Adult Health II Exam IV

The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client? 1. Alternate aspirin and acetaminophen to help with the pain. 2. Apply cold packs for 24 to 48 hours to the affected area. 3. Perform active range-of-motion exercise on the extremity. 4. Put the affected extremity in the dependent position.

2. Apply cold packs for 24 to 48 hours to the affected area. "RICE"; administration of Factor VIII; desmopressin (ADH --> vasoconstricts). SAFETY& bleeding precautions for these patients!

The nurse provides home care instructions to a client with SLE and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? A. "I should take hot baths because they are relaxing." B. "I should sit whenever possible to conserve energy." C. "I should avoid long periods of rest because it causes joint stiffness." D. "I should do some exercises, such as walking, when I am not fatigued.

A. "I should take hot baths because they are relaxing."

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? SATA A. Administer O2 B. Quickly assess the client's respiratory status C. Document the event, Interventions, and client's response D. Leave the client briefly to contact HCP E. Keep the client supine regardless of the blood pressure readings F. Start an IV infusion of D5W and administer a 500 mL bolus

A. Administer O2 B. Quickly assess the client's respiratory status C. Document the event, Interventions, and client's response

A client is to receive epoetin injections. What laboratory value should the nurse assess before giving the injection? A. Hematocrit B. Partial thromboplastin time C. Hemoglobin concentration D. INR

A. Hematocrit Epoetin is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. Given to patients undergoing chemo/radiation because they are at risk for developing anemia.

The nurse has been asked to present information regarding HIV risks to a group of young adults. Which populations are at risk for HIV infection? (Select all that apply.) A. Injection drug users B. Adolescents who engage in athletics (e.g. baseball, soccer, gymnastics) C. Patients who receive a transfusion with HIV-infected blood or blood products D. Neonates and breastfed infants of HIV-infected mothers (perinatal transmission) E. Laboratory technicians who use appropriate protocols for handling blood products F. Partners, including heterosexuals, who have unprotected sex with those infected with HIV

A. Injection drug users C. Patients who receive a transfusion with HIV-infected blood or blood products D. Neonates and breastfed infants of HIV-infected mothers (perinatal transmission) F.Partners, including heterosexuals, who have unprotected sex with those infected with HIV

The client diagnosed with sickle cell disease is experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement? A. Maintain IV fluids and administer pain medication prn. B. Encourage frequent ambulation in the hallways. C. Administer oxygen via NC at 10LPM. D. Monitor the client's RBC

A. Maintain IV fluids and administer pain medication prn. The nurse's priority is to treat the cause of the crisis and the pain. Not (B), because during a crisis and the administration of narcotic medication frequent ambulation is not encouraged. Not (C), The client has the ability to oxygenate the cells, if oxygen is used the rate would not be at 10lpm. Client's RBCs would be monitored but not every 4hrs.

A patient w/ carcinoma of the lung develops SIADH as a complication of the cancer. The nurse anticipates that the HCP will request which prescriptions? SATA A. Radiation B. Chemotherapy C. Increased fluid intake D. Decreased oral sodium intake E. Serum sodium level determination F. Medication that's antagonistic to ADH

A. Radiation B. Chemotherapy E. Serum sodium level determination F. Medication that's antagonistic to ADH

A patient has recently had CD4 level testing, and the result was found to be 118 cells/mm3. The nurse realizes which condition has developed? A. The patient has AIDS. B. The patient is HIV positive. C. The patient has leukopenia. D. The patient has neutropenia.

A. the patient has AIDS CD4 counts <200 indicate the patient is now in category C. When a patient progresses to Category C their immune system is SEVERELY compromised --> AIDS.

The nurse prepares to give a bath & change the bed linens of a pt w/ cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this pt? A. Wearing gloves B. Wearing a gown and gloves C. Wearing a gown, gloves, and a mask D. Wearing a gown and gloves to change the bed linens and gloves only for the bath

B. Wearing a gown and gloves

Which is considered an approximate normal hematocrit value? Hematocrit is approximately three times the hemoglobin value. What is the rationale for administering injections of vitamin B12 to patients with pernicious anemia? a. The patient's body does not normally manufacture enough vitamin B12. b. The patient may lack the intrinsic factor necessary for vitamin B12 absorption. c. Vitamin B12 is found in very small quantities in the patient's body.

