T3 Comp Exam
A client with a significant history of mitral valve prolapse is receiving client education regarding dietary recommendations to compensate for symptoms associated with hypovolemia. Which dietary recommendations would be appropriate? 1) liberal fluid intake 2) adequate sodium intake 3) avoid coffee 4) high fiber diet
Correct Response: liberal fluid intake adequate sodium intake Explanation: The nurse should recommend adequate sodium and fluid intake to clients with mitral valve prolapse to compensate for symptoms associated with hypovolemia.
The client asks the nurse if dipstick of urine can be used for monitoring glucose levels. Which is the best response by the nurse? 1) "Yes, it is a cheaper method of monitoring glucose and ketones in the urine." 2) "This test can detect ketones but not glucose levels." 3 "The most accurate way to monitor glucose levels is by blood testing." 4) "Dipstick of urine will only indicate lower levels of glucose and ketones."
Correct response: "The most accurate way to monitor glucose levels is by blood testing." Explanation: Because glycosuria and ketonuria may not become evident until glucose levels exceed the renal threshold, blood testing is the most helpful way to determine the effects of treatment and management of the diabetes mellitus. Dipstick of urine is a cheaper diagnostic test and can be useful in screening clients for diabetes.
A client with acromegaly is complaining of severe headaches. What does the nurse suspect is the cause of the headaches that is related to the acromegaly? 1) A pituitary tumor 2) A decrease in release in the growth hormone 3) A decrease in the glucose level 4) An increase in cerebral edema
Correct response: A pituitary tumor Explanation: When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica, a bony depression in which the pituitary gland rests, are common. There is actually an increase in the secretion of the growth hormone. The headaches would not be caused by decreases in glucose levels. The client does not have cerebral edema.
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? 1) Administer an over-the-counter decongestant. 2) Use an anti-allergy medication to decrease rhinitis. 3) Place a warm cloth over the sinus area of the forehead. 4) Gently blow the nose to eliminate nasal secretions
Correct response: Administer an over-the-counter decongestant. Explanation: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client? 1) Hives 2) Itching 3) Airway obstruction 4) Diarrhea
Correct response: Airway obstruction Explanation: Injectants, such as bee venom, and some other allergens can produce systemic and potentially fatal effects, including shock and airway obstruction caused by laryngeal swelling. Although all other answers can occur with an allergen, they are not the most serious complication.
Which nursing intervention should a nurse perform when a client with cardiomyopathy receives a diuretic? 1) Administer oxygen 2) Check regularly for dependent edema 3) Maintain bed rest 4) Allow unrestricted physical activity
Correct response: Check regularly for dependent edema Explanation: The nurse should regularly monitor for dependent edema if the client with cardiomyopathy receives a diuretic. Oxygen is administered either continuously or when dyspnea or dysrhythmias develop. Bed rest is not necessary. The nurse should ensure that the client's activity level is reduced and should sequence any activity that is slightly exertional between periods of rest.
Which of the following is the first barrier method that can be controlled by the woman? 1) Female condom 2) IUD 3) Diaphragm 4) Birth control pills
Correct response: Female condom Explanation: The female condom has the distinction of being the first barrier method that can be controlled by the woman. The IUD may increase the risk for HIV transmission through an inflammatory foreign body response. The female condom is as effective in preventing pregnancy as other barrier methods, such as the diaphragm and the male condom. Birth control pills are not a barrier method.
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus? 1) Respirations of 12 breaths/minute 2) Cloudy urine 3) Blood sugar 170 mg/dL 4) Fruity breath
Correct response: Fruity breath Explanation: The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul respirations (fast, labored breathing) and renal shutdown. A blood sugar of 170 mg/dL is not ideal but will not result in glycosuria and/or trigger the classic symptoms of diabetes mellitus. Cloudy urine may indicate a UTI.
Which is a primary chemical mediator of hypersensitivity? 1) Serotonin 2) Bradykinin 3) Histamine 4) Heparin
Correct response: Histamine Explanation: Histamine is a primary chemical mediator of hypersensitivity. Secondary mediators include serotonin, heparin, and bradykinin.
A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate? 1) Loss of vibratory and position senses 2) Neurologic involvement 3) Severity of the disease 4) Insufficient intake of dietary nutrients
Correct response: Neurologic involvement Explanation: In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms
The nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). The nurse notices that the client has become confused and extremely short of breath, and crackles are heard when lungs are auscultated. What is the first action by the nurse? 1) Administer a diuretic. 2) Notify the physician. 3) Lay the client flat. 4) Suction the client.
Correct response: Notify the physician. Explanation: The nurse closely monitors fluid intake and output and vital signs. The nurse carefully assesses LOC and immediately reports any changes to the physician. The nurse checks closely for signs of fluid overload (confusion, dyspnea, pulmonary congestion, hypertension) and hyponatremia (weakness, muscle cramps, anorexia, nausea, diarrhea, irritability, headache, weight gain without edema). Laying the client flat would increase the shortness of breath and would deoxygenate the client. The nurse cannot administer a diuretic without the physician's order. Suctioning of the client will not clear the airway at this time.
A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data? 1) Postural hypotension 2) Urinary output of 10 mL/hr 3) Altered consciousness 4) Extreme pallor
Correct response: Postural hypotension Explanation: Symptoms of chronic hypovolemic anemia include pallor, fatigue, chills, postural hypotension, and rapid heart rate and respiratory rates. The symptom of decreased urinary output, altered consciousness, and extreme pallor are all signs of acute hypovolemic anemia from severe blood loss. These signs indicate hypovolemic shock.
The period from infection with HIV to the development of antibodies to HIV is known as which of the following? 1) Primary infection 2) Viral load 3) Viral set point 4) Anergy
Correct response: Primary infection Explanation: Primary infection is the period from the infection with HIV to the development of antibodies to HIV. The viral load test measures plasma HIV RNA levels. Viral set point is the balance between the amount of HIV in the body and the immune response. Anergy is the absence of an immune response.
