unit 7

1. A clients white blood cell count is 7500/mm3. Calculate the expected range for this clients neutrophils. (Record your answer using whole numbers separated with a hyphen; do not use commas.) ______/mm3

4125-5625/mm3 The normal range for neutrophils is 55% to 75% of the white blood cell count. 7500 0.55 = 4125 7500 0.75 = 5625 So the range would be expected to be 4125/mm3 to 5625/mm3.

The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan? A. "Please report any increased redness, swelling, warmth, or pain to your health care provider." B. "Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed." C. "A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week." D. "Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions."

A. "Please report any increased redness, swelling, warmth, or pain to your health care provider." Instruction on increased signs and symptoms of inflammation could reveal signs of potential infection and is most important.Although information about having blood pressure taken or having blood drawn should be included, it is not the most important instruction for postoperative day 1 discharge. Referrals are important in helping with coping but are not the most important consideration when the client is being sent home on postoperative day 1. Positioning is important but is not the priority here.

Which statement accurately explains otitis media? A. The inflammatory response is triggered by the invasion of foreign proteins. B. Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders. C. It is caused by a left shift or increase in immature neutrophils. D. Many immune system cells released into the blood have specific effects.

A. The inflammatory response is triggered by the invasion of foreign proteins. The inflammatory bacterial response of otitis media is stimulated by invading foreign proteins caused by infection.Macrophages and neutrophils are involved in the process of inflammation, but otitis media is an inflammation caused by infection. It is not caused by a left shift or increase in immature neutrophil forms. The change in form is caused by infection, such as sepsis. The action of immune system cells occurs when encountering a non-self or foreign protein to neutralize, destroy, or eliminate a foreign invader. This does not cause inflammation.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

ANS: A Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted. DIF: Applying/Application REF: 315 KEY: Systemic lupus erythematosus| autoimmune disorders| nursing assessment| pain| steroids MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

ANS: A Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept. DIF: Understanding/Comprehension REF: 310 KEY: Rheumatoid arthritis| autoimmune disease| biologic response modifiers| client education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct? a. Inspect the client's distal finger joints. b. Palpate the client's abdomen for tenderness. c. Palpate the client's upper body lymph nodes. d. Perform range of motion on the client's wrists.

ANS: A Herberden's nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the client's distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists. DIF: Applying/Application REF: 292 KEY: Musculoskeletal system| musculoskeletal assessment| nursing assessment| osteoarthritis MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Baker's cysts. b. Inspect the client's feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

ANS: A Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker's cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate. DIF: Applying/Application REF: 306 KEY: Rheumatoid arthritis| autoimmune disorders| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

ANS: A The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs? a. Assess the client's coping skills and support systems. b. Explain that the surgery leads to a longer life expectancy. c. Refer the client to the social worker or hospital chaplain. d. Reinforce physical therapy to aid with ambulating normally.

ANS: A The first step in the nursing process is assessment. The nurse should assess coping skills and possible support systems that will be helpful in this client's treatment. Explaining that a limb salvage procedure will extend life does not address the client's psychosocial needs. Referrals may be necessary, but the nurse should assess first. Reinforcing physical therapy is also helpful but again does not address the psychosocial needs of the client.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the client's culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

ANS: A The nurse needs a more thorough understanding of the client's culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding. DIF: Applying/Application REF: 313 KEY: Rheumatoid arthritis| autoimmune disorders| coping| culture| patient-centered care| diversity MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best? a. Assess the neurovascular status of the right leg. b. Document the findings in the client's chart. c. Elevate the left leg on at least two pillows. d. Notify the provider of the findings immediately.

ANS: A The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.

A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate? a. Bending forward from the hips b. Sitting upright with arms outstretched c. Walking across the room and back d. Walking with both eyes closed

ANS: A To assess for scoliosis, a spinal deformity, the student should bend forward at the hips. Standing behind the student, the nurse looks for a lateral curve in the spine. The other actions are not correct.

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

ANS: A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

ANS: A, B, D Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence. DIF: Applying/Application REF: 311 KEY: Rheumatoid arthritis| autoimmune disorders| activities of daily living| musculoskeletal system| functional ability MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

ANS: A, B, D, E MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug. DIF: Applying/Application REF: 308 KEY: Rheumatoid arthritis| autoimmune disease| patient education| disease-modifying antirheumatic drugs (DMARDs)| acetaminophen MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization

ANS: A, B, D, E The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.) a. Edema - Increased capillary permeability b. Pallor - Increased blood blow to the area c. Unequal pulses - Increased production of lactic acid d. Cyanosis - Anaerobic metabolism e. Tingling - A release of histamine

ANS: A, C, D Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure.

A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn? (Select all that apply.) a. A lack of vitamin D can lead to rickets. b. Calcitonin increases serum calcium levels. c. Estrogens stimulate osteoblastic activity. d. Parathyroid hormone stimulates osteoclastic activity. e. Thyroxine stimulates estrogen release.

ANS: A, C, D Vitamin D is needed to absorb calcium and phosphorus. A deficiency of vitamin D can lead to rickets. Estrogen stimulates osteoblastic activity. Parathyroid hormone stimulates osteoclastic activity. Calcitonin decreases serum calcium levels when they get too high. Thyroxine increases the rate of protein synthesis in all tissue types.

A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "The device has been custom made specifically for you." b. "Your prosthetic is good for work but not for exercising." c. "A prosthetist will clean your inserts for you each month." d. "Make sure that you wear the correct liners with your prosthetic." e. "I have scheduled a follow-up appointment for you."

ANS: A, D, E A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the client's level of amputation, lifestyle (including exercise preferences), and occupation. In collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment.

