with an infection?

Make the client wait at least 30 minutes before leaving the health care facility. Explanation After administering injections of penicillin, the nurse should make the client wait at least 30 minutes before allowing him or her to leave the health care facility. This is because allergic reactions are frequent and can be severe enough to be fatal. The muscle in which the injection is given does not need to be massaged. There is no indication for the client to breathe deeply or to lie flat for 6 hours after the injection.

Fentanyl is categorized as which type of intravenous anesthetic agent?

Opioid Explanation Fentanyl is 75 to 100 times more potent than morphine and has about 25% of the duration of morphine (IV). Examples of tranquilizers include midazolam and diazepam. Ketamine is a dissociative agent.

The anesthesiologist is administering a stable and safe nondepolarizing muscle relaxant. What medication does the nurse anticipate will be administered?

Pavulon (pancuronium bromide) Explanation Pancuronium (Pavulon) is a nondepolarizing muscle relaxant with a longer onset and duration. Succinylcholine (Anectine) and decamethonium (Syncurine) are depolarizing muscle relaxants. Vercuronium (Norcuron) is a nondepolarizing muscle relaxant that requires mixing.

The nurse positions the client in the lithotomy position in preparation for

Perineal surgery

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

Pink color Explanation Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily Explanation In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia Explanation Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5° F Explanation Intra operative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.

A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza?

Pneumonia Explanation: Pneumonia is the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't associated with influenza.

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?

Position the client in the side-lying position. Explanation The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway. Explanation Maintaining a patent airway is the immediate priority in the PACU.

Painless chancres are associated with which systemic disease?

Syphilis Explanation Syphilis is manifested by a painless chancres. Psoriasis is exhibited by plaques with scales. Kaposi sarcomas are cutaneous lesions that are blue-red or dark brown in color. Urticaria is wheals or hives due to infection or allergic reactions.

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?

The Hemovac drain isn't compressed; instead it's fully expanded. Explanation The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

A nurse has performed disease prevention teaching with a female client who has genital herpes. Which client behavior indicates that the teaching has been successful?

The client washes her hands before and after touching lesions. Explanation Because hand-to-body contact is a common method of transmitting the herpes simplex virus, the client should wash her hands before and after touching the lesions to prevent the spread of the disease. To promote lesion drying and client comfort, the client should keep the affected area dry. To prevent scratching of the lesions, the client should keep her fingernails short, instead of long. Because tight-fitting clothes help retain heat and moisture, which can delay healing and cause discomfort, the client should wear loose-fitting garments.

Which statement reflects what is known about the Ebola virus?

The diagnosis should be considered in a client who has a febrile, hemorrhagic illness after traveling to Asia or Africa. Explanation The diagnosis should be considered in a client who has a febrile, hemorrhagic illness after traveling to Asia or Africa, or who has handled animals or animal carcasses from those parts of the world. Antibiotic therapy, such as penicillin, would not be effective for the treatment of viruses. Treatment must be largely supportive maintenance of the circulatory and respiratory systems. The infected client likely would need ventilator and dialysis support through the acute phases of illness. The viruses are usually spread by exposure to blood or other body fluid, insect bite, and mucous membrane exposure. Symptoms include fever, rash, and encephalitis, which progress rapidly to profound hemorrhage, organ destruction, and shock.

The school health nurse is conducting a teaching session for parents to provide information about the human papillomavirus (HPV) vaccination. What prevention information should the nurse include in the session?

The effect of the vaccination is optimized if it is administered before the child becomes sexually active. Explanation The nurse should advise the parents that the vaccination should ideally be administered before the onset of sexual activity, to prevent genital warts. The vaccination is available and effective when administered to both men and women. The HPV vaccination does not preclude women from having regular cervical cancer screening in the future. A Pap smear prior to the administration of the vaccination is not required, particularly for those woman who are not yet sexually active.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation. Explanation The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention Explanation Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.

A nurse would perform handwashing instead of using an alcohol-based product for which situation?

When hands are visibly soiled from client care Explanation: Handwashing would be done when the hands become visibly dirty or contaminated wtih biologic material from client care. Otherwise, an alcohol-based product could be used, for example, before putting on gloves for inserting a urinary catheter, after taking a client's temperature or blood pressure, or during client care when moving from a contaminated body site to clean body site.