ANS: B The patient with pernicious anemia lacks the intrinsic factor, found in the stomach, which is essential for vitamin B12 absorption. (common in gastric bypass pt due to that portion of stomach being removed-they need b12 the rest of their life!)

A nurse is conducting a wellness seminar on healthy eating and prevention of iron deficiency anemia. The food the nurse would describe as being high in iron is a. citrus fruits b. grains c. green leafy vegetables d. milk products

ANS: C (green leafy veggies) Encourage foods cooked in iron pots and ingestion of foods such as liver (the richest source), oysters, lean meats, kidney beans, whole wheat bread, kale, spinach, egg yolk, turnip tops, beet greens, carrots, apricots, and raisins.

A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous? A. Weight gain B. Subnormal temperature C. Elevated red blood cell count D. Rash on the face across the bridge of the nose

Answer: D Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client? A. Administer the iron at mealtimes B. Administer the iron through a straw C. Mix the iron with cereal to administer D. Add the iron to apple juice for easy administration

B. Administer the iron through a straw

Which is the nurse's PRIORITY action when managing a client experiencing a type I hypersensitivity? A. Management of arthralgia B. Airway management C. Stopping the blood transfusion D. Decreasing a fever

B. Airway management Type I hypersensitivity reactions can lead to anaphylaxis. Priorities are ABCs, skin integrity, pain (must look at your patient and how they are presenting).

The nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? A. Personal protective equipment B. Combination antiretroviral therapy C. Counseling to report blood exposures D. A negative evaluation by the manage

B. Combination antiretroviral therapy Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Personal protective equipment should be available although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed but would not occur first.

Which of the following are true of Rheumatoid Arthritis? SATA A. It's age-related B. It's an autoimmune disease C. It's a systemic inflammatory disease D. It causes degeneration of bone E. It is manifested by exacerbations and remissions

B. It's an autoimmune disease C. It's a systemic inflammatory disease E. It is manifested by exacerbations and remissions

When caring for a client w/ an internal radiation implant, the nurse should observe which principles? SATA A. Limiting the time w/ the client to 1 hour per shift B. Keeping pregnant women out of the client's room C. Placing the the client in a private room with a private bath D. Wearing a lead shield when providing direct client care E. Removing the dosimeter film badge when entering the client's room F. Allowing individuals younger than 16 in the room as long as they are 6 ft away from the client

B. Keeping pregnant women out of the client's room C. Placing the the client in a private room with a private bath D. Wearing a lead shield when providing direct client care

As part of chemotherapy education, the nurse teaches a female client about risk for bleeding and self-care during the period of greatest bone marrow suppression. The nurse understands that further teaching is needed if the client makes which statement? A. "I should avoid blowing my nose." B. "I may need a platelet transfusion if my platelet count is too low." C. "I'm going to take aspirin for my headache as soon as I get home." D. "I will count the number of pads and tampons I use when menstruating."

C. "I'm going to take aspirin for my headache as soon as I get home."

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? A. Cyanosis B. Arm edema C. Periorbital edema D. Mental status changes

C. Periorbital edema

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? A. Restrict all visitors B. Restrict fluid intake C. Teach the client and family about the need for hand hygiene D. Insert an indwelling urinary cath to prevent skin breakdown

C. Teach the client and family about the need for hand hygiene

Gout is a type of arthritis that occurs due to the accumulation of ____________ in the blood that causes needle-like crystals to form around the joints. A. purines B. creatinine C. uric acid D. amino acids

C. uric acid

The client w/ AIDS is diagnosed w/ cutaneous Kaposi's sarcoma. Based on the diagnosis, the nurse understands that this has been confirmed by which finding? A. Swelling in the genital area B. Swelling in the lower extremities C. Positive punch biopsy of the cutaneous lesions D. Appearance of reddish-blue lesions noted on the skin