Which group of clients should not receive potassium iodide? 1) Those who are allergic to corticosteroids 2) Those who are pregnant 3) Those taking medications such as cough medicines 4) Those who are allergic to seafood
Correct response: Those who are allergic to seafood Explanation: Potassium iodide should not be administered to anyone who is allergic to seafood, which is also high in iodine. Clients who take corticosteroids or cough medicines and those who are pregnant would be appropriate candidates for potassium iodide therapy.
A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action? 1) decreasing anxiety 2) maintaining an open airway 3) providing pain relief measures 4) encouraging activity
Correct response: maintaining an open airway Explanation: The priority action at this time is maintaining an open airway because the client is experiencing a severe allergic reaction that is compromising the airway and ability to inhale. There is no indication that the client's difficulty breathing is causing pain. Anxiety and activity are important, but the priority is the client's airway.
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? 1) "I sleep on three pillows each night." 2) "My feet are bigger than normal." 3) "My pants don't fit around my waist." 4) "I don't have the same appetite I used to."
"I sleep on three pillows each night." Correct response: "I sleep on three pillows each night." Explanation: Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply. A decreased respiratory rate Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 Nasal flaring with abdominal retractions Administration of a corticosteroid inhaler for quick relief Lung sounds of wheezing Increased respiratory effort
Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 Nasal flaring with abdominal retractions Lung sounds of wheezing Increased respiratory effort Explanation: The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated CO2 and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratory compromise. Administration of a corticosteroid decreases inflammation over a period of time.
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. 1) Infection 2) Blood loss 3) Abnormal erythrocyte production Destruction of normally formed red blood cells Inadequate formed white blood cells
Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells Explanation: Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.
The nurse is teaching a client with HIV how to use a male condom. The client demonstrates understanding of the information when he makes which statements? Select all that apply. 1) "I can reuse a condom two or three times when I'm having sexual intercourse." 2) "I need to hold the condom by the tip to squeeze out the air before putting it on." 3) "I should unroll the condom all the way over my erect penis." 4) "I can keep several condoms in my wallet in my back trouser pocket so they are readily available." 5) "I should avoid using baby oil or petroleum jelly with a condom."
Correct Response: "I need to hold the condom by the tip to squeeze out the air before putting it on." "I should unroll the condom all the way over my erect penis." "I should avoid using baby oil or petroleum jelly with a condom." Explanation: The client should apply a new male condom before any kind of sex and should use the condom only once. He also should use a new condom for sex in a different place, such as the anus and then in the vagina. The client should hold the condom by the tip to squeeze the air out and then unroll the condom all the way over the erect penis. Condoms should be stored in a cool, dry place, not the wallet or back pocket because the condom can break down. Products containing oil such as baby oil, skin lotions, or petroleum jelly should not be used because these products will cause the condom to break.
A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? Select all that apply. 1) Hypothermia 2) Hypertension 3) Hypotension 4) Hypoventilation 5) Hyperventilation
Correct Response: Hypotension Hypoventilation Hypothermia Explanation: Severe hypothyroidism is called myxedema. Advanced, untreated myxedema can progress to myxedemic coma. Signs of this life-threatening event are hypothermia, hypotension, and hypoventilation. Hypertension and hyperventilation indicate increased metabolic responses, which are the opposite of what the client would be experiencing.
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. 1) semen 2) urine 3) breast milk 4) blood 5) vaginal secretions
Correct Response: breast milk blood vaginal secretions semen Explanation: There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.
The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply. 1) Absence of secretions 2) Aspiration 3) Infection 4) Injury to the laryngeal nerve 5) Penetration of the anterior tracheal wall
Correct Response: Aspiration Infection Injury to the laryngeal nerve Explanation: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.
A client is taking methimazole (Tapazole) every 8 hours around the clock for the treatment of severe hyperthyroidism. The client has been taking the medication for 2 months. What should the nurse instruct the client to report immediately? Select all that apply. 1) Sore throat 2) Unusual bleeding 3) Fever 4) Pain in the leg 5) Cough
Correct Response: Sore throat Unusual bleeding Fever Explanation: The most serious adverse effect of antithyroid drugs is agranulocytosis, which occurs most often in the first 2 months of therapy and necessitates discontinuing the drug. Instruct the client to report sore throat, fever, chills, headache, malaise, weakness, or unusual bleeding or bruising.
The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include? 1) "Wash your feet in hot water every day." 2) "Use a razor to remove corns or calluses." 3) "Be sure to apply a moisturizer to feet daily." 4) "Wear well-fitting comfortable rubber shoes."
Correct response: "Be sure to apply a moisturizer to feet daily." Explanation: The nurse should advise the client to apply a moisturizer to the feet daily. The client should use warm water, not hot water, to bathe his feet. Razors to remove corns or calluses must be avoided to prevent injury and infection. The client should wear well-fitting comfortable shoes, avoiding shoes made of rubber, plastic, or vinyl, which would cause the feet to perspire.
The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question is most important for the nurse to ask? 1) "Who eats meals with you?" 2) "How do you prepare your food?" 3) "Do you eat three meals per day?" 4) "Do you snack in the evening?"
Correct response: "How do you prepare your food?" Explanation: Asking the client how food is prepared, gives the nurse and dietitian the ability to judge the sodium content. Typically, canned or prepared food and food from a restaurant will have elevated sodium levels. Sodium content in food prepared from fresh ingredients is usually minimal. Asking about whom the client eats with or the client's eating patterns are not as helpful in determining sodium content.
A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg and the health care provider diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension, since the client denies any discomfort. What would be the nurse's best response? 1) "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs." 2) "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group." 3) "Hypertension is the leading cause of death in people your age." 4) "Hypertension greatly increases your risk of stroke and heart disease."
Correct response: "Hypertension greatly increases your risk of stroke and heart disease." Explanation: Hypertension, particularly elevated systolic BP, increases the risk of death, stroke, and heart failure in people older than 50 years. Hypertension is not a direct precursor to pulmonary emboli, and it does not put older adults at increased risk of type 1 diabetes or cancer. It is not the leading cause of death in people 55 years of age.
The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia? "I feel hot all of the time." "I have a difficult time falling asleep at night." "I have an increase in my appetite." "I have difficulty breathing when walking 30 feet."