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth

ANS: A, D, E The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

A client has a bone density score of -2.8. What action by the nurse is best? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months

ANS: B A T-score from a bone density scan at or lower than -2.5 indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease. One class of such medications is bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either.

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

ANS: B All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first. DIF: Applying/Application REF: 305 KEY: Rheumatoid arthritis| nursing assessment| autoimmune disorder MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you compliant with following the diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"

ANS: B All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. "Compliant" is a word associated with negative images, and the client may deny being "noncompliant." Asking how much exercise the client "really" gets is accusatory. Asking if the client takes his or her medications "right?" is patronizing. DIF: Applying/Application REF: 295 KEY: Osteoarthritis| nursing assessment| supplements MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test? a. Administer sedation as prescribed. b. Assess for seafood or iodine allergy. c. Ensure that the client has no metal on the body. d. Provide preprocedure pain medication.

ANS: B Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this client's plan of care? a. Place pillows between the client's knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.

ANS: B Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractions and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-position, move, and exercise frequently, and therefore should not be restricted to bedrest.

A client has been prescribed denosumab (Prolia). What instruction about this drug is most appropriate? a. "Drink at least 8 ounces of water with it." b. "Make appointments to come get your shot." c. "Sit upright for 30 to 60 minutes after taking it." d. "Take the drug on an empty stomach."

ANS: B Denosumab is given by subcutaneous injection twice a year. The client does not need to drink 8 ounces of water with this medication as it is not taken orally. The client does not need to remain upright for 30 to 60 minutes after taking this medication, nor does the client need to take the drug on an empty stomach.

A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

ANS: B During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

ANS: B Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness. DIF: Remembering/Knowledge REF: 311 KEY: Rheumatoid arthritis| autoimmune disorders| ice| pain MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans

ANS: B SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events. DIF: Applying/Application REF: 316 KEY: Systemic lupus erythematosus| autoimmune disorders| coping| psychosocial response MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action? a. Pain of 4 on a scale of 0 to 10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

ANS: B The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse cares for a client who had a long-leg cast applied last week. The client states, "I cannot seem to catch my breath and I feel a bit light-headed." Which action should the nurse take next? a. Auscultate the client's lung fields anteriorly and posteriorly. b. Administer oxygen to keep saturations greater than 92%. c. Check the client's blood glucose level. d. Ask the client to take deep breaths.

ANS: B The client's symptoms are consistent with the development of pulmonary embolism caused by leg immobility in the long cast. The nurse should check the client's pulse oximetry reading and provide oxygen to keep saturations greater than 92%. Auscultating lung fields, checking blood glucose level, or deep breathing will not assist this client.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

ANS: B The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns. DIF: Applying/Application REF: 296 KEY: Joint replacement| informed consent| blood transfusions| preoperative nursing MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.) a. Allopurinol (Zyloprim) - Acute gout b. Colchicine (Colcrys) - Acute gout c. Febuxostat (Uloric) - Chronic gout d. Indomethacin (Indocin) - Acute gout e. Probenecid (Benemid) - Chronic gout

ANS: B, C, D, E Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout. DIF: Remembering/Knowledge REF: 320 KEY: Gout| pain| pharmacologic pain management MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

ANS: B, C, D, E Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss

ANS: B, C, E Late manifestations of RA include Felty's syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease. DIF: Remembering/Knowledge REF: 305 KEY: Rheumatoid arthritis| nursing assessment| musculoskeletal system| autoimmune disorders MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color

ANS: B, C, E With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the client's heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to determine whether shock is manifesting. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or neurovascular accidents.

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr

ANS: C A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

A hospitalized client is being treated for Ewing's sarcoma. What action by the nurse is most important? a. Assessing and treating the client for pain as needed b. Educating the client on the disease and its treatment c. Handling and disposing of chemotherapeutic agents per policy d. Providing emotional support for the client and family

ANS: C All actions are appropriate for this client. However, for safety, the nurse should place priority on proper handling and disposal of chemotherapeutic agents.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises.

ANS: C Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine. DIF: Applying/Application REF: 301 KEY: Joint replacement| delegation| continuous passive motion machine| unlicensed assistive personnel (UAP) MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client has a metastatic bone tumor. What action by the nurse takes priority? a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Handle the affected extremity with caution. d. Place the client on protective precautions.

ANS: C Bones invaded by tumors are very fragile and fracture easily. For client safety, the nurse handles the affected extremity with great care. Pain medication should be given to control pain. Elevation and heat may or may not be helpful. Protective precautions are not needed for this client.

A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess? a. Inability to maintain adduction of the affected arm for more than 30 seconds b. Shoulder pain that is relieved with overhead stretches and at night c. Inability to initiate or maintain abduction of the affected arm at the shoulder d. Referred pain to the shoulder and arm opposite the affected shoulder

ANS: C Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience referred pain to the opposite shoulder. Pain is usually more intense at night and with overhead activities.

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best? a. "A little sedation will help you get some rest." b. "Depression often accompanies fibromyalgia." c. "This drug works in the brain to decrease pain." d. "You will have more energy after taking this drug."

ANS: C Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate. DIF: Understanding/Comprehension REF: 322 KEY: Fibromyalgia| antidepressants| pain| pharmacologic pain management MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system? a. Cancellous tissue b. Collagen matrix c. Red marrow d. Yellow marrow

ANS: C Hematopoiesis occurs in the red marrow, which is part of the cancellous tissues containing both types of bone marrow.

An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38,000/mm3 but the client is afebrile. What action does the nurse take first? a. Administer acetaminophen (Tylenol). b. Educate the client on amputation. c. Place the client on contact isolation. d. Refer the client to the wound care nurse.

