Med Surg I (Adult Health - Immune/Integument, Respiratory, Hematological, Cardiovascular)

A client calls the primary health care provider's (PHCP's) office after testing positive for COVID-19 infection 5 days earlier. The client is asymptomatic and asks the nurse when it would be safe to stop self-isolation. Which is the appropriate nursing response?

"At least 10 days will need to have passed since your first positive COVID-19 test." Rationale:For a client with asymptomatic COVID-19 infection, the recommendation is for at least 10 days to pass after the client's first positive COVID-19 test before the client can safely end self-isolation. Therefore, option 3 is correct. The Centers of Disease Control and Prevention (CDC) may alter recommendations based on research so it is important to access their website for the most current updates.

The nursing student enrolled in an anatomy and physiology course is studying the immune system. The nursing instructor determines that the student understands the chemical barriers against a nonspecific immune response if which statement is made?

"Acids and enzymes found in body fluids function as chemical barriers." Rationale:Chemical barriers include various acids and enzymes found in body fluids. The skin, the mucous membranes, and the action of cilia lining the respiratory tract are physical barriers.

The nursing student conducting a clinical conference on immunity places an emphasis on active immunity. Which statement by fellow nursing students indicates successful teaching?

"Active immunity lasts for years and can be easily reactivated by a booster dose of antigen." Rationale:Active immunity lasts for years and is natural by infection or artificial by stimulation of the body's immune defenses—for example, by vaccination. It can be easily reactivated by a booster dose of antigen. Protection from active immunity takes 5 to 14 days to develop after the first exposure to the antigen and 1 to 3 days after subsequent exposures. Active immunity lasts much longer and is more effective at preventing subsequent infections than passive immunity; however, it does not last forever. Passively received human antibodies have a half-life of about 30 days. Passive immunity provides protection immediately.

A client asks the nurse why the primary health care provider (PHCP) changed to a different antibiotic for treating streptococcal throat infection. The nurse would make which best response?

"Bacteria are capable of developing resistance to frequently used antibiotics." Rationale:Many infections can have the same symptoms but are caused by different organisms or by organisms that have developed a resistance to a certain antibiotic and require a change to a different antibiotic. Antibiotics that are specific to the type of pathogen causing the infection are prescribed, and selection of the correct antibiotic is important. To say that the client misunderstood does not answer the client's question. The advice to try a medicine and wait 5 to 7 days does not give the client correct information, and the client might need to return sooner to the PHCP if symptoms are still evident.

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate?

"Blocked nasal passages impair the sense of smell." Rationale:When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate appetite through the sense of smell. The other options are incorrect and unrelated to this symptom.

The client with a history of chronic lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder?

"Do you have a headache or become confused?" Rationale:When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, along with hyperkalemia, a rapid irregular pulse, and dysrhythmias.

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which question would best help the nurse discriminate pain caused by a noncardiac problem?

"Does the pain get worse when you breathe in?" Rationale:Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). The remaining options may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

A client presents at the primary health care provider's office with complaints of a ringlike rash on the upper leg. Which question would the nurse ask first?

"Have you been camping in the last month?" Rationale:The nurse would ask questions to assist in identifying a cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ringlike rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another

A client presents at the primary health care provider's office with complaints of a bull's-eye rash on his upper leg. Which question would the nurse ask first?

"Have you been camping in the last month?" Rationale:The nurse would ask questions to assist in identifying the cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ringlike rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, or upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching?

"I can send my child to day care with a fever as long as it is a low-grade fever." Rationale:AIDS is a disorder caused by human immunodeficiency virus (HIV) and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever needs to be kept home and not brought to a day care center. Options 1, 2, and 3 are correct statements and would be actions a caregiver needs to take when the child has AIDS.

The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about the prevention of pressure injuries while the client has limited mobility. Which statement by the client indicates the need for further teaching?

"I can sit in my favorite chair all day." Rationale:Sitting in one position all day can be a risk factor for pressure injury development. Options 1, 3, and 4 are preventative measures for pressure injury development.

The home health nurse makes a home visit to a client who has an implanted cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary?

"I can stop taking my antidysrhythmic medicine now because I have a pacemaker." Rationale:Clients with an ICD usually continue to receive antidysrhythmic medications after discharge from the hospital. The nurse would stress the importance of continuing to take these medications as prescribed. The nurse would provide clear instructions about the purposes of the medications, dosage schedule, and side effects or adverse effects to report. Clients need to sit down if they feel an internal defibrillator shock. They cannot have an MRI because of the possible magnetic properties of the device. Also, knowledge of how to reach EMS is important.

The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments?

"I cannot give Legionnaires' disease to other people." Rationale:Legionnaires' disease is spread through infected aerosolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription; therefore, the remaining options are incorrect.

The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge?

"I don't have anyone to help me with doing heavy housework at home." Rationale:To ensure the best outcome, the client needs to be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital after an MI. All of the options except the correct one indicate that the client will be successful in these areas.

The nurse is providing teaching to a client diagnosed with influenza A about measures to decrease symptom severity and manage the condition at home. According to the client, the symptoms started approximately 3 days ago, including fever and severe body aches. Which of the following client statements would indicate a need for further teaching?

"I don't understand why the primary health care provider (PHCP) did not give me a prescription for an antiviral medication. I feel really sick and I need it!" Rationale:Depending on the client's comorbidities and presenting signs and symptoms, influenza may be largely managed in the outpatient setting. Treatment measures are largely supportive; they include increased fluid intake, ibuprofen or acetaminophen to decrease myalgia and fever, and decreasing the risk of transmission to others, which means avoiding close contact with others and engaging in frequent handwashing. Therefore, options 1, 2, and 3 are correct statements that do not require a need for further teaching. Antiviral medications may be prescribed for clients with influenza; however, these medications are most effective if given within 24 to 48 hours of symptom onset, which is not the case for this client. Therefore, option 4 is the correct answer as it is the client statement that requires a need for further teaching.

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed?

"I have to keep my nasal cannula oxygen levels between 4 and 6 L/min." Rationale:Clients with COPD have adapted to a high carbon dioxide level, so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Their stimulus to breathe is a decreased arterial oxygen (Pao2) level, so administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the Pao2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Therefore, oxygen administration levels for clients with COPD need to be kept within the range of 1 to 3 L/min (per primary health care provider prescription). Also, nutrition for the client with COPD requires a reduction in the percentage of carbohydrates in the diet. Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale. Alcohol and sedative medications need to be avoided. Active smoking, passive smoking (or secondhand smoke), and smoke that clings to hair and clothing (sometimes called "thirdhand" smoke) contribute to upper and lower respiratory problems, particularly for clients with COPD.

A 6-year-old child with human immunodeficiency virus (HIV) infection has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse would make which best response to the child?

"I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." Rationale:The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. The nurse must acknowledge the child's pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof would eliminate the pain is inaccurate. Allowing children to think that they can control pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken "all away" is neither truthful nor realistic.

The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed, and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions?

"I must take the medication exactly as prescribed." Rationale:Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza, and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate a change in activities, especially when driving or operating machinery if dizziness occurs.

The nurse is teaching a client who is beginning antiviral therapy for influenza. Which statement by the client indicates an understanding of the instructions?

"I must take the medication exactly as prescribed." Rationale:Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza, and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate a change in activities, especially when driving or operating machinery if dizziness occurs.

A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions?

"I need to adhere to my dietary restrictions." Rationale:After angioplasty, the client needs to be instructed on the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.

The nurse is providing home care instructions to a client after rhinoplasty. Which statement by the client indicates a need for further instruction?

"I need to be sure to run a dehumidifier in my home." Rationale:After rhinoplasty, the client is taught to sleep on at least two pillows; this elevates the head and reduces edema. The client also is told to avoid any activities, such as bending over, that would increase intracranial pressure and cause nasal bleeding. A humidifier (not a dehumidifier) decreases the dry throat associated with mouth breathing. The client need to be instructed to sneeze through the mouth and not blow through the nose.

The nurse is providing education to a client diagnosed with valley fever (coccidioidomycosis). Which statement from the client would require a need for further teaching?

"I need to isolate myself at home, as this condition is highly contagious." Rationale:Valley fever (coccidioidomycosis) is a fungal infection caused by Coccidiodes that is more common in certain areas of the world, including the southwestern United States, Central America, and South America. The microscopic fungal spores are inhaled via dust, and the condition is not contagious or transmissible from person-to-person. The condition may need to be treated with antifungal medication. Therefore, option 4 is the client statement that requires further teaching as this condition is not contagious.

The nurse has provided home care instructions to a client after dermabrasion. Which statement by the client indicates a need for further instruction?

"I need to keep my skin dry to allow it to heal." Rationale:After dermabrasion, the client is instructed to implement measures that will prevent dry skin. The client will be instructed to use wet soaks and to use emollients when the wet soaks are not being used. The client needs to avoid exposure to the sun. If the client plans to be outdoors, a sunscreen needs to be applied, and protective clothing and items such as a hat would be worn.

A client has undergone laser surgery to remove 2 nevi. The nurse determines that the client has understood discharge instructions if the client makes which statement?

"I need to protect the operated areas from direct sunlight for at least 3 months." Rationale:After laser surgery to remove any type of skin lesion, the skin needs to be protected from direct sunlight for a minimum of 3 months. There would be minimal or no discomfort after the procedure, and, if present, the discomfort would be relieved easily with acetaminophen. The operated area needs to be cleansed gently with half-strength hydrogen peroxide twice a day after the dressing is removed (24 hours after the procedure). Redness and swelling are expected after this procedure.

The nurse instructs a client with candidiasis (thrush) of the oral cavity on how to care for the disorder. Which client statement indicates the need for further instruction?

"I need to rinse my mouth 4 times daily with a commercial mouthwash." Rationale:Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. Candida stomatitis or esophagitis occurs often in immunocompromised clients. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish white plaques and inflammation. Clients with candidiasis cannot tolerate commercial mouthwashes because the high alcohol concentration in these products can cause pain and discomfort to the lesions. A solution of warm water or mouthwash formulas without alcohol are better tolerated and may promote healing. A change in diet to liquid or pureed food often eases the discomfort of eating. The client needs to avoid spicy foods, citrus juice, and hot liquids.

A client has just had a cast removed, and the underlying skin is yellow-brown and crusted. The nurse gives the client instructions for skin care. The nurse determines that the client needs further teaching of the directions if which statement is made?

"I need to scrub the skin vigorously with soap and water." Rationale:The skin under a casted area may be discolored and crusted with dead skin layers. The client needs to gently soak and wash the skin for the first few days. The skin needs to be patted dry, and a lubricating lotion would be applied. People often want to scrub the dead skin away, but scrubbing irritates the skin. The client would avoid overexposing the skin to the sunlight.

The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply.

"I need to take a hot bath every evening. "I need to rest for long periods of time every day." Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Hot baths may exacerbate the fatigue. To help reduce fatigue in the client with SLE, the nurse needs to instruct the client to sit whenever possible, avoid hot baths, engage in moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction?

"I need to take hot baths because they are relaxing." Rationale:To help reduce fatigue in the client with systemic lupus erythematosus, the nurse would instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further teaching if the client makes which statement?

"I need to use disposable plates, forks, and knives." Rationale:Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is not necessary to discard any of these. The client needs to cover the mouth with a tissue when laughing, coughing, or sneezing and would dispose of tissues carefully. The client also may need to wear a mask as advised by the primary health care provider. It is important to perform proper handwashing after contact with body substances, tissues, or face masks.

When evaluating an asthmatic client's knowledge of self-care, the nurse recognizes that additional instruction is needed when the client makes which statement?

"I use my corticosteroid inhaler each time I feel short of breath." Rationale:Most asthma medications are administered via inhalation because of their fast action via this route. Inhaled corticosteroids are preferred for long-term control of persistent asthma. They decrease inflammation and reduce bronchial hyperresponsiveness. Bronchodilator medications are considered "rescue" types because their onset is faster. Clients would use this type of medication to provide rapid relief of symptoms such as bronchospasm, which can be caused by a variety of triggers. Clients need to be evaluated for understanding of their disease, their ability to identify triggers, and the proper use of equipment and medications.

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement?

"I will discard used tissues in a plastic bag." Rationale:Used tissues are discarded in a plastic bag. The client with TB needs to wash the hands carefully after each contact with respiratory secretions. Oral care needs to be done more frequently than once a day. The client would not only turn the head but also cover the mouth and nose when laughing, sneezing, or coughing.

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed?

"I will lie on the affected side for an hour." Rationale:After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, need to be reported to the primary health care provider. A chest x-ray may be performed to evaluate the degree of lung reexpansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures to minimize injury indicates that discharge teaching was effective? Select all that apply.

"I will not blow my nose if I get a cold. I may continue to use an electric shaver. I would use a soft-bristled toothbrush to avoid mouth trauma." Rationale:Bleeding precautions are used to protect the client with thrombocytopenia from bleeding. The client with thrombocytopenia may experience internal and external bleeding. Bleeding is frequently provoked by trauma, but it also may be spontaneous. The client with thrombocytopenia needs to be educated about activities that increase the risk for bleeding, such as contact sports and trauma to oral, nasal, and rectal mucosa. This will help to eliminate options 3 and 4.

A client with a prescription to take theophylline daily has been given medication instructions by the nurse. What statement by the client indicates the need for further education regarding the prescription?

"I will take the daily dose at bedtime." Rationale:The client taking a single daily dose of theophylline, a xanthine bronchodilator, would take the medication early in the morning. This enables the client to have maximal benefit from the medication during daytime activities. In addition, this medication causes insomnia. The client would take in at least 2 L of fluid per day to decrease viscosity of secretions. The client would check with the primary health care provider (PHCP) before changing brands of the medication because levels of bioavailability may vary for different preparations. The client also would check with the PHCP before taking over-the-counter cough, cold, or other respiratory preparations because they could have interactive effects, increasing the side and adverse effects of theophylline and causing dysrhythmias.

Which statement made by a client taking montelukast indicates the need for further teaching?

"I will take the medication when I first notice I am having trouble breathing." Rationale:Montelukast cannot be used for quick relief of an asthma attack because effects of the medication develop too slowly. For prophylaxis and maintenance therapy of asthma, maximal effects develop within 24 hours of the first dose and are maintained with once-daily dosing in the evening. The remaining options are correct statements.

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement?

"I won't be contagious after 2 to 3 weeks of medication therapy." Rationale:The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative.

The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction?

"I would apply a lubricant to my skin after bathing when my skin is thoroughly dry." Rationale:The client needs to be instructed that a lubricant is applied immediately after the bath, while the skin is still damp, to help increase hydration of the stratum corneum. Options 1, 2, and 3 are appropriate home care measures to control the symptoms associated with pruritus.

The nurse is providing education to a client diagnosed with acute laryngitis. Which client statement indicates a need for further teaching?

"I would only whisper to talk." Rationale:Acute laryngitis refers to swelling and inflammation of the larynx that can result from a viral or bacterial infection, voice overuse, or exposure to inhalant chemicals. The treatment for acute laryngitis is supportive in nature; antibiotics are prescribed if the condition is caused by bacteria. Supportive measures include acetaminophen as needed for pain, humidifier use, throat lozenges, increased fluid intake, and avoidance of caffeine and alcohol. The client needs to be educated to limit the use of the voice to rest the larynx. Whispering needs to be avoided, as this causes more strain on the larynx. Therefore, option 1 is the client statement that would require further teaching from the nurse, as whispering would be avoided.

The nurse is teaching a client diagnosed with acute bacterial rhinosinusitis about supportive measures to increase client comfort. Which client statement would indicate a need for further teaching?

"I would run a dehumidifier in my bedroom at night while I'm sleeping." Rationale:Supportive therapy for rhinosinusitis includes humidification; nasal irrigation with saline solution; application of hot, wet packs; increasing fluid intake to at least 2 liters (L) per day, unless contraindicated; sleeping with the head elevated; and avoiding irritating agents, such as cigarette smoke or other allergens. Therefore, options 1, 2, and 3 indicate the client understands the appropriate supportive measures for rhinosinusitis. Option 4 indicates a need for further teaching, as humidification of air, not dehumidification of air, assists with the discomfort of rhinosinusitis.

The nurse working in a primary health care provider (PHCP) office is providing instructions to a family member of a client diagnosed with COVID-19 about measures to take in the home to prevent the spread of illness. The nurse determines that there is a need for further teaching if the family member makes which statement?

"If available, I need to use hand sanitizer with at least 60% alcohol instead of washing my hands with warm water and soap." Rationale:Many clients with mild COVID-19 infection are managed in the home setting, and there are certain measures that can be taken to prevent the spread of the infection throughout the household. If possible, the ill client would stay in their own bedroom and avoid sharing a bathroom with other household members. Caregivers would frequently disinfect high-touch surfaces in the home, such as doorknobs and remote controls. If possible, the individuals living in the same household as the ill client should quarantine to prevent community spread of COVID-19. If the caregiver must enter the ill client's room, both the caregiver and the ill client need to wear masks. Handwashing with warm soap and water for at least 20 seconds is the most effective way to wash hands and prevent the spread of COVID-19 infection. If water and soap are unavailable, the next best option would be to use hand sanitizer with at least 60% alcohol. Since handwashing is the preferred method to clean hands, option 4 is the client statement that requires a need for further teaching from the nurse and is the correct answer.

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement would the nurse make to try to motivate the client to quit smoking?

"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." Rationale:The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries. The statements in the remaining options are incorrect.

The nursing instructor is evaluating a nursing student for knowledge of antibody classes. Which statement by the nursing student indicates that teaching has been effective?

"Immunoglobulin M (IgM) is the first antibody produced in response to antigen." Rationale:IgM is the first antibody produced in response to antigen. IgM composes about 10% to 15% of the circulating antibody population. IgM is especially effective at the antibody actions of agglutination and precipitation because of having 10 potential binding sites per molecule. Because of their size, these antibodies are confined to the bloodstream. The remaining options are incorrect.

A client is seen in the health care clinic 2 weeks after rhinoplasty. The client tells the nurse that the upper lip is numb. Which nursing response would be appropriate?

"In many cases the nose and upper lip are numb for up to 6 months." Rationale:The nurse would instruct the client that after this procedure ecchymosis will last approximately 2 weeks, and the nose and upper lip may be numb for approximately 6 months. Options 1, 3, and 4 are inappropriate and inaccurate nursing responses.

The nursing instructor is reviewing the pathophysiology of influenza. The nursing instructor determines there is a need for further teaching if the nursing student makes which statement regarding influenza?

"Influenza A infects only humans." Rationale:Influenza is a highly contagious respiratory viral infection that is spread through infected droplets via inhalation of aerosolized particles or from direct contact with contaminated surfaces. Therefore, option 2 is a correct statement. Influenza is divided into four serotypes, or influenza A, B, C, or D, with each type having different characteristics. Of the four types, influenza C and D do not cause significant illness in humans; therefore, option 3 is an accurate statement. Influenza A is further classified by two characteristic surface proteins, known as the hemagglutinin protein and neuraminidase protein and are named based on their H and N type (for example, H1N1). Therefore, option 4 is a correct statement. Influenza A can infect both animals and humans and is the cause of both the swine and avian flu. Therefore, option 1 is an inaccurate statement and requires further teaching from the nursing instructor.

A client in the primary health care provider's (PHCP's) office for an annual well visit asks the nurse about the differences between influenza and the common cold (viral rhinitis). The nurse would make which response to the client?

"Influenza has a rapid symptom onset, while common cold symptoms appear gradually." Rationale:Influenza and the common cold, otherwise known as viral rhinitis, have various differences and similarities that assist in the diagnosis of each condition. Influenza is commonly associated with a high fever, whereas fevers with the common cold are rare. Therefore, option 2 is incorrect. Severe muscle pains, or myalgia, are common with the flu and rare with the common cold. Therefore, option 3 is incorrect. There is an annual vaccination available for influenza, not the common cold. Therefore, option 4 is incorrect. Influenza symptom onset is rapid, whereas symptom onset for the common cold is more gradual or insidious. Therefore, option 1 is the correct statement.

A client with chronic obstructive pulmonary disease (COPD) is being changed from an oral glucocorticoid to triamcinolone by inhalation. The client asks why this change is necessary. Which statement by the nurse to the client is accurate?

"Inhaled glucocorticoids are preferred because of decreased adverse effects." Rationale:Triamcinolone is an adrenocorticosteroid. Inhaled glucocorticoids are preferable for long-term management because there is a decreased incidence of adverse effects since the medication is not absorbed systemically. COPD is a progressive condition and cannot be cured. Options 2 and 3 are incorrect.

A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain?

"It hurts more when I breathe in." Rationale:Chest pain is assessed by using the standard pain assessment parameters, such as characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually worsens on inspiration

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education?

"It is important that I limit protein intake." Rationale:Obesity and sodium intake are modifiable risk factors for hypertension. These are of the utmost importance because they can be changed or modified by the individual through a regular exercise program and careful monitoring of sodium intake. Protein intake has no relationship to hypertension.

The nursing student is describing the differences between specific and nonspecific immunity to a group of classmates. Which statement made by the student to the classmates indicates accurate knowledge of specific immunity?

"It is the second line of defense against infection." Rationale:Specific immunity is the second line of defense against infection. The body uses this process to identify specific antigens. With this type of immunity, different reactions occur in response to different antigens, and the response must be learned and developed. The remaining options identify nonspecific immunity.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?

"It will enter the right main bronchus if inserted too far." Rationale:If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.

The nurse is providing instructions to a client with chronic obstructive pulmonary disease about using an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching?

"It will keep the small airways open." Rationale:Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not reasons for sustaining inflation.

A birthing parent with human immunodeficiency virus (HIV) infection brings a 10-month-old infant to the clinic for a routine checkup. The pediatrician has documented that the infant is asymptomatic for HIV infection. After the checkup the parent tells the nurse about being so pleased that the infant will not get HIV infection. The nurse would make which most appropriate response to the parent?

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old." Rationale:Acquired immunodeficiency syndrome (AIDS) is caused by HIV infection and characterized by generalized dysfunction of the immune system. Most children infected with HIV develop symptoms within the first 9 months of life. The remaining infected children become symptomatic sometime before age 3 years. With their immature immune systems, children have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect. Additionally, these options offer false reassurance.

The nurse has just administered the first dose of omalizumab to a client with asthma. Which statement by the client alerts the nurse of a life-threatening effect?

"My lips and tongue are swollen." Rationale:Omalizumab is an antiinflammatory and monoclonal antibody used for long-term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication would monitor for adverse reactions of the medication. Swelling of the lips and tongue are an indication of an anaphylaxis. The client statements in options 1, 2, and 3 are not indicative of an adverse reaction.

The nursing student is reviewing information related to the primary purpose of neutrophils in the inflammatory response. The nursing instructor determines that understanding is accurate when which statement is made by the student?

"Neutrophils phagocytize any potentially harmful agents." Rationale:In the inflammatory response, neutrophils appear in the area of injury within 30 to 60 minutes. Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as microorganisms. The remaining options are not actions of the neutrophils.

The nurse working in a primary care provider's (PHCP's) office receives a call from a client last seen 4 weeks ago who was diagnosed with acute bronchitis. The client states adherence to the supportive measures that were prescribed, yet the symptoms have not improved and the dyspnea has worsened. Which is the most appropriate response from the nurse?

"Please come into the office as soon as possible for further evaluation and treatment." Rationale:Acute bronchitis may be viral or bacterial in nature and is usually a self-limiting condition. Treatment is usually supportive with antitussives, bronchodilators, and air humidification. If influenza is the cause of the bronchitis, antivirals may be appropriate. If symptoms do not improve or are worsening after 4 weeks, such as increasing dyspnea or fever, the client needs to be reevaluated for potential complications of bronchitis that require further treatment, such as pneumonia. Therefore, option 2 is correct. Options 1, 3, and 4 do not address the client's concern; these options tell the client to continue the supportive measures despite worsening symptoms.

The nurse is teaching a client with a recurrent history of rhinosinusitis about the condition. Which statement from the client indicates a need for further teaching?

"Rhinosinusitis is caused only by an infectious organism." Rationale:Rhinosinusitis is inflammation of the mucous membranes of the sinuses. The etiology of rhinosinusitis can be infectious or noninfectious in nature. The most common cause of rhinosinusitis is viral infection, but bacterial infection can also cause this condition. The frontal and maxillary sinuses are more likely to be affected. Certain predisposing factors include conditions that impede sinus drainage, such as a deviated nasal septum, nasal polyps or masses, inhaled pollutants, allergies, intranasal illicit drug use, facial trauma, or dental infection. Seasonal allergies increase the risk of rhinosinusitis due to nasal mucosa edema impeding drainage of secretions. Therefore, since rhinosinusitis can occur due to a noninfectious etiology, option 2 is the client statement that requires a need for further teaching and is the correct answer.

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate?

"That isn't done because people often would develop pneumonia from the constricting effect on the lungs." Rationale:Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 1, 2, and 4 are incorrect.

A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective?

"The peripheral arteries and veins; when stimulated they cause vasoconstriction." Rationale:Found in the peripheral arteries and veins, alpha-adrenergic receptors cause a powerful vasoconstriction when stimulated. The remaining options are incorrect statements.

A primary health care provider (PHCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made?

"The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." Rationale:IMV/SIMV is one of the methods used for weaning. With this method, the respiratory rate is gradually decreased until the client assumes all of the work of breathing on their own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation. Therefore, the remaining options are incorrect.

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an altered immune system, and the role of interferons is discussed. Which statement by the nursing student indicates a need for further teaching?

"They are effective against a wide variety of bacteria." Rationale:Interferon is produced by several types of cells and is effective against a wide variety of viruses (not bacteria). It works on the host cells to induce protection and differs from an antibody, which inactivates viruses found outside the cells. Interferons have been effective to some degree in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma.

The nurse provides education to the client about the primary purpose of neutrophils. Which statement by the client indicates successful teaching?

"They destroy any harmful materials." Rationale:Neutrophil function provides protection after invaders, especially bacteria, enter the body. In the inflammatory response, neutrophils appear in the area of injury in 30 to 60 minutes. Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as microorganisms. The remaining options are incorrect.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis?

"This skin infection involves the deep dermis and subcutaneous fat." Rationale:Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red erythema without sharp borders and spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular, and the infection extends beyond the epidermis. It is not a superficial infection, and it is not simply inflammation. Options 1, 2, and 3 are incorrect descriptions.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client relating to these techniques?

"Use of an incentive spirometer will help prevent pneumonia." Rationale:Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation. Early ambulation and the administration of blood thinners help to prevent this complication; however, they are not related to coughing and deep-breathing techniques.

The nurse is caring for a client undergoing external radiation. The client has developed a dry desquamation of the skin in the treatment area, and the nurse is teaching about management of the skin reaction. Which comment made by the client suggests understanding of the instructions?

"When bathing I will use lukewarm water on the affected area." Rationale:Radiation therapy causes skin cells to break down and die. This can cause a disruption in skin integrity. The client needs to use special and gentle skin care during treatment. This means washing with lukewarm water and not rubbing skin. The client will need to protect the skin from the sun even after radiation therapy is completed. The sun can burn the skin even on cloudy days or when the client is outside even for just a few minutes. The primary health care provider (PHCP) may prescribe a high sun protection factor sunscreen. Care would be taken to not use extreme water temperatures, heating pads, ice packs, or other hot or cold items on the treatment area; these items can disrupt skin integrity. No products (creams, lotions, ointments, perfumes) would be used on the skin during radiation without approval of the PHCP.

