Exam 3
A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important. A. Assess the clients bedside glucose reading B. Instruct the client not to get up without help C. Monitor the client frequently for tachycardia D. Record the clients intake, output, and weight
B
A client presents to the clinic with pain, swelling, erythematous, and an open wound with purulent drainage to the left forearm. Which action should the nurse take immediately? a. Irrigate with sterile water b. Obtain a culture and send to the laboratory c. Administer the prescribed antibiotic d. Cover the area with a dry dressing
B
A client who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurse's priority action? a. Have the client lie down. b. Assess the client's airway. c. Administer high-flow oxygen. d.Remove the stinger from the site.
B
A client who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Avoid sexual intercourse when using injectable drugs." b. "It is important to participate in a needle-exchange program." c. "You should ask those who share equipment to be tested for HIV." d. "I recommend cleaning drug injection equipment before each use."
B
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? a. Positive Western blot test b. CD4-T-cell count 180 cells/mm c. Platelets 150,000/mm? d. WBC 5,000/mm?
B
A nurse is caring for a male client who has a new diagnosis of genital herpes (HSV 2). Which of the following findings should the nurse expect? a. Anuria b. Influenza-like symptoms C.White- or flesh-colored papillary growths in the genital area D. Green penile discharge
B
The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.
B
The nurse is caring for clients on the medical surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? A. Administering steroids for severe serum sickness B. Correctly identifying the client prior to a blood transfusion C. Keeping the client free of the offending agent D. Providing a latex free environment
B
A 29-year-old female client is diagnosed with Chlamydia during a routine pelvic examination. The nurse knows that teaching regarding the management of the condition has been effective when the client says which of the following? a. "My partner will need to take antibiotics at the same time I do." b. "Go ahead and give me the antibiotic injection, so I will be cured." c. "I will use condoms during sex until I finish taking all the antibiotics." d."I do not plan on having children, so treating the infection is not important."
A
A client develops wheezing, difficulty breathing and shortness of breath after eating peanuts. Which of the following actions should the nurse implement first? a. Administer high flow oxygen b. Call the rapid response team c. Place the client in Trendelenburg position d. Administer Atropine 5mg IV
A
A client who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the client's blood glucose within a normal range b. Ensuring that the client has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9°C) d.Redressing the surgical incision with a dry, sterile dressing twice daily
A
A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take? A. Cover the wound with a sterile saline-soaked dressing. B. Place the client in high-Fowler's position. c. Auscultate all quadrants of the abdomen for bowel sounds. d. Gently reinsert the protruding tissue.
A
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority? a. Stopping the transfusion b. Covering the client with a blanket c. Notifying the provider d. Assessing the client's skin for a rash
A
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. Use a transfer device to lift the client up in bed b. Apply cornstarch to keep sensitive skin areas dry. c. Massage the skin over the client's bony prominences. d. Elevate the head of the bed no more than 45°.
A
The nurse observes the unlicensed personnel caring for client who is at high risk for pressure injuries. Which action by the unlicensed personnel warrants the nurse to intervene immediately? a. The unlicensed personnel massage a reddened area on the client's buttock. b. The unlicensed personnel encourage the client to use the trapeze bar to assist with repositioning. c. The unlicensed personnel use a lift sheet to assist with repositioning. d. The unlicensed personnel turn the client every 2 hours to relieve pressure.
A
The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client
A
What is the MOST important step a nurse can take to prevent anaphylactic shock in a client? a. Assess and document allergies in the medical records b. Administer epinephrine prior to invasive procedures c. Administer corticosteroids prior to invasive procedures d. Start IV infusion of Normal Saline
A
When admitting a client with stage Ill pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The client takes insulin daily. b. The client states that the ulcers are very painful. c. The client has had the heel ulcers for the last 6 months. d. The client has several old incisions that have formed keloids.
A
The nurse teaches a diabetic client about infection prevention and control. Which statements made by the client indicates that the teaching has been effective? (Select all that apply) a. "I will practice good hand hygiene at all times." b. "I will keep my environment free from contaminated items." c. "I will notify my healthcare provider prior to having any invasive procedures." d. "I will follow-up with my healthcare provider if I accidently cut myself." e. "I will stop taking my antibiotics if they make me sick."
A, B, C
The nurse develops a teaching plan for client with a history of anaphylactic shock. Which of the following should be included in the plan? (Select all that apply). a. Always carry an Epi-Pen b. How to prepare and administer medication c. Avoid allergen and recognize signs/symptoms d. Replace EpiPen every 6 months e. Wear medical alert bracelet at all times
A, B, C, E
The nurse is caring for a client with a diagnosis of anaphylactic shock. Which of the manifestations should the nurse anticipate? (Select all that apply) a. Hypotension b. Tachycardia c. Watery eyes d. Wheezing e. Constipation
A, B, D
The nurse cares for client who had abdominal surgery for a bowel obstruction. Which assessment data should the nurse gather on initial contact with this client? (Select all that apply) a. Incision size, color and drainage b. Approximation of the incision c. Medical and medication history d. Dietary preference e. Last bowel movement
A, B, E
The nurse cares for a client with an open wound to the left foot. Which of the followings should the nurse report to the health care provider? (Select all that apply) a. BP 160/90 b. Heart rate 110 C. Respiration rate 22 d. Temperature 102° F e. Oxygenation level 95% on room air
A, D, E
The nurse cares for a client infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b.Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin
A,B,C
The nurse cares for a client with an open wound to the left foot. Which of the following clinical manifestations should the nurse expect? (Select all that apply) a. Redness b. Warm to touch c. Pain d. Swelling e. White blood count of 6,000/mm?
