Exam I more questions

ANS: C, E, F Of the disease processes listed, the ones that would make the client a candidate for carrier genetic testing would be hemophilia, sickle cell disease, and cystic fibrosis. Although Huntington disease, breast cancer, and colorectal cancer all have genetic components, there is no evidence that carrier genetic testing would be beneficial in diseases such as these. DIF: Remembering/Knowledge REF: 59 KEY: Genetics| genetic testing MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. A nurse completes pedigree charts for clients at a community health center. Which diagnosis should the nurse refer for carrier genetic testing? (Select all that apply.) a. Huntington disease b. Breast cancer c. Hemophilia d. Colorectal cancer e. Sickle cell disease f. Cystic fibrosis

A) "Primary thrombocythemia creates potential problems at both ends of the clotting spectrum: inappropriate clotting or inappropriate bleeding."

20. A woman's routine complete blood count (CBC) revealed a highly elevated platelet level, and subsequent diagnostic testing has resulted in a diagnosis of primary thrombocythemia. The nurse has begun the relevant health education with the patient. What should the nurse teach this woman about her health problem? A) "Primary thrombocythemia creates potential problems at both ends of the clotting spectrum: inappropriate clotting or inappropriate bleeding." B) "Your doctor will likely order a series of blood transfusions for you over the next several months." C) "It's very important that you try to adopt a diet that's high in organ meats and leafy green vegetables." D) "Primary thrombocythemia makes you quite vulnerable to hemorrhage, so you'll need regular injections of some important clotting factors."

A) Ethambutol

A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? A) Ethambutol B) Isoniazid C) Pyrazinamide D) Rifampin

The answer is A. Doxycycline is part of the Tetracycline antibiotic family. This medication can decrease the effectiveness of birth control pills. Since the patient is female and within child-bearing age, the question should be asked if she is taking birth control pills so you can educate her on using another form of birth control to prevent pregnancy.

A 25 year-old female patient with pneumonia is prescribed Doxycycline. What question is important to ask the patient prior to administration of this medication? A. "Do you take birth control pills?" B. "Are you allergic to Penicillin?" C. "Are you allergic to eggs?" D. "Do you have a history of diabetes?"

d.The importance of adhering to the prescribed treatment regimen

A 44-year-old homeless man presented to the emergency department with hemoptysis. The patient was diagnosed with tuberculosis (TB) after diagnostic testing and has just begun treatment with INH, pyrazinamide, and rifampin (Rifater). When providing patient education, what should the nurse emphasize? a.The rationale and technique for using incentive spirometry b.The correct use of a metered-dose inhaler (MDI) for bronchodilators c.The need to maintain good nutrition and adequate hydration d.The importance of adhering to the prescribed treatment regimen

B) Risk for fatigue

A 50-year-old woman recently sought care from her primary care provider and was diagnosed with hypoproliferative anemia following a diagnostic workup. The nurse at the clinic has been charged with the responsibility for organizing the woman's care and is consequently creating a nursing care plan. When planning this woman's care, what nursing diagnosis should the nurse prioritize? A) Decreased cardiac output B) Risk for fatigue C) Acute pain D) Risk for hypothermia

The answers are B and E. You would not keep the head-of-bed less than 30 degrees because this impedes breathing and increases the risk of aspiration. Also, since the patient has systolic heart failure you would NOT encourage 3L of fluids per day because the patient would not tolerate the extra fluid. However, in normal situations (if a patient does not have heart failure etc.) you would want to encourage fluids to keep secretions thin.

A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21, oxygen saturation 93% on 2L nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply: A. Keep head-of-the-bed less than 30 degrees at all times. B. Collect sputum cultures. C. Encourage 3L of fluids a day to keep secretions thin. E. Provide education about receiving the Pneumovax vaccine every 5 years.

D) Providing anticipatory interventions

A 72-year-old patient is status post right knee replacement, and the nurse recognizes the patient's risk of hospital-acquired pneumonia (HAP). What is a priority nursing measure for the prevention of HAP? A) Providing emotional support B) Giving antibiotics as ordered C) Providing extra nutrition for the elderly patient D) Providing anticipatory interventions

B) Collection of a sputum sample for submission to the hospital laboratory

A 72-year-old patient who was admitted to the hospital for a total hip arthroplasty has developed increasing dyspnea and leukocytosis over the past 48 hours and has been diagnosed with hospital-acquired pneumonia (HAP). The choice of antibiotic therapy for this patient will be primarily based on which of the nurse's assessments? A) Auscultation and percussion of the patient's thorax B) Collection of a sputum sample for submission to the hospital laboratory C) Analysis of the patient's leukocytosis and the white blood cell (WBC) differential D) Assessment of the patient's activities of daily living