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse would immediately ask the client which question?

"Where is the pain located?" Rationale:If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, location, duration, and quality. Although the questions in the remaining options all may be components of the assessment, none of these questions is the initial assessment question for this client.

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma." Rationale:Clients who have learned that they have a chronic illness may exhibit denial, anger, or sarcasm because of fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Eliminate options that are sarcastic or punitive. The only correct option is the one that respectfully addresses the concern presented by the client.

The nurse is caring for a client with no significant medical history who tested positive for COVID-19 and is experiencing moderate symptoms of cough, shortness of breath, and loss of sense of smell. The client asks the nurse when the infectious stage of the virus will end and the transmission-based precautions can be safely discontinued. Which is the appropriate nursing response? Select all that apply.

"Your symptoms need to have started to improve. At least 5 days will need to have passed since your symptoms first appeared. You need to be fever-free for at least 24 hours without using fever-reducing medications." Rationale:There are several criteria the client must meet before COVID-19 transmission-based precautions can be discontinued, and the criteria differ based on the severity of the illness. For mild to moderate illness in which the client is symptomatic, the three criteria that all must be met include (1) at least 5 days have passed since the onset of symptoms, (2) symptoms are improving, and (3) the client has been fever-free for at least 24 hours without antipyretic medications. Option 2 provides the client with inaccurate information. Option 5 is incorrect because only a 24-hour period, not a 48-hour period, without fevers is required for transmission-based precautions to be discontinued. Therefore, options 1, 3 and 4 are correct.

The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How would the nurse define and document this finding?

1+ edema Rationale:Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint the thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen.

The community health nurse is conducting a presentation on preventing the spread of COVID-19. The nurse would specify in the presentation that which duration of time is recommended for an individual to self-isolate after being exposed to COVID-19?

14 days Rationale:Current guidelines state that after being exposed to COVID-19, 14 days is the recommended amount of time to stay home after exposure to aid in preventing the spread of the disease. Therefore, option 3 is correct. Options 1, 2, and 4 are inappropriate lengths of time in this situation.

The nurse in the respiratory care unit completes a lung assessment and reviews the laboratory results of a serum medication level assay for a client with obstructive pulmonary disease receiving theophylline. The nurse determines that a therapeutic medication level has been achieved by indication of which value?

18 mcg/mL (100 mcmol/L) Rationale:The therapeutic range for serum theophylline is 10 to 20 mcg/mL (55.5 to 111 mcmol/L). If the level is less than the therapeutic range, the client may experience frequent exacerbations of the respiratory disorder. If the level is too high, the medication may need to be stopped or the dose may need to be lowered. Values of 8 and 9 mcg/dL (44 and 50 mcmol/L) indicate low values although some physicians may consider these levels acceptable for certain clients, while 26 mcg/dL (144 mcmol/L) indicates an elevated value, which can be harmful.

The nurse is assisting the primary health care provider (PHCP) in assessment of a 67-year-old client with suspected pneumonia using the Expanded CURB-65 scale. The client is alert and oriented. Vital signs are respiratory rate 32 breaths per minute and blood pressure 102/70 mm Hg. Laboratory results demonstrate a blood urea nitrogen (BUN) of 12 mg/dL (4.3 mmol/L), lactate dehydrogenase (LDH) level of 200 μ/L (200 μ/L), albumin 4.0 g/dL (40 g/L) and platelet count of 200,000/mm3 (200 × 109/L). Which score reflects the client's Expanded CURB-65 scale?

2 Rationale:The Expanded CURB-65 scale uses several criteria to calculate a score that helps determine the perceived severity of the client's pneumonia; it can assist the PHCP in determining the treatment plan. These criteria include confusion, BUN, respiratory rate, blood pressure, age, LDH, albumin, and platelet count. The client scores 1 point for each abnormal parameter, including confusion compared to baseline, BUN greater than 20 mg/dL (7.2 mmol/L), respiratory rate greater than 30 breaths per minute, systolic blood pressure (SBP) less than 90 mm Hg or diastolic blood pressure (DBP) less than 60 mm Hg, age greater than 65 years, LDH greater than 230 μ/L, albumin less than 3.5 g/dL (35 g/L), and platelet count less than 100,000/mm3 (100 × 109). The scores range from 0-2 (low perceived risk), 3-4 (intermediate perceived risk), and 5-8 (high perceived risk). This client scores 1 point for age greater than 65 years and scores another point for respiratory rate. Therefore, option 1 is the correct answer and the total score is 2.

The emergency room nurse is caring for a client rescued from a house fire that is exhibiting signs and symptoms of carbon monoxide poisoning. The client is complaining of the room spinning, ringing in the ears, headache, and nausea. The client is becoming increasingly irritable and confused. Physical assessment shows reddish-purple skin, and the ordered electrocardiogram (ECG) demonstrates a depressed ST segment. The nurse would determine that the severity of the client's carbon monoxide poisoning correlates with which range in the carboxyhemoglobin level?

21%-40% Rationale:A normal carbon monoxide, or carboxyhemoglobin, level is 1% to 10%. Mild poisoning is indicated by carbon monoxide levels ranging from 11% to 20%. The physiological effects with mild poisoning include headache, slight breathlessness, decreased cerebral function, and blurred vision. Moderate poisoning is indicated by carbon monoxide levels ranging from 21% to 40%. Signs and symptoms of moderate poisoning include headache, tinnitus (ringing in ears), nausea, drowsiness, vertigo (spinning sensation), altered mental status, confusion, stupor, irritability, pale to reddish-purple skin, hypotension, tachycardia, and dysrhythmias or ST segment depression on an ECG. Severe poisoning is indicated by carbon monoxide levels ranging from 41% to 60%. Clinical manifestations of severe poisoning include coma, convulsions, and cardiopulmonary instability. Lastly, fatal poisoning is indicated by carbon monoxide levels ranging from 61% to 80%, and death occurs. Therefore, the signs and symptoms the client is exhibiting are characteristic of moderate carbon monoxide poisoning and a carboxyhemoglobin level range of 21% to 40%. Therefore, option 3 is correct.

An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank.

22.5% Rationale:According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.

The nurse is caring for a client who underwent a pleurodesis procedure to treat a recurrent pleural effusion. The medication was instilled into the chest tube at 1600 and subsequently clamped. At what time will the nurse unclamp the chest tube?

2400 Rationale:During a pleurodesis procedure, a chemical irritant, such as doxycycline or bleomycin, is instilled into the pleural cavity via a chest tube. The medication needs to stay in place for at least 8 hours to be effective. Options 1, 2, and 3 are too early to unclamp the chest tube as the medication would be in place for only 2, 4, and 6 hours, respectively. Therefore, option 4 is correct.

A client has a prescription to receive purified protein derivative, 0.1 mL, intradermally. The nurse would administer the medication by using a tuberculin syringe according to which guidelines?

26-gauge, 5/8-inch needle inserted almost parallel to the skin, with the bevel side up Rationale:A tuberculin skin test is administered by giving 0.1 mL of purified protein derivative (PPD) intradermally. Administration involves drawing the medication into a tuberculin syringe with a 25- to 27-gauge, 5/8-inch needle. The injection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in formation of a wheal when the PPD is administered correctly.

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

36% Rationale:According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of the posterior torso, equaling 9%. This totals 36%.

A client who has been receiving theophylline by the intravenous (IV) route has the medication prescription changed to an immediate-release oral form of the medication. After discontinuing the IV medication, when would the nurse schedule the first dose of the oral medication?

4 hours after discontinuing the IV form Rationale:With immediate-release preparations, oral theophylline would be administered 4 to 6 hours after discontinuing the IV form of the medication. If the sustained-release form is used, the first oral dose would be administered immediately on discontinuation of the IV infusion. Therefore, the remaining options are incorrect.

The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long?

48 to 72 hours Rationale:The tuberculin skin test is an accurate and reliable test that will provide information to the primary health care provider about the client's possible exposure status to tuberculosis. Interpretation of the skin test result needs to be done 48 to 72 hours after the injection

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving theophylline. The nurse monitors the serum theophylline level and concludes that the medication dosage may need to be increased if which value is noted?

5 mg/mL (20 mcmol/L) Rationale:Theophylline is a bronchodilator. The nurse monitors the theophylline blood serum level daily when a client is on this medication to ensure that a therapeutic range is present and monitors for the potential for toxicity. The therapeutic serum level range is 10 to 20 mg/mL (40 to 79 mcmol/L). If the laboratory result indicated a level of 5 mg/mL (20 mcmol/L), the dosage of the medication would need to be increased.

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.

54% Rationale:According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%.

The nurse is assisting a pulmonologist with a pleurodesis to treat a client with recurrent pleural effusions. After the pulmonologist instills the medication into the pleural space, for how long would the nurse anticipate the chest tube drainage system will need to be clamped?

8 hours Rationale:Pleurodesis is a procedure in which a medication, such as doxycycline or bleomycin, is instilled into the pleural space via an existing chest tube. The medication triggers an inflammatory reaction that destroys the pleural space, thereby preventing future fluid accumulation. The chest tube drainage system needs to be clamped for a period of 8 hours after the procedure, after which it is unclamped and the medication is allowed to drain out of the lungs. Options 1, 2 and 3 are inadequate amounts of time for the medication to exert its therapeutic effect after this procedure. Therefore, option 4 is correct.

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn?

9600 mL of lactated Ringer's solution Rationale:The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.

A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan?

A 14- to 21-day course of doxycycline Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. A 14 to 21-day course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with IV antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.

A client is suspected of having stage I Lyme disease. The nurse anticipates that which will be part of the treatment plan for the client?

A 14- to 21-day course of oral antibiotic therapy Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Prevention, public education, and early diagnosis are vital to the control and treatment of Lyme disease. A 14- to 21-day course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with intravenously administered antibiotics, such as penicillin G. The remaining options are incorrect.

Which of the clients under the nurse's care is at an increased risk for sepsis or septic shock? Select all that apply.

A 40-year-old client receiving chemotherapy for breast cancer A 45-year-old client with a CD4 count of 180 cells/mm3 (0.18 × 109/L) A 52-year-old client with a glycosylated hemoglobin (HbA1c) of 9.2% (77 mmol/mol) A 63-year-old client with chronic kidney disease managed with dialysis 3 times per week Rationale:Sepsis and subsequently septic shock are usually caused by a bacterial infection (although in cases of immunodeficiency a fungal infection can be the cause) that overcomes the local protective mechanisms of the immune system and becomes systemically widespread. Many factors increase the risk of sepsis or septic shock. These factors include cancer, immunosuppression, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), diabetes mellitus, chronic kidney disease, and age older than 80 years. Therefore, the client in option 2 who is receiving chemotherapy for breast cancer is at increased risk. The client in option 3 has a decreased CD4 count that is indicative of immunodeficiency and is at an increased risk. The client in option 4 has an elevated HbA1c that is indicative of diabetes mellitus, as an HbA1c greater than 6% (42 mmol/mol) is indicative of diabetes mellitus. This HbA1c level puts this client at increased risk for the development of sepsis or septic shock. Lastly, the client in option 5 has chronic kidney disease, which is a risk factor for sepsis or septic shock. Therefore, options 2, 3, 4, and 5 are correct. The client in option 1 is younger than 80 years old, and hyperlipidemia is not an identified predisposing factor for sepsis or septic shock.

The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply.

A 47-year-old parent of a child with cystic fibrosis A 54-year-old client scheduled for a routine diabetes check A 35-year-old registered nurse scheduled for an annual pelvic exam An 87-year-old client from a nursing home scheduled for a surgical follow-up Rationale:Influenza vaccinations are recommended yearly and developed according to predicted strain for clients at high risk. Influenza immunization is recommended for high-risk clients. Anyone in close contact with clients with a chronic respiratory or other chronic disorder need to receive the vaccine. Adults with chronic metabolic disease such as diabetes mellitus are in the high-risk population. Residents of chronic care facilities are at risk for influenza. Health care workers are in the high-risk population. The influenza vaccine does not treat an active infection with the virus.

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism?

A 73-year-old client who has just had pinning of a hip fracturev Rationale:Clients frequently at risk for pulmonary embolism include those who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age.

A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study would the nurse be aware of before responding to the client?

A Western blot will be done to confirm these findings. Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. If the result of the ELISA is positive, the Western blot is done to confirm the findings. If the result of the Western blot is positive, the client is considered to be seropositive for the infection and to be infected with the virus. The remaining options are incorrect.

The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?

A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg Rationale:Complications of mechanical ventilation include the following: hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings.

The nursing student is presenting a clinical conference and discusses the cause of β-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

A child of Mediterranean descent Rationale:β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). This disorder is found primarily in individuals of Mediterranean descent. Options 1, 3, and 4 are incorrect.

Which individuals are most likely to be at risk for development of psoriasis? Select all that apply.

A client experiencing menopause A client with a family history of the disorder An individual who has experienced a significant amount of emotional distress Rationale:Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. Various forms exist, with psoriasis vulgaris being the most common type. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a cause. The disorder also may be exacerbated by the use of certain medications.

The nurse working on a medical-surgical unit is reviewing the day's client assignment. Which client(s) in the day's assignment would the nurse determine is at risk for the development of pneumonia? Select all that apply.

A client who had a total open hysterectomy 2 days ago A client with a fractured hip scheduled for a hip arthroplasty the following day A client with chronic obstructive pulmonary disease (COPD) with a tracheostomy A client who is nothing-by-mouth (NPO) receiving tube feeding via a nasogastric (NG) tube Rationale:There are several risk factors associated with the development of pneumonia. These include abdominal or chest surgery, a client on strict bed rest or an immobile client, artificial airways that bypass the protective mechanisms of the upper airway, chronic diseases (including chronic lung disease, liver disease, diabetes, and heart conditions) and NG or nasointestinal tubes, which increase the risk of aspiration. The client in option 2 underwent an invasive surgery with large abdominal incisions, which increases this client's risk for an ineffective breathing pattern related to pain with deep breathing and an increased risk for pneumonia due to alveolar collapse. The client in option 3 requires strict bed rest to prevent further injury to the hip and is also at an increased risk for an ineffective breathing pattern related to immobility and pain. The client in option 4 is at an increased risk for pneumonia due to the client's medical history of COPD and the presence of a tracheostomy, which increases the risk of infection. The client in option 5 has an NG tube, which increases the client's risk of aspiration pneumonia. The client in option 1 is not at an increased risk for pneumonia. Therefore, options 2, 3, 4, and 5 are correct.

The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder?

A client who tans in an indoor tanning bed Rationale:Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme conditions can damage the skin, posing the highest risk for skin disorders. An athlete would be at low risk of developing an integumentary problem. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. An older client may be at a higher risk than a younger person.

The experienced nurse is teaching a new graduate nurse about tracheostomy care. The experienced nurse would determine teaching has been effective if the new graduate nurse states that which client has an immature tracheostomy?

A client who underwent a tracheotomy 2 days ago Rationale:After a tracheotomy, the tracheostomy tract becomes more established and matured over time. Tube dislodgment within 72 hours after a tracheotomy is considered an emergency because replacement of the tube is difficult due to the immaturity of the tract. This factor makes it more likely the tube will enter subcutaneous tissue instead of the trachea during attempted replacement. Since the client in option 1 has had the tracheotomy most recently compared with the other clients and the tracheostomy is considered immature, this client would be more likely to have complications if tube dislodgment occurs. Therefore, option 1 is the correct answer.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.

A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise Rationale:Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication?

A kink in the ventilator circuit Rationale:A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarm activation include excess secretions; mucous plugs; the client biting on the endotracheal tube; kinks in the ventilator tubing; and the client coughing, gagging, or attempting to talk. The remaining options would trigger the low-pressure alarm.

A client reports to the health care clinic for testing for human immunodeficiency virus (HIV) immediately after being exposed to HIV. The test results are negative, and the client expresses relief about not contracting HIV. What would the nurse emphasize when explaining the test results to the client?

A negative HIV test result is not considered accurate immediately after exposure. Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A test for HIV needs to be repeated if results are negative. Seroconversion is the point at which antibodies appear in the blood. The average time for seroconversion is 2 months, with a range of 2 to 10 months. For this reason, a negative HIV test result is not considered accurate immediately after exposure. The remaining options are incorrect.

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply.

A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight Rationale:Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.

The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis?

A person who is an inspector for the U.S. Postal Service Rationale:Clients at high risk for acquiring tuberculosis include immigrants from Asia, Africa, Latin America, and Oceania; medically underserved populations (ethnic minorities, homeless); those with human immunodeficiency virus infection or other immunosuppressive disorders; residents in group settings (long-term care, correctional facilities); and health care workers.

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation?

A shunt unit exists. Rationale:When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?

A skin infection of the dermis and underlying hypodermis Rationale:Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, infection affecting the upper layers of the skin. Cellulitis is not superficial and extends deeper than the epidermis.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?

A skin infection of the dermis and underlying hypodermis Rationale:Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis.

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding?

Absence of dyspnea Rationale:The client who has undergone thoracentesis would experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

The nurse is providing care for a client recently admitted with new-onset pleurisy. Upon auscultation of the client's lungs, the nurse notes an absence of the pleural friction rub that was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds?

Accumulation of pleural fluid in the inflamed area Rationale:Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, friction between the visceral and parietal lung surfaces decreases, and the pleural friction rub disappears. The remaining options are incorrect interpretations.

The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse would tell the client that the vesicles are consistent with which condition?

Acne Rationale:Acne is characterized by vesicles filled with cloudy or purulent fluid. Freckles are flat lesions less than 1 centimeter. Psoriasis is presented by elevated, plateaulike patches more than 1 centimeter. Sebaceous cysts are nodules filled with either liquid or semisolid material that can be expressed.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. Which assessment is the nursing priority?

Activation status and settings of the device Rationale:The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to care after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse would assess which item based on priority?

Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver Rationale:The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse include on the list? Select all that apply.

Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary, because family members already have been exposed. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. Rationale:The nurse would provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance need to be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities need to be resumed gradually, and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection needs to be consumed. Respiratory isolation is not necessary, because family members already have been exposed. Instruct the client about thorough handwashing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

Adequacy of capillary filling Rationale:Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1, 2, and 4 may provide some information related to fluid volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How would the nurse instruct the client?

Adjust the oxygen depending on SpO2. Rationale:The client with COPD is often dependent on oxygen. The oxygen would be adjusted depending on the SpO2, which needs to be 88% to 92%. All other options are incorrect.

The nurse is caring for a client with acute respiratory distress syndrome on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse would take which action?

Administer a dose of a prescribed antacid. Rationale:The client on a mechanical ventilator who has a nasogastric tube in place needs to have the gastric pH monitored at the beginning of each shift or at least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) would be treated with prescribed antacids. If there is no prescription for the antacid, the primary health care provider would be notified. Documentation of the findings needs to be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment.

A client is diagnosed with scleroderma. Which intervention would the nurse anticipate to be prescribed?

Administer corticosteroids as prescribed for inflammation. Rationale:Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated, and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present.

The client has a prescription to receive pirbuterol 2 puffs and beclomethasone dipropionate 2 puffs by metered-dose inhaler. The nurse plans to give these medications in which way to ensure effectiveness?

Administering the pirbuterol before the beclomethasone Rationale:Pirbuterol is a bronchodilator. Beclomethasone is a glucocorticoid. Bronchodilators are administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply.

Administer oxygen to the client. Stop dialysis, and turn the client on the left side with head lower than feet. Notify the primary health care provider (PHCP) and Rapid Response Team. Rationale:If the client experiences air embolus during hemodialysis, the nurse would terminate dialysis immediately, position the client so that the air embolus is in the right side of the heart, notify the PHCP and Rapid Response Team, and administer oxygen as needed. Slowing the dialysis treatment or giving an intravenous bolus will not correct the air embolism or prevent complications.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which would be the initial nursing action?

Administer oxygen, 8 to 10 L/minute, by face mask. Rationale:If pulmonary embolism is suspected, oxygen needs to be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which would be the initial nursing action?

Administer oxygen, 8 to 10 L/minute, by face mask. Rationale:If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The primary health care provider diagnoses a pulmonary embolism. Which actions would the nurse take? Select all that apply.

Administer oxygen. Assess the blood pressure. Start an intravenous (IV) line. Prepare to administer morphine sulfate. Rationale:If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.

The nurse is responding to an adult client who aspirated while eating in a restaurant; the client is choking and becomes unresponsive. The client has a pulse with agonal breathing. The nurse has already called for an automatic external defibrillator (AED) and activated the emergency response system. Which of the following nursing interventions is appropriate in the care of this client?

Administer rescue breaths at a rate of 10 to 12 breaths per minute Rationale:Foreign body airway obstruction can result in a partial or complete obstruction of the airway. The initial response would be to check the client's mouth for the cause of the obstruction and to manually relieve the obstruction if possible. Abdominal thrusts or the Heimlich maneuver should be attempted to relieve the obstruction. If the client loses consciousness or becomes unresponsive, the nurse would lower the client to the floor and check for a pulse and respirations. If no pulse is present, the nurse would initiate cardiopulmonary resuscitation. However, in this case, remember that the client has a pulse and agonal breathing, which is not adequate for oxygenation. Rescue breaths need to be initiated immediately just as if the client were not breathing at all. The nurse would deliver rescue breaths every 5 to 6 seconds or at a rate of 10 to 12 breaths per minute and recheck the carotid pulse every 2 minutes until further help arrives. Option 1 is incorrect because the nurse would assess the client further and gather more information before initiating chest compressions. Also, the client has a pulse, so unless the client becomes pulseless, it is an inappropriate action to take. Option 2 is incorrect because every 5 minutes is too infrequent and the carotid pulse needs to be reassessed every 2 minutes while delivering rescue breaths. Option 3 is incorrect because it is an inappropriate rate; rescue breaths need to be administered at a rate of 10 to 12 breaths per minute.

The nurse is instructing a client with iron-deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction would the nurse tell the client?

Administer the iron through a straw. Rationale:In iron-deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement needs to be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. Clients need to be instructed to brush or wipe their teeth after administration. Iron is administered between meals, because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not mixed with liquids, cereal, or other food items.

The nurse is preparing to instruct the parents of a child with iron-deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction would the nurse give the parents?

Administer the iron through a straw. Rationale:In iron-deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement needs to be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The parents would be instructed to brush or wipe the child's teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items.

The nurse is caring for a client with chronic obstructive pulmonary disease who is dyspneic and has decreased breath sounds. The nurse would carry out which intervention to decrease the client's work of breathing?

Administer the prescribed bronchodilator. Rationale:Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and would ease the client's dyspnea. The client needs to be placed in high-Fowler's position to maximize chest expansion. Clients with increased production of mucus have increased airway resistance, which increases the work of breathing. Thus, fluids would be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.

A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What would the nurse suspect as a complication of the TPN?

Air embolism Rationale:Signs and symptoms of air embolism include decreased level of consciousness, tachycardia, dyspnea, anxiety, feelings of impending doom, chest pain, cyanosis, and hypotension. The signs and symptoms in the question do not indicate hyperglycemia, an infection (catheter-related sepsis), or an allergic reaction.

The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action would the nurse perform prior to reinserting the inner cannula?

Allow the inner cannula to dry after washing it with sterile water. Rationale:After washing the inner cannula with half strength peroxide and rinsing it with sterile water (per agency policy), the nurse taps it against a sterile surface to remove excess liquid and allows it to dry. The nurse then inserts the cannula into the tracheostomy tube and turns it clockwise to lock it in place. The nurse would not suction a client without an inner cannula in place. This is a sterile procedure; therefore, it is inaccurate to use a clean washcloth. Gauze is not used to dry the cannula because gauze particles can remain on the cannula.

In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem?

Altered body image Rationale:Psoriasis is an autoimmune dermatitis that is expressed as silvery scales on reddish-colored skin on areas such as scalp, elbows, hands, and knees. Onset of the disease generally occurs before age 40, with symptoms varying in intensity from mild to severe. Skin disorders, particularly when experienced by young persons and particularly when visible on exposed body parts, can cause significant psychosocial distress. Altered body image is a priority client problem that needs to be considered when planning care for a client with psoriasis. The remaining options are not priority client problems associated with psoriasis.

A client with myocardial infarction is experiencing new multiform premature ventricular contractions and short runs of ventricular tachycardia. The nurse plans to have which medication available for immediate use to treat the ventricular tachycardia?

Amiodarone Rationale:Amiodarone is an antidysrhythmic that may be used to treat ventricular dysrhythmias. Digoxin is a cardiac glycoside; verapamil is a calcium channel-blocking agent; acebutolol is a beta-adrenergic blocking agent. Digoxin can be used to treat supraventricular dysrhythmias but is inactive against ventricular dysrhythmias. Verapamil is used to slow the ventricular rate for a client with atrial fibrillation or atrial flutter, or to terminate supraventricular tachycardia. Acebutolol is a beta blocker used to treat dysrhythmias.

The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder?

An outdoor construction worker Rationale:Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. The outdoor construction worker would fit into a high-risk category for the development of an integumentary disorder. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. Immobility and lack of nutrition would increase the older client's risk, but the older client is not at as high a risk as the outdoor construction worker. The physical education teacher is at low or no risk of developing an integumentary problem.

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) has been on oral glucocorticoids and is currently being weaned to triamcinolone by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change when the client states the need to report which signs and symptoms?

Anorexia, nausea, weakness, and fatigue Rationale:The client being changed from oral to inhalation glucocorticoids could experience signs of adrenal insufficiency. The nurse teaches the client to report anorexia, nausea, weakness, and fatigue. Other signs that can be detected and that are objective include hypotension and hypoglycemia.

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply.

Anosmia Chronic cough Purulent nasal discharge Rationale:Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. Intolerance to hot weather and intolerance to strong aromas are not characteristics.

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?

Anti-streptolysin O titer Rationale:Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay. Options 1, 2, and 3 would not help confirm the diagnosis of rheumatic fever.

The nurse in the emergency department is preparing for the arrival of a client with suspected carbon monoxide poisoning. Which primary health care provider (PHCP) order would the nurse perform first upon the client's arrival?

Apply 100% oxygen via nonrebreather mask. Rationale:Carbon monoxide poisoning results in the displacement of oxygen from hemoglobin in the blood, resulting in tissue hypoxia. Although options 1, 2 and 4 are appropriate interventions in the care of a client with carbon monoxide poisoning, the first action the nurse would take to assist the client's airway and breathing would be to apply high-flow oxygen via a nonrebreather mask. Therefore, option 3 is correct.

When performing a surgical dressing change on a client's abdominal dressing, the nurse notes an increased amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse would take which action in the initial care of this wound?

Apply a sterile dressing soaked with normal saline. Rationale:Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the visible appearance of underlying tissues. Dehiscence usually occurs 6 to 8 days after surgery. The client needs to be instructed to remain quiet and to avoid coughing or straining. The client needs to be positioned to prevent further stress on the wound (semi-Fowler's position). Sterile dressings soaked with sterile normal saline would be used to cover the wound. The nurse must notify the primary health care provider after applying this initial dressing to the wound. Options 1, 2, and 4 are incorrect.