Correct response: "I have difficulty breathing when walking 30 feet." Explanation: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigued and able to sleep often with a decrease in appetite, not an increase.
A client is taking glyburide (DiaBeta), 1.25 mg P.O. daily, to treat type 2 diabetes. Which statement indicates the need for further client teaching about managing this disease? 1) "I always carry hard candy to eat in case my blood sugar level drops." 2) "I avoid exposure to the sun as much as possible." 3) "I always wear my medical identification bracelet." 4) "I skip lunch when I don't feel hungry."
Correct response: "I skip lunch when I don't feel hungry." Explanation: The client requires further teaching if he states that he skips meals. A client who is receiving an oral antidiabetic agent should eat meals on a regular schedule because skipping a meal increases the risk of hypoglycemia. Carrying hard candy, avoiding exposure to the sun, and always wearing a medical identification bracelet indicate effective teaching.
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? 1) "I have environmental allergies." 2) "I smoke a pack of cigarettes a day." 3) "I used my voice in excess over the weekend." 4) "I was chewing ice chips all day long."
Correct response: "I was chewing ice chips all day long." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes.
The nurse is instructing a client about taking corticosteroid therapy for adrenal insufficiency. What statement made by the client indicates a need for further instruction? 1) "I will take the corticosteroid medication until my adrenal glands begin to work." 2) "I will not omit any of the doses of my medication." 3) "I will seek medical attention for dosage readjustments whenever I am under stress." 4) "I will get plenty of rest and avoid exposure to infection."
Correct response: "I will take the corticosteroid medication until my adrenal glands begin to work." Explanation: The nurse should explain adrenal insufficiency and the importance of lifetime corticosteroid replacement. The other statements indicate that the client is educated about the medication administration.
A recently widowed diabetic comments that her blood sugar levels are running higher than usual. Which is the best response from the nurse? 1) "People who eat alone tend to eat more." 2) "Cooking lower carbohydrate meals for one person is a challenge." 3) "This must be a stressful time for you." 4) "Quit checking your blood sugars for now."
Correct response: "This must be a stressful time for you." Explanation: High stress levels can result in fluctuating blood sugar levels and may require treatment modifications. Cooking meals for one person can be challenging but not as significant as the added stress associated with grieving. People who are distracted while eating do tend to eat more but not as significant for this client. Blood sugars should be monitored to determine if modifications in treatment are needed.
A client is considering beginning sexual relations and wants to know the best way to be protected from a sexually transmitted infection and HIV. What is the best response by the nurse? 1) "Using a latex condom and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV." 2) "Using a diaphragm with spermicidal jelly will kill the bacteria and viruses that transmit STIs and HIV." 3) "Using a lamb skin condom will be the most effective way to decrease transmission of STIs and HIV." 4) "Douching immediately after intercourse will be the most effective way to kill bacteria and viruses."
Correct response: "Using a latex condom and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV." Explanation: Using a latex condom with spermicide is one of the most effective ways to reduce the risk of HIV infection. Condoms are available for both men and women. A diaphragm would not be the most effective way because there is no protection for the penis or vagina. A lamb skin condom is not effective to prevent the transmission of HIV. Douching after intercourse is not an effective method to avoid transmission and does not offer protection from secretions that are already present.
A client is receiving immunotherapy as part of the treatment plan for an allergic disorder. After administering the therapy, the client states, "I guess I can go home now." Which response by the nurse would be most appropriate? 1) "We need to schedule your next appointment first and then you can leave." 2) "You need to stay about another half-hour so we can make sure you don't have a reaction." 3) "It's okay to leave but make sure to call us if you start to feel strange after an hour or so." 4) "You must stay here so that you can get another injection of a different substance to which you're allergic."
Correct response: "You need to stay about another half-hour so we can make sure you don't have a reaction." Explanation: Although severe systemic reactions are rare, the risk of serious and potentially fatal anaphylaxis exists. Therefore, the client needs to remain in the office or clinic for at least 30 minutes after the injection to be observed for possible systemic symptoms. The client should not be allowed to leave until 30 minutes pass. If more than one allergen is being used, the injections typically occur at the same time.
A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well controlled? 1) 6.5% 2) 7.5% 3) 8.0% 4) 8.5%
Correct response: 6.5% Explanation: Normally, the level of glycosylated hemoglobin is less than 7%. Thus, a level of 6.5% would indicate that the client's blood glucose level is well controlled. According to the American Diabetes Association, a glycosylated hemoglobin of 7% is equivalent to an average blood glucose level of 150 mg/dl. Thus, a level of 7.5% would indicate less control. Amount of 8% or greater indicate that control of the client's blood glucose level has been inadequate during the previous 2 to 3 months.
A 17-year-old girl with spina bifida is helping her mother prepare for her younger brother's birthday party. After blowing up a balloon, the girl develops erythema and itching around her mouth. This is likely due to which of the following? A developing cold sore A food allergy A latex allergy Facial eczema
Correct response: A latex allergy Explanation: Health care workers and patients with exposure to latex, as in spina bifida, are at risk for developing a latex allergy. Symptoms of latex allergy can range from mild contact dermatitis and erythema to moderately severe symptoms of rhinitis and conjunctivitis, urticaria, and bronchospasm. Balloons, condoms, and catheters are some of the items that contain latex. The girl would not have a developing cold sore from blowing up balloons. Nor would she have a food allergy or facial eczema.
Hypertension is defined as "sustained elevations in systolic or diastolic blood pressures that exceed prehypertension levels." What are some of the consequences of hypertension that make it such a health menace in the United States? 1) All options are correct. 2) cardiac failure 3) cerebrovascular accident 4) renal disease
Correct response: All options are correct. Explanation: Healthcare professionals have revised guidelines for identifying hypertension because hypertension places people at risk for heart disease, heart failure, stroke, and kidney disease.