ANS: C In the presence of a heavily draining wound, the nurse should place the client on contact isolation. If the client has discomfort, acetaminophen can be used, but this client has not reported pain and is afebrile. The client may or may not need an amputation in the future. The wound care nurse may be consulted, but not as the first action.

The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

ANS: C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. Inflammatory is not a type of immunity.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise

ANS: C Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis. DIF: Understanding/Comprehension REF: 294 KEY: Client teaching| health promotion| osteoarthritis| weight loss MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

ANS: C Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery. DIF: Remembering/Knowledge REF: 295 KEY: Osteoarthritis| osteoporosis| joint replacement| surgical procedures MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse cares for an older adult client who is recovering from a leg amputation surgery. The client states, "I don't want to live with only one leg. I should have died during the surgery." How should the nurse respond? a. "Your vital signs are good, and you are doing just fine right now." b. "Your children are waiting outside. Do you want them to grow up without a father?" c. "This is a big change for you. What support system do you have to help you cope?" d. "You will be able to do some of the same things as before you became disabled."

ANS: C The client feels like less of a person following the amputation. The nurse should help the client to identify coping mechanisms that have worked in the past and current support systems to assist the client with coping. The nurse should not ignore the client's feelings by focusing on vital signs. The nurse should not try to make the client feel guilty by alluding to family members. The nurse should not refer to the client as being "disabled" as this labels the client and may fuel the client's poor body image.

A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen

ANS: C The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.

The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics

ANS: C, D, E Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first? a. Serum alkaline phosphatase (ALP): 108 units/L b. Serum aspartate aminotransferase (AST): 26 units/L c. Serum calcium: 10.2 mg/dL d. Serum phosphorus: 2 mg/dL

ANS: D A normal serum phosphorus level is 3 to 4.5 mg/dL; a level of 2 mg/dL is low, and this client should be assessed first. The values for serum ALP, AST, and calcium are all within normal ranges.

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? a. Administering pain medication before transport b. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility

ANS: D As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority. DIF: Applying/Application REF: 304 KEY: Hand-off communication| communication| The Joint Commission MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL b. Client who recently fell and has vertebral compression fractures c. Hypertensive client who takes calcium channel blockers d. Client with a spinal cord injury who cannot tolerate sitting up

ANS: D Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes clients bad candidates for this drug, but the client with a creatinine of 0.8 mg/dL is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

ANS: D Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider. DIF: Applying/Application REF: 306 KEY: Rheumatoid arthritis| autoimmune disorder| musculoskeletal system| communication| critical rescue MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year old female with type 2 diabetes and fractured ribs c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis

ANS: D Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.

An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).

ANS: D Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the clients TB test could be a false negative.

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

ANS: D Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels. DIF: Applying/Application REF: 311 KEY: Rheumatoid arthritis| autoimmune disorders| nursing assessment| biologic response modifiers MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

Which nursing activity can the nurse delegate to a home health aide? A. Changing the dressing for a client with a low absolute neutrophil count B. Assisting with bathing for a client with chronic rejection of a liver transplant C. Teaching a client with bacterial pneumonia how to take the prescribed antibiotic D. Assessing incisional tenderness for a client who had a recent kidney transplant

B. Assisting with bathing for a client with chronic rejection of a liver transplant Assisting with bathing for a client with chronic rejection of a liver transplant can be delegated to the home health aide.Changing the dressing for a client with a low absolute neutrophil count requires strict sterile technique by a licensed RN and should not be delegated because of the high risk for infection. Teaching about medications and assessments is within the scope of practice of the professional RN.

Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection? A. Older adult with Parkinson disease receiving a donation from an identical twin B. Grand multipara female with a history of subsequent blood transfusions C. Middle-aged man with a 20-pack-year history D. Young adult with type 1 diabetes

B. Grand multipara female with a history of subsequent blood transfusions The grand multipara female with a history of subsequent blood transfusions should be assessed first because multiple pregnancies and blood transfusions greatly increase the risk of a hyperacute rejection. Hyperacute rejection occurs mostly in transplanted kidneys but is less common now with better HLA matching. Symptoms of rejection are apparent within minutes of attachment of the donated organ to the recipient's blood supply. The process usually cannot be stopped once it has started, and the rejected organ must be removed as soon as hyperacute rejection is diagnosed.The older adult with Parkinson disease receiving a donation from an identical twin has less chance of hyperacute rejection because his donor is an identical twin. Smoking places the middle-aged man with a 20-pack-year history at higher risk for postoperative respiratory difficulties, but not for hyperacute rejection. Type 1 diabetes requires close postoperative monitoring of blood sugar, but does not predispose the client to a hyperacute rejection.

A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? A. Intact skin and mucous membranes B. Self-tolerance C. Inflammatory response against invading foreign proteins D. Antibody-antigen interaction

B. Self-tolerance Self-tolerance is the process of recognizing and distinguishing between the body's own healthy self cells and non-self proteins and cells. The presence of different proteins on cell membranes makes the process of self-tolerance possible.The body has some defenses to prevent organisms from gaining access to the internal environment, such as intact skin and mucous membranes; however, they are not perfect—invasion of the body's internal environment by organisms often occurs. Inflammation provides immediate protection against the effects of tissue injury and invading foreign proteins. The inflammatory response is immediate but short-term against injury or invading organisms; it does not provide true immunity. Seven steps, known as phagocytosis (See Figure 17-6), are needed to produce a specific antibody directed against a specific antigen. These steps are necessary whenever the person is exposed to that antigen.

The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching? A. "I will be on this medicine for the rest of my life." B. "I must undergo regular kidney function tests." C. "I must regularly monitor my blood sugar." D. "My gums may become swollen because of this drug."