A topical corticosteroid is prescribed by the pediatrician for a child with contact dermatitis (eczema). Which instruction would the nurse give the parent about applying the cream?

Apply a thin layer of cream and rub it into the area thoroughly. Rationale:Contact dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and would be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area would be cleaned gently before application. A topical corticosteroid would not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

The nurse is caring for a client with a pneumothorax who has a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action?

Apply an occlusive dressing Rationale:If a chest tube is accidentally pulled out, the nurse would immediately apply an occlusive dressing and then contact the PHCP or rapid response team, based on agency procedure. It is not appropriate and not a nursing role to reinsert a chest tube. It is not necessary to contact the respiratory therapist. The PHCP needs to be notified, but this is not the initial nursing action.

The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least three ribs. What is the nurse's priority action for this victim?

Apply firm but gentle pressure with the hands to the flail segment. Rationale:If flail chest is present, the nurse applies firm but gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the victim's respiratory status. The nurse does not move an injured client for fear of worsening an undetected spinal injury. Removing the victim's shirt is of no value in this situation and could in fact result in chilling the victim, which is counterproductive. Injured clients need to be kept warm until help arrives at the scene.

Permethrin is prescribed for a child with a diagnosis of scabies. The nurse would give which instruction to the parents regarding the use of this treatment?

Apply the lotion to cool, dry skin at least 30 minutes after bathing. Rationale:Permethrin is massaged thoroughly and gently into all skin surfaces (not just the areas that have the rash) from the head to the soles of the feet. Care needs to be taken to avoid contact with the eyes. The lotion would not be applied until at least 30 minutes after bathing and would be applied only to cool, dry skin. The lotion would be kept on for 8 to 14 hours, and then the child would be given a bath. The child would be clothed during the 8 to 14 hours of treatment contact time.

The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse would plan time for which activity after the arterial blood specimen is drawn?

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Rationale:Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold (not warm) compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

The nurse expects to note which prescription for a client with a skin infection that extends into the dermis?

Applying warm compresses to the affected area Rationale:Warm compresses may be prescribed to decrease the discomfort, erythema, and edema associated with a skin infection that is characteristic of cellulitis. The nurse would also provide supportive care as prescribed to manage associated symptoms such as fever or chills. After tissue and blood are obtained for culture, antibiotics are initiated. Heat lamps can cause more disruption to already inflamed tissue. Iced compresses are not prescribed because they can damage tissue.

A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary?

Ask the client about allergies and previous reactions. Rationale:A computed tomography scan is not performed in the operating room; therefore, it is not necessary that the nurse contact this department. There is no surgical entry site; therefore, shaving is unnecessary. The procedure is explained to the client, who also is asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water is avoided for 4 to 6 hours before the test.

A client calls the nurse in the emergency department and reports being just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action would the nurse take?

Ask the client if they ever sustained a bee sting in the past. Rationale:In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if they ever experienced a bee sting in the past. Option 1 is inappropriate advice. Option 3 is unnecessary. The client would not be told "not to worry."

A client with a documented exposure to tuberculosis is on medication therapy with isoniazid. The nurse is monitoring laboratory results and determines that which laboratory value indicates the need for follow-up?

Aspartate aminotransferase (AST) 55 U/L (55 U/L) Rationale:Because isoniazid therapy can cause elevated hepatic enzymes and hepatitis, liver enzymes are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years of age or who abuses alcohol. The normal AST level is 0 to 35 U/L (0 to 35 U/L). The other options are not monitored routinely and are also normal.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs during suctioning. Rationale:Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this complication.

Endovenous laser treatment (EVLT) is done on a client with varicose veins. Which interventions would the nurse include in the postprocedure plan of care?

Assess color and temperature of the affected limb to determine vascular status. Rationale:Endovenous laser treatment (EVLT) is a treatment for varicose veins that uses laser heat to ablate (occlude) the affected vessel. This procedure is less invasive than a ligation and removal of veins procedure. Using ultrasound guidance, the clinician advances a catheter into a vein (most commonly the saphenous vein) and injects an anesthetic agent around it. Then the vessel is ablated while the catheter is slowly removed. After the procedure, the client is taught the importance of using a GCS or other form of compression such as elastic compression bandages as prescribed for 24 hours a day (not just during the day), except for showers for at least the first week. A follow-up ultrasonography is done to ensure closure, so it is inappropriate to tell the client that the EVLT ensures closure; this needs to be verified. Circulation impairment is not expected. Nerve damage is not expected but can occur; if it does occur, it is usually temporary and minimal and resolves within a few months. The nurse needs to assess the vascular status of the affected limb and check for changes in color or temperature of the limb. The nurse would also monitor for pain, edema, and paresthesias that could indicate complications such as deep vein thrombosis or nerve damage.

A client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse would take?

Assess for anaphylaxis and prepare for emergency treatment. Rationale:Hypersensitivity or allergy is excessive inflammation occurring in response to the presence of an antigen to which the person usually has been previously exposed. If a client is experiencing an allergic or hypersensitivity response, the nurse's initial action is to assess for anaphylaxis. Promptly notifying the health care provider and preparing emergency equipment, including medication such as epinephrine and possible corticosteroids, is essential in preventing progression of anaphylaxis. Laboratory work is not a priority in this situation. The nurse would expect the IgE level to be elevated; the client may be hypoxic. The nurse would give the client supplemental oxygen; however, 100% is not given unless prescribed, and based on the information in the question, intubation is not the first thing the nurse would prepare this client for. Teaching the client is important; however, this is not the right time. When the client is stabilized, the nurse needs to teach or reinforce that allergies, including some medications, are common triggers for asthma attacks and that people with asthma are predisposed to more allergies than people without asthma.

The nurse is reviewing the interventions for relieving an airway obstruction. Which initial action would be taken in this situation?

Assess for the cause of the obstruction Rationale:Airway obstruction can be related to a variety of causes. The first step when intervening in this situation is to assess the cause of the obstruction in order to determine the appropriate interventions to relieve the obstruction. Therefore, option 4 is the correct answer. If the obstruction is due to the tongue blocking the airway or a buildup of excessive secretions, the client's head and neck would be extended and a nasal or oral airway would be inserted for suctioning. If the airway is blocked due to a foreign body, abdominal thrusts would be initiated.

The nurse is caring for a client with dysphagia who is diagnosed with pneumonia and prescribed a honey-thick diet. The nurse is preparing to assist the client with eating. Which is the priority nursing action?

Assess the client's gag reflex Rationale:The priority nursing action for a client with dysphagia is to assess for an intact gag reflex before attempting to feed the client in order to prevent aspiration. While options 2, 3, and 4 are all appropriate nursing interventions in the care of this client, these interventions would be done after assessing for a gag reflex and are not the highest priority. Therefore, option 1 is correct.

In order of priority, how would the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they would be performed. All options must be used.

Assess unconsciousness. Open the airway. Look in the mouth and remove the object blocking the airway, if seen. Attempt ventilation. Perform abdominal thrusts. Rationale:For health care providers, the sequence for removing a foreign body airway obstruction in an adult is as follows. After determining unconsciousness, the airway is opened and the rescuer looks into the mouth of the victim and removes the object blocking the airway, if it is seen. Next, the rescuer attempts to ventilate the victim. If unsuccessful, the victim's head is repositioned and ventilation is reattempted. Five abdominal thrusts are then delivered. The sequence is repeated until successful.

What actions would the nurse take when caring for a client having an anaphylactic medication reaction? Select all that apply.

Assess vital signs. Administer oxygen. Ensure a patent airway. Contact the primary health care provider (PHCP). Rationale:If anaphylaxis occurs, the nurse immediately assesses the client's respiratory status. The medication is also immediately stopped. If the client's airway needs to be established or stabilized, the Rapid Response Team is called. In addition, the PHCP is contacted. The intravenous (IV) line is not removed because IV access is needed to administer emergency medications such as diphenhydramine or epinephrine. The client is positioned appropriately. The legs and feet are elevated. The head of the bed is elevated to improve ventilation; elevate the head of the bed 10 degrees if hypotension is present and 45 degrees or higher if the blood pressure is normal. The nurse stays with the client and monitors the client's status, including the vital signs. The nurse documents the event, actions taken, and the client's response.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?

Assist the client to a sitting position with the head tilted forward. Rationale:The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client would be assisted to a sitting position with the head tilted slightly forward, and pressure needs to be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are unsuccessful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The primary health care provider also may prescribe packing of the nostrils. The client would be provided with an emesis basin and needs to be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.

The nurse is caring for a client with a tracheostomy receiving supplemental oxygen via a tracheostomy mask and is preparing to perform tracheostomy care. While preparing the supplies, the nurse notes the tracheostomy tube is pulsing, there is bleeding from the stoma, and the client is increasingly restless. The nurse calls for a rapid response team (RRT) and removes the tracheostomy tube. Which action would the nurse take next?

Assist the primary health care provider (PHCP) with endotracheal intubation Rationale:Bleeding from a tracheostomy can indicate a serious medical emergency known as trachea-innominate artery fistula. The tracheostomy tube will pulse simultaneously with the heartbeat, and heavy bleeding will be noted from the stoma. The tracheostomy tube needs to be removed immediately and an alternative airway will need to be secured. After calling for help, the nurse would first prepare for endotracheal intubation. Therefore, option 4 is correct. Options 1, 2, and 3 are appropriate actions by the nurse, but a patent airway is the priority. Furthermore, those nursing interventions can be carried out simultaneously with assistance from the RRT.

The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. How would the nurse interpret this rhythm?

Atrial fibrillation Rationale:In atrial fibrillation, the P waves are absent and replaced by fibrillatory waves. There is no PR interval, and the QRS duration usually is normal and constant and the rhythm is irregular. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR, a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second, and the QRS interval is 0.06 to 0.10 second.

A client's electrocardiogram shows that the ventricular rhythm is irregular and there are no discernible P waves. The nurse recognizes that this pattern is associated with which condition?

Atrial fibrillation Rationale:With atrial fibrillation, the ventricular rhythm is irregular and there are usually no discernible P waves. Therefore, an atrial rhythm cannot be determined. In atrial flutter, the QRS complexes may be either regular or irregular, and the P waves occur as flutter waves. A client in third-degree AV block (also known as complete heart block) has regular atrial and ventricular rhythms, but there is no connection between the P waves and the QRS complexes. In other words, the PR interval is variable and the QRS complexes are normal or widened, with no relationship with the P waves. With first-degree AV block, the PR interval is longer than normal, and there is a connection between the occurrence of P waves and that of QRS complexes.

A client is diagnosed with a full-thickness burn. What would the nurse anticipate will be used for final coverage of the client's burn wound?

Autograft Rationale:A full-thickness burn will require terminal coverage with an autograft—the client's own skin. Biobrane is porcine collagen bonded to a silicone membrane, which is temporary and lasts anywhere from 10 to 21 days. Homografts (cadaveric skin) and xenografts (pigskin) provide temporary coverage of the wound by acting as a dressing for up to 3 weeks before rejecting

A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse would tell the client to take which measure?

Avoid bathing in the shower or tub more than once daily. Rationale:Several things may be done to promote hydration of the skin. The client needs to limit tub or shower bathing to once daily or every other day and would sponge bathe on the other days. Room humidity needs to be maintained at greater than 40%. Bath water needs to be between 95° F and 100° F (35° C to 37.8° C) (tepid) and not very hot or very cold. Harsh soaps need to be avoided, and emollients would be applied generously to skin while it is still damp.

The nurse is assessing a client complaining of fatigue and facial pain. Upon assessment, the nurse notes tenderness to percussion above the bilateral eyebrows and bilateral cheeks. The client also complains of facial pressure that is worse when bending forward; thick, greenish-yellow nasal discharge; sore throat; and fever at home. Which condition would the nurse suspect?

Bacterial rhinosinusitis Rationale:The client's signs and symptoms are consistent with bacterial rhinosinusitis. Rhinosinusitis is characterized by pain with percussion over the frontal and maxillary sinuses, fever, sore throat, sinus pressure or pain that is exacerbated by bending forward, purulent nasal discharge or postnasal drip, fatigue, and ear pressure. Therefore, option 4 is correct. The assessment data collected by the nurse are not characteristic of laryngitis, pharyngitis, or a nasal polyp. However, a nasal polyp is a risk factor for the development of rhinosinusitis. Therefore, options 1, 2 and 3 are incorrect.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level would the nurse encourage for the client immediately after transfer?

Bathroom privileges and self-care activities Rationale:On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client would ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet (15, 30, and 60 meters).

The nurse is assigned to care for a client with acquired immunodeficiency syndrome (AIDS) suspected of having Kaposi's sarcoma. The nurse would prepare the client for which test to confirm this diagnosis?

Biopsy Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Kaposi's sarcoma is the most common AIDS-related malignancy. It manifests as small purplish-brown, raised lesions if they occur on the skin. Dyspnea occurs if they occur in the lungs. Lymph node swelling occurs if they are located in the lymph nodes. Kaposi's sarcoma also can occur in the gastrointestinal (GI) tract and manifests as an altered bowel pattern, including diarrhea or constipation. Chest x-ray, bronchoscopy, upper GI exam, colonoscopy, and computed tomography scan may be used to aid the diagnosis, but whether Kaposi's sarcoma manifests as a skin lesion or in the lungs or GI tract, the diagnosis is confirmed with a biopsy.

The nurse would report which assessment finding to the primary health care provider (PHCP) before initiating thrombolytic therapy in a client with pulmonary embolism?

Blood pressure of 198/110 mm Hg Rationale:Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the PHCP before initiating therapy.

The nurse would report which assessment finding to the primary health care provider (PHCP) before initiating thrombolytic therapy in a client with pulmonary embolism?

Blood pressure of 198/110 mm Hg Rationale:Thrombolytic therapy is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the PHCP before initiating therapy.

The nurse is providing home education for a client diagnosed with acute bronchitis. The nurse would tell the client to return to the clinic if which symptoms were present? Select all that apply.

Bloody sputum Difficulty breathing Symptoms lasting more than 4 weeks Rationale:Acute bronchitis is a condition of acute inflammation of the bronchi due to a viral or bacterial infection. The condition is self-limiting, and treatment is supportive to aid in relieving symptoms and client discomfort. The client with acute bronchitis would be educated to return to the clinic if certain symptoms develop, such as difficulty breathing, bloody sputum, temperature of 100.4° F (38° C) or higher, or if symptoms last longer than 4 weeks. Therefore, options 1, 2, and 4 are correct. The temperature in option 3 is not high enough to be concerning. Option 5 describes a normal heart rate.

The nurse is preparing a client diagnosed with a partial foreign body airway obstruction for a procedure to facilitate foreign body removal. The nurse would prepare the client for which of the following procedures?

Bronchoscopy Rationale:Bronchoscopy is a procedure in which a fiberoptic scope is introduced into the bronchi. This procedure is used for several purposes, including to suction mucous plugs, lavage the lungs, or remove foreign objects. Paracentesis is a procedure in which fluid is removed from the peritoneal space via a needle or catheter. Thoracentesis is a procedure in which pleural fluid is removed from the pleural space via a needle or catheter. A lung biopsy is a procedure in which lung tissue is obtained via several routes, including transbronchial or percutaneous biopsy, transthoracic needle aspiration, video-assisted thoracoscopic surgery (VATS), or open lung biopsy. Therefore, since bronchoscopy is a procedure to remove a foreign object from the lungs, option 4 is correct.

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and would tell the client that which undesirable effect is associated with this medication?

Bronchospasm Rationale:Cromolyn sodium is an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. Undesirable effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.

The nurse is caring for a client suspected of having lung cancer after a bronchoscopy and biopsy. Which finding, if noted in the client, would be reported immediately to the primary health care provider?

Bronchospasm Rationale:If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client needs to be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has begun to experience multiple opportunistic infections. Which laboratory test would be most helpful in assessing the client's need for reassessment of treatment?

CD4+ cell or T lymphocyte count Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The T lymphocyte or CD4+ cell count indicates whether the client is responding to the medication treatment. The count would increase if the client is responding and would decrease if the client's response is poor. The Western blot and ELISA are tests to assist in diagnosing HIV infection. The B lymphocyte count is not a priority marker to monitor with AIDS clients.

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action?

Call the primary health care provider. Rationale:If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and calls the primary health care provider. The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to call the health care provider in this emergency situation.

The nurse in the emergency department is caring for a client brought in from a house fire. The client is exhibiting dyspnea with clear breath sounds bilaterally and is complaining of a severe headache. The client is exhibiting signs of confusion and is oriented to self. The client's vital signs are as follows: temperature 98.2℉ (36.7℃), oxygen saturation 91%, respiratory rate 26 breaths per minute, heart rate 112 beats per minute, and blood pressure 100/62. Which of the following conditions would the nurse suspect?

Carbon monoxide poisoning Rationale:Carbon monoxide is present in many noxious substances, including cigarette smoke and fire smoke. Carbon monoxide has a higher affinity for hemoglobin than oxygen and displaces oxygen from hemoglobin, thereby inhibiting the body's ability to oxygenate tissues. Clinical manifestations include severe headache, dyspnea, tachypnea, confusion, tachycardia, cyanosis, and respiratory depression. Carbon monoxide poisoning results from inhaling combustion fumes, such as from a fire, and carbon monoxide displaces oxygen on the red blood cells, inhibiting the body's ability to carry and deliver oxygen to tissues. Since the client has been in a house fire, which is a risk factor for this condition, and is exhibiting signs and symptoms consistent with carbon monoxide poisoning, option 4 is correct.

A client returning to the nursing unit after a cardiac catheterization procedure has a stat prescription to receive a dose of intravenous procainamide. Which piece of equipment would be most appropriate for the nurse to use in determining the client's response to this medication?

Cardiac monitor Rationale:Procainamide is an antiarrhythmic medication often used to treat ventricular arrhythmias that do not respond adequately to lidocaine. The effectiveness of this medication is best determined by evaluating the client's cardiac rhythm. Therefore, a cardiac monitor would be the most appropriate device for determining the client's response, although the blood pressure cuff and the pulse oximeter would provide general information about the client's cardiovascular status. A glucometer is not needed for this client with the information presented.

A client has been started on long-term therapy with rifampin. The nurse would provide which information to the client about the medication?

Causes orange discoloration of sweat, tears, urine, and feces Rationale:Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently. Rifampin needs to be taken exactly as directed. Doses would not be doubled or skipped. The client would not stop therapy until directed to do so by a primary health care provider. It is best to administer the medication on an empty stomach unless it causes gastrointestinal upset; then it may be taken with food. Antacids, if prescribed, need to be taken at least 1 hour before the medication.

A client taking rifampin reports, "My urine has blood in it." When the nurse assesses the urine, it is brown. Which is the nurse's best action?A client taking rifampin reports, "My urine has blood in it." When the nurse assesses the urine, it is brown. Which is the nurse's best action?

Chart the finding as a normal response to the rifampin. Rationale:Brown-tinged urine is a normal finding associated with rifampin; thus, there is no need to notify the PHCP. There is no indication that the client is in shock, so eliminate the options that indicate to start prescribed IV fluids and to place the client in modified Trendelenburg's position. The nurse would also inform the client that this is a harmless side effect.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Check for an air leak because the bubbling needs to be intermittent. Rationale:Fluctuation with inspiration and expiration, not continuous bubbling, would be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this would decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse would check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes would be clamped only with a primary health care provider's prescription.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's Spo2 level is 86%. Based on this assessment, which action would the nurse take first?

Check the client's record to determine the client's baseline SpO2. Rationale:The nurse would first assess the client for signs of respiratory compromise and would check the client's record to determine the client's baseline value. The nurse would not increase the client's oxygen flow and titrate until the level is 100%. Oxygen flow rates are determined based on the client's normal baseline and would be titrated to the lowest amount needed; usually between 88% and 92% for a client with obstructive lung disease. Therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and oxygen via nasal cannula would be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, client assessment is done first, making option 4 incorrect.

The nurse is assessing a client with chronic obstructive pulmonary disease. With a finger sensor, the nurse measures the client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action?

Check the finger sensor's position and repeat the test. Rationale:Note that the low reading does not match the client's signs and symptoms. The first action by the nurse is to ensure that the test was done properly and the reading is accurate. The nurse would not increase the oxygen without a PHCP's prescription. The results of the test would be verified before any other actions are taken, and this can be done quickly.

A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported?

Chest pain that occurs suddenly Rationale:The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply.

Cigarette smoking Genetic risk factor Environmental factors Alpha-1 antitrypsin (AAT) deficiency Rationale:Risk factors for COPD include cigarette smoking, environmental factors, genetics, and AAT deficiency. Purified air and consumption of fruits and vegetables promote health.

The nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, what actions would the nurse take? Arrange the actions in the order that they would be performed. All options must be used.

Clamp the intravenous (IV) catheter. Contact the primary health care provider (PHCP). Position the client in a left Trendelenburg's position. Administer oxygen. Take the client's vital signs. Document the occurrence. Rationale:Air embolism occurs when air enters the catheter system during IV tubing changes or when the IV tubing disconnects. Air embolism is a critical situation. If air embolism is suspected, the nurse would first clamp the IV catheter to prevent further introduction of air and the air embolism from traveling through the heart to the pulmonary system. The nurse would next place the client in a left side-lying position with the head lower than the feet (to trap air in the right side of the heart). The nurse would notify the PHCP and administer oxygen as prescribed. The nurse would monitor the client closely and take the client's vital signs. Finally, the nurse documents the occurrence.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium. The client's prothrombin time is 20 seconds, with a control of 11 seconds. How would the nurse interpret these results?

Client results are within the therapeutic range. Rationale:The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds; therefore, the result is within the therapeutic range.

The nurse suspects herpes zoster (shingles) when which assessment finding is noted?

Clustered skin vesicles Rationale:The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because the lesions follow nerve pathways, they do not cross the midline of the body. Options 2, 3, and 4 are incorrect descriptions of herpes zoster.

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin?

Clustered skin vesicles Rationale:The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Options 2, 3, and 4 are incorrect descriptions.

A client has begun to use a methylxanthine bronchodilator. What beverage would the nurse plan to teach the client to avoid while taking this medication?

Coffee Rationale:Cola, coffee, and chocolate contain methylxanthine and need to be avoided by the client taking a methylxanthine bronchodilator. The additional methylxanthine could lead to increased incidence of cardiovascular and central nervous system side effects. Orange juice, mineral water, and cranberry juice are fluids that are allowed.

A client receiving oral theophylline is due to have a theophylline level drawn. The nurse would question the client to ensure that the client has not ingested which substance before the blood sample is drawn?

Coffee Rationale:Theophylline is a xanthine bronchodilator. Before a serum level of the medication is drawn, the client needs to avoid taking foods or beverages that contain xanthine, such as colas, coffee, or chocolate; therefore, the client is told to avoid coffee before the test. The items in the other options do not need to be avoided before this test.

A client has begun therapy with a xanthine bronchodilator. The nurse determines that the client understands dietary alterations if the client states to limit which items while taking this medication? Select all that apply.

Coffee Chocolate Rationale:The nurse teaches the client to limit the intake of xanthine-containing foods while taking a xanthine bronchodilator. These include coffee and chocolate. The other food items are acceptable to consume.

A client has begun therapy with theophylline. The nurse would teach the client to limit the intake of which items while taking this medication?

Coffee, cola, and chocolate Rationale:Theophylline is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence?

Collapse of alveoli and decreased compliance Rationale:Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

The clinic nurse reads the chart of a client just seen by the primary health care provider (PHCP) and notes that the PHCP has documented that the client has stage III Lyme disease. Which clinical manifestation would the nurse expect to note in this client?

Complaints of joint pain Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgias and enlargement or inflammation of joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage II. A rash occurs in stage I. Paralysis of the extremity on which the bite occurred is not a characteristic of Lyme disease.

The nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note?

Complaints of night sweats Rationale:The client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. When asked, what would the nurse tell the client about the purpose of the test?

Confirms the presence of inflammation or infection in the body Rationale:The ESR is a blood test that can confirm the presence of inflammation or infection in the body. It is particularly useful for the management of connective tissue disease because the rate measured directly correlates with the degree of inflammation and later with the severity of the disease. The other options are incorrect.

The nurse is reviewing the pleural fluid cytology report for a client with pleural effusion. The report describes the fluid as clear and pale yellow with no red blood cells (RBCs) or white blood cells (WBCs) detected. Based on these results, which underlying condition would the nurse suspect?

Congestive heart failure Rationale:There are various types of pleural fluid, including transudative fluid or exudative fluid, depending on the underlying cause. Exudate is typically cloudy and yellow and is cell-rich, including WBCs. Generally, exudate indicates an underlying infectious, inflammatory, or malignant process. Transudate is clear or pale yellow with few cells present. Transudate can be related to congestive heart failure due to fluid overload; cirrhosis due to decreased albumin production and subsequent decreased oncotic pressure; or renal disease, which contributes to fluid overload and increased capillary pressure. Options 1, 2 and 3 are either malignant or infectious processes and would likely cause an exudative pleural effusion. Since the client's pleural fluid is clear and pale yellow with no RBCs or WBCs, the transudate is present. Therefore, option 4 is correct as congestive heart failure is associated with transudative pleural effusion.

The nurse is caring for a client with a suspected lower airway infection. The nurse determines that the client is experiencing a productive cough with clear sputum, voice hoarseness, and myalgia. The client's chest x-ray (CXR) demonstrates consolidation in the right and left lower lung lobes, and laboratory results indicate leukocytosis. Based on these data, which client finding would rule out bronchitis?

Consolidation of the right and left lower lung lobes on CXR Rationale:Acute bronchitis is inflammation of the lower respiratory tract bronchi that is usually caused by a virus, but can also be bacterial in nature. Signs and symptoms include a cough, which is often productive with clear or purulent sputum, headache, fever, malaise, myalgia, dyspnea, and chest pain. Client assessment may reveal normal breath sounds or adventitious sounds, such as crackles or wheezes on expiration. However, with bronchitis, consolidation would be negative on the CXR and instead pneumonia would be suspected. Furthermore, leukocytosis, which is an elevated white blood cell (WBC) count, would be expected for an infectious or inflammatory process such as bronchitis. Therefore, option 4 is the correct answer; when consolidation is present on the client's CXR, a diagnosis other than bronchitis, such as pneumonia, would be suspected.

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority?

Contact the primary health care provider (PHCP). Rationale:The nurse who obtains a positive test reading would call the PHCP immediately. The PHCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on prophylactic TB precautions until a final diagnosis is made. Although the results of the test would be documented and the employee health service department would be notified, these are not the actions of highest priority among the options provided.

The nurse has assisted the primary health care provider (PHCP) with the insertion of a chest tube in a client who sustained a chest injury and has a pneumothorax. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

Continue to monitor the client. Rationale:The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has reexpanded. Because this finding is expected, it is not necessary to notify the PHCP. The presence of fluctuation of the fluid level in the water seal chamber does not indicate that the dressing needs reinforcement. Although it is important for the client to cough and deep breathe, this action is unrelated to the situation presented in the question.

The nurse determines that the client with pneumothorax who has a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this?