A client is undergoing sensitivity testing to define the allergen which is causing the client difficulty. Before the procedure begins, the nurse indicates the various routes in which an allergen can be introduced. What is an allergen introduction route? 1) All options are correct. 2) ingestion 3) inhalation 4) injection
Correct response: All options are correct. Explanation: Allergens can be introduced via ingestion, injection, inhalation, and contact
A nurse plans to have an education session with a client with cardiomyopathy and the client's spouse about ways to increase activity tolerance. What instructions would the nurse provide? 1) Alternate active periods with rest periods. 2) Gradually work up to strenuous activity. 3) Include isometric exercises in the daily routine. 4) Avoid all physical and emotional stress.
Correct response: Alternate active periods with rest periods. Explanation: The client should plan activities to occur in cycles, alternating rest with active periods. The client with cardiomyopathy must avoid strenuous activity and isometric exercises. It is impossible to avoid all physical and emotional stress.
A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times? 1) A medical alert bracelet 2) An H1 blocker 3) An EpiPen 4) An oral airway
Correct response: An EpiPen Explanation: All patients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed.
A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client? Aplastic anemia Pernicious anemia Iron-deficiency anemia Agranulocytosis
Correct response: Aplastic anemia Explanation: Clients with a plastic anemia experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells. The blood cell count shows insufficient numbers of blood cells. A bone marrow aspiration confirms that the production of stem cells is suppressed. This scenario does not describe a client with pernicious anemia, iron-deficiency anemia, or agranulocytosis.
A client has just been admitted to the unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis? Are you experiencing fever, chills, or night sweats? Do you use artificial respirators? Have you ever had a blood transfusion? Have you ever experienced fractures?
Correct response: Are you experiencing fever, chills, or night sweats? Explanation: In a client with Hodgkin's disease, the nurse should ask how long the client has noticed the enlarged lymph nodes. The nurse checks for the presence and the extent of tenderness in the area of the lymph node enlargement. The nurse should also ask the client about fever, chills, or night sweats. It is not pertinent to ask the client about any previous history of fractures, the use of artificial respirators, or any blood transfusions.
A client reports having diarrhea after every meal. The client has AIDS and wants to know what to do to stop having diarrhea. What should the nurse advise? 1) Avoid fibrous foods, lactose, fat, and caffeine. 2) Encourage large, high-fat meals. 3) Reduce food intake. 4) Increase the intake of iron and zinc.
Correct response: Avoid fibrous foods, lactose, fat, and caffeine. Explanation: Diarrhea may subside when the client avoids residue, lactose, fat, and caffeine. Although eating may seem to cause diarrhea, the client must understand that limiting the intake of food to control diarrhea only exacerbates wasting. The client will tolerate a low-fat, high-carbohydrate, and soft or liquid diet better than large, high-fat meals. The client should be advised to avoid large doses of iron and zinc because they can impair the functioning of the immune system.
A client with acquired immune deficiency syndrome (AIDS) informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the client has developed? 1) MAC 2) Wasting syndrome 3) Kaposi's sarcoma 4) Candidiasis
Correct response: Candidiasis Explanation: Candidiasis, a fungal infection, occurs in almost all clients with AIDS and immune depression (Durham & Lashley, 2010). Oral candidiasis is characterized by creamy-white patches in the oral cavity and, if left untreated, can progress to involve the esophagus and stomach. Associated signs and symptoms include difficult and painful swallowing and retrosternal pain.
A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching? 1) Caregiver washes hands before and after providing care to the client. 2) Caregiver cleans the client's anal area without wearing gloves 3) Caregiver disposes of syringe and needle in a metal coffee can with lid. 4) Caregiver uses a dilute bleach solution to clean up a urine spill.
Correct response: Caregiver cleans the client's anal area without wearing gloves Explanation: To prevent the risk of HIV transmission, standard precautions should be used. Cleaning the client's anal area without wearing gloves indicates that the nurse needs to reinstruct the caregiver in measures related to standard precautions. Handwashing before and after client care, disposing of sharps in a puncture-resistant container, and cleaning up spills with a dilute bleach solution are appropriate measures.
A client reports taking oral medication for control of sugar problems. Which is the best nursing interpretation of this verbal accounting? 1) Lack of knowledge of disease process 2) Client has type 2 diabetes mellitus. 3) Client has prediabetes mellitus. 4 ) Lack of knowledge on medication regime
Correct response: Client has type 2 diabetes mellitus. Explanation: Oral antidiabetic drugs are prescribed for the treatment of diabetes type 2. Not enough information in the report to determine if the client has a lack of knowledge of disease process and/or medication regime. Pre-diabetes is not treated with medication.
What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? 1) Come to the clinic for IV fluid therapy daily. 2) Limit the fluid intake at night. 3) Consume adequate amounts of fluid. 4) Weigh daily.
Correct response: Consume adequate amounts of fluid. Explanation: The nurse teaches the client to consume sufficient fluid to control thirst and to compensate for urine loss. The client will not be required to come in daily for IV fluid therapy. The client should not limit fluid intake at night if thirst is present. Weighing daily will not control thirst or compensate for urine loss.
A client sustained a head injury when falling from a ladder. While in the hospital, the client begins voiding large amounts of clear urine and reports being very thirsty. The client states feeling weak and having experienced an 8-pound weight loss since admission. What condition does the nurse expect the client to be tested for? 1) Diabetes insipidus (DI) 2) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) 3) Pituitary tumor 4) Hypothyroidism
Correct response: Diabetes insipidus (DI) Explanation: With diabetes insipidus, urine output may be as high as 20 L/24 hours. Urine is dilute, with a specific gravity of 1.002 or less. Limiting fluid intake does not control urine excretion. Thirst is excessive and constant. Activities are limited by the frequent need to drink and void. Weakness, dehydration, and weight loss develop. SIADH will have the opposite clinical manifestations. The client's symptoms are related to the trauma and not to a pituitary tumor. The thyroid gland does not exhibit these symptoms.
The nurse is performing an admission assessment on a patient with AIDS. When assessing the patient's gastrointestinal (GI) system what is most likely to be the priority nursing diagnosis? 1) Imbalanced nutrition: more than body requirements 2) Diarrhea 3) Bowel incontinence 4) Constipation
Correct response: Diarrhea Explanation: Diarrhea is a problem in 50% to 90% of all AIDS patients. In patients with AIDS, the effects of diarrhea can be devastating in terms of profound weight loss, fluid and electrolyte imbalances, perianal skin excoriation, weakness, and the inability to perform self-care activities. Although the patient may experience bowel incontinence related to the diarrhea, the priority GI-related nursing diagnosis for more than 50% of patients with AIDS is diarrhea.
