ATI Exam 2 (GI, Immune, Respiratory)
A nurse is providing discharge instructions to a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of the sexually transmitted infection (STI)? a. "I will bring my sexual partner in for treatment." b. "Now that I've had my first dose of medicine, I can resume sexual activity." c. "Once I have been treated, it is no longer necessary to use condoms." d. "Once treatment is completed and I am free of symptoms, I don't have to return to the clinic."
a. "I will bring my sexual partner in for treatment." The client should bring his partner in to be screened for genital warts and treated.
A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? a. Absence of breath sounds b. Expiratory wheezing c. Inspiratory stridor d. Rhonchi
a. Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.
A nurse is planning care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? a. Eat high-calorie foods first. b. Increase intake of water at meal times. c. Perform active range-of-motion exercises before meals. d. Keep saltine crackers nearby for snacking.
a. Eat high-calorie foods first. The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first.
A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? a. "I will be on a special shower table." b. "The water temperature will be very cool to ease my pain." c. "The nurse will use a firm-bristled brush to remove loose skin." d. "The nurse will use scissors to open small blisters."
a. "I will be on a special shower table." The special shower table facilitates examination and debridement of the wound during hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature and there is a lower risk of wound infection.
A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements by the nurse is appropriate? a. "After the surgeon removes the lung, you will not need to cough." b. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." c. "Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain." d. "I will show you how to splint your incision while coughing."
d. "I will show you how to splint your incision while coughing." The client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint her incision to reduce pain when coughing.
A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? a. "May I go with my family to the visitor's lounge?" b. "I'll see my friends when I get home." c. "My dad is coming to visit. Can you fix my hair for me?" d. "I told my cousins I'm in protective isolation."
a. "May I go with my family to the visitor's lounge?" This statement demonstrates a positive self-image. The client is asking to visit with her family in a public setting.
A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? a. "Wash your genitalia using an antimicrobial soap." b. "Rinse your dishes with cold water." c. "Clean your toothbrush once per month." d. "Incorporate raw fruits and vegetables into your diet."
a. "Wash your genitalia using an antimicrobial soap." The nurse should instruct the client to bathe daily using an antimicrobial soap to prevent the spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap is recommended.
A nurse is preparing to assist a provider to withdraw arterial blood from a client's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? a. Hyperventilate the client with 100% oxygen prior to obtaining the specimen. b. Apply ice to the site after obtaining the specimen. c. Perform an Allen's test prior to obtaining the specimen. d. Release pressure applied to the puncture site 1 min after the needle is withdrawn.
c. Perform an Allen's test prior to obtaining the specimen. The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.
A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? a. Hallucinations b. Pruritus c. Hand and foot syndrome d. Tinnitus
d. Tinnitus An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.
A nurse is teaching a client who has human immunodeficiency virus about the early manifestations of acquired immune deficiency syndrome. Which of the following statements should the nurse include in the teaching? a. "You can expect a persistent fever and swollen glands." b. "You can expect an elevated white blood cell count." c. "You can expect an increase in blood pressure and edema." d. "You can expect weight gain."
a. "You can expect a persistent fever and swollen glands." Clients who have AIDS can have persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of AIDS.
A nurse in an urgent care clinical is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? a. Dry cough b. Rhinitis c. Sore throat d. Swollen lymph nodes
a. Dry cough A dry cough is a clinical manifestation found in the prodromal stage of having inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis.
A nurse is teaching a client about manifestations of an allergic reaction. The nurse should explain that histamine release causes which of the following reactions? a. Increased mucus secretion b. Bronchial dilation c. Bradycardia d. Vertigo
a. Increased mucus secretion The nurse should instruct that the client that increased mucus secretion is a manifestation of histamine release. Histamine is the neurotransmitter the body produces during an allergic reaction.
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? a. Hyponatremia b. Leukopenia c. Hyperchloremia d. Elevated BUN
b. Leukopenia Transient leukopenia is an adverse effect of silver sulfadiazine.
A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include? a. "If the test is positive, it means you have an active case of tuberculosis." b. "If the test is positive, you should have another tuberculin skin test in 3 weeks." c. "You must return to the clinic to have the test read in 2 or 3 days." d. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."
c. "You must return to the clinic to have the test read in 2 or 3 days." The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hr, another tuberculin skin test is necessary.