Continuous bubbling is observed in the water seal chamber during inspiration and expiration. Rationale:Continuous bubbling in the water seal chamber during inspiration and expiration indicates that air is leaking into the drainage system or pleural cavity. Bubbling is an expected finding in the suction control chamber when the device is connected to suction. Tidaling is a normal phenomenon. Absence of tidaling can be indicative of reexpansion of the lung or obstruction or kinking of the chest tube.

A home care nurse is prescribing dressing supplies for a client who has an allergy to latex. Which item would the nurse ask the medical supply personnel to deliver?

Cotton pads and silk tape Rationale:Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. Cotton pads and plastic or silk tape are latex-free products. The items identified in the other options contain latex.

The nurse has been assigned to care for a client with an immune disorder. In developing a plan of care for this client, the nurse incorporates knowledge that the immune system consists of specific major types of cells. Which types of cells are associated with the immune system? Select all that apply.

Dendritic cells B lymphocytes Helper T lymphocytes Cytolytic T lymphocytes Rationale:Immunity is composed of many cell functions that protect against the effects of injury or invasion. The immune system has 5 major types of cells: dendritic cells, B lymphocytes or B cells, helper T lymphocytes or CD4+ cells, cytolytic T lymphocytes or CD8+ cells, and macrophages.

The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation?

Cough Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The client with P. jiroveci infection usually has a cough as the first sign. The cough begins as nonproductive and then progresses to productive. Later signs and symptoms include fever, dyspnea on exertion, and finally dyspnea at rest.

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply.

Cough Dyspnea Chills and night sweats Rationale:The client with TB usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What would the nurse include in client teaching to maximize the effects of the treatment?

Cover the application with a warm, moist dressing and an occlusive outer wrap. Rationale:Penetration of topical corticosteroid therapy can be enhanced by applying warm, moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or similar item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic adverse effects. The medication is applied but not rubbed into the skin. Dry sterile dressings are not used. A heat lamp can cause a burn injury.

A home care nurse is assigned to visit a client who has returned home from the emergency department following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and that the client needs instruction regarding crutch walking. On admission assessment, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, what action would the nurse take?

Cover the crutch pads with cloth. Rationale:Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. The rubber pads used on crutches may contain latex. If the client requires crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. No reason exists to contact the PHCP at this time. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may be inappropriate, considering this client's injury. Telling the client that the crutches must be removed from the house is inappropriate and may alarm the client.

A clinic nurse is assessing a client who has been on isoniazid for 6 months. Which client complaint would most concern the nurse?

Difficulty tying shoes Rationale:The client complaint that would most concern the nurse is difficulty tying shoes because this may indicate neuropathy. Dose-related peripheral neuropathy is one of the more common adverse effects of isoniazid. Dry mouth, cramping diarrhea, and frequent headaches are not concerns with administration of this medication.

The nurse prepares to assist a primary health care provider who is examining a client's skin with a Wood's light. Which step would the nurse include in the plan for this procedure?

Darken the room for the examination. Rationale:Examination of the skin under a Wood's light is always carried out in a darkened room. The procedure is painless. This is a noninvasive examination; therefore, an informed consent is not required. A hand-held, long-wavelength ultraviolet light or Wood's light is used. The skin does not need to be shaved and a local anesthetic is not necessary. Areas of blue-green or red fluorescence are associated with certain skin infections.

Which clinical manifestations of a tension pneumothorax would be of immediate concern to the nurse? Select all that apply.

Decreased cardiac output Hyperresonance to percussion Tracheal deviation to the opposite side Rationale:Tension pneumothorax is the rapid accumulation of air in the pleural space. This causes extremely high intrapleural pressures, resulting in tension on the heart and great vessels. This can cause decreased cardiac output (tachycardia, hypotension), hyperresonance on percussion, and a tracheal shift away from the affected side. Bradypnea and flattened neck veins are incorrect because the client would have tachypnea and distended neck veins.

A complete blood cell (CBC) count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE?

Decreased number of all cell types Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. In the client with SLE, a CBC count commonly shows pancytopenia, a decrease in the number of all cell types. This finding is most likely caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.

The nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment would the nurse plan to have at the bedside when the client returns from surgery?

Obturator Rationale:A replacement tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube becomes dislodged. In addition, a curved hemostat that could be used to hold the trachea open if dislodgment occurs needs to be kept at the bedside. An oral airway and epinephrine would not be needed.

The nurse is reviewing the pathophysiology of pleural effusion. The nurse knows that pleural fluid balance is managed by several mechanisms and correctly identifies which of the following as a cause for the development of pleural effusion? Select all that apply

Decreased oncotic pressure Lymphatic fluid outflow obstruction Increased pulmonary capillary pressure Increased pleural membrane permeability Rationale:The lungs are covered by a two-layered pleural membrane that contains a small amount of pleural fluid between the parietal and visceral pleura to lubricate lung movement. The fluid volume in the pleural space is managed by a balance between hydrostatic pressure, oncotic pressure, capillary permeability and lymphatic fluid outflow. Pleural effusion occurs when one of the previously mentioned mechanisms is disturbed and excessive fluid accumulates in the pleural space. Decreased oncotic pressure, lymphatic fluid outflow obstruction, increased capillary pressure (not decreased capillary pressure), and increased pleural membrane permeability can lead to the development of pleural effusion. Therefore, options 1, 2, 3, and 5 are correct.

The nurse is preparing to care for a client with chronic kidney disease and anemia. When planning care, which describes the relationship between chronic kidney disease and anemia?

Decreased production of erythropoietin is causing anemia. Rationale:Clients with chronic kidney disease do not manufacture adequate amounts of erythropoietin, which is a glycoprotein needed to synthesize red blood cells. Renin, aldosterone, and angiotensin are substances that assist in maintaining blood pressure.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child would monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased wheezing Rationale:Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition, because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute. The normal respiratory rate in a 10-year-old is 16 to 20 breaths per minute.

A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication would the nurse anticipate being prescribed?

Deferoxamine Rationale:β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). The major complication of long-term transfusion therapy is hemosiderosis. To prevent organ damage from too much iron, chelation therapy with either deferasirox or deferoxamine may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as prophylaxis for postoperative deep vein thrombosis. Meropenem is an antibiotic. Metoprolol is a beta blocker used to treat hypertension.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

Deflate the cuff on the tube. Rationale:Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.

A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse would take which action?

Determine whether there are any disconnections in the ventilator tubing. Rationale:The low-pressure alarm can be caused by disconnected tubing, ETT cuff leak, or apnea. High-pressure alarms can be triggered by increased airway resistance, which can occur with excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing.

The nurse is reviewing the pathophysiology of pneumonia. The nurse would correctly identify which infection source as an example of hematogenous spread in the pathogenesis of pneumonia?

Develops from a primary infection at a different site in the body Rationale:Pneumonia is an acute infection of the lung tissue. Several defense mechanisms protect the lung from infection; however, there are three identified methods by which pathogens reach the lung—aspiration, inhalation, or hematogenous spread. Options 2 and 3 both describe the aspiration route of the pathogenesis of pneumonia, in which normal inhabitants of the oropharynx and nasopharynx reach the lung tissue and cause infection. Option 1 describes the inhalation route. Option 4 describes the hematogenous spread route, as this refers to a primary infection elsewhere in the body, such as endocarditis, spreading to the lung tissue and causing a secondary infection. Therefore, option 4 is correct.

Terbutaline is prescribed for a client with bronchitis. Which disorder in the client's medical history requires caution by the nurse?

Diabetes mellitus Rationale:Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It is used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication would be used with caution?

Diabetes mellitus Rationale:Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It needs to be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.

When obtaining assessment data from a client with a microcytic normochromic anemia, which would the nurse question the client about?

Dietary intake of iron Rationale:Microcytic normochromic anemias involve the presence of small, pale-colored red blood cells. Causes are iron deficiency anemia, thalassemia, and lead poisoning. The only choice that fits this description is option 2. Folic acid deficiency is caused by macrocytic normochromic cells; these are large red blood cells. Gastric surgery can result in vitamin B12 deficiency. Sickle cell anemia results in sickled cells and erythrocyte destruction.

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that he or she will immediately report which finding?

Difficulty in discriminating the color red from green Rationale:Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin.

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that they will immediately report which finding?

Difficulty in discriminating the color red from green Rationale:Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin.

The nurse is teaching a client with chronic obstructive pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse plans to explain that gas exchange occurs through which process?

Diffusion Rationale:Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Ionization refers to the process whereby a molecule gains or loses electrons. Active transport is movement of molecules by carrying them across a cell membrane.

The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status has worsened if which is noted on assessment?

Diminished breath sounds Rationale:Diminished breath sounds may be an indication of severe obstruction and possibly respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may wheeze during both inspiration and expiration.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

Diminished breath sounds Rationale:This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort?

Directly observed therapy Rationale:Tuberculosis is a highly communicable disease that is reportable to the local public health department. This agency has regulations that may be enforced to ensure compliance with tuberculosis therapy. Ultimately the client may be required to have directly observed therapy to reduce the risk to the public. This involves having a responsible person actually observe the client taking the medication each day.

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?

Disconnection of the ventilator tube Rationale:The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound.

The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding?

Disconnection of the ventilator tubing Rationale:The low-pressure alarm sounds when little or no pressure is generated during the delivery of the machine breaths. Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure. The remaining options identify causes for triggering the high-pressure alarm.

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition?

Disseminated intravascular coagulopathy (DIC) Rationale:TSS is caused by infection and often is associated with tampon use. The client's clinical signs in this question are compatible with DIC, which is a complication of TSS. The nurse assesses the client at risk and notifies the primary health care provider promptly when signs and symptoms of DIC are noted. Although signs of bleeding may be seen with each of the conditions listed in the incorrect options, the initial diagnosis of TSS makes DIC the logical correct option.

The nurse is assisting the primary health care provider (PHCP) with insertion of a chest tube in a client who sustained a chest injury. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse would take which action?

Document the accurate functioning of the tube. Rationale:The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has reexpanded. There is no need to ask the client to breathe deeply or to reinforce the dressing. The suction needs to be turned on if prescribed, but there are no data in the question to indicate this PHCP prescription.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

Document the findings. Rationale:Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the primary health care provider and changing the chest tube drainage system are not indicated at this time.

The nurse is caring for a client with a pneumothorax who has a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate?

Document the findings. Rationale:With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings.

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.

Drainage system maintained below the client's chest 50 mL of drainage in the drainage collection chamber Occlusive dressing in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Rationale:The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions?

Droplet precautions Rationale:Droplet precautions are required for a client with mycoplasmal pneumonia because this type of pneumonia is transmitted by droplet nuclei larger than 5 mm. The nurse wears a mask while in the client's room. Enteric precautions are necessary when exposure from feces is likely; gloves are necessary and possibly a gown and face shield if splashes are expected to occur. Contact precautions are implemented when exposure to contaminated material, such as wound drainage, can occur and require the use of gloves and possibly a gown. Protective isolation is instituted when it is necessary to protect the client from others.

The nurse is preparing a room for a client diagnosed with pertussis. Which type of precautions would the nurse plan to implement for the client?

Droplet precautions Rationale:Pertussis is an extremely contagious bacterial infection of the lower respiratory tract caused by the organism Bordetella pertussis (B. pertussis). The condition is characterized by a whooping-like cough. Although the clinical presentation may be more severe in infants and children, pertussis also can affect adults. Pertussis is transmitted via respiratory droplets, and droplet precautions are appropriate when treating a client with this condition. Therefore, option 1 is correct.

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply.

Dry air Exercise An upper respiratory infection (URI) Nonsteroidal anti-inflammatory drugs (NSAIDs) Rationale:Triggers for asthma include response to the presence of specific allergens; general irritants such as cold air, dry air, or fine airborne particles; microorganisms; and aspirin and other NSAIDs. Increased airway sensitivity (hyperresponsiveness) can occur with exercise, with an upper respiratory illness, and for unknown reasons. Clean air and adequate rest and sleep help to promote lung function.

The client questions the nurse as to why the primary health care provider switched the usual prescription from a metered-dose inhaler (MDI) to a dry powder inhaler (DPI). The nurse would respond correctly by providing which facts? Select all that apply.

Dry powder inhalers pose no environmental risks. Dry powder inhalers deliver more medication to the lungs. Dry powder inhalers require less hand-to-lung coordination. Rationale:DPIs are used to deliver medications in the form of a dry, micronized powder directly to the lungs. DPIs do not require the hand-to-lung coordination needed with MDIs; thus, DPIs are much easier to use. Compared with MDIs, DPIs deliver more medication to the lungs (20% of the total released versus 10%) and less to the oropharynx. Because DPIs do not require propellant, they are not a risk to the environment. Both types of inhalers have side effects. Frequency of use is prescribed by the primary health care provider.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse would assess the client for which expected finding?

Dyspnea Rationale:Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.

The nurse is caring for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder?

Dyspnea Rationale:In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism?

Dyspnea Rationale:The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply.

Dyspnea Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum Rationale:Tuberculosis should be considered for any client with a persistent cough with mucoid sputum production, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis needs to also be assessed and correlated with the clinical manifestations.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings would the nurse anticipate in this client? Select all that apply.

Dyspnea at rest Clubbed fingers Muscle retractions Prolonged expiratory breathing phase Rationale:The client with COPD who is eligible for a lung transplantation has end-stage COPD and will have clinical manifestations of hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide. Option 4 is incorrect because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is incorrect because an elevated temperature would not be present unless the client has an infection.

The nurse is conducting staff in-service training on von Willebrand's disease. Which would the nurse include as characteristics of von Willebrand's disease? Select all that apply.

Easy bruising occurs. Gum bleeding occurs. It is a hereditary bleeding disorder. Treatment and care are similar to that for hemophilia. The disorder causes platelets to adhere to damaged endothelium. Rationale:Von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. Treatment and care are similar to measures implemented for hemophilia, including administration of clotting factors. An elevated creatinine level is not associated with this disorder.

The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse plans to provide which instruction to the client?

Eat foods that are not seasoned or not spicy. Rationale:Foods that are seasoned or spicy are irritating to the throat and need to be avoided. The client with pharyngitis needs to be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Citrus products need to be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production. The client need to be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless contraindicated.

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term?

Ecchymosis Rationale:Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and would include which intervention in the plan?

Elevate and immobilize the grafted extremity. Rationale:Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action would be included in the client's plan of care?

Eliminating sources of caffeine from meal trays Rationale:Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia. Measuring the pulse each shift will not decrease the heart rate. In addition, the pulse needs to be taken more frequently than each shift.

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action would the nurse take to eliminate the problem?

Empty excess accumulated water from the ventilatory circuit tubing. Rationale:High-pressure alarms can be triggered by increased airway resistance caused by excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing. Excess water needs to be emptied from the tubing. Alarms would never be silenced until the cause has been identified and corrected. In addition, this will not eliminate the problem. The low-pressure alarm would sound with a disconnection. Filling the cuff to 25 mm Hg can result in impaired circulation to the tracheal mucosa.

The primary health care provider prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions would the nurse plan to include in the client's plan of care? Select all that apply.

Encourage coughing with deep breathing. Encourage increased oral intake of water daily. Place thigh-length elastic stockings on the client. Rationale:The client with DVT may require bed rest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bed rest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with high-Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.

The parent of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The parent tells the nurse that the child complains of discomfort on the right side and that ibuprofen is ineffective. Which instruction would the nurse provide to the parent?

Encourage the child to lie on the right side. Rationale:Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort. It would be inappropriate to advise the parent to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid which action?

Encouraging the client to breathe slowly and shallowly Rationale:The client with respiratory acidosis is experiencing elevated carbon dioxide levels caused by insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.

To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what would the nurse do first?

Ensure that the client is experiencing adequate pain control. Rationale:Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways and prevent atelectasis. The client with an abdominal incision is hesitant to cough unless pain control is adequate. The incision in an open cholecystectomy is just under the diaphragm in the right upper quadrant of the abdomen, making coughing and deep breathing painful. The nurse would first ensure that pain control is adequate so that pulmonary hygiene measures are maximally effective. A cardiopulmonary consult is requested for clients with preexisting risk caused by lung pathology or for clients already experiencing postoperative respiratory complications. Splinting the incision is an effective postoperative strategy for assisting with effective coughing and deep breathing, but it would follow pain control. Huff coughing, although it can be used in the postoperative client, is an effective coughing strategy that is most often recommended for clients with chronic obstructive airway disorders.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse would wear which items when performing this care?

Particulate respirator, gown, and gloves Rationale:The nurse who is in contact with a client with tuberculosis needs to wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.

A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse would take which action in caring for this client?

Ensure that the client uses an electric razor for shaving. Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach or without food and would not be taken with an antacid.

The nurse is preparing a client for punch biopsy. What would the nurse do to prepare for this procedure?

Ensure that the consent form has been signed. Rationale:A punch biopsy involves use of a punch instrument that punctures the skin and is rotated to obtain some of the dermis and fat. It is used for diagnostic purposes. A signed consent form is required for this procedure. A Foley catheter is not indicated and would be avoided if possible for any condition or procedure due to the risk for catheter-associated urinary tract infection. Chlorhexidine wipes are not specifically indicated for this procedure; usually an antibacterial such as povidone-iodine is used. There is not typically a lot of bleeding with this procedure; therefore, units of blood are not typically made available for the client undergoing punch biopsy.

A client is admitted to the hospital with a diagnosis of parasitic worms. After reviewing the client's complete blood cell (CBC) count, the nurse would expect an increased laboratory value for which cells?

Eosinophils Rationale:Eosinophils attack and destroy foreign particles that have been coated with antibodies of the immunoglobulin E (IgE) class. Their usual target is helminths (parasitic worms). Basophils mediate immediate hypersensitivity reactions. Dendritic cells perform the same antigen-presenting task as macrophages. Neutrophils phagocytize foreign particles such as bacteria.

A client is admitted to the hospital with a diagnosis of parasitic worms. On assessment of the client's complete blood cell (CBC) count results, which cells indicate attack by these foreign bodies?

Eosinophils Rationale:Eosinophils attack and destroy foreign particles that have been coated with antibodies of the immunoglobulin E (IgE) class. Their usual target is helminths (parasitic worms). Basophils mediate immediate hypersensitivity reactions. Neutrophils phagocytize foreign particles such as bacteria. Dendritic cells perform the same antigen-presenting task as macrophages.

The nurse is performing an assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity?

Erythema Rationale:Cellulitis presents with erythema (redness), which is localized inflammation. Options 1, 2, and 3 are not signs or symptoms of cellulitis.

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse would base the response on which interpretation?

Exposure to tuberculosis Rationale:A client who tests positive on a tuberculin skin test either has been exposed to tuberculosis (TB) or has inactive (dormant) TB. The client must then undergo chest radiography and sputum culture to confirm the diagnosis. Options 1, 2, and 4 are incorrect interpretations of the data presented in the question.

The nurse is performing an assessment on a client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What would the nurse further assess for that also is indicative of SLE?

Facial rash Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A butterfly rash on the cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboli are found in many conditions but are not associated with SLE. Two hemoglobin S genes are found in sickle cell anemia.

The nurse is doing volunteer work in a homeless shelter. The nurse would monitor the individuals for which initial signs and symptoms of tuberculosis? Select all that apply.

Fatigue Lethargy Morning cough Low-grade fever Rationale:The symptoms of tuberculosis include a slight morning cough, fatigue, lethargy, and low-grade fever. The other symptoms listed are advanced (not initial) signs and symptoms.

A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse would ask the client about which manifestations of the disorder? Select all that apply.

Fatigue Malaise Anorexia Rationale:Silicosis is a chronic lung fibrosis that results from the long-term inhalation of silica dust. It is characterized by nodule formation between alveoli, leading to fibrosis. Malaise, extreme fatigue, anorexia, weight loss, and dyspnea on exertion (not at rest) would occur in a client with silicosis. Additional manifestations include reduced lung volume and upper lobe fibrosis.

The nurse caring for a client with sepsis as a result of bacterial pneumonia is monitoring for signs of systemic inflammatory response syndrome (SIRS). Which conditions are indicative of this complication? Select all that apply.

Fever Altered mental status Development of severe hypotension Development of acute respiratory distress syndrome (ARDS) Rationale:SIRS is a systemic inflammatory response characterized by generalized inflammation in organs separate from the initial affected area and is caused by severe bacterial infections, trauma, or pancreatitis. A fever will occur related to the infection. The client will have global vasodilation and thus will have decreased blood pressure and perfusion to the other important organs such as the lungs and brain, affecting breathing and mentation. SIRS can also be triggered by many other complications associated with tissue trauma, such as burns.

A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply.

Fever Vasodilation Inflammation Excessively high environmental temperature Rationale:Erythema (or redness) of the skin can be caused by vasodilation from high environmental temperatures, fever, or inflammation. The presence of deoxygenated hemoglobin is responsible for cyanosis of the skin.

The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection?

Fever, hypertension, and graft tenderness Rationale:Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection usually occurs within 3 months after transplantation, although it can occur up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment with corticosteroids, and possibly also with monoclonal antibodies and antilymphocyte agents, is begun immediately.

The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction?

Fluid overload Rationale:Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The parents of a child with sickle cell disease would encourage fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

Flushing Rationale:Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse would anticipate observing which sign or symptom?

Flushing Rationale:The signs and symptoms worsen as the carbon monoxide level rises in the bloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing and headache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of 21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, and syncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than 50% lead to coma and death with higher levels.

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client?

Foam pad Rationale:The client who cannot shift weight unassisted would have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for this purpose are those that have a tendency to equalize the client's weight on the pad. These include foam, water, gel, and alternating air products. A pillow provides cushion but does not distribute weight equally. A plastic-lined pad and folded blankets provide no pressure relief.

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn would be classified as which type?

Full-thickness Rationale:Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.

The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is unrelated to the aneurysm?

Hyperactive bowel sounds in the area Rationale:Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Not all clients with an abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass.

A client is diagnosed with Goodpasture's syndrome. The nurse determines that this client's renal disease is caused by a type II hypersensitivity response. Which laboratory result would be most important for the nurse to evaluate?

Glomerular filtration rate (GFR) Rationale:In the autoimmune disease known as Goodpasture's syndrome, autoantibodies attack the glomerulular basement membrane and neutrophils. As a result, the affected person will begin to experience decreased GFR with development of signs of chronic kidney disease. There will be an increased blood urea nitrogen (BUN) and creatinine but decreased GFR due to declining kidney function. Therefore, the remaining options are incorrect.

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)?

Glucose intolerance Rationale:Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors for CAD. Age is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor.

A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine. The nurse assesses the complete blood cell (CBC) count, knowing that which is an adverse effect of this medication?

Granulocytopenia Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Zidovudine is a nucleoside-nucleotide reverse transcriptase inhibitor used to treat the virus. An adverse effect of this medication is granulocytopenia with anemia. The nurse carefully monitors CBC count results for changes that could indicate this occurrence. With early infection in the client who is asymptomatic, the CBC count is monitored monthly for 3 months and then every 3 months thereafter. In clients with advanced disease, the CBC count is monitored every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. The remaining options are not side or adverse effects of the medication.

While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action?

Grasp the retention sutures to spread the opening. Rationale:If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts to replace the tube immediately. Calling ancillary services or the primary health care provider will delay treatment in this emergency situation. Covering the tracheostomy site will block the airway.

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?

Hairdressers Rationale:Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action?

Hyperoxygenate the client. Rationale:The nurse needs to hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion Rationale:When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

The nurse is reviewing the risk factors for severe COVID-19 illness. The nurse would determine that which criteria increase the risk of a severe COVID-19 illness? Select all that apply.

Heart failure Hypertension Diabetes mellitus Chronic kidney disease (CKD) Chronic obstructive pulmonary disease (COPD) Rationale:There are several risk factors for severe COVID-19 illness caused by the SARS-CoV-2 virus. These risk factors include older age, with individuals over the age of 80 experiencing increased mortality; cardiovascular diseases, including heart failure and hypertension; chronic respiratory diseases such as COPD and asthma; CKD; and diabetes mellitus. Therefore, options 1, 2, 3, 4, and 6 are correct. Option 5 is incorrect as older age is a risk factor for severe COVID-19 illness.

An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply.

Heels Elbows Sacrum Back of the head Rationale:When the client is lying supine, the heels, sacrum, and back of the head are all at risk, as are the elbows and scapulae. The greater trochanter and ankles are at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position.

The nurse caring for a client diagnosed with hypovolemic shock due to blood loss is reviewing the client's most recent laboratory tests. Which of the following laboratory values is supportive of the diagnosis of hypovolemic shock?

Hemoglobin 10 g/dL (100 g/L) Rationale:Hypovolemic shock occurs when there is an inadequate circulating volume due to a variety of causes, including dehydration, fluid shift, or hemorrhage. With blood loss, hemoglobin and hematocrit would be decreased. A normal hemoglobin ranges from 12 to 16 g/dL (120 to 160 g/L). Therefore, option 1, which indicates a hemoglobin of 10 g/dL (100 g/L), is low and is supportive of the diagnosis of hypovolemic shock. Options 2, 3, and 4 are within normal limits.

A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear?

High-efficiency particulate air (HEPA) filter mask Rationale:The hospitalized client with TB is placed on airborne isolation. A HEPA filter mask must be worn whenever the nurse enters the client's room because these masks can remove almost 100% of the small TB particles. This mask must fit snugly around the nose and mouth. Option 1 is an incorrect option; although gloves may be needed, the nurse must wear a HEPA mask. Option 2 is incorrect. The mask must be a HEPA mask. Option 3 is an incorrect choice. The mask must be a HEPA mask, and there is no need for gown and gloves unless a wound, body fluid, or blood is involved.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which finding documented in the client's record is an expected finding with this client?

Hyperinflation of lungs documented by chest x-ray Rationale:The clinical manifestations of COPD are several, including hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. Chest x-ray results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced.

The nurse is auscultating breath sounds in a hospitalized client with emphysema and hears these sounds. The nurse would document this finding as which sound? Refer to audio.

High-pitched wheezes Rationale:The sounds that the nurse hears are high-pitched wheezes. These are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger. Crackles occur with the sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles are heard in conditions such as congestive heart failure or pulmonary edema. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When they are heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue such as in a lung mass, atelectasis, or pneumonia. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity.

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The primary health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse would provide which instruction?

Hold the gum between the cheek and teeth periodically. Rationale:Nicotine gum needs to be chewed for 30-minute intervals with periods of holding the gum between the cheek and teeth; food and drink would be avoided 15 minutes before and during use.

A client asks the nurse about obtaining a home test kit to test for human immunodeficiency virus (HIV) status. What would the nurse plan to tell the client?

Home test kits may not be as reliable as laboratory blood tests. Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Should a client wish to know their HIV status, testing is available from a physician or a local public health clinic, or a home test kit can be used. Some test kits may not be as reliable as a laboratory blood test. It is also recommended that a home test be performed at least 3 months after a risk event occurs. If a positive result on a home test occurs, then the individual requires additional testing.

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition?

Hypertrophy of collagen fibers Rationale:Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve.

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis?

I have an autoimmune disease that causes blistering in the skin." Rationale:Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?