The nurse is caring for a client diagnosed with infectious mononucleosis who is having trouble eating. What would the nurse advise this client to improve his oral intake? 1) Eat warm food and drink warm liquids. 2) Eat soft, bland foods and drink cool liquids. 3) Avoid spicy foods and drink warm liquids. 4) Eat soft, bland foods and drink warm liquids.
Correct response: Eat soft, bland foods and drink cool liquids. Explanation: The nurse inspects the client's throat for the extent of inflammation or edema. He or she gently palpates the lymph nodes to detect swelling and encourages fluids. Soft, bland foods and cool liquids are best for clients with ulcerations of the oral mucosa. Warm food and liquids and spicy food are not recommended.
The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect? 1) Infection 2) Postoperative bleeding 3) Edema of the upper airway 4) Plugged tracheostomy tube
Correct response: Edema of the upper airway Explanation: With severe respiratory distress in a status post adenoidectomy client, the nurse would suspect an airway issue related to edema of the upper airway. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube.
A nurse is providing information on food allergies to a group of teachers. What food items would the nurse inform the teachers are common allergens? 1) Citrus fruit and rice 2) Root vegetables and tomatoes 3) Eggs and nuts 4) Rye flour and cheese
Correct response: Eggs and nuts Explanation: The most common allergy offenders are seafood (lobster, shrimp, crab, clams, fish), legumes (peanuts, peas, beans, licorice), seeds (sesame, cottonseed, caraway, mustard, flaxseed, sunflower seeds), tree nuts, berries, egg white, buckwheat, milk, and chocolate.
Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? 1) Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding. 2) Put on a mask, gown, and gloves when entering the client's room. 3) Provide a clear liquid, low-sodium diet. 4) Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.
Correct response: Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. Explanation: Neutropenia occurs when the absolute neutrophil count falls below 1,000/mm3, reflecting a severe risk of infection. The nurse should provide a low-bacterial diet, which means eliminating fresh fruits and vegetables, avoiding invasive procedures such as enemas, and practicing frequent hand washing. Using a soft toothbrush, avoiding straight-edged razors and enemas, and monitoring for bleeding are precautions for clients with thrombocytopenia. Putting on a mask, gown, and gloves when entering the client's room are reverse isolation measures. A neutropenic client doesn't need a clear liquid diet or sodium restrictions.
The nurse is taking the history of a client with diabetes who is experiencing autonomic neuropathy. Which would the nurse expect the client to report? 1) Skeletal deformities 2) Paresthesias 3) Erectile dysfunction 4) Soft tissue ulceration
Correct response: Erectile dysfunction Explanation: Autonomic neuropathy affects organ functioning. According the American Diabetes Association, up to 50% of men with diabetes develop erectile dysfunction when nerves that promote erection become impaired. Skeletal deformities and soft tissue ulcers may occur with motor neuropathy. Paresthesias are associated with sensory neuropathy.
The nurse is caring for a client who is status post nasal polypectomy. What would the nurse instruct this client to report? 1) Excessive swallowing 2) Nasal stuffiness 3) Diarrhea 4) Coughing
Correct response: Excessive swallowing Explanation: The nurse inspects the nasal packing and dressings frequently for bleeding and asks the client to report excessive swallowing, which can indicate bleeding. Nasal stuffiness and diarrhea do not indicate postoperative bleeding. Coughing can loosen or expel scabs on the surgical wounds.
A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection? 1) Limit interactions with people who are not HIV infected. 2) Limit interactions with people who are already HIV infected. 3) Follow the same sexual precautions as someone who has been diagnosed with AIDS. 4) Quit their job and get admitted to a hospital or a cancer treatment center.
Correct response: Follow the same sexual precautions as someone who has been diagnosed with AIDS. Explanation: The healthcare worker will be tested for HIV at regular intervals and treated with antiretrovirals depending on the results of the tests or the potential for infection. While awaiting the results, the healthcare worker should follow the same sexual precautions as someone who has been diagnosed with AIDS. The healthcare worker should not limit interactions with either non-HIV-infected or HIV-infected people. In addition, the healthcare worker should not quit and be admitted to a hospital for treatment. Treatment, if required, can begin if the result of the test is positive.
When teaching a client about hypertension and lifestyle changes what does the nurse emphasizes should be included in the diet? Fresh fruits and vegetables Chloride-containing foods Whole milk and cheeses A glass of red wine
Correct response: Fresh fruits and vegetables Explanation: The dietary approach to stop hypertension states that a diet high in fruits and vegetables and low in fat and sodium will prevent or control hypertension. There is no need to consume chloride-containing foods. Whole mile milk and cheeses are high in saturated fats and should be avoided. While alcohol is considered acceptable in low quantities, it is not something that must be included in the diet.
The nurse is reviewing a client's history which reveals that the client has had an oversecretion of growth hormone (GH) that occurred before puberty. The nurse interprets this as resulting in which condition? 1) Gigantism 2) Dwarfism 3) Acromegaly 4) Simmonds disease
Correct response: Gigantism Explanation: When oversecretion of GH occurs before puberty, gigantism results. Dwarfism occurs when secretion of GH is insufficient during childhood. Oversecretion of GH during adulthood results in acromegaly. An absence of pituitary hormonal activity causes Simmonds disease.
A client with Addison disease has a blood glucose level above 80 mg/dL 30 minutes after receiving 15 g of carbohydrates for symptoms of hypoglycemia. Which action would the nurse take next? 1) Inform the physician immediately. 2) Give the client milk and graham crackers. 3) Instruct the client to remain in bed. 4) Check the client's blood glucose level before each meal.