C. "I must regularly monitor my blood sugar." Further teaching is needed when the client says, "I must regularly monitor my blood sugar." Blood sugar is not affected by taking cyclosporine, so the client has no need to monitor blood sugar.The client must take cyclosporine for the rest of his or her life. (See chart 17-2) Kidney dysfunction is a side effect of cyclosporine, so regular monitoring is required. Swollen gums are a side effect of taking cyclosporine.

Which home health nurse should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? A. RN who has worked for the home health agency for 5 years in maternal-child health B. RN who has extensive critical care nursing experience and has worked in home health for a year C. RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit D. RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency

D. RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency The RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency has the experience and understanding of the needs of a posttransplantation client, as well as knowledge of cyclosporine, and would be the best choice.An RN who has worked for the home health agency for 5 years in maternal-child health, an RN who has extensive critical care nursing experience and has worked in home health for a year, and an RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit would not have specific knowledge and information on the care provided and medications used in posttransplantation clients.

Natural Passive Acquired a. crosses the placenta, we get it from mom b. got the disease and produced antibodies c. get someone else's antibodies: very time limiting d. get vaccinated with attenuated serum so person produces antibodies; needs boosters

a. crosses the placenta, we get it from mom

neutrophil are a reaction to? a. acute inflammatory or infection b. viral and chronic bacterial infection c. parasitic infection & IgE-mediated allergic responses

a. acute inflammatory or infection

Active Natural Acquired a. crosses the placenta, we get it from mom b. got the disease and produced antibodies c. get someone else's antibodies: very time limiting d. get vaccinated with attenuated serum so person produces antibodies; needs boosters

b. got the disease and produced antibodies

Lymphocytes are a reaction to? a. acute inflammatory or infection b. viral and chronic bacterial infection c. parasitic infection & IgE-mediated allergic responses

b. viral and chronic bacterial infection

Basophils a. 0.3-2% b. 0.5-4% c. 0.5-1%

c. 0.5-1%

Eosinophils a. 1-10% b. 1-6% c. 1-4%

c. 1-4%

Monocytes a. 2-10% b. 4-9% c. 2-8%

c. 2-8%

Lymphocytes a. 10%-20% b. 60%-70% c. 20%-40%

c. 20%-40%

Neurophils (the MARINES 1st on scene)? a. 20%-30% b. 40%-50% c. 50%-70%

c. 50%-70%

Eosinophils and Basophils are a reaction to? a. acute inflammatory or infection b. viral and chronic bacterial infection c. parasitic infection & IgE-mediated allergic responses

c. parasitic infection & IgE-mediated allergic responses

Artificial Active Acquired a. crosses the placenta, we get it from mom b. got the disease and produced antibodies c. get someone else's antibodies: very time limiting d. get vaccinated with attenuated serum so person produces antibodies; needs boosters

d. get vaccinated with attenuated serum so person produces antibodies; needs boosters

An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

ANS: A A client's medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.

A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next? a. Immobilize the left arm. b. Assess the client's distal pulse. c. Monitor for signs of infection. d. Administer prescribed steroids.

ANS: A A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client's arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

ANS: A All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met. DIF: Evaluating/Synthesis REF: 312 KEY: Rheumatoid arthritis| autoimmune disorder| coping| psychosocial response MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Psychosocial Integrity

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

ANS: A All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug. DIF: Remembering/Knowledge REF: 293 KEY: Osteoarthritis| acetaminophen| pharmacologic pain management| patient teaching MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the client's fingers are pale, cool, and slightly swollen. Which action should the nurse take first? a. Raise the arm above the level of the heart. b. Encourage range of motion. c. Apply heat to the affected hand. d. Bivalve the cast to decrease pressure.

ANS: A Arm casts can impair circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should re-assess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Encouraging range of motion would not assist the client as much as elevating the arm. Heat would cause increased edema and should not be used. If the cast is confirmed to be too tight, it could be bivalved.

A client is distressed at body changes related to kyphosis. What response by the nurse is best? a. Ask the client to explain more about these feelings. b. Explain that these changes are irreversible. c. Offer to help select clothes to hide the deformity. d. Tell the client safety is more important than looks.

ANS: A Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client's feelings as possible. Explaining that the changes are irreversible discounts the client's feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar.

ANS: A Back pain with tenderness is indicative of a spinal compression fracture, which is the most common type of osteoporotic fracture. The nurse should consult the provider about an x-ray. Motrin may be indicated but not until there is a diagnosis. Range of motion of the hips is not related, although limited spinal range of motion may be found with a vertebral compression fracture. Since the defect is in the thoracic spine, a cervical collar is not needed.

A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.

ANS: A Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

After teaching a client who is recovering from a vertebroplasty, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I can drive myself home after the procedure." b. "I will monitor the puncture site for signs of infection." c. "I can start walking tomorrow and increase my activity slowly." d. "I will remove the dressing the day after discharge."

ANS: A Before discharge, a client who has a vertebroplasty should be taught to avoid driving or operating machinery for the first 24 hours. The client should monitor the puncture site for signs of infection. Usual activities can resume slowly, including walking and slowly increasing activity over the next few days. The client should keep the dressing dry and remove it the next day.

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

ANS: A Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively. DIF: Applying/Application REF: 293 KEY: Postoperative nursing| nonsteroidal anti-inflammatory drugs (NSAIDs)| musculoskeletal disorders MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

ANS: A Fear of falling can limit participation in activity. The nurse should first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises, or weight lifting.