Immobilization of the affected leg Rationale:Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.

A client taking theophylline has a serum theophylline level of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this laboratory value?

In the middle of the therapeutic range Rationale:The normal therapeutic range for the theophylline level is 10 to 20 mcg/mL (40 to 79 mcmol/L). A level above 20 mcg/mL (79 mcmol/L) is considered toxic. The value of 15 mcg/mL places the client in the middle of the therapeutic range.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority?

Inability to clear the airway related to inability to expectorate sputum Rationale:COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern, is not as important as airway. The client is cyanotic, but this probably is because of the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support low cardiac output as being most important at this time.

The nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is non-reddened, with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell count is 7500 mm3 (7.5 × 109/L). How would the nurse interpret these findings?

Incision is slightly edematous but shows no active signs of infection. Rationale:Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. An elevated temperature and white blood cell count 3 to 4 days postoperatively usually indicate infection. Therefore, the option indicating that there is slight edema and no active signs of infection is correct.

The nurse is administering a dose of pirbuterol to a client. The nurse would monitor for which side or adverse effect of this medication?

Increased pulse Rationale:Pirbuterol is an adrenergic bronchodilator. Side and adverse effects include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache. The nurse monitors for these effects during therapy. The other options are not side and adverse effects of this medication.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse would assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate Rationale:The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

The nurse is assessing a client presenting with a temperature of 103° F (39.4° C), severe muscle aches, and headache who states that the symptoms "came out of nowhere." The client states that other family members in the home are having similar symptoms. The client's lung sounds are clear to auscultation, the sinuses are nontender to palpation, there is no nasal drainage, the tympanic membranes are pearly gray bilaterally, the tonsils are without redness or exudates, and the anterior and posterior cervical lymph nodes are negative for lymphadenopathy. Which condition would the nurse suspect?

Influenza Rationale:Influenza is a viral illness characterized by the sudden onset of high fever ranging from 103° F to 104° F (39.4° C to 40° C) with severe myalgia. Lung sounds are often clear to auscultation, and the client may or may not have a headache, sore throat, or nasal congestion. Option 1 is not as likely since the client's sinuses are nontender to palpation and there is no nasal drainage present. Option 3 is unlikely due to the physical exam finding that the tonsils are free of redness and exudates. Option 4 is not as likely as high fevers are rare with viral rhinitis. Therefore, option 2 is correct.

The nurse is reviewing the pathophysiology of influenza and the various strains of the disease. The nurse would correctly identify H3N2 as which type of influenza?

Influenza A Rationale:Influenza is divided into four different serotypes: A, B, C, and D. Influenza A is further delineated into different strains based on two viral surface proteins: hemagglutinin (H) and neuraminidase (N). An example of influenza A is H1N1, otherwise known as the swine flu. Therefore, option 1 is the correct answer, as influenza A viruses are further named based on the H and N proteins.

Cromolyn sodium is prescribed for the client with allergic asthma. What goal does the nurse expect to achieve by administration of this medication?

Inhibition of the release of mediators from mast cells after exposure to an antigen Rationale:Cromolyn sodium is an antiasthmatic, antiallergic, and mast cell stabilizer that inhibits the release of mediators from mast cells after exposure to an antigen. It can also interrupt the migration of eosinophils into the inflammatory site and decrease the number of eosinophils. These actions decrease airway hyperresponsiveness in some clients with asthma. It has no bronchodilating action.

The nurse works with high-risk clients in an urban outpatient setting. Which groups would be tested for human immunodeficiency virus (HIV)? Select all that apply.

Injection drug abusers Prostitutes and their clients People with sexually transmitted infections (STIs) Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Injection drug abusers, those engaged in prostitution, and people with STIs are high-risk groups that should be tested for HIV per the Centers for Disease Control and Prevention's recommendations. Those who have had frequent episodes of pneumonia and those who recently received a blood transfusion for a surgical procedure are not at risk for HIV unless another compounding factor places them at risk. However, if a blood transfusion was received between 1978 and 1985, the client need to be tested.

The nurse is assessing for the presence of pallor in a dark-skinned client suspected of having anemia. What finding would the nurse look for?

Loss of normal red tones in the skin Rationale:In dark-skinned clients, pallor results in the loss of normal red tones in the skin. A yellow-tinged skin could indicate jaundice. Bluish discoloration of the skin and an ashen-gray color could indicate cyanosis and circulatory compromise.

A nursing student is developing a plan of care for a client with a chest injury who has a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student?

Instruct the client to avoid coughing and deep breathing. Rationale:It is important to encourage the client to cough and breathe deeply when a chest tube drainage system is in place. This will assist in facilitating appropriate lung reexpansion. The client is positioned in semi-Fowler's position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection.

The clinic nurse develops a plan of care for a client with emphysema who will be started on long-term corticosteroid therapy. Which specific instruction would the nurse include in the plan of care?

Instruct the client to return to the clinic for monitoring of blood glucose levels. Rationale:Corticosteroid therapy can cause calcium and potassium depletion, sodium retention, and glucose intolerance. The client needs to be monitored for hyperglycemia. Also, an increase in potassium and a decrease in sodium intake are recommended to prevent potassium depletion and sodium retention while taking the corticosteroid. Although increased fluids are important for the client with emphysema to maintain thin respiratory secretions, this action is not specific to the use of corticosteroids.

A 10-year-old child with hemophilia A has slipped on the ice and bumped the knee. The nurse would prepare to administer which prescription?

Intravenous infusion of factor VIII Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed, depending on the source of bleeding from the disorder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Factor X and iron are not used to treat children with hemophilia A.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) would the nurse place at the client's bedside?

Intubation tray Rationale:The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside.

A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). In planning care, the nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply.

Is a primary marker of immunocompetence Plays a role in the cell-mediated immune response Guides decision making regarding timing of initiation of treatment Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. CD4 T cells are a subgroup of lymphocytes that play an important role in the cell-mediated immune response; as such, CD4 T cells are a primary marker of immunocompetence. Viral load is the direct measure of the magnitude of HIV replication. The CD4 T-cell count rises in response to a declining viral load. CD4 T-cell counts also guide decision making regarding initiation of treatment, when to change medications when treatment is failing, and the need for initiation of treatment against opportunistic infections.

The nurse assesses for one-sided chest movement on the right while a client is being intubated by the primary health care provider. Which could occur with the endotracheal tube?

It could enter the right main bronchus if inserted too far. Rationale:If the endotracheal tube is inserted too far, the tube will travel past the trachea and enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. The other options are incorrect.

A nursing instructor asks a nursing student about a client admitted with tuberculosis (TB). What comment by the student indicates that there is a need for further teaching?

It is a fast-growing infectious disease." Rationale:Mycobacterium tuberculosis is a nonmoving, slow-growing (not fast-growing), acid-fast rod transmitted via the airborne route. The other options are accurate statements.

The nurse provides education to the student about the process of phagocytosis. Which statement by the student indicates successful teaching?

It is a process of ingesting and destroying any potentially foreign materials, such as germs." Rationale:Phagocytosis, an important nonspecific immune response, is a process in which the particle is ingested and digested by a cell. This rids the body of debris after tissue injury. The other options are incorrect.

The nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. How does the nurse correctly interpret these findings?

It is at the bifurcation of the right and left main bronchi. Rationale:The carina is a cartilaginous ridge that separates the openings of the 2 main (right and left) bronchi. The optimal position of the endotracheal tube is approximately 2.0 cm above the carina so that movement of the head does not raise the tube out of the airway nor push it into the bronchus. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected because only the right lung will have breath sounds and rise and fall with ventilation. Options 1, 3, and 4 are incorrect interpretations.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What would the nurse expect to note in the client?

Low arterial Pao2 Rationale:The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a Pao2 lower than 60 mm Hg

The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 500 mL. How does the nurse interpret this setting?

It is the amount of air delivered with each set breath. Rationale:Tidal volume is the amount of air delivered with each set breath on the mechanical ventilator. A sigh is a breath that has a greater volume than the preset tidal volume. The respiratory rate is the number of breaths to be delivered by the ventilator each minute. The FiO2 delivered to the client is indicated by the FiO2 indicator on the ventilator.

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location?

Just under the left clavicle Rationale:The apex of the lung is the rounded, uppermost part of the lung. The nurse would place the stethoscope just under the left clavicle. The other options are incorrect locations.

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle Rationale:The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left apex.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?

Keep the client on NPO (nothing by mouth) status. Rationale:The client needs to be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also would be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care need to be given as appropriate to alleviate the sensation of thirst.

The nurse provides discharge instructions to a client after skin patch testing to assess for allergies. Which instruction would be included on the discharge sheet for the client?

Keep the test sites dry. Rationale:The nurse instructs the client to keep the test sites dry at all times. The nurse also discourages excessive physical activity that will result in sweating. If the client reapplies patches that come loose, this can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later.

The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse would perform which actions for this procedure? Select all that apply.

Keeping a supply of suction catheters at the bedsidev Auscultating breath sounds to determine the need for suctioning Hyperoxygenating the client before, during, and after suctioning Rationale:Suction equipment needs to be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine whether suctioning is needed. The client needs to be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Intermittent suction would be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning would not be performed for longer than 10 seconds at a time to prevent cerebral hypoxia and a rise in intracranial pressure.

The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"?

Leave the dressing intact for 3 to 5 days. Rationale:After surgery, graft sites are immobilized with a bulky cotton pressure dressing for 3 to 5 days to allow vascularization, or "take," of the newly grafted skin. Dressings would not be disturbed. Elevation and complete rest of the grafted area is required to allow blood vessels to connect the graft with the wound bed. Any activity that might cause movement of the dressing against the body and separation of the graft from the wound is prohibited, such as application of an ice pack. Additionally, cold promotes vasoconstriction.

The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms would the nurse look for?

Lesions with well-defined geometric margins Rationale:Contact dermatitis findings include skin lesions with well-defined geometric margins. Option 1 describes a medication eruption. Option 3 describes nonspecific eczematous dermatitis. Option 4 describes atopic dermatitis.

The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition?

Level of consciousness Rationale:The neurological system is primarily affected by carbon monoxide poisoning. With high levels of carbon monoxide, the neurological status progressively deteriorates. Although skin color, apical rate, and respiratory rate would be components of the assessment of the client with carbon monoxide poisoning, assessment of the neurological status of the client would elicit data specific to a deterioration in the client's condition.

The nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgment of the pacing catheter?

Limiting both movement and abduction of the right arm Rationale:In the first several hours after insertion of a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site. Therefore, the remaining options are incorrect.

The nurse is assessing a dark-skinned client for signs of anemia. The nurse would focus the assessment on which structures? Select all that apply.

Lips Conjunctiva Mucous membranes Rationale:Changes in skin color can be difficult to assess in the dark-skinned client. Color changes are most easily seen in areas of the body where the epidermis is thin and in areas where pigmentation is not influenced by exposure to sunlight. The nurse needs to assess the lips, conjunctiva, and oral mucous membranes for signs of anemia in the dark-skinned client. Signs of anemia are less easily observed in the tongue and earlobes.

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing?

Liquefaction necrosis Rationale:Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function?

Listening to lung sounds Rationale:The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.

The nurse asks a nursing student to identify the locations of macrophages in the body. The student responds correctly if the student indicates which organs and tissues contain a large number of these cells? Select all that apply.

Liver Spleen Intestinal tract Rationale:Macrophage functions include phagocytosis, repair, antigen presenting/processing, and secretion of cytokines for immune system control. The liver, spleen, and intestinal tract contain large numbers of macrophages. Bone marrow and tonsils contain no macrophages.

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse would ensure that which baseline study has been completed?

Liver enzyme levels Rationale:Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years or abuses alcohol. The laboratory tests in options 1, 2, and 4 are not necessary.

A client with tuberculosis is starting antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse would ensure that which baseline study has been completed?

Liver enzyme levels Rationale:Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years or who abuses alcohol. The laboratory tests in options 1, 2, and 4 are not necessary.

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?

Liver function tests Rationale:Zafirlukast is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests need to be performed to obtain a baseline, and the levels need to be monitored during administration of the medication. It is not necessary to perform the other laboratory tests before administration of the medication.

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?

Liver function tests Rationale:Zafirlukast is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests would be performed to obtain a baseline, and the levels need to be monitored during administration of the medication. It is not necessary to perform the other laboratory tests before administration of the medication.

The nurse is teaching a client with chronic obstructive pulmonary disease about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing?

Lying on the back in a low-Fowler's position Rationale:The client would not lie on the back because this reduces movement of a large area of the client's chest wall. The client would use positions that allow for maximal chest expansion. Sitting, if possible, is better than standing. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not for posture control.

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning?

Lying on the back in a low-Fowler's position Rationale:The client would use the positions outlined in options 1, 2, and 3. These allow for maximal chest expansion and decreased use of accessory muscles of respiration. The client would not lie on the back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing rather than posture control.

The nurse is reinforcing instructions to a client with pneumonia about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit?

Maintain inflation of the alveoli. Rationale:Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation.

The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which action would the nurse perform when administering this test to the client?

Make a circular mark around the injection site after administration of the tuberculin test. Rationale:An intradermal injection is administered with the needle bevel facing upward at a 10- to 15-degree angle. The medication is injected slowly, and a bleb would form under the skin with injection. After withdrawing the needle, the area may be patted dry with a 2 × 2 sterile gauze pad, but pressure would not be applied. The area would not be rubbed because this will cause the medication to spread beyond the area of injection. The area of injection is outlined or circled for later reference and interpretation of the results of the test.

The nurse is caring for a client who underwent a thoracentesis to treat pleural effusion. The pleural fluid testing results indicate the pleural fluid is cloudy and confirm the presence of white blood cells (WBCs). Which condition would the nurse suspect?

Malignancy Rationale:Pleural effusion is a sign of an underlying disease process and the type of pleural fluid can provide information about what underlying disease is responsible for the effusion. Pleural fluid is described as transudative or exudative. Transudative pleural fluid is typically a clear, pale yellow fluid due to the lack of protein or cells in the fluid. Congestive heart failure, chronic liver disease such as cirrhosis, or renal disease may be the underlying cause of a transudative pleural effusion. Exudative fluid is cloudy due to the presence of WBCs and is a sign of an inflammatory or infectious process, including malignancy. In this situation, the pleural fluid is exudative since it is cloudy and WBCs are present. Since options 1, 3 and 4 are likely related to transudative, clear pleural fluid, option 2 is the correct answer.

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse would ask the client whether the client wears which item during periods of exposure to silica particles?

Mask Rationale:Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client needs to wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary.

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis who is at risk for vitamin B12 deficiency. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.

Meat Liver Rationale:Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as meats and liver.

The nurse is teaching a client with tuberculosis about nutrition and foods that would be increased in the diet. The nurse would suggest that the client increase which food items?

Meats and citrus fruits Rationale:The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron and protein include liver and other meats. Less than 10% of iron is absorbed from eggs, and less than 5% is absorbed from grains and vegetables.

The presence of which finding leads the home health nurse to suspect infestation of a client with scabies?

Multiple straight or wavy, thread-like lines beneath the skin Rationale:Scabies can be identified by the presence of multiple straight or wavy, thread-like lines beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the skin and lays its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 4 are not characteristics of scabies.

A client who has just suffered a severe flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition would the nurse interpret that the client is experiencing?

Mediastinal flutter Rationale:The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client's CVP rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. The client with fat embolism experiences chest pain and dyspnea, but this condition occurs as a complication of a bone fracture. Mediastinal shift is a condition in which the structures of the mediastinum shift or move to the opposite side of the chest cavity; this may be caused by a pleural effusion or tension pneumothorax. In hypovolemic shock, the blood pressure falls and the pulse rises; this occurs following hemorrhage.

The nurse mentor is describing the phases of the immune response to a recent nursing graduate. The mentor determines that the graduate needs additional information if the graduate states that which is a phase of the immune response?

Memory phase Rationale:Immunity is composed of many cell functions that protect against the effects of injury or invasion. The purpose of inflammation and immunity is to provide protection by neutralizing, eliminating, or destroying organisms that invade the body. Specific immune responses have 3 main phases: the recognition phase, the activation phase, and the effector phase. Memory is not a feature of an immune response.

The nurse is assessing a client diagnosed with COVID-19. Objective data include a respiratory rate of 20 breaths per minute, oxygen saturation of 95% on room air, temperature of 101.6° F (38.6° C), lungs clear to auscultation bilaterally, and a chest x-ray (CXR) negative for an acute pulmonary process. Subjective findings include fatigue, malaise, and muscle aches, but the client denies shortness of breath. How would the nurse classify the client's illness severity?

Mild illness Rationale:COVID-19 severity can be determined by several client factors. Mild illness is defined as clients who have signs of COVID-19, such as cough, fevers, sore throat, headache, or malaise with no evidence of shortness of breath or abnormal chest imaging. Moderate illness is defined as clients with evidence of pathological respiratory disease as demonstrated on imaging or assessment and an oxygen saturation equal to or greater than 94% on room air. Severe illness is defined as clients with a respiratory rate greater than 30 breaths per minute, an oxygen saturation of less than 94% or a decrease of 3% from baseline in clients with chronic hypoxemia, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (Pao2/Fio2) less than 300 mm Hg or lung infiltrates greater than 50%. Critical illness is defined as clients experiencing respiratory failure, septic shock, or multiple organ dysfunction syndrome (MODS). Since the client's respiratory rate and oxygen saturation are stable, the CXR is negative, and the client is not experiencing shortness of breath, the nurse would determine that the client is experiencing a mild illness.

The nurse is assessing a client diagnosed with COVID-19. The client is experiencing dyspnea with a respiratory rate of 24 breaths per minute, oxygen saturation of 94% on room air, and a temperature of 102° F (38.8° C). Lung auscultation reveals fine crackles in the bilateral lung bases, and chest x-ray demonstrates bilateral pulmonary infiltrates. How would the nurse classify the client's illness severity?

Moderate illness Rationale:COVID-19 severity can be determined by several client factors. Mild illness is defined as clients who have signs of COVID-19, such as cough, fevers, sore throat, headache, or malaise with no evidence of shortness of breath or abnormal chest imaging. Moderate illness is defined as clients with evidence of pathological respiratory disease as demonstrated on imaging or assessment and an oxygen saturation greater than or equal to 94% on room air. Severe illness is defined as clients with a respiratory rate greater than 30 breaths per minute, an oxygen saturation of less than 94% on room air or a decrease of 3% from baseline in clients with chronic hypoxemia, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (Pao2/Fio2) of less than 300 mm Hg, or lung infiltrates greater than 50%. Critical illness is defined as clients experiencing respiratory failure, septic shock, or multiple organ dysfunction syndrome (MODS). Since the client's oxygen saturation is not less than 94%, the respiratory rate is below 30 breaths per minute, and there is radiographic evidence of pulmonary disease on the chest x-ray, the nurse would determine the client is experiencing moderate illness from COVID-19.

The nurse in the emergency department is reviewing laboratory results for a client with carbon monoxide poisoning. The client's carboxyhemoglobin level is 25%. How would the nurse interpret the severity of carbon monoxide poisoning?

Moderate poisoning Rationale:Carbon monoxide is a colorless, odorless, and tasteless gas that is released into the air due to combustion. Carbon monoxide has a higher affinity for hemoglobin than oxygen, forming carboxyhemoglobin and thereby impeding the body's ability to oxygenate tissues. Laboratory testing to determine the severity of carbon monoxide poisoning is a serum carboxyhemoglobin level. A normal carbon monoxide, or carboxyhemoglobin, level is 1% to 10%. Mild poisoning is indicated by carbon monoxide levels ranging from 11% to 20%. Moderate poisoning is indicated by carbon monoxide levels ranging from 21% to 40%. Severe poisoning is indicated by carbon monoxide levels ranging from 41% to 60%. Lastly, fatal poisoning is indicated by carbon monoxide levels ranging from 61% to 80%. Therefore, a carboxyhemoglobin level of 25% indicates moderate carbon monoxide poisoning. Therefore, option 4 is correct.

A client with a burn injury has undergone fasciotomy to treat compartment syndrome of the leg. The nurse would anticipate that which type of wound care to the fasciotomy site will be prescribed?

Moist sterile saline dressings Rationale:The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. Because this is an open wound, dry dressings would not be used. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so povidone-iodine would not be required. Also, this agent is irritating to tissues.

A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse would include which measures in the care of this client? Select all that apply.

Monitor the client's temperature. Use sterile technique when suctioning. Use the closed-system method of suctioning. Monitor sputum characteristics and amounts. Rationale:Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning. Water in the ventilator tubing would be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.

The nurse in the ambulatory care clinic is reviewing a plan of care for a client who will be returning from the postanesthesia care unit after a blepharoplasty. Which nursing interventions would be a component of the postoperative care plan for this client? Select all that apply.

Monitoring for swelling Elevating the head of the bed Instructing the client to avoid Valsalva maneuvers Assessing the function of the extraocular eye muscles Rationale:Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Postoperatively, the client is assessed for swelling, bruising, bleeding, and eye pain. The head of the bed needs to be elevated, and cool eye compresses are applied to the area to reduce swelling. The client is instructed to avoid the Valsalva maneuver, which increases intracranial pressure and also pressure in the head and eye, thereby increasing the risk of hemorrhage. The function of extraocular eye muscles also is assessed. Gauze pads are not used because cotton is thick and pulls the skin when it is removed; in addition, warm compresses will increase the swelling.

The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful?

My nails may become clubbed." Rationale:A client with COPD will have clubbing of the nails, described as an angle between the nail plate and the proximal nail fold exceeding 180 degrees. Psoriasis is represented by multiple small pits in the nail bed. Flattening of the nail plate is caused by several conditions, such as iron-deficiency anemia and poorly controlled diabetes for greater than 15 years. Horizontal depression across the nail beds is caused by medical problems, such as acute, severe illness and isolated periods of severe malnutrition.

The nurse in an intensive care unit is preparing to perform oral care and suctioning on a client diagnosed with COVID-19 with an endotracheal tube receiving mechanical ventilation. Which personal protective equipment (PPE) would the nurse don?

N95 respirator, gloves, gown, and face shield Rationale:During aerosol-generating procedures, such as suctioning or administering nebulizer treatments, the nurse and other health care personnel in close contact with the client should wear an N95 respirator, gloves, a gown, and a face shield or goggles to protect against sprays or splashes of bodily fluids. During aerosol-generating procedures, a surgical mask is not recommended. Therefore, options 2 and 3 are incorrect. Option 1 is incorrect because it does not include a protective splash shield such as goggles or a face shield. Therefore, option 4 is correct.

The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse would plan to assess which part of the integumentary system first?

Nails Rationale:Paronychia is a fungal infection that most often is caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The affected area generally is tender to touch and has purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. A variety of disorders may involve the epithelial skin layer.

The client arrives at the emergency department with pinpoint pupils, respiratory depression, and decreased level of consciousness (LOC) despite sternal rub. The nurse anticipates that which medication will be prescribed?

Naloxone Rationale:Naloxone is an opioid antagonist used to reverse and block the effects of opioid overdose. Signs or symptoms of opioid overdose include pinpoint pupils, respiratory depression, decreased level of consciousness (LOC), vomiting, inability to speak, pale skin, and cyanosis. Disulfiram is an enzyme inhibitor used to treat chronic alcoholism. Lorazepam is a benzodiazepine used to treat anxiety and seizures. Methadone is an opioid agonist used in detoxification and maintenance therapy for opioid use disorder.

The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How would the nurse interpret the result?

Negative Rationale:A positive reading has an induration measuring 10 mm or larger and is considered abnormal. A small area of ecchymosis is insignificant and probably is related to injection technique. The remaining options are incorrect interpretations.

The nurse is performing an assessment on a client with a diagnosis of pemphigus vulgaris. How would the nurse assess for the presence of Nikolsky's sign?

Note skin blistering and sloughing with finger pressure. Rationale:Nikolsky's sign, epidermal blistering and sloughing precipitated by lateral finger pressure, commonly is present in pemphigus vulgaris. Option 3 identifies an assessment technique to determine the presence of a Candida infection in the mouth. Draining blisters are not characteristic of this disorder. Although a foul odor may be noted from the skin of a client with this disorder, this characteristic is not related to Nikolsky's sign.

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do not resuscitate (DNR) prescription. What is the nurse's priority action?

Notify the primary health care provider (PHCP) that the client is rescinding the DNR prescription. Rationale:COPD cannot be cured. End-of-life issues are important for clients and families to understand; however, the client always has the right to rescind the decision as long as they are mentally competent. The nurse needs the PHCP to reverse the DNR prescription on the chart. The PHCP also needs to be informed about the conflict between the client and his family. Option 1 is incorrect because the decision to take this action is determined by the PHCP. Option 2 is incorrect because the PHCP would handle this. The action identified in option 3 can help but could alter the client's mental capacity to make decisions. Some states offer DNR Comfort Care and DNR Comfort Care Arrest protocols. Protocols in these instances list specific actions that health care providers will take when providing cardiopulmonary resuscitation.

The nurse caring for a client who sustained a chest injury and who has a chest tube drainage system notes constant bubbling in the water seal chamber. Which nursing action is appropriate?

Notify the primary health care provider (PHCP). Rationale:Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the options provided, the appropriate action is to notify the PHCP. The remaining options are incorrect.

A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the best nursing action?

Notify the primary health care provider (PHCP). Rationale:Immediately after laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves within the first few hours. Otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential threat to life, and the PHCP is notified to further evaluate the client and suture or repair the source of the bleeding. The other options do not address the urgency of the problem. Failure to notify the PHCP places the client at risk.

A client's arterial blood gas results reveal a Pao2 of 55 mm Hg. The client's admitting diagnosis is acute respiratory failure secondary to community-acquired pneumonia. What is the nurse's best action?

Notify the primary health care provider (PHCP). Rationale:Respiratory failure is defined as a Pao2 of 60 mm Hg or lower. The nurse needs to notify the PHCP for further prescriptions. Common causes of hypoxemic respiratory failure are pneumonia, pulmonary embolism, and shock. This client needs to be receiving oxygen. Repeating the arterial blood gases and maintaining continuous pulse oximetry do nothing to correct the problem.

The nurse is caring for a client with a pneumothorax and a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse immerses the end of the tube in sterile water. What immediate action would the nurse take?

Obtain a new drainage system. Rationale:If the drainage system is broken or interrupted or the tube disconnects, the end of the tube needs to be placed in a bottle of sterile water held below the level of the chest. A new drainage system is then immediately obtained and set up. Placing the client in the prone position and asking the client to hold their breath are not helpful. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the tube disconnection. The nurse would also perform an assessment on the client and contact the primary health care provider.

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply.

Oliguria Fluid retention Serum creatinine of 3.2 mg/dL (282 mcmol/L) Rationale:Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection is the most common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria; temperature higher than 100° F (37.8° C); increased blood pressure; enlarged, tender kidney; lethargy; elevated serum creatinine, blood urea nitrogen, and potassium levels; and fluid retention.

A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse would immediately place the client in which position?

On the left side, with the head lower than the feet Rationale:Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client needs to be placed in a left side-lying position. The head needs to be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected.

The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client?