A) Rifampin (Rifadin); contact lenses can become stained orange B) Isoniazid (INH); report yellowing of the skin or darkened urine D) Ethambutol (Myambutol); report any changes in vision

A client has been admitted to the hospital with suspected TB. What drugs should the nurse plan to teach the client about before discharge? Select all that apply. A) Rifampin (Rifadin); contact lenses can become stained orange B) Isoniazid (INH); report yellowing of the skin or darkened urine C) Pyrazinamide (PZA); maintain a fluid restriction of 1200 mL/day D) Ethambutol (Myambutol); report any changes in vision E) Amoxicillin (Amoxil); take this drug with food or milk

A) Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol)

A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client? A) Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) B) Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) C) Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) D) Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

C) Place a respiratory mask on the client.

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? A) Contact the health care provider for tuberculosis (TB) medications. B) Perform a TB skin test. C) Place a respiratory mask on the client. D) Test all family members for TB.

ANS: D d. "This conversation may be difficult for both of you; I will be there to provide support." A nurse should provide emotional support while the client tells her daughter the information she has learned about the test results. The nurse should not interpret the results or counsel the client or her daughter. The nurse should refer the client for counseling or support, if necessary. DIF: Applying/Application REF: 60 KEY: Genetics| advocacy| support MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Psychosocial Integrity

A client who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present when she discloses this information to her adult daughter. How should the nurse respond? a. "I will request a genetic counselor who is more qualified to be present for this conversation." b. "The test results can be confusing; I will help you interpret them for your daughter." c. "Are you sure you want to share this information with your daughter, who may not test positive for this gene mutation?" d. "This conversation may be difficult for both of you; I will be there to provide support."

B) Draw aerobic and anaerobic blood cultures.

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? A) Administer levofloxacin (Levaquin) 500 mg IV. B) Draw aerobic and anaerobic blood cultures. C) Give lorazepam (Ativan) as needed for agitation. D) Refer to social worker for alcohol counseling.

D) Splenectomy

A critical care nurse is caring for a patient with autoimmune hemolytic anemia. The patient is not responding to conservative treatments, and her condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include what? A) Hepatectomy B) Vitamin K administration C) Platelet transfusion D) Splenectomy

ANS: C' c. "It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them." This situation represents an ethical dilemma. It is the client's decision whether to disclose the information. However, the information can affect others in the client's family. The law does not require the client to tell family members about the results, nor can the client be held liable for not telling them. The nurse may consider it ethically correct for the client to tell family members so that they can take action to prevent the development of cancer, but the nurse must respect the client's decision. DIF: Applying/Application REF: 61 KEY: Genetics| autonomy| confidentiality MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Psychosocial Integrity

A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer. The client states that he does not want any family to know about this result. How should the nurse respond? a. "It is required by law that you inform your siblings and children about this result so that they also can be tested and monitored for colon cancer." b. "It is not necessary to tell your siblings because they are adults, but you should tell your children so that they can be tested before they decide to have children of their own." c. "It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them." d. "It is your decision to determine with whom, if anyone, you discuss this test result. However, you may be held liable if you withhold this information and a family member gets colon cancer."

ANS: A, B, E The medical-surgical nurse can assess the client's response to the test results, discuss potential risks for other family members, encourage genetic counseling, and assist the client to make a plan for prevention, risk reduction, and early detection. For some positive genetic test results, such as having a BRCA1 gene mutation, the risk for developing breast cancer is high but is not a certainty. Because the risk is high, the client should have a plan for prevention and risk reduction. One form of prevention is early detection. Breast self-examinations may be helpful when performed monthly, but those performed every week may not be useful, especially around the time of menses. A client who tests positive for a BRCA1 mutation should have at least yearly mammograms and ovarian ultrasounds to detect cancer at an early stage, when it is more easily cured. Owing to confidentiality, the nurse would never reveal any information about a client to an insurance company or family members without the client's permission. DIF: Applying/Application REF: 61 KEY: Genetics| genetic testing| confidentiality| support MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse cares for a client who recently completed genetic testing that revealed that she has a BRCA1 gene mutation. Which actions should the nurse take next? (Select all that apply.) a. Discuss potential risks for other members of her family. b. Assist the client to make a plan for prevention and risk reduction. c. Disclose the information to the medical insurance company. d. Recommend the client complete weekly breast self-examinations. e. Assess the client's response to the test results. f. Encourage support by sharing the results with family members.