What information does the nurse teach a women's group about osteoporosis? a. "For 5 years after menopause you lose 2% of bone mass yearly." b. "Men actually have higher rates of the disease but are underdiagnosed." c. "There is no way to prevent or slow osteoporosis after menopause." d. "Women and men have an equal chance of getting osteoporosis."

ANS: A For the first 5 years after menopause, women lose about 2% of their bone mass each year. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

The client's chart indicates genu varum. What does the nurse understand this to mean? a. Bow-legged b. Fluid accumulation c. Knock-kneed d. Spinal curvature

ANS: A Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis.

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. "I always wear long sleeves, pants, and a hat when outdoors." b. "I try not to use cosmetics that contain any type of sunblock." c. "Since I tend to sweat a lot, I use a lot of baby powder." d. "Since I can't be exposed to the sun, I have been using a tanning bed."

ANS: A Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds. DIF: Evaluating/Synthesis REF: 316 KEY: Systemic lupus erythematosus| nursing evaluation| self-care| patient teaching| integumentary system MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis

ANS: A Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? a. "Drink 1 to 2 liters of water each day." b. "Have 10 to 12 ounces of juice a day." c. "Liver is a good source of iron." d. "Never eat hard cheeses or sardines."

ANS: A Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines. DIF: Understanding/Comprehension REF: 320 KEY: Gout| musculoskeletal system| patient education| nutrition MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

ANS: A Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal. DIF: Applying/Application REF: 314 KEY: Systemic lupus erythematosus| autoimmune disease| renal system MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety? a. Meperidine (Demerol) 50 mg IV every 4 hours b. Patient-controlled analgesia (PCA) with morphine sulfate c. Percocet 2 tablets orally every 6 hours PRN for pain d. Ibuprofen elixir every 8 hours for first 2 days

ANS: A Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this client's pain management.

A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. It increases the elimination of T lymphocytes from circulation. b. It inhibits cytokine production in most lymphocytes. c. It prevents DNA synthesis, stopping cell division in activated lymphocytes. d. It prevents the activation of the lymphocytes responsible for rejection.

ANS: A Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

ANS: A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. Avoid large crowds and people who are ill. b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You have a higher risk of developing cancer.

ANS: A Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How should the nurse respond? a. "Skeletal traction will assist in realigning your fractured bone." b. "This treatment will prevent future complications and back pain." c. "Traction decreases muscle spasms that occur with a fracture." d. "This type of traction minimizes damage as a result of fracture treatment."

ANS: A Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.

A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best? a. Ensure the client gets 15 minutes of sun exposure daily. b. Give the client daily vitamin D injections. c. Hide vitamin D supplements in favorite foods. d. Plan to serve foods naturally high in vitamin D.

ANS: A Sunlight is a good source of vitamin D, and the nursing staff can ensure some sun exposure each day. Vitamin D is not given by injection. Hiding the supplement in food is unethical. Very few foods are naturally high in vitamin D, but some are supplemented.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client's vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowler's position. c. Increase the intravenous flow rate. d. Assess response to pain medications.

ANS: A The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowler's position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless.

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the client's leg.

ANS: A The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed. DIF: Applying/Application REF: 299 KEY: Joint replacement| safety| falls| musculoskeletal system MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best? a. "Your feet have less blood flow, so healing is slower." b. "The bones in your feet are hard to operate on." c. "The surrounding bones and tissue are damaged." d. "Your feet bear weight so they never really heal."

ANS: A The feet are the most distal to the heart and receive less blood flow than other organs and tissues, prolonging the healing time after surgery. The other explanations are not correct.

An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first? a. Assess the pedal pulses. b. Apply oxygen by nasal cannula. c. Increase the IV flow rate. d. Loosen the traction.

ANS: A These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a provider's prescription.

A client is in the internal medicine clinic reporting bone pain. The client's alkaline phosphatase level is 180 units/L. What action by the nurse is most appropriate? a. Assess the client for leg bowing. b. Facilitate an oncology workup. c. Instruct the client on fluid restrictions. d. Teach the client about ibuprofen (Motrin).

ANS: A This client has manifestations of Paget's disease. The nurse should assess for other manifestations such as bowing of the legs. Other care measures can be instituted once the client has a confirmed diagnosis.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

ANS: A This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client. DIF: Applying/Application REF: 297 KEY: Nursing assessment| joint replacement| musculoskeletal system MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels.

ANS: A This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the client's condition at discharge.

A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include? a. "Avoid large crowds or people who are ill." b. "Stay upright for 1 hour after taking this drug." c. "This drug may cause your hair to fall out." d. "You may double the dose if pain is severe."

ANS: A This drug has a Food and Drug Administration black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill. The other instructions do not pertain to golimumab. DIF: Applying/Application REF: 321 KEY: Psoriatic arthritis| autoimmune disorders| patient education| biologic response modifiers MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A hospitalized client's strength of the upper extremities is rated at 3. What does the nurse understand about this client's ability to perform activities of daily living (ADLs)? a. The client is able to perform ADLs but not lift some items. b. No difficulties are expected with ADLs. c. The client is unable to perform ADLs alone. d. The client would need near-total assistance with ADLs.

ANS: A This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotic as ordered. b. Assess the client's white blood cell count. c. Instruct the client to shower the night before. d. Monitor the client's temperature postoperatively.

ANS: A To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it. DIF: Applying/Application REF: 296 KEY: Joint replacement| Surgical Care Improvement Project (SCIP)| wound infection| antibiotics MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with systemic sclerosis. The client's facial skin is very taut, limiting the client's ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? a. Dentist b. Massage therapist c. Occupational therapy d. Physical therapy

ANS: A With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth. DIF: Applying/Application REF: 317 KEY: Systemic sclerosis| autoimmune disorder| oral care| collaboration MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education? a. High school football team b. High school homeroom class c. Middle-aged men d. Older adult women

ANS: A Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group.