Oral mucosa Rationale:In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa and in areas of lighter melanization such as the abdomen and buttocks. Jaundice would best be noted in the sclera of the eye. Cyanosis is best noted on the palms of the hands and soles of the feet.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding?

Pain, especially with inspiration Rationale:Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding?

Pain, especially with inspiration Rationale:Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include shallow respirations, splinting or guarding the chest protectively to minimize chest movement, pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

The nurse is assessing a client's tracheostomy and notes that the skin around the stoma appears swollen with no redness or drainage present. Which action would the nurse take next?

Palpate the skin around the stoma. Rationale:A complication of a tracheostomy is subcutaneous emphysema, in which air leaks into the subcutaneous tissue due to a misplaced tracheostomy tube. An important nursing assessment for the client with a tracheostomy is to examine the neck for swelling and then to palpate the swollen area. If subcutaneous emphysema is present, the nurse will feel a popping or crackling sensation when pressing on the skin. The nurse would then contact the PHCP for further interventions after collecting more assessment data. Therefore, option 1 is correct. Option 2 is appropriate after further assessing the area. Options 3 and 4 are inappropriate interventions for subcutaneous emphysema.

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder would the nurse expect to note?

Pao2 49 mm Hg, Paco2 52 mm Hg Rationale:Respiratory failure is described as a Pao2 of 60 mm Hg or lower and a Paco2 of 50 mm Hg or higher in a client with no history of respiratory disease. In a client with a history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more (Paco2) from the client's baseline are considered diagnostic.

A home care nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. The nurse understands that this is the result of which occurrence?

Paradoxical bronchospasm, which must be reported to the primary health care provider (PHCP) Rationale:The client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client's wheezing. This can occur with excessive use of inhalers. Further medication would be withheld, and the PHCP needs to be notified. The remaining options are incorrect interpretations.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

Paradoxical chest movement Rationale:Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child?

Partial thromboplastin time Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia.

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

Partial-thickness skin loss of the dermis Rationale:In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulceration with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

Partial-thickness skin loss of the dermis Rationale:In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage, the nurse will perform which action to help loosen secretions?

Percussion and vibration Rationale:Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus move from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not actions that will loosen secretions.

The nurse is monitoring the chest tube drainage system in a client with a pneumothorax. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action?

Perform a focused respiratory assessment. Rationale:Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. A focused respiratory assessment needs to be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema. Changing the chest tube drainage system is not indicated at this time. Continuing to monitor the bubbling delays necessary intervention. Although documenting is necessary, it is not the most appropriate initial action.

The nurse is assisting a primary health care provider with the removal of a chest tube in a client with a resolved pneumothorax. The nurse would instruct the client to take which action?

Perform the Valsalva maneuver Rationale:When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath and hold it, bear down, and exhale). After premedicating the client for pain 30 minutes prior to the procedure if desired, the tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse would assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems?

Pericardial friction rub Rationale:A pericardial friction rub is heard when inflammation of the pericardial sac is present during the inflammatory phase of pericarditis. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints and could accompany a variety of disorders. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy.

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

Peripheral neuritis Rationale:Isoniazid is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6) intake. Options 1, 3, and 4 are not associated with the information in the question.

The nurse is assessing a client and notes unilateral swelling on the left side of the throat with deviation of the uvula toward the right side, halitosis, left-sided cervical lymphadenopathy, and fever. The client reports throat pain and difficulty swallowing. Which condition would the nurse suspect?

Peritonsillar abscess Rationale:Peritonsillar abscess can occur due to acute tonsillitis when the infection spreads from the tonsil to the surrounding area, resulting in abscess formation. Signs and symptoms include unilateral swelling of the throat due to pus collection in the abscess, which causes the uvula to deviate to the unaffected side; lymphadenopathy on the affected side; halitosis (bad breath); fever; severe throat pain with radiation to the ear or teeth; difficulty swallowing or breathing; and tonic contraction of the chewing muscles. Therefore, option 4 is correct. Based on the client's signs and symptoms, the nurse would suspect peritonsillar abscess rather than laryngitis, pharyngitis, or rhinosinusitis. Options 1, 2, and 3 are incorrect.

A primary health care provider (PHCP) tells the nurse that a client's chest tube is to be removed since pneumothorax is resolved. The nurse would bring which dressing materials to the bedside for the PHCP's use?

Petrolatum gauze and sterile 4 × 4 gauze Rationale:On removal of the chest tube, sterile petrolatum gauze and sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa dressing, Neosporin ointment, hydrocolloid dressing, or benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the PHCP as the tape of choice to make the dressing occlusive.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and would incorporate which action as a priority in the plan?

Protecting the client from infection Rationale:The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions would the nurse take to perform this procedure? Arrange the actions in the order that they would be performed. All options must be used.

Place the client in a semi-Fowler's position. Turn on the suction device and set the regulator at 80 mm Hg. Attach the suction tubing to the suction catheter. Hyperoxygenate the client. Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm. Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth. Rationale:The nurse positions the client first and then prepares the necessary equipment before donning gloves. The nurse hyperoxygenates the client both before and after suctioning. Next, the nurse inserts the catheter into the tracheostomy until resistance is met and then pulls it back 1 cm, applies intermittent suction, and slowly withdraws the catheter while rotating it back and forth. The catheter is then rinsed, and the nurse performs oropharyngeal suctioning to clear the upper airways; the catheter is contaminated after the oropharyngeal area is suctioned.

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?

Place the client in high-Fowler's position Rationale:Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used. A noncuffed tube may be used when mechanical ventilation is not required. If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse would inflate the cuff to prevent aspiration of food or fluids. However, even a cuffed tube does not protect against aspiration because breathing and swallowing move the tube. The best measure to protect against aspiration is to place the client in high-Fowler's position. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. The head of the bed would always be elevated; low-Fowler's position could lead to aspiration.

A client with pneumonia is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?

Plan short sessions with the client to obtain data. Rationale:The best source of information is the client. Option 1 is incorrect; the physical examination is not part of the health history. Option 2 is incorrect because it refers to all information. Option 4 is incorrect because the primary health care provider's medical history provides data that are different from the nurse's assessment. All efforts need to be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse would assess the client for which signs and symptoms associated with this problem?

Pleural pain and fever Rationale:The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.

The nurse is assisting a radiologist to facilitate a thoracentesis for a client with pleural effusion. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area?

Pleural space Rationale:Thoracentesis is the needle aspiration of fluid or air from the pleural space for diagnostic or management purposes. Thoracentesis may be done at the bedside and is often done with imaging for guidance. The other options are incorrect.

An emergency department nurse is performing a respiratory assessment on a client who is complaining of painful breathing. On palpation the nurse notes a coarse grating sensation during inspiration, and on auscultation the nurse hears this breath sound. The nurse interprets these findings as characteristic of which condition? Refer to audio.

Pleurisy Rationale:The sound that the nurse hears is a pleural friction rub. A pleural friction rub is the result of pleural inflammation, often associated with pleurisy, pneumonia, or pleural infarction. It is a superficial, low-pitched, coarse rubbing or grating sound that sounds like two rough surfaces rubbing together. A pleural friction rub is heard throughout inspiration and expiration and is loudest over the lower anterolateral surface. It is not cleared by a cough. Disorders that cause airflow obstruction, such as emphysema or asthma, would produce high- or low-pitched wheezes (musical sounds similar to a squeak). Crackles occur with the sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema.

The nurse is assessing a client presenting with a productive cough, fever, chills, dyspnea, tachypnea, and chest pain that is worse with deep inspiration. Lung auscultation reveals bilateral crackles in the lower lobes. The client's chest x-ray (CXR) reveals bilateral pulmonary infiltrates in the lower lobes. Which condition would the nurse suspect?

Pneumonia Rationale:The nurse would suspect pneumonia, as pneumonia is characterized by a cough (which may or may not be productive), fever, chills, dyspnea, tachypnea, and inspiratory chest pain. Lung auscultation will reveal adventitious sounds, such as crackles. Options 1 and 2 are incorrect as the client data suggest a lower respiratory tract infection, and sinusitis and laryngitis are upper respiratory tract infections. Bronchitis and pneumonia share similar symptoms; however, the CXR for a client with acute bronchitis is normal and will not demonstrate infiltrates. Therefore, option 3 is incorrect. A CXR of a client with pneumonia will demonstrate infiltrates or the fluid buildup that occurs in this disease. Therefore, option 4 is correct.

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse would interpret these results as which finding?

Positive Rationale:Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in children with chronic illness or at high risk for exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as a child with an immunosuppressive condition or a child with human immunodeficiency virus (HIV) infection. A reaction of 15 mm or more is positive in children 4 years or older without any risk factors.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

Positive Rationale:The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.

A client is prescribed mupirocin intranasally twice daily. The nurse correlates this prescription with the client's medical record and expects to note which result specifically related to the indication for this medication?

Positive MRSA by polymerase chain reaction (PCR) Rationale:Mupirocin is applied intranasally twice daily for the client with colonization of MRSA in the nares. Clients are at risk for this colonization if they live in a health care facility because it is a common health care-acquired infection. MRSA in the surgical wound and VRE in the urine would likely be treated with intravenous antibiotics. Streptococci in the blood and an elevated lactic acid level are indicative of sepsis and would also likely be treated with intravenous antibiotics as well as intravenous fluids.

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

Positive culture results Rationale:With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chicken pox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis Rationale:The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding?

Positive punch biopsy of the cutaneous lesions Rationale:Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

Spironolactone is prescribed for a client with heart failure. In providing dietary instructions to the client, the nurse identifies the need to avoid foods that are high in which electrolyte?

Potassium Rationale:Spironolactone is a potassium-retaining diuretic, and the client should avoid foods high in potassium. If the client does not avoid foods high in potassium, hyperkalemia could develop. The client does not need to avoid foods that contain calcium, magnesium, or phosphorus while taking this medication.

Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse anticipate in this client if PVCs are occurring?

Premature beats followed by a compensatory pause Rationale:PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, the presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.

The nurse is preparing to ambulate a client on the third day after cardiac surgery. What would the nurse plan to do to enable the client to best tolerate the ambulation?

Premedicate the client with an analgesic. Rationale:The nurse needs to encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Providing the client with a walker and encouraging the client to cough and breathe deeply will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated unless prescribed.

The nurse instructs a client with chronic obstructive pulmonary disease (COPD) to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

Promote carbon dioxide elimination. Rationale:Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate?

Provide nasotracheal suctioning as needed to remove secretions. Rationale:Ineffective airway clearance reflects the client's inability to expectorate secretions. The intervention specifically addressing retained secretions is the correct option. Options 1 and 4 are interventions addressing impaired problem with gas exchange. Option 2 is an intervention aimed at addressing a problem with activity intolerance.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse would incorporate which intervention as the best strategy to assist the client in coping with the illness?

Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. Rationale:A primary role of the nurse working with a client with TB is to teach the client about medication therapy. An anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids), and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy that will eradicate it. This gives the client a measure of power over the situation and outcome. Allowing the client to deal with the disease in an individual fashion gives no active assistance to the client. Asking family members whether they wish a psychiatric consultation does not involve the client. Although visiting with the pastoral care department's chaplain may be helpful, it is not the best strategy among the options provided.

A client with an endotracheal tube who is being mechanically ventilated is visibly anxious. What is the best nursing action?

Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed. Rationale:Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse needs to speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions would the nurse plan to promote client safety? Select all that apply.

Provide the client with a soft toothbrush. Instruct the client to use an electric razor. Monitor all secretions for frank or occult blood. Rationale:Fibrinogen is produced by the liver and is necessary for normal clotting. A client who has insufficient levels is at risk for bleeding. The PT is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client's risk for bleeding is also increased. A soft toothbrush, an electric razor, and monitoring secretions for evidence of bleeding are measures that provide for client safety.

The nurse would anticipate that the primary health care provider (PHCP) would add which medication to the regimen of the client receiving isoniazid?

Pyridoxine Rationale:Isoniazid is an antituberculosis medication. Clients receiving isoniazid can develop neuropathy, and the agent of choice to help prevent this adverse effect is pyridoxine, vitamin B6. Niacin is used to lower the cholesterol level. Gabapentin is used to prevent seizures and for peripheral neuropathy, and cyanocobalamin is used to treat anemia.

The nurse prepares to treat a client with frostbite of the toes. Which action would the nurse anticipate will be prescribed for this condition?

Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs Rationale:Acute frostbite is treated ideally with rapid and continuous rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because they can contribute to increased cellular damage. Cold or hot water is not used. Thawing can cause considerable pain, and the nurse administers analgesics as prescribed.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation?

Rapid, shallow respirations Rationale:An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.

A community health nurse is preparing to administer a tuberculin skin test. The nurse would select which syringe to administer the medication? Click on the image to indicate your answer.

Rationale:A tuberculin skin test is done to determine exposure to tuberculosis. The nurse uses a tuberculin or a small hypodermic syringe for skin testing. The correct option identifies a tuberculin syringe that is used for skin testing. The top figure identifies a 3-mL syringe. The second figure identifies a 5-mL syringe. The bottom figure identifies an insulin syringe marked in 100 units.

The nurse is assisting a client with a tracheostomy turn in bed when the tube gets caught under the client, causing the tracheostomy tube to be pulled out. The nurse calls a rapid response team (RRT) and attempts to replace the tracheostomy tube with the same size tube as the tube that was pulled out and is unsuccessful. While waiting for the RRT, which action would the nurse take?

Reattempt the insertion with a tracheostomy tube that is one size smaller than the original tracheostomy tube. Rationale:As part of the nursing care for a client with a tracheostomy, a tracheostomy kit with both a same-sized tube as the tube in place and a tube that is one size smaller than the tube in place, as well as an obturator and a curved Kelly clamp, needs to be kept at the bedside at all times in the event of accidental decannulation. During accidental decannulation and after asking for additional assistance, the nurse would insert an obturator into the same-sized tracheostomy tube and attempt to reinsert the tube into the stoma. If the nurse is unsuccessful, the nurse would attempt to perform the reinsertion procedure with a tracheostomy tube that is one size smaller than the original tube. Therefore, option 4 is correct. Option 1 would be an appropriate nursing assessment once the tracheostomy tube has been replaced to assess whether reinsertion has been successful and the client's airway is patent. Option 2 is incorrect because high Fowler's position, not low Fowler's position, is recommended for clients in respiratory distress. Option 3 is incorrect because manually ventilating the client with the stoma unoccluded would not ventilate the client, as the stoma would need to be occluded for the lungs to be ventilated.

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply.

Record site, date, and time of the test. Give the client a list of potential allergens if identified. Rationale:Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected. A list of potential allergens is identified and reviewed and given to the client. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients need to be monitored for only about 30 minutes to assess for any adverse effects.

Laboratory studies are performed for a child suspected to have iron-deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic Rationale:In iron-deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in children with iron-deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

The nurse is preparing to care for a client with immunodeficiency. The nurse would plan to address which problem as the priority?

Risk for infection Rationale:The client with immunodeficiency has inadequate or no immune bodies and is at risk for infection. The priority concern would be risk for infection. The question presents no data indicating that the client is experiencing anxiety. Fatigue may be a problem and the client may need to be placed on protective isolation, but these are not the priority problems for this client. Infection can be life-threatening and is the priority.

Laboratory studies are performed for a client suspected to have iron-deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic Rationale:In iron-deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in clients with iron-deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply.

Red, raised papules Large plaques covered by silvery scales Rationale:Psoriasis lesions appear as red, raised papules that may coalesce into large plaques covered by silvery scales. Eczema can manifest as tiny red vesicles that weep serous or purulent material. Erythema noted mostly under the breast area is characteristic of seborrheic dermatitis. Pink to dark red patchy eruptions on the skin may be indicative of exfoliative dermatitis.

The nurse has applied a hypothermia blanket to a client with an infection who has a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use?

Skin breakdown Rationale:When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. Options 1, 3, and 4 are not complications.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse would include which measure in the dietary plan?

Remove dairy products and red meat from the meal. Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client with AIDS who has nausea and vomiting needs to avoid fatty products such as dairy products and red meat. Meals would be small and frequent to lessen the chance of vomiting. The client needs to avoid spices and odorous foods because they aggravate nausea. Foods are best tolerated cold or at room temperature.

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse would first perform which action?

Remove the dressing. Rationale:Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse would remove the dressing immediately, allowing air to escape. Therefore, reinforcing the dressing is an incorrect action. The nurse would measure oxygen saturation by oximetry and would call the PHCP, but these would not be the first actions in this situation.

A client with coronavirus-2019 (COVID-19) has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse would take which action?

Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. Rationale:The client would have oxygen supplementation removed for at least 15 minutes before ABGs are drawn if the client has a prescription for the ABGs to be drawn on room air. This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the primary health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal. Therefore, the remaining options are incorrect.

A client is to begin a 6-month course of therapy with isoniazid. The nurse would teach the client to take which action?

Report yellow eyes or skin immediately. Rationale:Isoniazid is hepatotoxic; therefore, the client is taught to immediately report signs and symptoms of hepatitis, such as yellow skin and sclera. For the same reason, alcohol would be avoided during therapy. The client needs to avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or light-headedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B6) during the course of isoniazid therapy.

A client is to begin a 6-month course of therapy with isoniazid. The nurse would plan to teach the client to take which action?

Report yellow eyes or skin immediately. Rationale:Isoniazid is hepatotoxic; therefore, the client is taught to immediately report signs and symptoms of hepatitis, which include yellow skin and sclera. For the same reason, alcohol needs to be avoided during therapy. The client needs to avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or light-headedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B6) during the course of isoniazid therapy.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Respiratory acidosis from inadequate ventilation Rationale:Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.

A client with a tracheostomy tube who is on a ventilator is at risk for reduced gas exchange. The nurse would assess for which finding as the best indicator of adequate ongoing respiratory status?

Respiratory rate of 16 breaths/minute Rationale:Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. A respiratory rate of 16 breaths/minute is in the normal range.

The baseline vital signs for a client with pneumonia are as follows: temperature 98.8° F (37.1° C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103° F (39.4° C). Which corresponding respiratory rate would the nurse anticipate in this client as part of the body's response to the change in status?

Respiratory rate of 22 breaths/min Rationale:Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. Therefore, the remaining options are incorrect.

The nurse is reviewing a pediatrician's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record would the nurse question? Select all that apply.

Restrict fluid intake. Give meperidine, 25 mg intravenously, every 4 hours for pain. Rationale:Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted?

Rhonchi are auscultated. Rationale:The presence of rhonchi is an indication that there are secretions in the large airways. The client requires suctioning if the client cannot expectorate them. A pulse oximetry reading of 96% is an acceptable reading. A pleural friction rub is indicative of inflamed pleural surfaces. Fine crackles are indicative of air moving into previously deflated alveoli.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?

Right pneumothorax Rationale:Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.

A client has sustained a superficial skin tear to the arm. The nurse would plan to apply which dressing as the best type of bandage for this wound?

Semipermeable film dressing Rationale:Semipermeable film dressings are used on superficial wounds, on ulcers, and occasionally on some deep, draining, or necrotic ulcers. These dressings have the advantage of staying in place for several days, allowing tissues to heal underneath. Dry sterile dressings would stick to the wound and are inappropriate. Wet to dry dressings are unnecessary because the tissue does not need debridement. Gelfoam sponge dressings are a type of enzyme dressing used in the treatment of necrotic tissue.

The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time?

Several weeks to months Rationale:The client with TB may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.

The nursing student is reviewing the pathophysiology of carbon monoxide poisoning. After reviewing the material, how would the nursing student correctly interpret a carboxyhemoglobin level of 56%?

Severe poisoning Rationale:A normal carbon monoxide, or carboxyhemoglobin, level is 1% to 10%. Mild poisoning is indicated by carbon monoxide levels ranging from 11% to 20%. Moderate poisoning is indicated by carbon monoxide levels ranging from 21% to 40%. Severe poisoning is indicated by carbon monoxide levels ranging from 41% to 60%. Lastly, fatal poisoning is indicated by carbon monoxide levels ranging from 61% to 80%. Therefore, a carboxyhemoglobin level of 56% indicates severe carbon monoxide poisoning. Therefore, option 3 is correct.

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Shortness of breath Rationale:Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

he nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Shortness of breath Rationale:Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse would expect to find which sign or symptom in the client as a result of the anemia?

Shortness of breath with activity Rationale:The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Muscle cramps are an unrelated finding. Increased respiratory rate is not an associated finding.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side and adverse effects of the medication would the nurse monitor? Select all that apply.

Signs of hepatitis Flulike syndrome Low neutrophil count Ocular pain or blurred vision Rationale:Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side and adverse effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange-colored bodily secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flulike syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid.

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How would the nurse interpret the client's neurovascular status?

The neurovascular status is expected because of increased blood flow through the leg. Rationale:An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse would monitor for which side and adverse effects of rifabutin? Select all that apply.

Signs of hepatitis Flulike syndrome Low neutrophil count Ocular pain or blurred vision Rationale:Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side and adverse effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange-colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flulike syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid.

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse interpret this rhythm?

Sinus tachycardia Rationale:Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats per minute.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing fatigue. The nurse would plan to teach the client which strategy to conserve energy after discharge from the hospital?

Sit for as many activities as possible. Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, and ironing. The client also needs to sit in a shower chair instead of standing while bathing. The client needs to prioritize activities, such as eating breakfast before bathing, and would intersperse each major activity with a period of rest.

A client enters the hospital emergency department with a nosebleed. On assessment, the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action?

Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. Rationale:The initial nursing action for a client with a nosebleed is to sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. Inserting nasal packing or preparing a nasal balloon is not an appropriate initial intervention. These interventions are used when conservative measures fail. Placing the client in a semi-Fowler's position would promote swallowing blood, which is not helpful because of the risk of vomiting and resultant aspiration.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply.

Sitting up and leaning on a table Standing and leaning against a wall Sitting up with the elbows resting on knees Rationale:The client would use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client would not lie on the back because this reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position would the nurse instruct the client to assume?

Sitting up and leaning on an overbed table Rationale:Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

A client is suspected of having discoid lupus erythematosus (DLE). Which diagnostic test will primarily confirm the diagnosis?

Skin biopsy Rationale:Discoid lupus erythematosus (DLE) is one classification of lupus. DLE is not a systemic condition and affects only the skin; therefore, the only significant test is a skin biopsy. A microscopic evaluation of skin cell scrapings from the rash will reveal the characteristic lupus cell and a number of inflammatory cells. Other specific immunological tests, such as anti-SS-a (RO), anti-SS-b (La), anti-Smith, anti-DNA, and extractable nuclear antigens, may be performed. High titers of some of these antibodies are associated with lupus, but some can also be found in persons without the disease.

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse would expect to note documentation of which characteristic sign of SLE?

Skin lesions Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. The major skin manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE.

The registered nurse is teaching a new graduate nurse on a medical-surgical unit about the early signs and symptoms of worsening disease in clients with COVID-19. The registered nurse determines that the new graduate nurse understands the teaching if the new graduate nurse identifies which as warning signs and symptoms? Select all that apply.

Somnolence Circumoral cyanosis Bluish-gray nail beds Persistent chest pressure Rationale:COVID-19 is a disease caused by the SARS-CoV-2 virus, which can vary in severity on an individual basis. Some individuals may experience only mild symptoms, whereas others may experience moderate, severe, or critical illness. Mild symptoms include cough, sore throat, headache, myalgia, fatigue, and fever. Therefore, options 1 and 6 can be eliminated. Symptoms that are considered warning signs and that warrant further medical intervention include somnolence; circumoral cyanosis; peripheral cyanosis, such as pale or bluish-gray nail beds; persistent chest pain or pressure; and new-onset confusion. Therefore, options 2, 3, 4, and 5 are considered warning signs and are correct.

An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions?

Spider angioma Rationale:Spider angiomas have a bright red center with legs that radiate outward. Spider angiomas are commonly seen in liver disease and vitamin B deficiency, although they occasionally can occur without underlying pathology. Purpura results from hemorrhage into the skin. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Cherry angioma occurs with increasing age and has no clinical significance. It appears as a small, round, bright red lesion on the trunk or extremities.

A client has been taking pyrazinamide for 6 months. The nurse determines that the medication is effective if which cultures yield a negative result?

Sputum Rationale:Pyrazinamide is an antituberculosis medication that is given in conjunction with other antituberculosis medications. Its use may be discontinued by the prescriber if sputum cultures become negative. The remaining options are incorrect.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection and notes a diagnosis of cryptococcosis in the client's medical record. The nurse understands that this opportunistic infection most likely was diagnosed by which test?

Sputum culture Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Cryptococcosis is a fungal infection caused by Cryptococcus neoformans (brain and spinal cord), but it can also affect other parts of the body. Symptoms of lung involvement include cough, shortness of breath, chest pain, and fever. When it spreads to the brain, manifestations include headache, fever, neck pain, nausea and vomiting, sensitivity to light, confusion, or changes in behavior. Diagnostic tests to confirm its presence in the lungs include chest x-ray studies and a sputum culture.

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse would check the results of which diagnostic test that will confirm this diagnosis?

Sputum culture Rationale:Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

The nurse is performing a skin assessment on a client and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tissue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse classify this pressure injury?

Stage 3 pressure injury Rationale:A stage 3 pressure injury is characterized by full-thickness skin loss in which adipose tissue is apparent with slough or eschar. There may also be granulation tissue and rolled wound edges. There is no exposed fascia, muscle, tendon, ligament, cartilage, or bone; this would be noted in a stage 4 pressure injury.

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?

Stop the procedure and reoxygenate the client. Rationale:During suctioning, the nurse would monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure.

Stage IV pressure injury Rationale:In a stage IV pressure injury, there is full-thickness tissue loss with exposed bone, tendon, or muscle. Eschar or slough may be present in some parts of the wound. In a stage II pressure injury, there is partial-thickness loss of the dermis manifesting as a shallow open ulcer with a pink/red wound bed and no slough. In a stage III pressure injury, there is full-thickness tissue loss with subcutaneous fat visible but no exposure of tendon or muscle, and slough may be present. Deep tissue injury appears as localized areas of purple or maroon discolored intact skin or a blood-filled blister.

The nurse notes that a client is choking but is awake and alert at this time. The nurse rushes to perform the abdominal thrust maneuver. The client becomes unconscious. What procedure would the nurse perform next?

Start chest compressions. Rationale:To perform the abdominal thrust maneuver for a conscious client, the rescuer stands behind the client and places the arms directly under the axillae and then around the client. The thumb side of one fist is placed against the client's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand, and upward thrusts are delivered. If the client becomes unconscious, the nurse would start cardiopulmonary resuscitation, first beginning compressions. Performing a blind finger sweep is not recommended. If the object can be visualized and is retrievable, it is acceptable to attempt to remove the object. Rescue breathing is not appropriate at this time but may be necessary later. It will be necessary at some point to determine what happened, but this would not be the nurse's next action.

The nurse is assessing the client's condition after cardioversion. Which observation would be of highest priority to the nurse?

Status of airway Rationale:Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority,

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse?

Stop the TPN solution. Rationale:Although stopping the TPN solution will not treat the problem, it will prevent it from worsening and is a quick action that can be completed first. Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. The high-Fowler's position is not helpful at this time. The PHCP needs to be notified, but this is not the first action.

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse would report which sign immediately if experienced by the client?