Correct response: Give the client milk and graham crackers. Explanation: Milk and graham crackers contain forms of carbohydrates that take longer to absorb and tend to maintain the blood glucose level for an extended period. The physician should be informed if the client continues to be symptomatic and the blood glucose level is below 80 mg/dL. Maintaining bed rest protects the client from injuries from a fall but does not address the blood glucose issue. Assessing the client's blood glucose level provides a numeric assessment of the blood glucose level and would be performed in an ongoing fashion.
A woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV? 1) Rashes on the face, trunk, palms, and soles 2) Muscle and joint pain 3) Gynecologic problems 4) Weight loss
Correct response: Gynecologic problems Explanation: In women with HIV, gynecologic problems, such as abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may be the focus of a majority of complaints. Acute retroviral syndrome (viremia) may be the chief complaint in one third to more than one half of those infected, not necessarily women. Its manifestations include rashes, muscle and joint pain, and weight loss.
Which of the following precautions would be most appropriate when caring for a client being treated with radioactive iodine (RAI) for a thyroid tumor? 1) Administer prescribed corticosteroids carefully. 2) Handle body fluids carefully. 3) Monitor the respiratory status. Administer the prescribed medications at the same time each day.
Correct response: Handle body fluids carefully. Explanation: The nurse handles body fluids carefully to prevent spread of contamination. Corticosteroids are not prescribed for thyroid tumor. Monitoring the respiratory status and administering prescribed medicines at the same time each day are unrelated to the care of a client receiving RAI.
A client with Addison's disease is being discharged from the hospital and is being instructed about the dietary regimen. What type of diet should the nurse provide written and verbal instructions about? 1) Low-carbohydrate, low-protein diet 2) Low-fat, high-protein diet 3) Low-protein, high-carbohydrate diet 4) High-protein, moderate-carbohydrate diet
Correct response: High-protein, moderate-carbohydrate diet Explanation: A high-protein, moderate-carbohydrate diet that is low in refined carbohydrates is recommended to reduce the risk of hypoglycemia from excess insulin secretion. The risk of hypoglycemia is also lessened by consuming frequent meals and snacks, especially a substantial bedtime snack. The other dietary regimens are not effective in the treatment of Addison's disease.
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? 1) Epistaxis, twice last week 2) Aphonia following a football game 3) Hoarseness for 2 weeks 4) Laryngitis following a cold
Correct response: Hoarseness for 2 weeks Explanation: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery? Hypocalcemia Hyponatremia Hyperkalemia Hypermagnesemia
Correct response: Hypocalcemia Explanation: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.
A client who suffered blunt chest trauma in a motor vehicle accident reports chest pain during deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. To relieve this chest pain, which position should the nurse encourage the client to assume? 1) Semi-Fowler's 2) Leaning forward while sitting 3) Supine 4) Prone
Correct response: Leaning forward while sitting Explanation: The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, thus helping to relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action, and therefore, do not relieve chest pain associated with pericarditis.
Which of the following would the nurse expect the physician to order for a client with hypothyroidism? 1) Levothyroxine sodium 2) Methimazole 3) Propranolol 4) Propylthiouracil
Correct response: Levothyroxine sodium Explanation: Hypothyroidism is treated with thyroid replacement therapy, in the form of desiccated thyroid extract or a synthetic product, such as levothyroxine sodium (Synthroid) or liothyronine sodium (Cytomel). Methimazole and propylthiouracil are antithyroid agents used to treat hyperthyroidism. Propranolol is a beta blocker that can be used to treat hyperthyroidism.
The nurse is developing a teaching plan for a client diagnosed with hypertension. What would be important for the nurse to emphasize as part of the plan of care? 1) Limiting sodium intake in the diet 2) Limiting cigarette smoking to 1 pack a week 3) Limiting alcohol to a can of beer to four times a day to thin the blood 4) Limiting activity to prevent over exertion
Correct response: Limiting sodium intake in the diet Explanation: Research findings indicate that smoking cessation, weight loss, reduced alcohol and sodium intake, and regular physical activity are effective lifestyle adaptations to reduce blood pressure. Limiting one's daily alcohol to 24 ounces of beer for men is recommended. Table salt should be limited to 1 teaspoon daily.
Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis? 1) Maintain the client on bed rest 2) Administer a prescribed antipyretic 3) Elevate the client's head 4) Administer supplemental oxygen
Correct response: Maintain the client on bed rest Explanation: The nurse should maintain the client on bed rest to reduce cardiac workload and promote healing. The nurse should administer supplemental oxygen to relieve tachycardia that may develop from hypoxemia. If the client has a fever, the nurse should administer a prescribed antipyretic along with independent nursing measures like minimizing layers of bed linen, promoting air circulation and evaporation of perspiration, and offering oral fluids. The nurse should elevate the client's head to promote maximal breathing potential.
For a client with Graves' disease, which nursing intervention promotes comfort? 1) Restricting intake of oral fluids 2) Placing extra blankets on the client's bed 3) Limiting intake of high-carbohydrate foods 4) Maintaining room temperature in the low-normal range
Correct response: Maintaining room temperature in the low-normal range Explanation: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
Grace Walters, a 73-year-old female, is a client on the surgical floor where you practice nursing. She is returning from surgical hip repair and has an adhesive patch covering her incision. She has a history of an allergic disorder. Which of the following nursing actions is most important when assessing the dressing site of Mrs. Walters? 1) Observe Mrs. Walters for signs of allergic reaction. 2) Apply moisturizer to the site before sticking the patch. 3) Apply pressure to ensure that the patch is firmly in place. 4) Ensure that Mrs. Walters is lying down in a comfortable position.
Correct response: Observe Mrs. Walters for signs of allergic reaction. Explanation: Though it is important to ensure that the client is comfortable and the patch is firmly in place, it is not as essential as observing for an allergic reaction. Applying moisturizer to the site may interfere with the results of the patch test.
The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action? 1) Observe the client's stools for blood. 2) Evaluate the client's dietary intake. 3) Monitor the client's body temperature. 4) Monitor the client's blood pressure.
Correct response: Observe the client's stools for blood. Explanation: If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.