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection Explanation Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

experiences pain within tolerable limits. Explanation Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention. Explanation Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

Flu and cold season offers excellent examples of physiologic reflexes to ward off illness. One problem is that an effective mechanical defense for one person can complete a link in the chain of infection for someone else. To which link is the above referring?

means of transmission Explanation As a person sneezes or coughs, if he or she does not cover his or her mouth and nose, the airborne microbes can be spread to others, finding a susceptible host. Covering up when coughing or sneezing is vital protection against infection. The reservoir refers to the environment in which the infectious agent can survive and reproduce. Portal of entry refers to the route by which the infectious agent escapes from the environment in which it lives and reproduces. Infectious agent refers to the agent that has the power to produce disease.

Hypothermia may occur as a result of

open body wounds Explanation Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open wounds or cavities, decreased muscle activity, advanced age, or particular pharmaceutical agents.

A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

place saline-soaked sterile dressings on the wound. Explanation The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply.

• Ambulate the length of the client's house • Get out of bed without assistance • Be able to self-toilet

Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level?

20% Explanation The patient would receive a cardiovascular/circulation score of 2 if the blood pressure is 20% of the preanesthetic level.

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?

7 Explanation Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient's condition in the PACU. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU.

Patients who have had pelvic inflammatory disease (PID) are prone to which of the following complications?

Ectopic pregnancy Explanation: All patients who have had PID need to be informed of the signs and symptoms of ectopic pregnancy because they are prone to this complication. Other complications include bacteriemia with septic shock and thrombophlebitis with possible embolization. Patients who have PID are not prone to inguinal lymphadenopathy.

The nurse is assessing a client in the emergency department who grimaces and reports swelling of the testicles, burning on urination and a green discharge from the penis. The nurse suspects the client will be diagnosed with which infection?

Gonorrhea Explanation When symptoms of gonorrhea are present in male clients, the symptoms may include burning during urination and penile discharge. Clients with Neisseria gonorrhoeae infection also may report painful swollen testicles. The latter symptoms distinguishes this infection from the infections in the alternate options. Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless lesion at the site of infection is called a chancre. Untreated, these lesions usually resolve spontaneously within about 2 months. With herpes genitalis primary infection may begin with macules (small flat spots on skin) and papules (small circumscribed elevations) and progress to vesicles (small, serous-filled elevated spots) and ulcers. The vesicular state often appears as a blister, which later coalesces, ulcerates, and encrusts. Influenza-like symptoms may occur 3 or 4 days after the lesions appear, often with inguinal lymphadenopathy (enlarged lymph nodes in the groin). Men with trichomoniasis may notice itching or irritation inside the penis, burning after urination or ejaculation, discharge from the penis.

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

The client reports a small bowel movement. Explanation: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. All of the other options are components of meeting the outcome of functioning.

When a hospitalized client is in contact precautions, which action is necessary?

The client should be placed in a private room when possible. Explanation When possible, the client requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed and doors do not need to be closed.

The nurse is assessing a client who reports stiff joints and alopecia. While taking the client's health history, the client reports having multiple sexual partners in the past 6 months and finding a lesion on her labia about 1 month before today's appointment. What should the nurse anticipate based on the signs and symptoms presented?

The client will require treatment for the secondary stage of syphilis. Explanation In the secondary stage of syphilis, generalized signs of infection may include lymphadenopathy (abnormal enlargement of lymph nodes), arthritis, meningitis (inflammation of the pia mater, arachnoid, and the subarachnoid space), hair loss, fever, malaise, and weight loss. Hair loss and arthritis are not common symptoms associated with a chlamydial infection or pelvic inflammatory disease. The information collected in the health history confirms that the client has moved past the primary stage of the infection. A colposcopy is a diagnostic procedure carried out to determine if there have been any changes in cervical cells (dysplasia). Given the client's reported health history, secondary syphilis should be further investigated first.

An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking properly. When assessing the client for dehydration, the nurse would expect to find:

tachycardia. Explanation With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended jugular veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic hypotension may occur