A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.) a. Administer additional opioids as prescribed. b. Elevate the extremity on pillows. c. Apply ice to the fracture site. d. Place a heating pad at the site of the injury. e. Keep the extremity in a dependent position.

ANS: A, B, C The client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Administration of an additional opioid within the dosage guidelines may be ordered. Heat will increase edema and may increase pain. Dependent positioning will also increase edema.

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the client's patient-controlled analgesia button. d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

ANS: A, B, D Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client.

A client is admitted with a bone tumor. The nurse finds the client weak and lethargic with decreased deep tendon reflexes. What actions by the nurse are best? (Select all that apply.) a. Assess the daily serum calcium level. b. Consult the provider about a loop diuretic. c. Institute seizure precautions for the client. d. Instruct the client to call for help out of bed. e. Place the client on a 1500-mL fluid restriction.

ANS: A, B, D The client is exhibiting manifestations of possible hypercalcemia. This disorder is treated with increased fluids and loop diuretics. The nurse should assess the calcium level, consult with the provider, and instruct the client to call for help getting out of bed due to possible fractures and weakness. The client does not need seizure precautions or fluid restrictions.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

ANS: A, B, D, E Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees. DIF: Applying/Application REF: 301 KEY: Joint replacement| osteoarthritis| home safety| assistive devices MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A client is suspected to have muscular dystrophy. About what diagnostic testing does the nurse educate the client? (Select all that apply.) a. Electromyography b. Muscle biopsy c. Nerve conduction studies d. Serum aldolase e. Serum creatinine kinase

ANS: A, B, D, E Diagnostic testing for muscular dystrophy includes electromyography, muscle biopsy, serum aldolase and creatinine kinase levels. Nerve conduction is not related to this disorder.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

ANS: A, B, D, E Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.

When assessing gait, what features does the nurse inspect? (Select all that apply.) a. Balance b. Ease of stride c. Goniometer readings d. Length of stride e. Steadiness

ANS: A, B, D, E To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings assess flexion and extension or joint range of motion.

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash - Systemic lupus erythematosus (SLE) b. Esophageal dysmotility - Systemic sclerosis c. Excess uric acid excretion - Gout d. Footdrop and paresthesias - Osteoarthritis e. Vasculitis causing organ damage - Rheumatoid arthritis

ANS: A, B, E A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis. DIF: Remembering/Knowledge REF: 305, 314, 317 KEY: Autoimmune disorders MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.) a. It leads to minimal blood loss. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing.

ANS: A, B, E External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse should assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this client's teaching? (Select all that apply.) a. Frequently assess the ergonomics of the equipment being used. b. Take breaks to stretch fingers and wrists during working hours. c. Do not participate in activities that require repetitive actions. d. Take ibuprofen (Motrin) to decrease pain and swelling in wrists. e. Adjust chair height to allow for good posture.

ANS: A, B, E Health promotion activities to prevent carpal tunnel syndrome include assessing the ergonomics of the equipment being used, taking breaks to stretch fingers and wrists during working hours, and adjusting chair height to allow for good posture. The client should be allowed to participate in activities that require repetitive actions as long as precautions are taken to promote health. Pain medications are not part of health promotion activities.

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain

ANS: A, C Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis. High fever, swelling, and redness are more often seen in acute osteomyelitis. Pain or tenderness can be in either case.

The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.

ANS: A, C, D, E Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.

A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.) a. Bone changes lead to potential safety risks. b. Increased bone density leads to stiffness. c. Osteoarthritis occurs due to cartilage degeneration. d. Osteoporosis is a universal occurrence. e. Some muscle tissue atrophy occurs with aging.

ANS: A, C, E Many age-related changes occur in the musculoskeletal system, including decreased bone density, degeneration of cartilage, and some degree of muscle tissue atrophy. Osteoporosis, while common, is not universal. Bone density decreases with age, not increases.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the client's legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

ANS: A, C, E The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurse's responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility. DIF: Applying/Application REF: 297 KEY: Joint replacement| delegation| abduction pillow| unlicensed assistive personnel (UAP)| nursing assessment MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment

ANS: A, C, E The client going home with chronic osteomyelitis will need long-term antibiotic therapy—first intravenous, then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.

A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? a. Blood pressure increases to 130/86 mm Hg b. Traction weights are resting on the floor c. Oozing of clear fluid is noted at the pin site d. Capillary refill is less than 3 seconds

ANS: B The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this client's pain? a. Meperidine (Demerol) injections every 4 hours around the clock b. Patient-controlled analgesia (PCA) pump with morphine c. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain d. Morphine 4 mg intravenous push every 2 hours PRN for pain

ANS: B The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling

ANS: B The recipients immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

ANS: B This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the client's red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The client's white blood cell count is normal, so avoiding infection is not the priority. DIF: Applying/Application REF: 296 KEY: Joint replacement| anemia| colony-stimulating factors| nursing intervention MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority? a. Allow the client to rest in a position of comfort. b. Assess the client's cardiac and respiratory systems. c. Assist the client with ambulating and position changes. d. Position the client on one side propped with pillows.

ANS: B This degree of curvature of the spine affects cardiac and respiratory function. The nurse's priority is to assess those systems. Positioning is up to the client. The client may or may not need assistance with movement.

A client is having a myelography. What action by the nurse is most important? a. Assess serum aspartate aminotransferase (AST) levels. b. Ensure that informed consent is on the chart. c. Position the client flat after the procedure. d. Reinforce the dressing if it becomes saturated.

ANS: B This diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.