A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE? a. Exercise b. Pregnancy c. Infection d. Sunlight
a. Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and the manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with her provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active.
A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest x-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? a. Have the client wear a surgical mask. b. Wear a gown for protection from the client's infection. c. Ask the radiology staff to perform a portable chest x-ray in the client's room. d. Place an N95 respirator on the client.
a. Have the client wear a surgical mask. The nurse should instruct the client to wear a surgical mask. The mask will protect anyone who comes into contact with the client, including the nurse.
A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement? a. Immobilize the limb at the level of the heart. b. Apply a tourniquet to the affected limb. c. Use a sterile scapula to incise the wound. d. Apply ice to the skin over the snakebite wound.
a. Immobilize the limb at the level of the heart. The emergency management of a client who has a snakebite focuses on limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart.
A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which of the following skin lesions? a. Papules b. Macules c. Wheals d. Vesicles
a. Papules A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles.
A nurse is teaching a client who has Raynaud's disease. Which of the following information should the nurse include in the teaching? a. Protect against the cold by wearing layers of clothing. b. Begin an exercise program of 2-mile walks once per week. c. Increase vitamin A in the diet. d. Elevate the hands above heart level when resting.
a. Protect against the cold by wearing layers of clothing. Clients who have Raynaud's disease are prone to attacks during cold weather. Extreme cold can lead to tissue damage. Therefore, the client needs to be protected with layers of clothing to promote warmth and increase circulation to the extremities.
A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? a. Sudden onset of dyspnea b. Tracheal deviation c. Bradycardia d. Difficulty swallowing
a. Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.
A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? a. Total lung capacity b. Vital lung capacity c. Functional residual capacity d. Residual volume
a. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.
A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a potential malignancy of a mole? a. Ulceration b. Blanching of surrounding skin c. Dimpling d. Fading of color
a. Ulceration Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.
A nurse is teaching a client who has human immunodeficiency virus about how the virus is transmitted. Which of the following statements should the nurse include the teaching? a. "HIV can be transmitted as soon as a person develops manifestations." b. "HIV can be transmitted to anyone who has had contact with the infected blood." c. "HIV is transmitted through the respiratory route through droplets." d. "HIV is transmitted only during the active phase of the virus."
b. "HIV can be transmitted to anyone who has had contact with the infected blood." The concentration of the virus is highest in blood but also has been isolated in other body fluids, including sputum, saliva, cerebrospinal fluid, urine, and semen. Clients who have HIV are cautioned to practice safe sex, avoid donating blood, and abstain from sharing needles with others.
A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome. Which of the following statements by the client's partner indicates the need for further teaching? a. "I will dispose soiled tissues in separate plastic bags." b. "I'll clean up blood spills immediately with hot water." c. "I know that hand washing is an important preventive measure." d. "I will wash soiled clothes in hot water."
b. "I'll clean up blood spills immediately with hot water." The client's partner should clean blood or potentially contaminated body substances with a bleach solution and wear gloves when coming into contact with blood products.
A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? a. Zoster vaccine b. Acyclovir c. Amoxicillin d. Infliximab
b. Acyclovir The nurse should anticipate a prescription for acyclovir, an antiviral medication, because it inhibits replication of the virus that causes herpes zoster.
A nurse is caring for a client who is 2 days postoperative. Which of the following findings should alert the nurse that the client is developing an infection? a. Temperature 37.8° C (100° F) b. Erythema at the incision site c. WBC count 9,000/mm3 d. Pain reported as 6 on a scale of 0 to 10
b. Erythema at the incision site Redness, or erythema, at the incision site is an initial sign of a wound infection and requires intervention by the nurse.
A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? a. Excessive salivation b. Finger contractures c. Periorbital edema d. Alopecia
b. Finger contractures Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are two types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs. The manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma, the body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma unless clients follow a regimen of range-of-motion and muscle-strengthening exercises.
A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? a. An assistive device to use when the client is ambulating b. Heat paraffin therapy applied to the client's joints c. Gentle massage of the client's hands d. Active range-of-motion exercises on the client's affected joints
b. Heat paraffin therapy applied to the client's joints The nurse should anticipate the use of heat paraffin to be prescribed as a nonpharmacologic intervention. The elevated ESR indicates an acute inflammatory process due to client's rheumatoid arthritis. The use of the warm paraffin relives the stiffness of the client's joints and provides comfort.