A,B,C,D
The registered nurse (RN) caring for an HIV-positive client admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the client about how to use tissues to dispose of respiratory secretions. b.Stock the client's room with all the necessary personal protective equipment. c. Interview the client to obtain the names of family members and close contacts. d. Tell the client's family members the reason for the use of airborne precautions.
B
Your client is having a sudden and severe anaphylactic reaction to a medication. You immediately stop the medication and call a rapid response. The client's blood pressure is 80/52, heart rate 120, and oxygen saturation 87%. Audible wheezing is noted along with facial redness and swelling. Which of the following actions should the nurse implement first? a. Administer IV Diphenhydramine b. Administer IV Normal Saline Bolus c. Administer IM Epinephrine d. Administer Nebulized Albuterol treatment
B
A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan? a. Massage the client's red bony prominences. b. Assess the client's skin for increased coolness. c. Reposition the client every 2 hr. d. Keep the client's skin moist.
C
After receiving a change-of-shift report, which client should the nurse assess first? a. The client who has multiple black wounds on the feet and ankles b. The newly admitted client with a stage IV pressure ulcer on the coccyx c. The client who has been receiving chemotherapy and has a temperature of 102 F d. The client who needs to be medicated with multiple analgesics before a scheduled dressing change
C
After the nurse has taught a client with a newly diagnosed sexually transmitted infection about expedited partner therapy, which client statement indicates that the teaching has been effective? a. "I will tell my partner that it is important to be examined at the clinic." b."I will have my partner take the antibiotics if any STI symptoms occur." c. "I will make sure that my partner takes all of the prescribed medication." d."I will have my partner use a condom until I have finished the antibiotics."
C
The nurse cares for a client who had an appendectomy 3 days ago develops abdominal pain, fever of 102.3, and malaise. Which intervention should the nurse implement first? a. Administer the prescribed antipyretic b. Document the findings c. Notify the charge nurse d. Obtain a prescription for a stool softener
C
Which of these clients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Client whose latest CD4+ count is 250/uL b. Client whose rapid HIV -antibody test is positive c. Client who has had 10 liquid stools in the last 24 hours d. Client who has nausea from prescribed antiretroviral drugs
C
A client is having an anaphylactic reaction to an IV medication. What is the FIRST action the nurse should take? a. Administer Epinephrine b. Call the Rapid Response Team c. Stop the medication D. Administer a breathing treatment
D
A client is hospitalized with Pneumocystitis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? A. Administer sleeping medication B. Perform most activities for the client C. Increase the clients oxygen during activity D. Pace activities, allowing for adequate rest
D
A client is in the preoperative holding are prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? A. Assess that the client has been NPO as directed B. Communicate this information with the dietary staff C. Document the information in the client's chart D. Ensure the information is relayed to the surgical team
D
A client who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is best? a. "Thinking about dying will not improve the course of AIDS." b. "It is important to focus on the good things about your life now." c. "Do you think that taking an antidepressant might be helpful to you?" d. "Can you tell me more about the kind of thoughts that you are having?"
D
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses the lesions sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and atter care d. Disposing of soiled dressings properly
D
A male client who has a profuse, purulent urethral discharge with painful urination is seen at the clinic. Which information should be most important for the nurse to obtain? a. Contraceptive use b. Sexual orientation c. Immunization history d.Recent sexual contacts
D
A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions? a. Halitosis b.Gingivitis c. Xerostomia d. Candidiasis
D
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? a. Exposed bone b. Blood filled blisters c. Partial-thickness skin loss. d. Necrotic subcutaneous tissue
D
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? a. Dobutamine b. Methylprednisolone c. Furosemide d. Epinephrine
D
A paraplegic client has a stage II sacral pressure ulcer and is cared for at home. To prevent further tissue damage, what instructions are most important for the nurse to teach the caregiver? a. Change the client's bedding frequently. b. Use a hydrocolloid dressing over the ulcer c. Record the size and appearance of the ulcer weekly. d.Change the client's position at least every 2 hours.
D
The nurse is caring for a client for a diabetic client who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose 136 mg/dL b. Oral temperature 101° F (38.3° C) c. Client complaint of increased incisional pain d. Separation of the proximal wound edges by 1 cm
D
The nurse will perform which action when doing a wet-to-dry dressing change on a client's stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b.Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d.Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
D
When caring for a client who has received a general anesthetic, the circulating nurse notes red, raised wheals on the client's arms. Which action should the nurse take immediately? a. Apply lotion to the affected areas. b. Cover the arms with sterile drapes. c. Recheck the client's arms in 30 minutes. d. Notify the anesthesia care practitioner (ACP) immediately.
D