A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client? 1) Peripheral neuropathy 2) Circumoral paresthesia 3) Alterations in the renal function 4) Pancreatitis
Correct response: Peripheral neuropathy Explanation: The most common adverse effects associated with the administration of zidovudine is peripheral neuropathy. The drug does not cause circumoral paresthesia, alterations in the renal function, or pancreatitis.
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? 1) Platelet count 2) Potassium 3) Calcium 4) White blood cell (WBC) count
Correct response: Potassium Explanation: Diuretics, such as furosemide (Lasix), are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin (Lanoxin), and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective? 1) Increased salivation 2) Increased tearing 3) Reduced sneezing 4) Headache
Correct response: Reduced sneezing Explanation: Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, the client shouldn't experience increased salivation or tearing. Because decongestants alleviate congestion, they also relieve headaches, which may be caused by congestion.
The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order? 1) Provides best information on the body's ability to maintain normal blood functioning 2) Best indicator for the nutritional state of the client 3) Is less costly than performing daily blood sugar test 4) Reflects the amount of glucose stored in hemoglobin over past several months.
Correct response: Reflects the amount of glucose stored in hemoglobin over past several months. Explanation: Hemoglobin A1c tests reflect the amount of glucose that is stored in the hemoglobin molecule during its life span of 120 days. This test provides a more accurate picture of overall glucose control in a client. Glycosylated hemoglobin test does not indicate normal blood functioning or nutritional state of the client. Self-monitoring with a glucometer is still encouraged in clients who are taking insulin or have unstable blood glucose levels.
A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously? 1) Glargine 2) Regular 3) NPH 4) Lente
Correct response: Regular Explanation: Regular insulin is administered intravenously to treat DKA. It is added to an IV solution and infused continuously. Glargine, NPH, and Lente are only administered subcutaneously.
A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add? 1) Related to bone demineralization resulting in pathologic fractures 2) Related to exhaustion secondary to an accelerated metabolic rate 3) Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces 4) Related to tetany secondary to a decreased serum calcium level
Correct response: Related to bone demineralization resulting in pathologic fractures Explanation: Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This increase, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn't accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn't associated with tetany.
The nurse administers an injection to a client with AIDS. When finished, the nurse attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse? 1) Obtain counseling. 2) Call the lab to draw the nurse's blood. 3) Fill out a risk management report. 4) Report the incident to the supervisor.
Correct response: Report the incident to the supervisor. Explanation: Because post exposure protocols can reduce the risk of HIV infection if initiated promptly, nurses must immediately report any needlestick or sharp injury to a supervisor. Obtaining counseling will occur after all other procedures are adhered to. The lab will draw blood from the client if required for documentation and other blood transmitted disorders.
A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? 1) Croup 2) Rheumatic fever 3) Severe staphylococcal infection 4) Medullary sponge kidney
Correct response: Rheumatic fever Explanation: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, may eventually lead to hypertension but doesn't damage heart structures.
A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize? 1) Rising slowly from a lying or sitting position 2) Increasing fluids to maintain BP 3) Stopping medication if dizziness persists 4) loolTaking medication first thing in the morning
Correct response: Rising slowly from a lying or sitting position Explanation: Clients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these clients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Clients should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse's scope of practice.
A client is transferred to a rehabilitation center after being treated in the hospital for a stroke. Because the client has a history of Cushing's syndrome (hypercortisolism) and chronic obstructive pulmonary disease, the nurse formulates a nursing diagnosis of: Risk for imbalanced fluid volume related to excessive sodium loss. Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion. Ineffective health maintenance related to frequent hypoglycemic episodes secondary to Cushing's syndrome. Decreased cardiac output related to hypotension secondary to Cushing's syndrome.
Correct response: Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion. Explanation: Cushing's syndrome causes tissue catabolism, resulting in thinning skin and connective tissue loss; along with immobility related to stroke, these factors increase this client's risk for impaired skin integrity. The exaggerated glucocorticoid activity in Cushing's syndrome causes sodium and water retention which, in turn, leads to edema and hypertension. Therefore, Risk for imbalanced fluid volume and Decreased cardiac output are inappropriate nursing diagnoses. Increased glucocorticoid activity also causes persistent hyperglycemia, eliminating Ineffective health maintenance related to frequent hypoglycemic episodes as an appropriate nursing diagnosis.
The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: 101.2° F, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are coarse in the bases. Which afternoon assessment finding suggests the advancement to an infectious process? Achiness Headache Temperature rise Increased respiratory rate
Correct response: Temperature rise Explanation: Coryza refers to the common cold many times associated with a virus such as the rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature is interpreted that the client continues to have a sustained elevated temperature which suggests a bacterial infection. All viruses can include symptoms of achiness, headache, and an increase in the respiratory rate. Increased respiratory rate does not always indicate infection because it can be a sign of a multitude of other problems.
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse? 1) The client has converted from HIV infection to AIDS. 2) The client has advanced HIV infection. 3) The client's T4-cell count has decreased due to the Pneumocystis pneumonia. 4) The client has another infection present that is causing a decrease in the T4-cell count.
Correct response: The client has converted from HIV infection to AIDS. Explanation: AIDS is the end stage of HIV infection. Certain events establish the conversion of HIV infection to AIDS: a markedly decreased T4 cell count from a normal level of 800 to 1200/mm3 and the development of certain cancers and opportunistic infections. The client does not have advanced HIV; they meet the criteria for the development of AIDS. The T4-cell count is not decreasing due to an infection.
A patient, newly diagnosed with thrombocytopenia, is admitted to the medical unit. After the admission assessment the patient asks the nurse to explain the disease. What should the nurse explain to the patient about this condition? 1) There could be an attack on the platelets by the antibodies 2) There could be decreased production of platelets 3) There could be elevated platelet production. 4) There could be decreased white blood cell production.
Correct response: There could be decreased production of platelets Explanation: Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets. Increased production of platelets is associated with thrombocythemia. Decreased white blood cell production is associated with leukopenia.
The nurse is performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would the nurse ask the client about the use of herbal supplements? 1) They produce anorexia. 2) They impair the immune system. 3) They may prolong bleeding. 4) They lower high-density lipoprotein levels.