A client with Paget's disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering ibuprofen (Motrin) b. Applying a heating pad c. Providing a massage d. Referring the client to a support group e. Using a bed cradle to lift sheets off the feet

ANS: B, C Comfort measures for Paget's disease include heat and massage. Administering medications and referrals are done by the nurse. A bed cradle is not necessary.

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

ANS: B, C RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment. DIF: Remembering/Knowledge REF: 304 KEY: Rheumatoid arthritis| musculoskeletal system| autoimmune disorder MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

An older client's serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this result? (Select all that apply.) a. Good dietary intake of calcium and vitamin D b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteomalacia d. Potential for metastatic cancer or Paget's disease e. Recent bone fracture in a healing stage

ANS: B, C This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease such as osteoporosis or osteomalacia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Paget's disease, or healing bone fractures will elevate calcium.

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. "Let's ask the provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."

ANS: C Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a "hot" or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints. DIF: Applying/Application REF: 311 KEY: Rheumatoid arthritis| autoimmune disorders| nonpharmacologic pain management| heat MSC: Integrated Process: Caring NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first? a. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago b. Client taking ibandronate (Boniva) who cannot remember when the last dose was c. Client taking raloxifene (Evista) who reports unilateral calf swelling d. Client taking risedronate (Actonel) who reports occasional dyspepsia

ANS: C The client on raloxifene needs to be seen first because of the manifestations of deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

A client is scheduled for a bone biopsy. What action by the nurse takes priority? a. Administering the preoperative medications b. Answering any questions about the procedure c. Ensuring that informed consent is on the chart d. Showing the client's family where to wait

ANS: C The priority is to ensure that informed consent is on the chart. The preoperative medications should not be administered until the nurse is confident the procedure will occur and the client has already signed the consent, if the medications include anxiolytics or sedatives or opioids. The provider should answer questions about the procedure. The nurse does show the family where to wait, but this is not the priority and could be delegated.

1. The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance

ANS: C The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. "I can bend down to pick something up." b. "I no longer need to do my exercises." c. "I will not sit with my legs crossed." d. "I won't wash my incision to keep it dry."

ANS: C There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry. DIF: Evaluating/Synthesis REF: 298 KEY: Joint replacement| discharge planning/teaching| nursing evaluation MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT

ANS: C This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care.

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)? a. "Assess distal pulses for potential compartment syndrome." b. "Turn the client every 3 to 4 hours to promote cast drying." c. "Use a cloth-covered pillow to elevate the client's leg." d. "Handle the cast with your fingertips to prevent indentations."

ANS: C When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should be assessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the client's pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client's bladder or perform a bladder scan.

ANS: C With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related. DIF: Applying/Application REF: 302 KEY: Postoperative nursing| joint replacement| nursing assessment| musculoskeletal system MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

ANS: C, D, E Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? a. "Remove the traction when re-positioning the client." b. "Inspect the client's skin when performing a bed bath." c. "Provide pin care by using alcohol wipes to clean the sites." d. "Ensure that the weights remain freely hanging at all times."

ANS: D Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the client's skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

ANS: D For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate. DIF: Applying/Application REF: 302 KEY: Joint replacement| continuous passive motion machine| infection control| delegation MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, "The cast is loose enough to slide off." How should the nurse respond? a. "Keep your arm above the level of your heart." b. "As your muscles atrophy, the cast is expected to loosen." c. "I will wrap a bandage around the cast to prevent it from slipping." d. "You need a new cast now that the swelling is decreased."

ANS: D Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After the swelling has resolved, if the cast is loose enough to permit two or more fingers between the cast and the client's skin, the cast needs to be replaced. Elevating the arm will not solve the problem, and the client's muscles should not atrophy while in a cast for 6 weeks or less. An elastic bandage will not prevent slippage of the cast.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the client's hands. d. Use an abduction pillow.

ANS: D Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the client's mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation. DIF: Applying/Application REF: 297 KEY: Joint replacement| abduction pillow| musculoskeletal system| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse obtains the health history of a client with a fractured femur. Which factor identified in the client's history should the nurse recognize as an aspect that may impede healing of the fracture? a. Sedentary lifestyle b. A 30-pack-year smoking history c. Prescribed oral contraceptives d. Paget's disease

ANS: D Paget's disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the client's white blood cell count. b. Culture any drainage from the wound. c. Monitor the client's temperature every 4 hours. d. Use aseptic technique for dressing changes.

ANS: D Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present. DIF: Applying/Application REF: 297 KEY: Joint replacement| infection control| wound infection| dressings MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A client has an ingrown toenail. About what self-management measure does the nurse teach the client? a. Long-term antibiotic use b. Shoe padding c. Toenail trimming d. Warm moist soaks

ANS: D Treatment of an ingrown toenail includes a podiatrist clipping away the ingrown part of the nail, warm moist soaks, and antibiotic ointment if needed. Antibiotics are not used long-term. Padding the shoes will not treat or prevent ingrown toenails. Clients should not attempt to trim ingrown nails themselves.

A phone triage nurse speaks with a client who has an arm cast. The client states, "My arm feels really tight and puffy." How should the nurse respond? a. "Elevate your arm on two pillows and get ice to apply to the cast." b. "Continue to take ibuprofen (Motrin) until the swelling subsides." c. "This is normal. A new cast will often feel a little tight for the first few days." d. "Please come to the clinic today to have your arm checked by the provider."

ANS: D Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and ibuprofen are acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse should not reassure the client that this is normal.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren's syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity

ANS: D Sjögren's syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjögren's syndrome. DIF: Applying/Application REF: 306 KEY: Rheumatoid arthritis| nursing assessment| musculoskeletal system| visual disturbances| autoimmune disorder| sensory system MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse working with clients who have autoimmune diseases understands that what component of cell- mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells

ANS: D Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.