ANS: A a. Provide information about the risks and benefits of genetic testing. Genetic counseling is to be nondirective. The nurse should provide as much information as possible about the risks and benefits but should not influence the client's decision to test or not test. Once the client has made a decision, the nurse should support the client in that decision. Carrier testing will determine if a client without symptoms has an allele for a recessive disorder that could be transmitted to his or her child. Genetic testing will not minimize transmission of the disorder. DIF: Applying/Application REF: 61 KEY: Genetics| genetic counseling MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Psychosocial Integrity

A nurse cares for a pregnant client who has a family history of sickle cell disease. The client is unsure if she wants to participate in genetic testing. What action should the nurse take? a. Provide information about the risks and benefits of genetic testing. b. Empathize with the client and share a personal story about a hereditary disorder. c. Teach the client that early detection can minimize transmission to the fetus. d. Advocate for the client and her baby by encouraging genetic testing.

ANS: B b. "Genetic testing can be a stressful experience. Counseling can provide support and education throughout the process. Genetic testing is a stressful experience, and clients should be provided with support, education, and assistance with coping. Genetic testing should be performed only after genetic counseling has occurred. The client has the right to decide whether to have children or to participate in genetic testing. Nursing staff should provide both benefits and risks to genetic testing so that the client can make an informed decision. Financial support is not part of genetic counseling. DIF: Applying/Application REF: 60 KEY: Genetics| genetic counseling MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity

A nurse consults a genetic counselor for a client whose mother has Huntington disease and is considering genetic testing. The client states, "I know I want this test. Why do I need to see a counselor?" How should the nurse respond? a. "The advanced practice nurse will advise you on whether you should have children or adopt." b. "Genetic testing can be a stressful experience. Counseling can provide support and education throughout the process." c. "There is no cure for this disease. The counselor will determine if there is any benefit to genetic testing." d. "Genetic testing is expensive. The counselor will advocate for you and help you obtain financial support."

ANS: C c. "The incidence of X-linked recessive disorders is higher in males because they do not have a second X chromosome to balance expression of the gene." Because the number of X chromosomes in males and females is not the same (1:2), the number of X-linked chromosome genes in the two genders is also unequal. Males have only one X chromosome, a condition called hemizygosity, for any gene on the X chromosome. As a result, X-linked recessive genes have a dominant expressive pattern of inheritance in males and a recessive expressive pattern of inheritance in females. This difference in expression occurs because males do not have a second X chromosome to balance the expression of any recessive gene on the first X chromosome. It is incorrect to say that one X chromosome of a pair is always inactive in females, or that females have a decreased penetrance rate for this gene mutation. X-linked recessive disorders cannot be transmitted from father to son, but the trait is transmitted from father to all daughters who will be carriers. DIF: Understanding/Comprehension REF: 59 KEY: Genetics| sex-linked recessive MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse is educating a client about genetic screening. The client asks why red-green color blindness, an X-linked recessive disorder noted in some of her family members, is expressed more frequently in males than females. How should the nurse respond? a. "Females have a decreased penetrance rate for this gene mutation and are therefore less likely to express the trait." b. "Females have two X chromosomes and one is always inactive. This inactivity decreases the effect of the gene." c. "The incidence of X-linked recessive disorders is higher in males because they do not have a second X chromosome to balance expression of the gene." d. "Males have only one X chromosome, which allows the X-linked recessive disorder to be transmitted from father to son."

a. Middle-aged woman whose mother died at age 48 of breast cancer ANS: A A client with a family history of breast cancer should be provided information about predisposition testing. Predisposition testing should be discussed with clients who are at high risk of hereditary breast, ovarian, and colorectal cancers so that the client can engage in heightened screening activities or interventions that reduce risk. The client with symptoms of rheumatoid arthritis should be given information about symptomatic diagnostic testing. The client with a familial history of sickle cell disease and the client who is of Eastern European Jewish ancestry should be given information about carrier genetic testing. DIF: Applying/Application REF: 58 KEY: Genetics| genetic testing MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse obtains health histories when admitting clients to a medical-surgical unit. With which client should the nurse discuss predisposition genetic testing? a. Middle-aged woman whose mother died at age 48 of breast cancer b. Young man who has all the symptoms of rheumatoid arthritis c. Pregnant woman whose father has sickle cell disease d. Middle-aged man of Eastern European Jewish ancestry

