Exam 2 practice adult health

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

"I will limit my alcohol Intake.

A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

325

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Administer antibiotics to the client.

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply)

An increase in neutrophils Localized edema

The nurse is planning care for a client recovering from a total hip surgery. Which task(s) will the nurse delegate to unlicensed assistive personnel (UAP) to complete? Select all that apply

Assist with daily hygiene needs Encourage fluid intake throughout the day Measure intake and output throughout the shift

During a routine physical examination, a nuse observes a 1 cm (0.4 in) lesion on a clients chest. The lesion is raised and flesh colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Basal cell carcinoma

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP), When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for

Bleeding

A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that this disease is caused by which of the following types of hypersensitivities?

Cytotoxic

A nurse if providing teaching about preventing skin cancer. which of the following client statements indicates a need for further teaching?

Eating a high fiber diet will reduce my risk for developing skin caner

A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

Encourage increased fluid intake

A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which of the following changes is an early manifestation of RA?

Fatigue

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to hnd in this client?

Kyphosis

A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis?

Localized erythema

The nurse is caring for an elderly client with rheumatoid arthritis. Which measure(s) should the nurse implement to help prevent pressure injuries? Select all that apply.

Perform a thorough skin assessment. Educate the client about pressure injury Utilize pressure relieving devices.

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?

Report of exposure to skin irritant

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus. which of the following values should give the nurse the best indication of the client's renal function

Serum creatinine

A nurse is caring for an older adult client who has a WBC count of 2,000/mm after three rounds of chemotherapy. Which of the following actions should the nurse take?

Serve cooked fruit with meals.

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)

Slight pain at insertion site Serous drainage on the dressing

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest

Swimming

A nurse is caring for a client who has AIDS. Nurses' Notes Client admitted to medical-surgical floor from the emergency department (ED). Client has a history of HIV, first diagnosed 15 years ago, that has recently progressed to AIDS. Client presents with headache, diarrhea, night sweats, and • weight loss for appraximately 1 week. Vital Signs Day 1: Temperature: 37.3° C (99.1° F) Heart rate: 98/min Respiratory rate: 16/min BP: 104/74 mm Hg Oxygen saturation: 96% on room air Day 2: Temperature 38.4 C (101.1 F) Heart rate 100/min Respiratory rate 18/min BP 98/54 mm Hg Oxygen saturation 95% on room air Diagnostic Rosults Day 1: WBC count 3,500/mm° (5,000 - 10,000 mm% Hemoglobin 16 g/dL (12 to 18 g/dL) Hematocrit 48% (37% to 52%) Potassium 3.7 mEa/L (3.5 to 5 mEo/L) Sodium 141 mEa/L (136 to 145 mEq/L) CD4 t-cell count 200 mm% (800 to 1,000 mm% Day 2: WBC count 3,100/mm% (5,000 to 10,000 mm*) Heroglobin 17 g/dL (12 t

The client is at highest risk for developing infection due to their CD4-T cell count

The nurse who works in a dermatology clinic is concerned about the spread of infection. Which skin condition is most easily spread to others?

Tinea corporis

A muse is caring for a clier who has a dlayed hyper sensitivity reaction. The murse should expect which of the following manifestations?

Tissue damage at site

A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells?

Transplant rejection

A nurse is caring for a client who has anemia. Diagnostic Results Het 28% (37% to 47%) Hgb 9 p/dl (12 g/dL to 16 g/dL) WBC 6,000/mm% (5000 to 10,000/mm% Potassium 3.8 mEa/L (3.5 mE/L to 5 mEa/L) Nurses' Notes 1000: One unit of packed RBCs started through a #18 g IV in right antecubital. Unit of blood infusing well. IN site dry and intact, without redness or swelling 1015; Client appears flushed and reports new onset of low back pain and chills. Client voided 300 mL of brown-colored urine. Bilateral breath sounds clear and present throughout. Vital Signs 1000: Temperature 37,2° C (99° F) Blood pressure 104/56 mm Hg Heart rate 106/min Respirations 22/min Oxygen saturation 96% on room air Temperature 39.6° C (103.3° F) Blood pressure 78/50 mm Hg Heart rate 122/min Respirations 28/mi Select the 3 findings that require immediate follow-up.

Urine color Report of low back pain Temperature

a clinical nurse is performing a physical assessment on a client who has systemic lupus. which of the following should the nurse expect?

a dry, red rash across the bridge of the nose and on the cheeks

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurses priority intervention?

count the respiratory rate

After obtaining a shift change handoff report, which client will the nurse assess first?

• A client with decreased capillary refill after the application of a cast one hour ago to stabilize a tibia fracture.

The nurse is caring for a client in skeletal traction for treatment of a femur fracture. Which action by a graduate nurse (GN) requires intervention by a nursed

• Removal of traction pins to clean the skin at the traction site.