A nurse is assesing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? a. I b. II c. III d. IV
b. II With a stage II pressure ulcer, there is partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage.
A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which of the following traits places a client at risk for developing malignant melanoma? a. Brown eyes b. Light skin c. Black hair d. Dark skin
b. Light skin Light skin and less pigmentation place a client at risk for developing malignant melanoma.
A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate? a. Basal cell carcinomas b. Melanomas c. Actinic keratoses d. Squamous cell carcinomas
b. Melanomas Melanomas are malignant neoplasms with atypical melanocytes in both the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases in the bone, liver, lungs, spleen, the CNS, and lymph nodes.
A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? a. Tympanic temperature 38° C (100.4° F) b. PaO2 50 mm Hg c. Rhonchi d. Hypopnea
b. PaO2 50 mm Hg The client who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.
A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? a. Cadaver skin b. Pig skin c. Amniotic membranes d. Beef collagen
b. Pig skin Heterografts are obtained from an animal, usually a pig.
A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. The nurse should explain that this breathing technique accomplishes which of the following? a. Increases oxygen intake b. Promotes carbon dioxide elimination c. Uses the intercostal muscles d. Strengthens the diaphragm
b. Promotes carbon dioxide elimination The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.
A nurse is caring for an older adult client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis
b. Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.
A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory tests can indicate arthritis? a. Reticulocyte count b. Rheumatoid factor c. Direct Coombs' test d. Platelet count
b. Rheumatoid factor An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective tissue diseases.
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? a. Hemoglobin 10 g/dL b. Sodium 132 mEq/L c. Albumin 3.6 g/dL d. Potassium 4.0 mEq/dL
b. Sodium 132 mEq/L This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.
A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? a. How to eliminate environmental triggers that precipitate attacks b. The client's perception of the disease process and what might have triggered past attacks c. The client's medication regimen d. Manifestations of respiratory infections
b. The client's perception of the disease process and what might have triggered past attacks Assess the client's current knowledge.
A nurse is teaching about daily chest physiotherapy with a client who has cystic fibrosis. The nurse should instruct the client that which of the following is the purpose of the treatments? a. To encourage deep breaths b. To mobilize secretions in the airways c. To dilate the bronchioles d. To stimulate the cough reflex
b. To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.
A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about the skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses should the nurse give? a. "Keep the lesions covered with a light sterile dressing when going outdoors." b. "Rub lesions with a washcloth to dry after washing." c. "Apply moisturizer after bathing the lesions with warm water." d. "Apply antibiotic cream twice per day until scabs form on the lesions."
c. "Apply moisturizer after bathing the lesions with warm water." The nurse should instruct the client to clean, dry, and moisturize the skin using warm (not hot) water, along with an unscented lotion.
A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? a. "I should take this medication with food." b. "I need to take a B-complex vitamin while taking this medication." c. "I can expect this medication to turn my skin orange." d. "I can expect this medication to make my vision blurry."
c. "I can expect this medication to turn my skin orange." The nurse should instruct the client to expect his skin and urine to turn a reddish-orange tinge while taking rifampin.
A nurse in a provider's office is providing teaching to a client who has a recent diagnosis of rheumatoid arthritis and has a new prescription for naproxen tablets. Which of the following statements by the client requires further teaching? a. "This medication will take 4 weeks for me to notice relief in my joints." b. "I can take an antacid with this medication for indigestion." c. "I can take this medication with aspirin." d. "The naproxen goes down easier when I crush it and put it in applesauce."
c. "I can take this medication with aspirin." The nurse should instruct the client to avoid taking this medication with any other NSAIDs, such as aspirin, because this can increase the risk for bleeding and gastrointestinal ulceration.
A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? a. Clamp the chest tube if there is continuous bubbling in the water seal chamber. b. Keep the chest tube drainage system at the level of the right atrium. c. Tape all connections between the chest tube and drainage system. d. Empty the collection chamber and record the amount of drainage every 8 hr.
c. Tape all connections between the chest tube and drainage system. The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting.