ANS: A, D, E Breast cancer, Huntington disease, and Marfan syndrome have an autosomal dominant pattern of inheritance. Alzheimer's disease is a complex disorder with familial clustering, hemophilia is a sex-linked recessive disorder, and cystic fibrosis has an autosomal recessive pattern of inheritance. DIF: Remembering/Knowledge REF: 57 KEY: Genetics| patterns of inheritance MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse teaches clients about patterns of inheritance for genetic disorders among adults. Which disorders have an autosomal dominant pattern of inheritance? (Select all that apply.) a. Breast cancer b. Alzheimer's disease c. Hemophilia d. Huntington disease e. Marfan syndrome f. Cystic fibrosis

A. Macrolide which one? The answer is A. Marcolides are used to treat gram-positive bacterial infections and are used in patients with penicillin allergies. Penicillin G is a penicillin antibiotic and would not be used because of the patient's allergy. In addition, usually if a patient is allergic to penicillin there is an increased chance they are allergic to cephalosporin....therefore it would not be used as well.

A patient is admitted with pneumonia. Sputum cultures show that the patient is infected with a gram positive bacterium. The patient is allergic to Penicillin. Which medication would the patient most likely be prescribed? A. Macrolide B. Cephalosporins C. Pencillin G D. Tamiflu

The answer is B. Fluroquinolones can cause tendon rupture along with c.diff infection and cardiac arrhythmia such as prolonged QT interval.

A patient is admitted with rupture of the Achilles tendon. The patient was recently treated with antibiotics for pneumonia. Which of the following medications below can cause this adverse effect? A. Penicillin B. Fluroquinolones C. Tetracyclines D. Macrolides

The answer is A. Doxycycline increases the skin's sensitivity to the sun, so the patient should wear sunscreen when outdoors. Also, the patient should not take this medication with antacids or milk products because this affects the absorption of the medication. Options B and C are incorrect statements.

A patient is being discharged home on Doxycyline for treatment of pneumonia. Which statement by the patient indicates they understood your education material? A. "I will wear sunscreen when outdoors." B. "I will avoid green leafy vegetables while taking this medication." C. "I will monitor my blood glucose regularly due to the side effects of hypoglycemia." D. "I will take this medication with a full glass of milk."

B. Streptococcus pneumoniae

A patient is presenting with mild symptoms of pneumonia. The doctor diagnoses the patient with "walking pneumonia". From your nursing knowledge, you know this type of pneumonia is caused by what type of infectious agent? A. Fungi B. Streptococcus pneumoniae C. Mycoplasma pneumoniae D. Influenza

C. Hospital-acquired pneumonia The answer is C. The key words to let you know this is hospital-acquired pneumonia and NOT community-acquired is that the patient was admitted with a gunshot wound AND has been hospitalized for 48 hours. If the patient presents with signs and symptoms of pneumonia 48-72 hours after admission it is classified as hospital-acquired. This is not ventilator acquired because the patient is not on mechanical ventilation and there is nothing in the scenario that leads us to think it is aspiration pneumonia.

A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 'F. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia? A. Aspiration pneumonia B. Ventilator acquired pneumonia C. Hospital-acquired pneumonia D. Community-acquired pneumonia

A) A transfusion of PRBCs may have the potential to create fluid volume overload and pulmonary edema.

A patient with megaloblastic anemia is being treated in an inpatient setting and has daily blood work ordered. This morning's blood work has become available, and the patient's hemoglobin and hematocrit are continuing to trend downward. The nurse has contacted the patient's health care provider to determine whether the health care provider wants to order a transfusion of packed red blood cells (PRBCs). When considering the efficacy of this treatment the nurse should understand that: A) A transfusion of PRBCs may have the potential to create fluid volume overload and pulmonary edema. B) The patient's body is likely to destroy the transfused red cells soon after they are transfused. C) The patient is deficient in oxygen-carrying capacity more than in the absolute number of RBCs. D) The patient will require multiple transfusions over several days to achieve an increase in Hgb and Hct.

B) A decreased hemoglobin and hematocrit

A patient with renal failure is experiencing decreased erythropoietin production. Upon analysis of the patient's complete blood count (CBC), the nurse will expect which of the following results? A) An increased hemoglobin and hematocrit B) A decreased hemoglobin and hematocrit C) A decreased mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration (MCHC) D) An increased MCV and MCHC

B) There could be decreased production of platelets

A patient, newly diagnosed with thrombocytopenia, is admitted to the medical unit. After the admission assessment the patient asks the nurse to explain the disease. What should the nurse explain to the patient about this condition? A) There could be an attack on the platelets by the antibodies B) There could be decreased production of platelets C) There could be elevated platelet production. D) There could be decreased white blood cell production.