Stridor Rationale:Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the primary health care provider (PHCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the PHCP.

The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding would be reported to the primary health care provider (PHCP) immediately?

Stridor Rationale:The nurse reports the presence of stridor to the PHCP immediately. This is a high-pitched coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. Lung congestion and a respiratory rate of 26 breaths/min are abnormal, but additional data are needed to determine whether these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time.

A client with smoke inhalation is experiencing severe dyspnea, and the nurse listens to the client's breath sounds and hears this sound. The nurse would document this finding as which sound? Refer to audio.

Stridor Rationale:The sound that the nurse hears is stridor. Stridor is a harsh, high-pitched sound associated with breathing and is the major manifestation of airway obstruction. The nurse immediately notifies the primary health care provider (PHCP). The nurse also places the client in a high-Fowler's position to aid in breathing and proper alignment of airway structures. The nurse then monitors the client, including vital signs, and prepares the client for endotracheal intubation or tracheostomy. Rhonchi (low-pitched, coarse, loud, low-snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. High-pitched wheezes are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema

The nurse is reviewing the clinical manifestations of foreign body airway obstruction. Which of the following would the nurse identify as signs or symptoms of this condition? Select all that apply.

Stridor Cyanosis Wheezing Intercostal retractions Rationale:Acute airway obstruction is a medical emergency that needs to be recognized quickly with interventions begun early. The clinical manifestations of acute airway obstruction include choking, stridor, accessory muscle use, suprasternal or intercostal retractions, nasal flaring, wheezing, restlessness, tachycardia, cyanosis, and altered level of consciousness. Tachycardia, not bradycardia, is a clinical manifestation of acute airway obstruction. Therefore, option 4 is incorrect and options 1, 2, 3 and 5 are correct.

The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the primary health care provider with this procedure, which is the initial nursing action?

Suction the ET tube. Rationale:Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. In addition, resuscitative equipment would already be available at the client's bedside. Option 3 is not the initial action.

A client with an endotracheal tube attached to mechanical ventilation begins to cough, and the client's face appears flushed. Which action would the nurse take first?

Suction the client through the endotracheal tube. Rationale:The client is choking on secretions, which need to be removed by suctioning of the endotracheal tube. There is no need at this time to contact the physician or call for respiratory therapy. The nurse would check the client's blood pressure, but suctioning is the priority.

A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action would the PACU nurse take first?

Suction the client through the endotracheal tube. Rationale:The client is choking on secretions, which need to be removed by suctioning the endotracheal tube. The client is unable to use an incentive spirometer while an endotracheal tube is in place. The client's inability to breathe impairs ability to learn how to use a communication board. Turning the client assists in clearing the airway, but a supine position will worsen the airway problem. Suctioning the client is the best nursing intervention because it will have the most immediate effect.

The nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse would plan to perform which action?

Suction the client. Rationale:When the high-pressure alarm sounds on a ventilator, it is most likely because of an obstruction. The obstruction can be caused by the client's biting on the tube, kinking of the tubing, or mucous plugging that requires suctioning. A cuff leak and disconnection would cause the low-pressure alarm to sound, so options 2 and 3 can be eliminated. Notifying the respiratory therapist delays necessary treatment.

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse would assess the infant for which early sign of HF?

Tachycardia Rationale:HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in an infant with HF, but it is not an early sign.

When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse would include which measures in the plan? Select all that apply.

Suction the oral cavity whenever needed. Practice frequent oral hygiene, including toothbrushing. Wear gloves when suctioning or handling the endotracheal tube. Rationale:Measures to prevent VAP include removing subglottic secretions every 2 hours and whenever needed; frequent oral hygiene, which includes toothbrushing; hand hygiene before and after each client contact; and application of gloves after handwashing and before suctioning. Topical antibiotics have no effect. Ventilator circuit tubing does not need to be changed every 2 hours; depending on agency policy, tubing is changed every 24 or 48 hours. Head of the bed elevation is maintained at a minimum of 30 degrees; a supine position can lead to aspiration.

The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction?

Suctioning the client every hour Rationale:The client would be suctioned as needed. Unnecessary suctioning would be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client needs to be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are used during withdrawal.

The nurse is preparing to care for a client arriving at the emergency department who is in suspected hypovolemic shock. How would the nurse plan to position the client?

Supine position with lower extremities elevated Rationale:Hypovolemic shock occurs when circulating volume is inadequate to properly perfuse and meet the metabolic demands of organs and tissues. Placing the client in the supine position with the lower extremities elevated aids in promoting venous return from the lower extremities, thereby increasing cardiac output. Therefore, option 4 is correct.

The primary health care provider prescribes cromolyn for the client with asthma. The nurse identifies that the client correctly understands the purpose of this medication when the client states that the medication will produce which effect?

Suppress an allergic response Rationale:Cromolyn is a first-line therapy for prophylactic treatment of asthma; it is a mast cell stabilizer, antiasthmatic, and antiallergic. The medication acts in part by stabilizing the cytoplasmic membrane of mast cells, thereby preventing the release of histamine and other mediators. It is not a bronchodilator. It does not decrease the risk of infection. It does not eliminate the need for the rescue inhaler.

The nurse is preparing home care instructions for the parents of a 10-year-old child with hemophilia. Which sport activity would the nurse suggest for this child?

Swimming Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Children with hemophilia need to avoid contact sports and to take precautions with other sports, such as wearing elbow and knee pads and helmets. The safe activity for them is swimming.

The nurse is reviewing the diagnostic tests prescribed for an assigned client and notes that an "LE cell prep" has been prescribed. Which immune disorder would the nurse primarily anticipate?

Systemic lupus erythematosus (SLE) Rationale:A lupus erythematosus (LE) cell test is a blood test that measures the presence of a special cell found mostly in individuals with systemic lupus erythematosus. The LE cell prep (lupus erythematosus cell preparation) may be performed in a client suspected of having SLE. It also may be used to screen for progressive systemic sclerosis but is used primarily to screen for SLE. The other options are not associated with this diagnostic test.

A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder?

Systemic lupus erythematosus (SLE) Rationale:An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia is exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of the fingers.

A client seen in an ambulatory clinic has a facial rash that is present on both cheeks and across the bridge of the nose. The nurse interprets that this finding is consistent with manifestations of which disorder?

Systemic lupus erythematosus (SLE) Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A major skin manifestation of SLE is the appearance of a rash on both cheeks and across the nose. It is known as a "butterfly rash." Hyperthyroidism is associated with moist skin and increased perspiration. Pernicious anemia causes pallor of the skin. Cardiopulmonary disorders may lead to clubbing of the fingers.

The nurse would monitor the client receiving the first dose of albuterol for which side or adverse effect of this medication?

Tachycardia Rationale:Albuterol is a bronchodilator. Side and adverse effects include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache. The nurse monitors for these effects during therapy. The items in the other options are not side and adverse effects of this medication.

What early signs and symptoms would the nurse assess for in a client with a suspected pulmonary embolism? Select all that apply.

Tachypnea Restlessness Feeling of impending doom Rationale:Signs and symptoms of a pulmonary embolism include the sudden onset of dyspnea, apprehension and restlessness, a feeling of impending doom, cough, hemoptysis, tachypnea, crackles, petechiae over the chest and axillae, and a decreased arterial oxygen saturation. If a pulmonary embolism is suspected, the nurse immediately notifies the Rapid Response Team and primary health care provider. The nurse stays with the client, reassures the client, and elevates the head of the bed. The nurse prepares to administer oxygen and obtains the vital signs and checks lung sounds. The nurse continues to monitor the client closely, prepares the client for tests prescribed to confirm the diagnosis, and prepares to obtain an arterial blood gas. When prescribed, the client is prepared for the administration of heparin therapy or other therapies such as embolectomy or placement of a vena cava filter if necessary. Finally, the nurse documents the event, the interventions taken, and the client's response to treatment.

A client diagnosed with active tuberculosis has been prescribed a combination of isoniazid and rifampin for treatment. The nurse teaches the client to perform which action?

Take both medications together once a day. Rationale:Rifampin in combination with isoniazid prevents the emergence of medication-resistant organisms. This combination, taken together daily, eliminates the tubercle bacilli from the sputum and improves clinical status. Rifampin produces a harmless red-orange color in all body fluids and needs to be taken along with the isoniazid 1 hour before or 2 hours after eating to maximize absorption. The treatment regimen is maintained for at least 6 months for effectiveness, and the therapeutic effect may be evident in 2 to 3 weeks.

A client who has been diagnosed with pneumonia has been given a prescription for erythromycin. Client teaching about this medication would include which best instruction?

Take the medication on an empty stomach. Rationale:Erythromycin is a macrolide antibiotic. Oral erythromycin would best be administered on an empty stomach with a full glass of water (1 hour before or 2 hours after ingestion of food). Some preparations may be administered with food if gastrointestinal upset occurs, but it is best to administer on an empty stomach.

A client with tuberculosis receiving cycloserine orally twice daily must have blood drawn in 1 week to measure the serum concentration of the medication. The nurse prepares the client for this test by providing which information to the client?

Take the morning dose, and have the blood drawn 2 hours after taking the dose. Rationale:Cycloserine is an antituberculosis medication that requires weekly serum medication level determinations to monitor for neurotoxicity and other adverse effects. Peak concentrations are measured 2 hours after dosing and would be between 25 and 35 mcg/mL.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply.

Teach diaphragmatic and pursed-lip breathing. Encourage alternating activity with rest periods. Teach the client techniques of chest physiotherapy. Rationale:Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea. The client needs to be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

A nurse working in a primary health care provider's office receives a call from a client's caregiver. The caregiver sounds concerned and states that the client was diagnosed with COVID-19, has labored breathing with intercostal retractions, and is now acting confused. Which is the appropriate nursing response?

Tell the caregiver to immediately seek emergency medical care for the client. Rationale:COVID-19 is a disease caused by the SARS-CoV-2 virus with symptoms ranging in severity from mild to severe. COVID-19 is spread through several mechanisms, including breathing in air contaminated with the virus; having droplets land in the mucous membranes, such as the eyes, nose, or mouth; or touching a contaminated surface and then touching the eyes, nose, or mouth. While many cases can be managed in the home setting, there are emergency warning signs that warrant immediate medical attention. These warning signs include difficulty breathing, chest pain, new-onset confusion, somnolence, and peripheral or central cyanosis. Since the client is experiencing difficulty breathing and confusion, the nurse would tell the caregiver to seek emergency medical care for the client immediately to prevent further complications, including acute respiratory distress syndrome, sepsis, multiorgan dysfunction syndrome (MODS), and death. Options 2, 3, and 4 are inappropriate responses and would further delay the client's care. Therefore, option 1 is correct.

The nurse prepares to assist the primary health care provider to examine the client's skin with a Wood's lamp. Which would be included in the preprocedure plan of care?

Tell the client that the procedure is painless. Rationale:A Wood's light examination is a painless procedure. The skin does not need to be shaved, and a local anesthetic is not necessary. Examination of the skin under a Wood's lamp is always carried out in a darkened room. This is a noninvasive examination; therefore, an informed consent is not required. A hand-held long-wavelength ultraviolet light source or Wood's lamp is used. Areas of blue-green or red fluorescence are associated with certain skin infections.

A client arrives at the health care clinic and tells the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that the tick was removed and flushed down the toilet. Which actions are most appropriate? Select all that apply.

Tell the client to avoid any woody, grassy areas that may contain ticks. Instruct the client to immediately start to take the antibiotics that are prescribed. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. Rationale:A blood test is available to detect Lyme disease; however, the test is unreliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks need to be removed with tweezers; then the area is washed with an antiseptic. Options 1 and 5 are incorrect.

A client arrives at the health care clinic and tells the nurse about just being bitten by a tick and would like to be tested for Lyme disease. The client reports that the tick was removed and flushed down the toilet. The nurse would take which nursing action?

Tell the client to return to the clinic in 4 to 6 weeks. Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. A blood test is available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks after the tick bite. Antibody formation takes place in the following manner: Immunoglobulin M (IgM) is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, then gradually disappears; IgG is detected 2 to 3 months after infection and may remain elevated for years. The actions in the remaining options are inaccurate.

The cardiologist has written a prescription for a client to have an echocardiogram. Which action would the nurse take to prepare the client for the procedure?

Tells the client that the procedure is painless and takes 30 to 60 minutes Rationale:Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client.

The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply.

The T-piece is connected to the client's artificial airway. The client is removed from the mechanical ventilator for a short period of time. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting. Rationale:The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a FiO2 that is 10% higher than the ventilator setting. Option 4 describes intermittent mandatory ventilation/synchronized intermittent mandatory ventilation. Pressure support may be prescribed to open alveoli in some clients while on mechanical ventilation.

The nurse caring for a client with pneumothorax who has a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence?

The chest tube may be obstructed. Rationale:Fluid in the water seal chamber would rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. The remaining options are incorrect interpretations.

The clinic nurse is reviewing the pediatrician's prescription for a child who has been diagnosed with lice. Lindane shampoo has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?

The child is 18 months old. Rationale:Lindane shampoo is a pediculicide product that may be prescribed to treat lice. It is contraindicated for children younger than 2 years because they have more permeable skin, and high systemic absorption may occur, placing the children at risk for central nervous system toxicity and seizures. Lindane shampoo also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members can be treated simultaneously. Options 2 and 4 are unrelated to the use of lindane. Lindane is not recommended for use by a breast-feeding/chest-feeding parent because the medication is secreted into human milk.

The nurse instructs a client with chronic obstructive pulmonary disease on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly?

The client breathes out slowly through the mouth. Rationale:Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client would close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client would spend at least twice the amount of time breathing out that it took to breathe in. The client needs to use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity—to inhale before beginning the activity and exhale while performing the activity. The client is also instructed to never hold the breath.

After instruction on the application of antiembolism stockings for treatment of a vascular disorder, the nurse determines that the client requires further teaching if which of these actions is performed?

The client bunches up the stockings for easier application. Rationale:When applying antiembolism stockings, the client would not bunch up the stockings. Instead, the client would place the hand inside the stocking and pull the heel out. The foot of the stocking should then be placed over the client's foot and the rest of the stocking pulled up the leg. This will help to prevent wrinkling and twisting of the stocking. The remaining options demonstrate correct application of the stockings.

A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How would the nurse interpret this assessment finding?

The client has disseminated histoplasmosis infection. Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory infection in the client with AIDS and then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver. The client experiences dyspnea, fever, cough, and weight loss. The remaining options are incorrect.

A client tells the nurse that the primary health care provider (PHCP) has stated a diagnosis of silicosis. The nurse determines that which finding is consistent with this respiratory disorder?

The client has reduced lung volume and fibrosis on chest x-ray. Rationale:The client with silicosis has evidence of fibrosis on chest x-ray. Pulmonary function studies reveal some decreases in vital capacity and total lung volume. This disease is restricted to the respiratory system only.

The nurse is caring for a hospitalized client with chronic obstructive pulmonary disease who is retaining carbon dioxide (CO2). The nurse anticipates which physical response will initially occur?

The client's arterial blood gas results will reflect acidosis. Rationale:When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect and are not associated with this initial physical response.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation would the nurse make?

The client's test result will be positive, and a chest x-ray study will be required for evaluation. Rationale:The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive. This client needs to be evaluated for TB with a chest radiographic study. The remaining options are incorrect interpretations.

A client who sustained a chest injury has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse would ensure that which intervention is implemented?

The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site. Rationale:The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses.

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse's response to the client's question is based on which correct understanding of TB transmission?

The disease is transmitted by droplet nuclei. Rationale:TB is spread by droplet nuclei or via the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. It is unnecessary to remove carpeting from the home. Bleaching of clothing and linens is unnecessary, although the client and family members would use good handwashing technique.

The nurse is caring for a client with a chest injury who has a dry suction chest drainage system. During assessment of the drainage system, what would the nurse expect to find? Select all that apply.

The dry suction control regulation set to the prescribed amount The drainage in the collection chamber marked each shift to monitor the amount of drainage Rationale:There are two types of chest drainage systems: the wet drainage system and the dry drainage system. On routine assessment of the system, the nurse would look at the different chambers. For a dry drainage system, the nurse needs to check the dry suction control regulation to make sure it is set to the prescribed amount. The nurse would also look for the orange floater ball to appear in the window; this indicates that the suction is being applied correctly. Tidaling would be noted in the water seal chamber. The nurse would also check the water seal chamber; if the system is connected to suction (as opposed to gravity), tidaling may not be seen and the suction needs to be turned off to check for tidaling. If continuous bubbling is noted or the bubbling increases, an air leak may be present and the connections need to be checked. In a dry drainage system, water is not added to the suction control chamber; this is done with a wet drainage system. The drainage collection chamber needs to be monitored and marked each shift to monitor the amount of drainage, if any.

The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply.

The exact cause of acne is unknown. Acne requires active treatment for control until it resolves. Oily skin and a genetic predisposition may be contributing factors for acne. The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules. Rationale:Acne is a chronic skin disorder that usually begins in puberty and is more common in males. Lesions develop on the face, neck, chest, shoulders, and back. Acne requires active treatment for control until it resolves. The types of lesions include comedones (open and closed), pustules, papules, and nodules. The exact cause is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes (and the enzymes that reduce lipids to irritating fatty acids). Exacerbations coincide with the menstrual cycle because of hormonal activity. Oily skin and a genetic predisposition may be contributing factors.

A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How would the nurse respond to provide reassurance?

The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Rationale:Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client usually is not contagious after taking the medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or medication-resistant tuberculosis.

A client who has been exercising in a gymnasium stops to measure the pulse and places the fingers over both carotid arteries simultaneously. The nurse exercising nearby is correct when cautioning the client to check the pulse on only one side, primarily for which reason?

The heart rate and blood pressure could drop. Rationale:Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to drop reflexively. In addition, the manual pressure could interfere with the flow of blood to the brain, causing possible dizziness and syncope. Although the information in the remaining options may be correct, these are not the primary reasons.

A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder?

The inflamed pleurae cannot glide against each other as they normally do. Rationale:Pleurisy is an inflammation of the visceral and parietal pleurae. The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. As a result, the client experiences pain, especially with inspiration. The remaining options are incorrect.

The nurse is changing the tracheostomy securement device on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?

The nurse places 1 finger loosely between the tie and the neck Rationale:The nurse needs to assess the tracheostomy securement device to ensure that it is not too tight. The nurse ensures that there is room for 1 finger loosely or 2 fingers snugly to slide comfortably under the device. Options 1, 2, and 4 are incorrect actions.

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions, knowing that as the client's CO2 level rises, what will occur with the blood pH?

The pH will fall Rationale:CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. The nurse plans care understanding that which is the most appropriate time frame for the emergent phase?

The period from the time the burn was incurred to the time when the client is considered physiologically stable Rationale:The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society.

A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result would the nurse anticipate?

The presence of unusual antibodies of the IgG and IgM types Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The rheumatoid factor assay tests for the presence of unusual antibodies of the IgG and IgM types, which develop in a number of connective tissue diseases. The test result in a person without RA would be negative or <60 units/mL by nephelometric method of laboratory testing. The other options are incorrect.

A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure?

The use of Montgomery straps Rationale:The use of Montgomery straps is recommended to prevent skin breakdown with frequent dressing changes. They limit the friction and shear that could irritate skin with frequent removal and reapplication of tape. Hypoallergenic tape is used on clients with thin, fragile skin; clients whose skin is sensitive to standard tape; and clients who require less frequent dressing changes. Cleansing with povidone-iodine and obtaining a wound culture are not indicated.

The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity?

The use of some types of condoms Rationale:Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. Mucosal exposure to latex can occur on contact with latex condoms. The nurse most appropriately would provide instructions to the client about the need to avoid the use of condoms unless they are latex-free. No reason exists for the client to avoid outdoor activities or sunlight or to avoid parties; however, the client needs to be informed that certain forms of balloons are made of latex.

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed chest drainage system. How would the nurse interpret this finding?

There is an air leak somewhere in the system. Rationale:Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.

The nurse is caring for a client who has a dysfunction associated with the B lymphocytes in the immune system. The nurse plans care, knowing that which is a function of B lymphocytes?

They produce antibodies. Rationale:B lymphocytes have the job of making antibodies and mediating humoral immunity. They do not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is phagocytosis.

The nursing instructor is reviewing the risk factors for upper airway obstruction with a group of nursing students. The nursing instructor determines there is a need for further teaching if the nursing student identifies which of the following as a risk factor?

Thin oral secretions Rationale:There are several risk factors for upper airway obstruction. These include burns of the head or neck; anaphylaxis; absent gag reflex; upper airway abscesses; trauma of the face, trachea, or larynx; tongue occlusion; or edema and conditions with neurological sequelae, such as stroke or cerebral edema. Thick secretions that are poorly managed can harden into a crust and block the airway. Therefore, thick secretions, not thin secretions, increase the risk of airway obstruction. Therefore, option 4 is the correct answer, as this response would indicate a need for further teaching.

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply.

Thinner and decrease in number of reddish papules Rationale:Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply.

Thinner reddish papules and a decrease in their number Scarce amount of silvery-white scaly patches on the arms Rationale:Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.

A client is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. Which outcome would the nurse expect as a result of the administration of this medication?

Thinning of respiratory secretions Rationale:Acetylcysteine is administered to thin bronchial secretions and is considered a mucolytic. The remaining options are the outcomes of respiratory medication therapy but not of acetylcysteine.

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What would the nurse tell the client?

This is expected, and the client would gradually increase activity as tolerated. Rationale:The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this symptom will resolve as the therapy progresses and that the client would gradually increase activity as energy levels permit. Options 1, 3, and 4 are incorrect information.

A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs?

Three sputum cultures are negative Rationale:The client must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. Therefore, the remaining options are incorrect. A negative chest x-ray does not mean that the client is noninfectious. A positive tuberculin skin test never reverts to negative.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor would the nurse include when responding to the client?

Three sputum cultures are negative. Rationale:The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.

The nurse is caring for a client diagnosed with COVID-19 experiencing hypercoagulability. Which laboratory result trends would the nurse anticipate? Select all that apply.

Thrombocytopenia Increased D-dimer level Prolonged prothrombin time (PT) Prolonged activated partial thromboplastin time (aPPT) Rationale:Coagulopathy is a complication of COVID-19 infection that is seen more in clients with moderate to severe illness. The most common pattern of coagulopathy associated with COVID-19 infection includes elevated D-dimer and fibrinogen levels, slightly prolonged PT and aPPT, and mild thrombocytopenia. Therefore, since an increased fibrinogen, not a decreased fibrinogen, is associated with COVID-19 coagulopathy, option 2 is incorrect and options 1, 3, 4 and 5 are correct.

The nurse is monitoring the function of a chest tube that is attached to a drainage system in a client with pneumothorax. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring?

Tidaling is present. Rationale:When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as tidaling and indicates proper function of the system. Options 2, 3, and 4 are inaccurate interpretations.

The nursing instructor is reviewing the various complications of a tracheostomy. The nursing instructor determines teaching has been effective if the nursing student correctly identifies which of the following conditions as tracheal dilation and cartilage erosion?

Tracheomalacia Rationale:Several complications can arise from the creation of a tracheostomy related to increased cuff pressure or tube positioning that result in impaired tissue integrity. Some of these complications include tracheomalacia, tracheal stenosis, TEF, and trachea-innominate artery fistula. Tracheal stenosis describes narrowing of the tracheal lumen due to growth of scar tissue in response to tissue irritation from the cuff. TEF describes erosion of the posterior tracheal wall from continuous, excessive cuff pressure that creates an opening between the trachea and anterior esophagus. Trachea-innominate artery fistula is a medical emergency that results from lateral malplacement of the tracheostomy tube that causes pressure and subsequent necrosis and erosion of the innominate artery. Tracheomalacia is tracheal dilation and cartilage erosion from continuous cuff pressure. Therefore, option 1 is correct.

The nurse is reviewing the prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply.

Transfusions Splenectomy Corticosteroid medication Immunosuppressive agents Rationale:Idiopathic autoimmune hemolytic anemia is a decrease in the number of red blood cells due to increased destruction by the body's defense (immune) system. It is an acquired disease that occurs when antibodies form against a person's own red blood cells. In the idiopathic form of this disease, the cause is unknown. Idiopathic autoimmune hemolytic anemia is treated with corticosteroids. Other treatments that may be prescribed as necessary include transfusions, splenectomy, and, occasionally, immunosuppressive medications. Radiation therapy is not used to treat this disorder.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)?

Tripod position Rationale:The tripod position (leaning forward with elbows flexed) helps to decrease the work of breathing in clients who have severe shortness of breath caused by asthma, COPD, or respiratory failure. Positioning the arms in this manner increases the anterior-posterior diameter of the chest, thereby changing the pressures within the chest cavity. The sitting position and high-Fowler's position decrease the anterior-posterior diameter. The supine position will make breathing more difficult.

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result would the nurse anticipate in the presence of this disease?

Unusual antibodies of the IgG and IgM type Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases. The other options are incorrect.

Which is the nurse's priority assessment for monitoring for adverse effects for the client taking isoniazid?

Urine color Rationale:Isoniazid is an antituberculosis medication. The most serious adverse effect associated with isoniazid is hepatic injury, which on rare occasions has been fatal; therefore, monitoring of liver function tests and monitoring the client for signs and symptoms of liver injury are the priority. Dark urine is a sign of liver injury, and the client would be taught to report this, and the nurse would assess for this. Skin color, hydration status, and respiratory effort are not directly related to adverse effects of this medication.

A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates that the medication has achieved the expected effect?

Urine output increases from 10 mL/hour to greater than 50 mL hourly. Rationale:Bumetanide is a diuretic, and expected outcomes include increased urine output, decreased crackles, and decreased weight. Options 1, 3, and 4 are incorrect. A cough with productive frothy sputum is indicative of pulmonary edema, a complication of heart failure. A change in serum potassium is a side effect of the medication. An increase in the BNP level indicates worsening of the condition.

The nurse has assisted the primary health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement?

Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. Rationale:The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is checked radiographically. The nurse marks the ET tube at the point where it enters the nose or mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. Noting the tidal volume and the client's toleration of the tidal volume prescribed is not a measure of appropriate ET tube placement.

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

Use nonlatex gloves. Use medications from glass ampules. Keep a latex-safe supply cart available in the client's area. Avoid the use of medication vials that have rubber stoppers. Rationale:Most health care facilities use latex-free products and supplies but there may be some supplies that are not available as latex-free. If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is unnecessary to place the client in a private room.

The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse would identify which client action as contributing to this goal?

Using a bedside commode Rationale:Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Most times these clients are on diuretics and have the urge to urinate frequently. A bedside commode could also be helpful when the client is discharged to home. Additionally, a toilet seat raised to at least 17 inches is helpful to decrease cardiac workload with the effort needed to go from a sitting to a standing position. The supine position increases respiratory effort and decreases oxygenation. Elevating the client's legs increases venous return to the heart thus increasing cardiac workload. Seasonings may be high in sodium and promote further fluid retention.

A client who has had a myocardial infarction asks the nurse why it is not advised to bear down or strain to ensure having a bowel movement. The nurse provides education to the client based on which physiological concept?

Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. Rationale:Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. Stimulation of the sympathetic nervous system has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis.