A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching? a. "I should limit my exposure to sunlight." b. "I should avoid drinking alcohol." c. "I should not smoke." d. "I should limit of intake of foods high in purine."
c. "I should not smoke." Raynaud's disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities to feel numb and cool in response to cold temperatures or stress. During a Raynaud's attack, these arteries narrow, limiting blood circulation to affected areas. Strong emotion or exposure to the cold causes these areas to become white, due to a lack of blood flow in the area. They then turn blue, as tiny blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood returns, the area becomes red and then later returns to normal color. This can cause tingling, swelling and painful throbbing. The attacks can last from minutes to hours. If the condition progresses, blood flow to the area could become permanently decreased, causing the fingers to become thin and tapered, with smooth, shiny skin and slow-growing nails. If an artery becomes blocked completely, gangrene or ulceration of the skin can occur. Smoking cessation, not just reduction, is an action the client should take to prevent the onset of the manifestations of Raynaud's disease.
A nurse is providing teaching to a client who has a diagnosis of Hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? a. "I am unable to donate blood." b. "I will need to get a booster shot of immune serum globulin every year." c. "I should stop eating raw clams." d. "I can get this disease by getting a tattoo."
c. "I should stop eating raw clams." Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish. Individuals who eat raw or steamed shellfish are at increased risk for acquiring hepatitis A.
A nurse is teaching a client who has tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen when she states which of the following? a. "I will begin vacuuming once a week." b. "Carpeting the entire house will be very expensive, but it will be worth it." c. "I will apply a mattress cover to my bed." d. "Installing curtains on the windows will help control the dust in the house."
c. "I will apply a mattress cover to my bed." The nurse should instruct the client to apply a hypoallergenic mattress cover that can be zipped over her bed to control the amount of dust. The client should remove the mattress cover periodically and machine wash to clean.
A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse give? a. "That is your decision alone." b. "I would if I were you." c. "It sounds like you are unsure what to say to your partner." d. "Your provider is required by law to notify your partner."
c. "It sounds like you are unsure what to say to your partner." This response uses the therapeutic communication tools of clarifying and restatement. It identifies that the client is unsure about if or how to approach the issue of being HIV positive with his partner, a common concern of clients due to fear of rejection. This response shows that the nurse is open to further communication with the client and encourages his expression of feelings.
A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following information should the nurse include in the teaching? a. "PCP is sexually transmitted from person to person." b. "You were most likely exposed to a contaminated surface, such as a drinking glass." c. "PCP results from an impaired immune system." d. "You may have contracted PCP from a family pet."
c. "PCP results from an impaired immune system." The nurse should explain that the organism that causes PCP exists as part of the normal flora of the lungs and develops into a fungus. It becomes an aggressive pathogen when the immune system is compromised and the infection results from an impaired immune system.
A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? a. Apply a broad-spectrum sunscreen 5 min before sun exposure. b. Wear a sun visor instead of a hat when outside in the sun. c. Avoid exposure to the midday sun. d. Use a tanning booth instead of sunbathing outdoors.
c. Avoid exposure to the midday sun. The nurse should instruct clients to avoid skin exposure to the sun, especially during the midday hours of 1000 to 1600 because sun rays are the strongest at that time.
A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? a. Friction rub b. Crackles c. Crepitus d. Tactile fremitus
c. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.
A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? a. Pericardial friction rub b. Weight gain c. Night sweats d. Cyanosis of the fingertips
c. Night sweats Night sweats and fevers are clinical manifestations of tuberculosis.
A nurse is caring for client who has human immunodeficiency virus. Which of the following types of isolation should the nurse implement to prevent transmission of HIV? a. Protective isolation b. Droplet precautions c. Standard precautions d. Airborne precautions
c. Standard precautions Standard precautions should be implemented with every client, to prevent the spread of infection transmitted by direct or indirect contact with infectious blood or body fluids. Because HIV is spread through blood and bodily fluids, standard precautions are appropriate.
A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? a. Partial-thickness burn b. Stage III pressure ulcer c. Surgical incision d. Dehisced sternal wound
c. Surgical incision With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention.
A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? a. First-degree frostbite b. Second-degree frostbite c. Third-degree frostbite d. Fourth-degree frostbite
c. Third-degree frostbite When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled and the skin does not blanch.
A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? a. Confluent, honey-colored, crusted lesions b. Large, tender nodule located on a hair follicle c. Unilateral, localized, nodular skin lesions d. A fluid-filled vesicular rash in the genital region
c. Unilateral, localized, nodular skin lesions Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces unilateral, localized, nodular skin lesions.