Ans: C Feedback: End-of life issues that often involve ethical dilemmas include pain control, do not resuscitate orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patient's respiratory status should be carefully monitored and any changes should be reported to the physician.

A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patient's respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take? A) Decrease the rate of IV infusion. B) Stimulate the patient in order to increase respiratory rate. C) Report the decreased respiratory rate to the physician. D) Allow the patient to rest comfortably.

ANS: C Influenza is transmitted via droplets. Droplets are produced when a person talks or sneezes and travel short distances (up to 3 feet) but are not suspended in the air for long. Staff should stay at least 3 feet (1 m) away from a client with droplet infection. Actual physical contact with the client is not necessary for infection to occur. It is not necessary for staff to wear an N95 respirator mask for Droplet Precautions; these masks are used in the care of clients with tuberculosis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control— Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Planning)

After an infection control in-service, which statement by the nurse demonstrates an accurate understanding of the mode of transmission of influenza? a. "I will not develop the infection unless I have physical contact with the client." b. "I should wear an N95 respirator to provide care for the client with influenza." c. "I should try to stay at least 3 feet away from the client, if at all possible." d. "The infection is spread through droplets suspended in the air and inhaled."

Ans: B Feedback: The nurse must honor the patient's wishes and continue to provide required nursing care. Discussing the matter with the physician may lead to further communication with the family, during which the family may reconsider their decision. It is not normally appropriate for the nurse to seek the assistance of a social worker or mediator. A slow code is considered unethical.

An adult patient has requested a do not resuscitate (DNR) order in light of his recent diagnosis with late stage pancreatic cancer. The patient's son and daughter-in-law are strongly opposed to the patient's request. What is the primary responsibility of the nurse in this situation? A) Perform a slow code until a decision is made. B) Honor the request of the patient. C) Contact a social worker or mediator to intervene. D) Temporarily withhold nursing care until the physician talks to the family.

Ans: B Feedback: A living will is one type of advance directive. In most situations, living wills are limited to situations in which the patient's medical condition is deemed terminal. The other answers are incorrect because living wills are not always honored, they are not binding for the duration of the patient's life, and they are not drawn up by the patient's family.

An elderly patient is admitted to your unit with a diagnosis of community-acquired pneumonia. During admission the patient states, I have a living will. What implication of this should the nurse recognize? A) This document is always honored, regardless of circumstances. B) This document specifies the patient's wishes before hospitalization. C) This document that is binding for the duration of the patient's life. D) This document has been drawn up by the patient's family to determine DNR status.

B) Fever usually not present

How may pneumonia present differently in the older adult than in the younger adult? A) Crackles on auscultation B) Fever C) Headache D) Wheezing

The answers are A and D. These are the only options that are considered narrow spectrum antibiotics which means they target specific family of bacteria.

Select all the medications used to treat pneumonia that are narrow-spectrum? A. Macrolides B. Tamiflu C. Fluroquinolones D. Penicillins

C) Client with possible pulmonary tuberculosis who currently has hemoptysis

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A) Client with bacterial pneumonia and a cough productive of green sputum B) Client with neutropenia and pneumonia caused by Candida albicans C) Client with possible pulmonary tuberculosis who currently has hemoptysis D) Client with right empyema who has a chest tube and a fever of 103.2° F

B) Stop the transfusion immediately.

The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and is experiencing chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's health care provider. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs.

A) A stroke patient with dysarthria

The nurse educator is discussing aspiration with new nursing graduates. Which patient would the educator tell the nurses is at the greatest risk for aspiration? A) A stroke patient with dysarthria B) An ambulatory patient with Alzheimer's disease C) A 92-year-old patient who needs help with activities of daily living (ADLs) D) A patient with severe, deforming rheumatoid arthritis

B) Monitoring the patient closely and administering antipyretics

The nurse has been monitoring a patient's vital signs closely after initiating a transfusion of packed red blood cells (PRBCs). The nurse has observed that the patient's temperature is trending upward, and the patient is complaining of chills. The nurse has stopped the transfusion and informed the patient's health care provider, who believes that the patient is experiencing a febrile nonhemolytic transfusion reaction (FNHTR). What course of action should the nurse anticipate? A) Administering a bolus of normal saline B) Monitoring the patient closely and administering antipyretics C) Initiating apheresis and administering IV antihistamines D) Performing a stat cross-match and beginning a transfusion of the correct blood type