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse would take what initial action?

Ventilate the client manually. Rationale:If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.

The nurse is admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse would plan to admit the client to a room that has which properties?

Venting to the outside, six air exchanges per hour, and ultraviolet light Rationale:A client suspected of having TB is admitted to a private room that has at least six air exchanges per hour and negative pressure in relation to surrounding areas. The room would be vented to the outside and needs to have ultraviolet lights installed.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?

Venturi mask Rationale:The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

A client with a respiratory tract infection is receiving intravenous tobramycin sulfate. The nurse would assess for which adverse effect of this medication?

Vertigo Rationale:Tobramycin sulfate is an aminoglycoside. Ringing in the ears and vertigo are symptoms of ototoxicity that may indicate dysfunction of the eighth cranial nerve. This is a frequent adverse effect of therapy with the use of aminoglycosides and could result in permanent hearing loss. In clients with these symptoms, the nurse would withhold the dose of the medication and notify the primary health care provider. Nausea, vomiting, and hypotension are rare side effects of the medication.

A client is taking a prescribed course of therapy with ethambutol. The home health nurse assesses the client at each home visit for which adverse effect of this medication?

Visual disturbances Rationale:Ethambutol causes optic neuritis, which decreases visual acuity and impairs the ability to discriminate between red and green. This form of color blindness poses a potential safety hazard in driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if GI upset occurs. Impaired hearing results from antituberculosis therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin.

The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which action would the nurse take before entering the client's room?

Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. Rationale:The nurse wears a HEPA respirator mask when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Options 1, 2, and 4 offer inadequate protection. In addition, a surgical mask will not protect against Mycobacterium tuberculosis.

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply.

Water or a kink in the tubing Biting on the endotracheal tube Increased secretions in the airway Rationale:Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.

A client has begun a course of therapy with rifampin. The home care nurse instructs the client on which measure due to an anticipated side effect?

Wear dark clothing to avoid staining Rationale:Rifampin causes orange-red discoloration of body secretions and will permanently stain light clothing as well as soft contact lenses. The medication needs to be taken on an empty stomach unless it causes gastrointestinal upset; then it may be taken with food. Antacids, if prescribed, would be taken at least 1 hour before the medication. Rifampin needs to be taken exactly as directed, and doses would not be doubled or skipped. The client would not stop therapy until directed to do so by a primary health care provider.

A client with tuberculosis (TB) has a prescription for rifampin. What instruction would the nurse include in the client's teaching plan?

Wearing glasses instead of soft contact lenses will be necessary. Rationale:Soft contact lenses may be permanently damaged by the orange discoloration in body fluids caused by rifampin. Any sign of possible jaundice (yellow-colored skin) would always be reported. If rifampin is not tolerated on an empty stomach, it may be taken with food. The client may be on the medication for 12 months even if cultures give negative results.

A client with heart failure is scheduled to be discharged to home with digoxin and furosemide as daily prescribed medications. The nurse tells the client to report which finding as an indication that the medications are not having the intended effect?

Weight gain of 2 to 3 lb in a few days Rationale:Clients with heart failure would immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in urine output during the day is expected with diuretic therapy. A cough resulting from respiratory infection does not necessarily indicate that heart failure is worsening.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes Rationale:Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

A pediatrician has prescribed oxygen as needed for an infant with heart failure. Which situation would likely increase the oxygen demand, requiring the nurse to administer oxygen to the infant?

When drawing blood for electrolyte level testing Rationale:Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are unlikely to produce crying in the infant.

The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check for lice?

White sacs attached to the hair shafts in the occipital area Rationale:Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.

The nurse reviews the record of a client with acquired immunodeficiency syndrome (AIDS) and notes that the client has a diagnosis of Candida. When performing history-taking and assessment, which finding would the nurse anticipate?

Yellowish-white, curd-like patches in the oral cavity Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. In a person with AIDS, candidiasis (overgrowth of the Candida fungus) occurs because the immune system can no longer control fungal growth. Candida stomatitis or esophagitis occurs often in AIDS. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish-white plaques and inflammation. The remaining options are not findings in this disorder.

The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions?

You will need to wear dark eye goggles during the treatment." Rationale:Safety precautions are required during UV light therapy. Protective dark eye goggles are required to prevent exposure of the eyes to the UV light; it may be necessary to wear the goggles for the remainder of the day following treatment. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Most UV light therapies require the client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UV light. Direct contact with the light bulbs used for the treatment needs to be avoided to prevent burning of the skin.

A pediatrician prescribes laboratory studies for the infant of a birthing parent positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant?

p24 antigen assay Rationale:Infants born to HIV-infected mothers need to be screened for the HIV antigen. The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L Rationale:A client with COPD will exist in a state of respiratory acidosis. Options 2 and 4 reflect an acidotic pH. However, option 2 demonstrates increased CO2; a decreased pH and an increased CO2 indicate respiratory acidosis. Increased CO2 acts as an acid in the body, and CO2 is elevated in the client with COPD because of an inability to exhale well and eliminate CO2. Therefore, with a rise in CO2, there is a corresponding fall in pH. The other options are incorrect.

The nursing instructor asks a nursing student to define the process of phagocytosis. The nursing instructor determines that the student has an accurate understanding if which statement is made?

"It is a process by which a particle is ingested and digested by a cell." Rationale:Phagocytosis, an important nonspecific immune response, is a process by which a particle is ingested and digested by a cell. The statements made in the remaining options are incorrect.

The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply.

Antibiotic therapy Warm compresses to the affected area Rationale:Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse needs to provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.

A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults. Rationale:Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

A white color to the skin, which is insensitive to touch Rationale:Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.

A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result would be most closely monitored?

Amylase Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Didanosine is toxic to the pancreas and the liver. A serum amylase level that is increased by 1.5 to 2 times normal may signify pancreatitis and may be fatal in the client with AIDS. Therefore, the nurse needs to monitor the results of amylase and liver function studies closely. Alterations in protein, glucose, and cholesterol levels are unrelated to this medication.

The nurse notes that an older adult has a number of bright ruby-colored round lesions scattered on the trunk and thighs. How would the nurse document these lesions in the medical record?

Appears to have cherry angiomas on trunk and thighs Rationale:A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright ruby-colored round lesions on the trunk and/or extremities. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology. Purpura results from hemorrhage into the skin.

The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure would the nurse recommend for the client to alleviate this discomfort?

Apply emollients to the skin after bathing. Rationale:One bath or one shower per day for 15 to 20 minutes with warm water and a mild soap needs to be followed immediately by the application of an emollient to prevent evaporation of water from the hydrated epidermis. The client needs to avoid using a dehumidifier because this will further dry room air. The client would be instructed to avoid applying rubbing alcohol, astringents, or other drying agents to the skin. A bath using a dilute alcohol solution will cause further drying of the skin.

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse would question the client about an allergy to which food item?

Bananas Rationale:Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy.

Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage?

Cardiac conduction deficits Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Stage II of Lyme disease develops within 1 to 6 months in a majority of untreated persons. The most serious problems include cardiac conduction deficits and neurological disorders such as Bell's palsy and paralysis. Arthralgias and joint enlargement are noted in stage III. A rash appears in stage I.

A client complains of chronic pruritus. Which diagnosis would the nurse expect to note documented in the client's medical record that would support this client's complaint?

Chronic kidney disease Rationale:Clients with chronic kidney disease often have pruritus, or itchy skin. This is because of impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with diabetes mellitus are at risk for skin infections and skin breakdown.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

Elevated hematocrit levels Rationale:The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia, and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

An infant of a birth parent infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign?

Cough Rationale:Acquired immunodeficiency syndrome (AIDS) is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. The most common opportunistic infection of children infected with HIV is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cough is a common sign of this opportunistic infection. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Liver failure is a common sign of this complication. Although gastrointestinal disturbances and neurological abnormalities may occur in a child with HIV infection, options 3 and 4 are not specific opportunistic infections noted in the HIV-infected child. Watery stool is noted with gastroenteritis, and nuchal rigidity is seen in meningitis.

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test?

Decreased numbers of all cell types Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. In the client with SLE, a complete blood cell count commonly shows pancytopenia, a decrease in all cell types. This probably is caused by a direct attack on all blood cells or bone marrow by immune complexes. The other options are incorrect.

For the client with stomatitis resulting from chemotherapy, the care plan would include which intervention?

Encourage foods with neutral or cool temperatures. Rationale:Stomatitis is inflammation of the oral cavity, and using commercial mouthwashes containing alcohol or encouraging spicy foods will cause pain. Foods are better tolerated by the client with stomatitis when the food is cool or of neutral temperature. It is important to monitor for oral fungal infections, but this assessment should be completed at least daily.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse would recognize that which are early clinical manifestations of this disorder? Select all that apply.

Fatigue Anorexia Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade fever, and paresthesias. Weight loss is one of the late manifestations.

The nurse in the postanesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring?

Frequent swallowing Rationale:The client needs to be assessed for frequent swallowing, which may be the only sign of bleeding. Bleeding may not always be externally visible after rhinoplasty because blood may run down the back of the client's throat. The surgical procedure and the packing may be uncomfortable, so discomfort is expected and analgesics would be prescribed. The area around the client's eyes is expected to be edematous and ecchymotic, and ice compresses are applied. Some blood on the external nasal dressing is expected.

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and would plan to question which prescription?

Gastric lavage Rationale:The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

A clinic nurse notes that large numbers of clients present with flu-like symptoms. Which recommendations would the nurse include in the plan of care for these clients? Select all that apply.

Get plenty of rest. Increase intake of liquids. Take antipyretics for fever. Eat fruits and vegetables high in vitamin C. Rationale:Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. The nurse needs to teach clients to sneeze or cough into the upper sleeve of their arm rather than into the hand. Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms.

An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area?

Greater trochanter Rationale:The greater trochanter is at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position. When the client is lying supine, the heels, sacrum, and back of the head all are at risk, as are the elbows and scapulae.

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation?

Heart rate of 95 beats/minute Rationale:When fluid resuscitation is adequate, the heart rate needs to be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary?

High pressure alarm keeps sounding on the ventilator Rationale:A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction.

The nurse is reviewing the diagnostic tests performed in an adult with a connective tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 35 mm/hr (35 mm/hr). How would the nurse interpret this finding?

Indicating mild inflammation Rationale:The ESR is a blood test that can confirm the presence of inflammation or infection in the body. The normal ESR range is less than or equal to 15 mm/hr in a male and less than or equal to 20 mm/hr in a female. Generally, an ESR value of 30 to 40 mm/hr indicates mild inflammation, 40 to 70 mm/hr indicates moderate inflammation, and 70 to 150 mm/hr indicates severe inflammation.

The nurse is providing an educational session to community members regarding Lyme disease. The nurse would provide what information in the teaching plan regarding this disease?

It is caused by a tick bite. Rationale:Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from 1 person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused from the inhalation of cysts from contaminated cat feces or the consumption of rare or raw meat.

The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse reviews the client's health care record and notes documentation of toxoplasmosis encephalitis. On the basis of this information, the nurse would assess for which manifestation?

Mental status changes Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Toxoplasmosis encephalitis, caused by Toxoplasma gondii, is acquired through contact with contaminated cat feces or by ingesting infected, undercooked meat. It manifests with signs and symptoms such as an altered mental status, neurological deficits, headaches, and fever. Additional manifestations include seizures and difficulties with speech, gait, and vision. The other options are not associated with toxoplasmosis.

The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding would the nurse expect to note if scabies is present?

Multiple straight or wavy thread-like lines underneath the skin Rationale:Scabies can be identified by the multiple straight or wavy thread-like lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

Partial-thickness skin loss with exposed dermis Rationale:In a stage 2 pressure injury, the skin is not intact. Partial-thickness skin loss with exposed dermis is present. It presents with a viable red-pink and moist wound bed. It may also present as an intact or ruptured serum-filled blister. The skin is intact in stage 1. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe?

Pink or red color Rationale:Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold.

The nurse is providing skin care instructions to a client with acne vulgaris. What would the nurse instruct the client to do?

Remove cosmetics from the face at bedtime. Rationale:The client would be instructed to wash the face 2 or 3 times daily with a mild cleanser. Vigorous rubbing of the face is avoided, and cosmetics need to be removed from the face at bedtime. The client is instructed to use only water-based cosmetics and to avoid exposure to skin products that contain oils because products that are oily may cause skin flare-ups.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

Return of distal pulses Rationale:Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas exchange. Which finding indicates that the expected outcome of care has yet to be achieved?

The client limits fluid intake. Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The status of the client with a problem concerning gas exchange would be evaluated against the standard outcome criteria for a P. jiroveci infection. These would include options 2, 3, and 4, where breath sounds are clear, the nurse notes that secretions are being coughed up effectively, and the client states that breathing is easier. The client would not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse would provide which instruction to the parent?

The inactivated influenza vaccine will be given yearly. Rationale:Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. The inactivated influenza vaccine that is given intramuscularly will be administered (influenza vaccine would be given yearly). The hepatitis B vaccine is administered according to the recommended immunization schedule. Varicella-zoster virus vaccine would not be given, because it is a live virus vaccine; varicella-zoster immunoglobulin may be prescribed after exposure to chicken pox. Option 4 is unnecessary and inaccurate.

A nursing instructor is reviewing information on the organs of the immune system. The instructor asks a nursing student to name the location of Kupffer cells. Which organ identified by the nursing student indicates successful teaching?

The liver Rationale:The liver contains a large number of macrophages called Kupffer cells. Kupffer cells are a part of the body's reticuloendothelial system and are a protective function of the liver. They help filter blood by phagocytizing microorganisms and other foreign particles passing through the liver. The organs in the remaining options are incorrect.

The nursing instructor asks a nursing student to identify the location of Peyer's patches. The nursing instructor determines that the student has an understanding of the location if which organ is identified?

The small intestine Rationale:Peyer's patches are lymphoid nodules located in the small intestine, where T cells congregate. Peyer's patches are most important in the secondary immune response, although they play a role in the primary immune response as well. These organs may enlarge as they become highly active in the immune response. The organs noted in the remaining options are incorrect.

A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. What would the nurse tell the client?

The test will need to be confirmed with a Western blot. Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A negative result on an ELISA indicates that infection is absent or that not enough time has passed since exposure for seroconversion. A positive ELISA result must be confirmed with a Western blot. The other options are incorrect.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

Urine output Rationale:Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume would be 30 to 50 mL.

The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse notes recent documentation of herpes simplex in the client's medical record. On assessment, the nurse would expect to note which type of lesion?

Vesicular lesions that rupture Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. HSV in people with HIV or acquired immunodeficiency syndrome (AIDS) occurs in the perirectal, oral, and genital areas. Numbness or tingling at the site of infection occurs up to 24 hours before blisters form. Lesions are painful, with chronic open areas after blisters rupture. The nurse would assess for fever, pain, bleeding, and enlarged lymph nodes in the affected area. The nurse needs to also assess for headache, myalgia, and malaise. The other options are not characteristic of herpesvirus infection.

A client with human immunodeficiency virus (HIV) infection is diagnosed with herpes simplex virus (HSV). The nurse would prepare the client for which diagnostic test to determine the presence of herpesvirus infection?

Viral culture Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome (AIDS), which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. HSV in people with HIV or AIDS occurs in the perirectal, oral, and genital areas. Numbness or tingling at the site of infection occurs up to 24 hours before blisters form. Lesions are painful, with chronic open areas after blisters rupture. Diagnostic tests for herpes simplex include a viral culture and gross examination. The tests in the other options will not diagnosis herpes simplex.

A client receiving chemotherapy is experiencing mucositis. The nurse would suggest to the client to use which item as the best substance to rinse the mouth?

Weak salt and bicarbonate mouth rinse Rationale:An acidic environment in the mouth is favorable for bacterial growth, particularly in an area already compromised from chemotherapy. Therefore, the client is advised to rinse the mouth before every meal and at bedtime with a weak salt and sodium bicarbonate mouth rinse. This lessens the growth of bacteria and limits plaque formation. The other substances are irritating to oral tissue. If hydrogen peroxide must be used because of the presence of severe plaque, it needs to be a weak solution, because hydrogen peroxide dries the mucous membranes.

The nurse has completed discharge teaching for a client who visited the clinic for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions?

"I need to assess my skin for lesions that appear net-like." Rationale:Reticular skin lesions resemble a net in appearance. Linear lesions appear in a straight line, whereas annular lesions are ring shaped. Arciform lesions are shaped like an arc.

The nurse has provided home care instructions to a client after blepharoplasty. Which statement by the client indicates a need for further instruction?

"I need to keep ice on my eyes for at least 3 days." Rationale:Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Home care instructions after blepharoplasty include the administration of cool compresses for 24 (not 72) hours. Vigorous activities, such as sports, need to be avoided for 1 month. Because lying on the side increases the possibility of swelling in the dependent eye area, the client needs to sleep supine with at least 2 pillows to elevate the head. The client needs to understand the importance of not bending over at the waist for the first 48 hours after the procedure. Bending would increase pressure to the operative area.

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an immune disorder, and they discuss the classes of human antibodies. Which statement by the nursing student indicates a need for further teaching?

"Immunoglobulin G (IgG) is the minor serum antibody." Rationale:The major serum antibody is IgG, which constitutes about 70% of the total circulating antibodies. It is antiviral, antibacterial, and effective against toxins. IgM is the first antibody produced in response to antigen and makes up about 7% of the total serum antibodies. IgE accounts for only about 0.5% of the total antibody level in the blood.

A CD4+ lymphocyte count is performed in a client with human immunodeficiency virus (HIV) infection. When providing education about the testing, what would the nurse tell the client?

"It establishes the stage of HIV infection." Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A CD4+ lymphocyte count is performed to establish the stage of HIV infection, to help with decisions regarding the timing of initiation of antiretroviral therapy and prophylaxis for opportunistic infections, and to monitor treatment effectiveness. The remaining options are unrelated to the CD4+ lymphocyte count.

The nursing instructor asks a nursing student to identify the components of natural resistance as it relates to the immune system. Which statement by the nursing student indicates a need for further research?

"It includes all antigen-specific immunities a person develops during a lifetime." Rationale:Natural resistance, also called innate inherited or innate-native immunity, is the immunity with which a person is born. It does not require previous exposure to the antigen. Acquired immunity includes all antigen-specific immunities that a person develops during a lifetime.

The nurse provides home care instructions to a client diagnosed with impetigo. Which statement by the client indicates the need for further instruction?

"It is not necessary to separate my linens and towels from those of other household members." Rationale:The client needs to separate linens and towels from those of other household members. Thorough hand washing, separating linens and towels, and separate washing of the client's dishes are required because the infection is contagious so long as skin lesions are present. Antibiotics are administered and would be continued as prescribed.

The nurse asks the student nurse, "What does it mean when an antibiotic is classified as a bactericidal agent?" The nurse determines that the student nurse has a correct understanding when which statement is made?

"It kills the infectious agent." Rationale:Bactericidal agents cause bacterial cell death and lysis and thus kill the infectious agent. Potency refers to the strength of an antibiotic, and efficacy is related to antibiotic effectiveness. An antibiotic is classified as bacteriostatic if the agent slows bacterial growth, allowing the body to complete the cycle of destruction.

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?

"Lesions most often are located on the arms and chest." Rationale:Impetigo is a contagious bacterial infection of the skin caused by group A streptococcus (GAS; Streptococcus pyogenes) and Staphylococcus aureus. Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose but may be present on the hands and extremities.

A client calls the emergency department after experiencing direct contact with poison ivy shrubs. The client tells the nurse that nothing is visible on the skin and asks what to do. The nurse would provide which response?

"Take a shower immediately, lathering and rinsing several times." Rationale:When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.

Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction?

"The UV light treatments are given on consecutive days." Rationale:UV light treatments are limited to 2 or 3 times a week and are not given on consecutive days. Safety precautions are required during UV light therapy. It is best to expose only those areas requiring treatment to the UV light. Protective wraparound goggles prevent exposure of the eyes to UV light. The face needs to be shielded with a loosely applied pillowcase if it is unaffected. Direct contact with the light bulbs of the treatment unit needs to be avoided to prevent burning of the skin.

After a client stepped on a nail while walking on the beach, the nurse provided education to the client about the tetanus toxoid and administered it via injection. Which statement by the client indicates successful teaching?

"This tetanus shot is produced by altering bacteria so that they are no longer toxic." Rationale:Toxoids are toxins produced by bacteria that have been altered so that they are no longer toxic. Their important antigenic receptor sites remain intact, enabling antibodies to the antigen-producing toxin to be produced. The remaining options are incorrect statements.

An adult client with a burn injury just arrived at the emergency department. Place the nursing actions in the care of this client in order of priority. All options must be used.

1.Assess for airway patency. 3.Administer oxygen as prescribed. 2.Obtain vital signs. 6.Initiate an intravenous (IV) line and begin fluid replacement as prescribed. 4.Elevate the extremities. 5.Keep the client warm. Rationale:The primary goals for a burn injury are to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and to maintain a patent airway. The nurse then prepares to administer oxygen. The type of oxygen delivery system is prescribed by the primary health care provider. Oxygen is necessary to perfuse tissues and organs. Vital signs should be assessed so that a baseline is obtained, which is needed for comparison of subsequent vital signs once fluid resuscitation is initiated. The nurse then initiates an IV line and begins fluid replacement as prescribed. The extremities are elevated (if no obvious fractures are present) to assist in preventing shock. The client is kept warm (using sterile linens) and is placed on NPO status because of the altered gastrointestinal function that occurs as a result of the burn injury. A Foley catheter may be inserted so that the response to the fluid resuscitation can be carefully monitored. Once these actions are taken, the nurse performs a complete assessment, stays with the client, and monitors the client closely. In addition, tetanus toxoid may be prescribed for prophylaxis.

The parent of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?

Fine grayish red lines Rationale:Scabies is a parasitic skin disorder caused by an infestation of Sarcoptes scabiei (itch mite). Scabies appears as burrows or fine, grayish red, threadlike lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid-filled vesicles are seen in herpesvirus infection.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply.

Keep liquids at the bedside. Place a towel over the pillowcase. Make sure the pillow has a plastic cover. Keep a change of bed linens nearby in case they are needed. Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The pillow would have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is profuse. The client needs to have liquids at the bedside to drink.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse recognizes that melanoma has which characteristics? Select all that apply

Lesion is highly metastatic. Lesion is a nevus that has changes in color. Rationale:Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by signs of inflammation. Although sun exposure increases the risk of melanoma, lesions may occur any place on the body, especially where birthmarks or new moles are apparent.

A client with severe psoriasis has a problem of chronic low self-esteem. The nurse would incorporate which nursing action when working with this client?

Listening attentively Rationale:Clients with chronic skin disorders may experience chronic low self-esteem because of the disorder itself and possible rejection by others. The nurse demonstrates acceptance of the client by using a quiet, unhurried manner and by using appropriate visual contact, facial expression, and therapeutic touch. Communications that seem brief and formal may reinforce the feelings of rejection, as well as avoidance of looking at the affected skin areas.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and would incorporate which action as a priority in the plan?

Protecting the client from infection Rationale:The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply.

Reposition every 2 hours. Use a bed cradle as indicated. Apply protective pads to heels and elbows. Provide perineal care every 8 hours and after incontinence. Rationale:Unconscious clients are completely immobile, having lost the protective reflexes to shift body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours. Use of a bed cradle can protect the client's toes from breakdown due to weight from linens. Protective pads can be applied to the heels and elbows to reduce friction and shear. Appropriate perineal care is essential to keep waste products from excoriating the skin. The nurse can reduce skin dryness and irritation by adding a superfatty solution (i.e., baby oil or castile soap) to the daily bath water. Drying agents such as alcohol are avoided because dry skin can crack and break down.

A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which would the nurse expect to note as the hallmark characteristic of this stage?

Skin rash Rationale:Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. The hallmark finding in stage I is a skin rash that appears within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance (however, not all clients develop this characteristic). The lesion enlarges to up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. Not all persons exhibit a skin rash, but in addition, in stage I, most infected persons experience flu-like symptoms that last 7 to 10 days and may recur later in the disease course. Arthralgias, neurological deficits, and enlarged and inflamed joints develop in later stages of the disease.

A client with human immunodeficiency virus (HIV) infection has a fever, and histoplasmosis is suspected. The nurse would prepare the client for which diagnostic test to confirm the presence of histoplasmosis?

Sputum culture Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Histoplasmosis is an opportunistic infection that affects the lungs and can occur in the client with HIV infection. Diagnostic tests include chest x-ray, sputum culture, lung biopsy, and bronchoscopy. The other options are incorrect. A Western blot test is used to confirm a diagnosis of HIV. A skin biopsy may be done if the client had Kaposi's sarcoma. An upper gastrointestinal series is done for a client suspected to have a gastrointestinal disorder.

A client is admitted to the hospital with a partial-thickness skin loss and blister on the sacrum. The nurse would develop a plan of care for which stage of pressure ulcer? Refer to figure.

Stage II ulcer Rationale:A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage I ulcer is characterized by a reddened area and intact skin. Stage III ulcers are full-thickness lesions of the skin. Stage IV ulcers also are full-thickness lesions, with exposed muscle, bone, or supportive tissue.

A client with human immunodeficiency virus infection (HIV) has signs and symptoms of cryptosporidiosis. The nurse would prepare the client for which test that will assist in confirming the diagnosis?

Stool culture Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Cryptosporidiosis is an intestinal infection caused by Cryptosporidium organisms. The client with cryptosporidiosis will present with signs and symptoms of watery diarrhea, flatus, abdominal distention, pain, and fever. It is important for the nurse to monitor for an electrolyte imbalance. Diagnostic tests include a stool culture with a bowel biopsy. The other options are incorrect.

Which information would the nurse plan to include while providing education for a client scheduled for a rhinoplasty?

The nasal bone is fractured, and the cartilage and bone are remolded into the desired shape. Rationale:In a rhinoplasty procedure, the nasal bone is fractured, excess tissue is removed, and cartilage and bone are remolded into the desired shape. The client usually receives a local anesthetic in combination with intravenous sedation or general anesthesia. The packing is removed on the day after the surgery, and the splint remains in place for 1 week. Incisions are made inside the nose, so scars are not visible.

The nurse has been working with a client diagnosed with candidiasis (thrush). What would the nurse assess for in this client?

The presence of white patches Rationale:Assessment of the client with candidiasis (thrush) will reveal white patches on the tongue, palate, and buccal mucosa. The lesions adhere firmly to the tissues and are difficult to remove. The lesions often are referred to as "milk curds" because of their appearance. Clients often describe the lesions as dry and hot. Options 1, 3, and 4 are not characteristics of thrush.

The nurse is caring for a client with a diabetic ulcer. What discharge instructions would the nurse provide to the client? Select all that apply.

Use a mild soap when washing the feet. Use lanolin on the feet to prevent dryness. Exercise the feet daily by walking and flexing at the ankle. Rationale:The client with a diabetic ulcer needs to take strict precautions and implement very specific measures to allow for wound healing. Interventions include washing the feet with warm (not hot) water daily with a mild soap, using lanolin to prevent drying and cracking, wearing closed-toed shoes that are well fitting while avoiding high-heeled and open-toed shoes, and exercising the feet daily by walking and flexing at the ankle to promote circulation.