Correct response: They may prolong bleeding. Explanation: The nurse must find out the bleeding tendencies of clients scheduled for tonsillectomy and adenoidectomy. Therefore, the nurse asks the clients about any recent use of herbal supplements. The nurse must ask about the use of these supplements because they may prolong bleeding. A client may experience anorexia because of a diminished sense of taste and smell following a laryngectomy. Similarly, excess zinc impairs the immune system and lowers the levels of high-density lipoproteins. These symptoms are not caused by herbal supplements.
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse? 1) Trauma and microabrasions from a non-electric razor may contribute to anemia. 2) Strong tissues and intact clotting mechanisms may prevent hemorrhage. 3) The client is at risk for spontaneous and uncontrolled bleeding. 4) The client is not at risk for infection from microorganisms.
Correct response: Trauma and microabrasions from a non-electric razor may contribute to anemia. Explanation: In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.
The nurse understands that a client with diabetes mellitus is at greater risk for developing which of the following complications? 1) Low blood pressure 2) Urinary tract infections 3) Lifelong obesity 4) Elevated triglycerides
Correct response: Urinary tract infections Explanation: Elevated levels of blood glucose and glycosuria supports bacterial growth and places the diabetic at greater risk for urinary tract, skin, and vaginal infections. Obesity, elevated triglycerides, and high blood pressure are considered symptoms of metabolic syndrome, which can result in type 2 diabetes mellitus.
The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion? 1) Hematuria 2) Blood pressure of 90/60 mm Hg 3) Jaundice of the sclera 4) Urine output of 15 mL/hour
Correct response: Urine output of 15 mL/hour Explanation: Urine output of less than 30 to 50 mL/hour reflects inadequate renal perfusion. The kidneys must excrete 30 to 50 mL/hour or 500 mL/24 hours to eliminate wastes sufficiently. Hematuria is an indicatory of other problems such as hemorrhagic cystitis, trauma to the bladder, etc. It is not an indicator of renal perfusion. A blood pressure of 90/60 mm Hg does not indicate that the client is having a decrease in renal perfusion nor does jaundice. Jaundice is present when the liver starts to fail.
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: 1) p24 antigen test for confirmation of diagnosis. 2) Western blot test for confirmation of diagnosis. 3) polymerase chain reaction test for confirmation of diagnosis. 4) T4-cell count for confirmation of diagnosis.
Correct response: Western blot test for confirmation of diagnosis. Explanation: The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.
The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs? 1) dopamine 2) enalapril 3) furosemide 4) metoprolol
Correct response: dopamine Explanation: Dopamine, a sympathomimetic drug, is used to treat cardiogenic shock. It increases perfusion pressure to improve myocardial contractility and blood flow through vital organs. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta-adrenergic blocker that slows heart rate and lowers blood pressure, undesirable effects when treating cardiogenic shock.
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of: 1) severe hypotension. 2) excessive thirst. 3) profound neuromuscular irritability. 4) acute gastritis.
Correct response: profound neuromuscular irritability. Explanation: Hypoparathyroidism may slow bone resorption, reduce the serum calcium level, and cause profound neuromuscular irritability (as evidenced by tetany). Hypoparathyroidism doesn't alter blood pressure or affect the thirst mechanism, which usually is triggered by fluid volume deficit. Gastritis doesn't cause or result from hypoparathyroidism.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: 1) lie supine with his neck extended. 2) sit upright, leaning slightly forward. 3) blow his nose and then put lateral pressure on his nose. 4) hold his nose while bending forward at the waist.
Correct response: sit upright, leaning slightly forward. Explanation: Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.
It is important for a nurse to refer an HIV-positive client to support groups and resources because: 1) support groups and resources provide information about new HIV drug development and clinical drug trials to clients. 2) after a point in time, management of HIV-positive clients is not practical for the nurse. 3) support groups and resources provide better emotional and psychological support to HIV-positive clients. 4) it is mandatory, as per the state health guidelines, to refer HIV-positive clients to support groups.
Correct response: support groups and resources provide information about new HIV drug development and clinical drug trials to clients. Explanation: A very important nursing intervention is to refer HIV-positive clients to support groups and resources for information about new HIV drug development, clinical drug trials, AIDS drug assistance programs, and progress on vaccine development. It is not true that support groups only provide better emotional and psychological support to HIV-positive patients or that the nurses become incapable of managing such patients after a point of time. In addition, it is not mandatory by the state to refer HIV-positive patients to support groups.
When caring for a client with diabetes insipidus, the nurse expects to administer: vasopressin. furosemide. regular insulin. 10% dextrose.
Correct response: vasopressin. Explanation: Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.
A nurse suspects that a client has digoxin toxicity. The nurse should assess for: 1) hearing loss. 2) vision changes. 3) decreased urine output. 4) gait instability.
Correct response: vision changes. Explanation: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.
A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity? 1) visual disturbances. 2) taste and smell alterations. 3) dry mouth and urine retention. 4) nocturia and sleep disturbances.
Correct response: visual disturbances. Explanation: Digoxin toxicity may cause visual disturbances (e.g., flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (e.g., headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (e.g., abnormal heart rate, arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.
A nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will order daily supplements of calcium and: 1) folic acid. 2) vitamin D. 3) potassium. 4) iron.
Correct response: vitamin D. Explanation: Typically, clients with hypoparathyroidism are ordered daily supplements of vitamin D along with calcium because calcium absorption from the small intestine depends on vitamin D. Hypoparathyroidism doesn't cause a deficiency of folic acid, potassium, or iron. Therefore, the client doesn't require daily supplements of these substances to maintain a normal serum calcium level.
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor? 1) fluid intake and output. 2) urine specific gravity. 3) vital signs. 4) weight.
Correct response: weight. Explanation: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.
The nurse is educating a patient with allergic rhinitis about how the condition is induced. What should the nurse include in the education on this topic? Airborne pollens or molds Ingested foods Parenteral medications Topical creams or ointments
Correct response: Airborne pollens or molds Explanation: Allergic rhinitis is induced by airborne pollens or molds, occurring typically in early spring (tree pollen), early summer (rose and grass pollen), and early fall (weed pollen).