A) Incentive spirometry

The nurse is caring for a patient at risk for atelectasis and chooses to implement a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? A) Incentive spirometry B) Intermittent positive pressure-breathing (IPPB) C) Positive end-expiratory pressure (PEEP) D) Bronchoscopy

A) Lack of production of red blood cells (RBCs)

The nurse is caring for a patient with a diagnosis of hypoproliferative anemia. When planning this patient's care, the nurse should be aware that this type of anemia is due to what? A) Lack of production of red blood cells (RBCs) B) Loss of RBCs C) Injury to the RBCs in circulation D) Abnormality of RBCs

A) Interdermal injection into the inner forearm

The nurse is helping to give Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? A) Interdermal injection into the inner forearm B) Intramuscular injection into the vastus lateralis C) Subcutaneous injection into the umbilical area D) Insert at a 45-degree angle into the deltoid

D) Wash hands frequently

The nurse is performing patient teaching with a young mother who has brought her 3-month-old to the clinic for a well-baby check. Knowing that it is cold season, what information should the nurse provide to the mother to best prevent transmission of organisms? A) Take prescribed antibiotics B) Use warm salt-water gargles C) Dress warmly D) Wash hands frequently

C) "Iron will likely cause your stools to darken in color."

The nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What statement should the nurse include in patient education? A) "Take the iron with dairy products to enhance your body's absorption of it." B) "You should increase your intake of vitamin E while you're taking iron." C) "Iron will likely cause your stools to darken in color." D) "Limit foods high in fiber due to the risk for diarrhea."

C) Cellulitis

The triage nurse in the emergency department (ED) is assessing a patient who presents complaining of pain and swelling in her right lower leg beginning last night along with fever, chills, and sweating. The patient states that she hit her leg on the car door 4 or 5 days ago, and it has been sore ever since. The patient has a history of chronic venous insufficiency. The nurse should suspect that this patient might have: A) Thrombocytopenia B) Arterial insufficiency C) Cellulitis D) Phlebothrombosis

The answers are B, C, E, and G. These are typical signs and symptoms of pneumonia. Stridor is not very common. A PRODUCTIVE cough that can be nagging is very typical, and there is usually a HIGH PCO2 of 45 or greater due to the lungs retaining carbon dioxide.

Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply: A. Stridor B. Coarse crackles C. Oxygen saturation less than 90% D. Non-productive, nagging cough E. Elevated white blood cells F. Low PCO2 of less than 35 G. Tachypnea

The answers are A, C, and D. Risks factors for pneumonia include: recent surgery, lung disorder (ex: COPD), and viral infection (ex: RSV). Option B is a preventive measure in preventing pneumonia.

Which of the following patients are MOST at risk for developing pneumonia? Select-all-that-apply: A. A 53 year old female recovering from abdominal surgery. B. A 69 year old patient who recently received the pneumococcal conjugate vaccine. C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula. D. A 8 month old with RSV (respiratory syncytial virus) infection.

B. 36 y.o. trauma pt on mechanical ventilator

Which pt is at higher risk for developing pneumonia? A. any hospitalized pt between 19 - 64 y.o. B. 36 y.o. trauma pt on mechanical ventilator C. disabled 51 y.o. with abdominal pain, d/c home D. Any pt who has not received the pneumonia vaccine

The answer is D. Vancomycin can cause ototoxicity. Roaring or ringing in the ears are a possible sign/symptom of this adverse effect. Option A happens with Digoxin toxicity. Options B and C are vague and are not a common adverse reaction to Vancomycin.

You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. Which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately? A. "I'm seeing yellow halos around the light." B. "My mouth tastes like metal." C. "My head hurts." D. "I have this constant ringing in my ears."

The answer is B. All the other options are correct statements regarding the prevention of pneumonia. However, option B is incorrect because although the patient has had pneumonia they should still receive the Pneumovax vaccine to prevent other forms of pneumonia.

You're providing discharge teaching to a patient who was admitted for pneumonia. You are discussing measures the patient can take to prevent pneumonia. Which of the following statements by the patient indicates they did NOT understand your education material? A. "I'll use hand sanitizer regularly while I'm out in public." B. "It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia." C. "I will try to avoid large crowds of people during the peak of flu season." D. "It is important I try to quit smoking."