A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which of the following nutrients promotes wound healing? a. Vitamin B1 b. Calcium c. Vitamin C d. Potassium
c. Vitamin C A diet high in protein and vitamin C is recommended because these nutrients promote wound healing.
A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? a. "Apply warm compresses to the face." b. "Take aspirin 650 milligrams by mouth for mild pain." c. "Close your mouth when sneezing." d. "Lie on your back with your head elevated 30° when resting."
d. "Lie on your back with your head elevated 30° when resting." The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.
A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse plan to include? a. "Avoid the use of NSAIDs." b. "Stop taking the corticosteroids when your symptoms resolve." c. "Exposure to ultraviolet light will help control the skin rashes." d. "Monitor your body temperature and report any elevations promptly."
d. "Monitor your body temperature and report any elevations promptly." SLE is a chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temperature and report any elevations promptly, as fever can suggest either an exacerbation or a potentially life-threatening infection.
A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? a. "Move between the bed and the wheelchair once every 2 hours." b. "Make sure that your caregiver massages your skin daily." c. "Use a rubber ring when sitting at the bedside." d. "Shift your weight in the wheelchair every 15 minutes."
d. "Shift your weight in the wheelchair every 15 minutes." This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure.
A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client? a. A diffuse maculopapular rash b. Dyspnea c. Double vision d. A progressive, circular rash
d. A progressive, circular rash Early Lyme disease is characterized by fever, influenza-like manifestations, and erythema migrans, a distinct progressive circular or bulls-eye rash that often develops at the bite site, but can also develop at other sites, such as the thighs and knees.
A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching? a. Use an alcohol-based soap to clean lesions. b. Wear a condom during sexual activity when lesions are present. c. Take a sitz bath once per day. d. Apply a warm compress to the lesions.
d. Apply a warm compress to the lesions. The nurse should instruct the client to apply a warm compress to the lesions to relieve discomfort.
A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that the purpose of a Mantoux skin test using purified protein derivative (PPD) is to do which of the following actions? a. Identify if a client lacks immunity to tuberculosis. b. Find out if a client has active tuberculosis. c. Decrease the hypersensitivity of the client's reaction to PPD. d. Identify if a client has been infected with mycobacterium tuberculosis.
d. Identify if a client has been infected with mycobacterium tuberculosis. The nurse should inform the client that the Mantoux test is used to identify individuals who have been infected with mycobacterium tuberculosis.
A nurse is caring for a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies. The nurse should anticipate an elevation in which of the following laboratory tests? a. IgM (immunoglobulin M) b. IgA (immunoglobulin A) c. IgG (immunoglobulin G) d. IgE (immunoglobulin E)
d. IgE (immunoglobulin E) RAST testing involves measuring the quantity of IgE present in serum after exposure to specific antigens selected on a basis of the client's symptom history. An elevated IgE indicates a positive response and is common among clients who have a history of allergic manifestations, anaphylaxis, and asthma.
A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of a malignant melanoma? a. Rough, dry, scaly lesion b. Firm nodule with crust c. Pearly papule with ulcerated center d. Irregularly shaped lesion with blue tones
d. Irregularly shaped lesion with blue tones Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client's upper back and lower legs.
A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? a. A nonproductive cough, fever, and shortness of breath b. Lesions on the retina that produce blurred vision c. Onset of progressive dementia d. Reddish-purple skin lesions
d. Reddish-purple skin lesions Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following biopsy, the lesions are treated with radiation and/or chemotherapy.
A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client? a. Lying flat on the affected side b. Prone with the arms raised over the head c. Supine with the head of the bed elevated d. Sitting while leaning forward over the bedside table
d. Sitting while leaning forward over the bedside table When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client's ribs and allows for aspiration of accumulated fluid and air.
A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures? a. Curettage b. External radiation therapy c. Regional chemotherapy d. Surgical excision
d. Surgical excision The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting.
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? a. Edema in the burned extremities b. Severe pain at the burn sites c. Urine output of 30 mL/hr d. Temperature of 39.1° C (102.4° F)
d. Temperature of 39.1° C (102.4° F) An elevated temperature is an indication of infection and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms.
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? a. The client is unable to speak. b. The client's airway secretions were last suctioned 2 hr ago. c. The client coughs and expectorates a large mucous plug. d. The nurse auscultates coarse crackles in the lung fields.
d. The nurse auscultates coarse crackles in the lung fields. The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.