After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? a. Baked fish with orange juice and a vitamin D supplement b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement c. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement

ANS: D The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation are appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.

A client is admitted with a large draining wound on the leg. What action does the nurse take first? a. Administer ordered antibiotics. b. Insert an intravenous line. c. Give pain medications if needed. d. Obtain cultures of the leg wound.

ANS: D The nurse first obtains wound cultures prior to administering broad-spectrum antibiotics. The nurse would need to start the IV prior to giving the antibiotics as they will most likely be parenteral. Pain should be treated but that is not the priority.

A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond? a. "The pain you are feeling does not actually exist." b. "This type of pain is common and will eventually go away." c. "Would you like to learn how to use imagery to minimize your pain?" d. "How would you describe the pain that you are feeling?"

ANS: D The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the client, the nurse must assess the client's pain before determining the best action.

A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury? a. Hypertension b. Constipation c. Infection d. Hematuria

ANS: D The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture.

A nurse cares for a client in skeletal traction. The nurse notes that the skin around the client's pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next? a. Request a prescription to decrease the traction weight. b. Apply an antibiotic ointment and a clean dressing. c. Cleanse the area, scrubbing off the crusty areas. d. Obtain a prescription to culture the drainage.

ANS: D These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse should obtain a culture and assess vital signs. The provider should be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated.

A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the client's risk for infection? a. Wash the traction lines and sockets once a day. b. Release traction tension for 30 minutes twice a day. c. Do not place the traction weights on the floor. d. Schedule for pin care to be provided every shift.

ANS: D To decrease the risk for infection in a client with skeletal traction of external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the client's skin; these do not need to be washed. Although traction weights should not be removed or released for any period of time without a prescription, or placed on the floor, this does not decrease the risk for infection.

A client has a possible connective tissue disease and the nurse is reviewing the client's laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.) a. Elevated antinuclear antibody (ANA) - Normal value; no connective tissue disease b. Elevated sedimentation rate - Rheumatoid arthritis c. Lowered albumin - Indicative only of nutritional deficit d. Positive human leukocyte antigen B27 (HLA-B27) - Reiter's syndrome or ankylosing spondylitis e. Positive rheumatoid factor - Possible kidney disease

ANS: D, E The HLA-B27 is diagnostic for Reiter's syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation. DIF: Remembering/Knowledge REF: 307 KEY: Autoimmune disorders| laboratory values MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner? A. Older adult client with a history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 150,000 mm3 (15.5 × 109/L), segmented neutrophils (segs) (8.0 × 109/L), bands 5% (0.5 × 109/L), lungs with slight crackles in bases, able to assist with activities of daily living, and afebrile B. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9,500 mm3 (9.5 × 109/L), segs (6.0 × 109/L), bands 1.0% (0.1 × 109/L), oxygen saturation of 93% on room air, and afebrile C. Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, WBC count 20,000 mm3 (20.0 × 109/L), segs (7.0 × 109/L), bands 10.0% (1.1 × 109/L), oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4°F (38°C)

B. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9,500 mm3 (9.5 × 109/L), segs (6.0 × 109/L), bands 1.0% (0.1 × 109/L), oxygen saturation of 93% on room air, and afebrile The client most ready for discharge is the middle-aged client with history of multiple sclerosis because the complete blood count (CBC) is within normal limits.The older adult client with a history of congestive heart failure and elevated WBC and segs and slight crackles in lung bases is not ready for discharge. The young adult client with crackles in all lung lobes is not ready for discharge because of elevated WBCs, left shift, and febrile status. The older adult client with recent history of right hip replacement is not ready for discharge because the WBC is below normal even though the other parts of the differential are within normal limits. This client may have a viral infection with crackles in the lungs and low oxygen saturation.

Which statement best exemplifies a client's protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos? A. Cytotoxic and cytolytic T cells destroy cells that contain the major histocompatibility complex of a processed antigen. B. Helper and inducer T cells recognize self cells versus non-self cells and secrete lymphokines that can enhance the activity of white blood cells. C. Suppressor T cells prevent hypersensitivity when a client is exposed to non-self cells or to proteins. D. Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1.

D. Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1. After exposure to asbestos, a client's protection from cancer depends on a balance between helper and inducer T cells and suppressor T cells. This balance occurs when helper and inducer T cells outnumber suppressor T cells by a ratio of 2:1.The activity of cytotoxic and cytolytic T cells is most effective against self cells infected by parasites. Overreactions can cause tissue damage if an imbalance exists between helper and inducer T cells. When suppressor T cells are increased, immune function is suppressed and the client is at risk for infection.

A complete blood count with differential is performed on a client with chronic sinusitis. Which finding does the nurse expect? A. Segmented neutrophils, 62% B. Lymphocytes, 28% C. Bands, 5% D. Basophils, 4%

D. Basophils, 4% The normal count for basophils (basos) is 0.5%; an elevated count indicates inflammation. This is common with chronic sinusitis.62% is a normal segmented neutrophil and refers to mature neutrophils, which, along with macrophages, eliminate invaders (infection) by phagocytosis. For lymphocytes, 28% is a normal count in the differential. For bands, 4% is a normal count. Bands are elevated only when an infection is present and the bone marrow cannot keep up with mature segmented neutrophils.

Artificial Passive Acquired a. crosses the placenta, we get it from mom b. got the disease and produced antibodies c. get someone else's antibodies: very time limiting d. get vaccinated with attenuated serum so person produces antibodies; needs boosters

get someone else's antibodies: very time limiting