D. Appearance of reddish-blue lesions noted on the skin

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a patient w/ metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency? A. Headache B. Dysphagia C. Constipation D. Electrocardiographic changes

D. Electrocardiographic changes

While giving care to a client w/ am internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? A. Call the HCP B. Reinsert the implant into the vagina C. Pick up the implant w/ gloved hands and flush it down the toilet D. Pick up the implant w/ long-handles forceps and place it in the lead container

D. Pick up the implant w/ long-handles forceps and place it in the lead container

You're developing a nursing care plan for a patient with gout present in the right foot. What specific nursing interventions will you include in this patient's plan of care? Select all that apply:* A. Encourage fluid intake of 2-3 liter per day. B. Provide patient with foods high in purine with each meal daily. C. Place patient's right foot in a foot board while patient is in bed. D. Administer PRN dose of Aspirin for a pain rating greater than 5 on 1-10 scale. E. Apply alternating cold and warm compresses to right foot as tolerated by the patient daily.

The answers are A, C, E. These options are correct nursing intervention for this patient. Option B is wrong because the patient should consume food LOW in purines (remember purines increase uric acid levels). Option D is wrong because patient should AVOID aspirin. Aspirin (even low doses) increase uric acid levels.

When caring for a client with suspected SIADH, the nurse reviews the medical record to uncover which signs and symptoms consistent with this syndrome? (select all that apply) A. Hyponatremia B. Mental status changes C. Azotemia D. Bradycardia E. Weakness

a,b,e: ADH is secreted or produced ectopically, resulting in water retention and sodium dilution which causes confusion and changes in mental status and weakness. Tachycardia may result from fluid volume excess. Treatments?

The client diagnosed with sickle cell anemia comes to the ER complaining of joint pain throughout the body. The oral temp is 102.4degF and the pulse ox reading is 91%. Which action would the nurse implement first? A. request arterial blood gases STAT b. administer oxygen via NC c. start an IV with an 18-G angiocath D. Prepare to administer analgesics.

b. administer oxygen via NC

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

c. Discuss a change in antiretroviral therapy. Common side effects of ARVTs include hyperlipidemia, insulin resistance, renal disease, and cardiovascular disease (among others). Some of the long term metabolic effects include hyperglycemia and hyperlipidemia that can cause changes in body shape. Can have an abnormal fat deposits ("buffalo hump, lipoatrophy aka facial wasting, central adiposity). If you see these effects need to change the ARVT.

The nurse is monitoring the effectiveness of antiretroviral therapy (ART) for a 56-year-old man with acquired immunodeficiency syndrome (AIDS). What laboratory study result indicates the medications have been effective? a. Increased viral load b. Decreased neutrophil count c. Increased CD4+ T cell count d. Decreased white blood cell count

c. Increased CD4+ T cell count Antiretroviral therapy is effective if there are decreased viral loads and increased CD4+ T cell counts

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. HIV genotype and phenotype b. Patient's social support system c. Potential medication side effects d. Patient's ability to comply with ART schedule

d. Patient's ability to comply with ART schedule Adherence to ART's is critical for them to be effective (i.e. to maintain sustained viral suppression, and prevent drug resistance) These medications are lifelong.

The nurse is providing postoperative care for a 30-year-old female patient after an appendectomy. The patient has tested positive for human immunodeficiency virus (HIV). What type of precautions should the nurse observe to prevent the transmission of this disease? a. Droplet precautions b. Contact precautions c. Airborne precautions d. Standard precautions

d. Standard precautions Standard precautions are indicated for prevention of transmission of HIV to the health care worker. HIV is not transmitted by casual contact or respiratory droplets. HIV may be transmitted through sexual intercourse with an infected partner, exposure to HIV-infected blood or blood products, and perinatal transmission during pregnancy, at delivery, or though breastfeeding.