EAQs Adult Health 1: Exam 2

Which assessment finding in a client reporting severe itching with redness and wheals on the uncovered parts of the legs after sleeping in an old bed supports the primary healthcare provider prescribing antihistamines and topical corticosteroids?

Urticaria grouped in threes surrounded by vivid flare, transforming into a persistent lesion.

Which condition may be present in the client with localized vasodilation, transudation of fluid, and erythema?

Urticaria.

Which second-line medication would the nurse prepare to give after administering epinephrine to a client experiencing an anaphylactic reaction? Select all that apply.

Dexamethasone, Diphenhydramine hydrochloride, hydrocortisone sodium succinate.

Which action would the nurse anticipate when admitting a client having a sickle cell crisis to the nursing unit? Select all that apply.

Administer hydroxyurea, apply oxygen via nasal cannula, administer intravenous (IV) hydration.

Which type of reaction is being experienced by a client who develops acute dyspnea, Generalized urticaria, a heart rate of 128 bpm, and a blood pressure of 70/38 mm Hg while receiving a blood transfusion?

Anaphylactic

Which hypersensitivity condition would the nurse suspect when a client presents with cutaneous lesions, swelling of the face, eyelids, and lips from dilation and engorgement of the capillaries but no observable welts or vesicles?

Angioedema

Which clinical manifestation would the nurse expect to find in a client with hypokalemia? Select all that apply.

Anorexia, leg cramps.

Which nursing assessment finding is consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy? Select all that apply.

Bounding pulse, presence of dependent edema, neck vein distention in the upright position.

Which prescribed medication would the nurse teach a client with Lyme disease who presents with dyspnea, dizziness, and facial paralysis?

Ceftriaxone

Which skin infection has the primary clinical manifestation of an ulcer with a vesicular ring, induration, and erythema on the skin?

Cutaneous anthrax

Which signs of hypokalemia with the nurse monitor in the postoperative surgical client with a nasogastric tube attached to continuous low suction?

Dysrhythmias, muscle weakness.

Which statement indicates the meaning of "a shift to the left" evaluating the white blood cell count differential?

Increased immature neutrophils

Which statement by a client with pruritus about personal care interventions indicates understanding of the interventions?

"I will trim my fingernails regularly."

Which instruction would the nurse teach a client about preventative measures for Lyme disease?

"Tuck your shirt into your pants."

Which curative treatment would a nurse administer for a client reporting severe nighttime itching with borrows in the flexor surfaces of the wrists and in the anterior axillary folds?

Permethrin 5% topical lotion

Which disorder would the nurse suspect in a client who reports hair loss, joint pain, and a facial rash and has a medical record showing the presence of a butterfly rash?

Systemic lupus erythematosus

Which type of hypersensitivity reaction is associated with systemic lupus erythematosus (SLE)

Type III

Which factor is a likely cause of hyponatremia? Select all that apply.

Profuse diaphoresis, rapid intravenous (IV) infusion of 5% dextrose in water (D5W.)

Which prescription would the nurse question when a client's serum sodium is 123 mEq/liter?

Provide 0.45% sodium chloride (NaCl) intravenously at 125 mL/hr.

Which action will the nurse take to determine whether therapy for vitamin B12 deficiency is effective?

Review hemoglobin and hematocrit levels.

Which sign of hypokalemia will the nurse monitor for in a client receiving furosemide?

Muscle weakness

Which finding would be most important to communicate to the healthcare provider when the nurse is assessing a 20-year-old client who has come to the clinic reporting recent unintended weight loss and fatigue?

Nontender enlarged cervical lymph node.

List the nurses activities in the order that they will be performed when administering a blood transfusion.

1. Verify that a type and crossmatch blood sample has been sent to the laboratory. 2. Obtain venous access, preferably with a 19-gauge needle or larger. 3. Prime the blood infusion set tubing with normal saline at the bedside. 4. Ask another nurse to check the blood identification at the client's bedside. 5. Run the blood at a slower rate during the first 10 minutes of the transfusion.

Which symptom would the nurse monitor for when caring for a client who has hyponatremia?

Change in level of consciousness.

Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration?

Change in mental status

Which intervention would the nurse expect to be included in the plan of care of a client diagnosed with multiple myeloma?

Chemotherapy employing a combination of medications.

Which manifestation in a client who is having a third transfusion of packed red blood cells may be evident if the client experiences a febrile transfusion reaction? Select all that apply.

Chills, hypotension, tachycardia.

Which prescribed treatment would the nurse question when a client who has sickle cell anemia has been admitted with acute chest syndrome?

Daily iron supplement.

Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply.

Decreased urine, hypotension, dry mucous membranes, poor skin turgor

Which abnormal laboratory value will the nurse expect when caring for a client with iron-deficiency anemia?

Increased total iron-binding capacity (TIBC)

Which action would the nurse implement when a client develops an anaphylactic reaction? Select all that apply.

Initially, apply oxygen at 90% to 100% per nasal cannula; call the rapid response team and have the crash cart retrieved; elevate the head of the bed to 45°; ensure emergency airway equipment is at the bedside.

Which clinical indicator is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarrhea for three days?

Loss of body weight.

Which action will the urgent care clinic nurse anticipate taking for a 24-year-old client who is dehydrated after a long run and has a pulse rate of 103 and blood pressure 102/56 mm Hg?

Offer oral fluids at frequent intervals.

A female client with Hodgkin disease is to be getting chemotherapy and is concerned that sterility may result because of treatment. On which information would the nurse base the response?

Ova can be harvested and frozen for future use.

Which fluid therapy will the nurse prepare to infuse when a client with hypovolemic shock has a hematocrit value of 25%?

Packed red blood cells.

Which finding would the nurse expect when assessing a client hospitalized for dehydration? Select all that apply.

Postural hypotension, skin on forehead remains tented after being pinched.

Which assessment would be brought to the health care provider's attention before administration of intravenous potassium chloride?

Urinary output of 200 mL during the previous eight hours.

A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse expect to be prescribed for the client?

Vitamin B12 injections.

Which client statement about self-care measures to prevent dry skin indicates the need for further teaching?

" I will use deodorant soap in place of alkaline soap."

Which skin change supports the diagnosis of allergic contact dermatitis?

Red papules and plaques.

Which intravenous (IV) solution would a nurse anticipate administering when caring for a client with a history of severe diarrhea for the past three days who is admitted for dehydration?

0.9% sodium chloride

After the nurse has taught self-care management to a client admitted with sickle cell crisis, which client action indicates a need for more education?

Raises the knee position of the bed.

Which statement would the nurse use to respond to an older adult client who states, "I walk 2 miles (3.2 km) a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated"?

"Fluids should be increased if the urine becomes darker."

Which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia?

"I have abnormal hemoglobin."