exam 3

an older client reports fatigue, pallor, and orthostatic hypotension. The clients lab results show low hemoglobin, red blood cells and hematocrit counts family member states that the client has poor appetite and eating habits which treatment would the nurse anticipate will be prescribed by the health care provider? a) opioid b) vitamin b12 c) ferrous sulfate d) fresh frozen plasma

c

which complication would the nurse anticipate in a client who recently underwent gastric bypass surgery? a) aplastic anemia b) sickle cell anemia c) pernicious anemia d) iron deficiency anemia

c

which information would the nurse include when teaching parents about the side effects of oral iron supplements? a) the urine may turn red b) the skin may turn yellow c) the teeth may become stained d) the stools may take on a clay color

c

which time is the most appropriate for the nurse to collect daily sputum specimens from a client? a) after activity b) before meals c) on awakening d) before a respiratory treatment

c

which type of asepsis would a nurse use to prevent introducing microorganisms into the incision when changing a postoperative clients dressing a) wound asepsis b) medical asepsis c) surgical asepsis d) concurrent asepsis

c

after a modified radical mastectomy a client has two portable wound drainage systems in place which intervention would be initiated for these drainage systems? a) irrigating the tubes with normally saline to ensure patency b) attaching the tubes to straight drainage to monitor the output c) leaving the drains open to the air to ensure maximum drainage d) compressing the drainage receptacles after emptying them to maintain suction

d

because of its role in wound healing which vitamin would the nurse expect the healthcare provider to prescribe for a client with large surgical incision? a) vit a b) cyanocobalamin c) phytonadione d) Ascorbic acid

d

which action by a family member of a client with a wound requiring sterile dressing would indicate the need for additional teaching? a) placing the old dressing in a plastic bag b) changing the dressing without wearing a mask c) donning nonsterile gloves before removing the old dressing d) using back and fourth motion while cleaning the wound

d

which appearance would a use expect to find when a client is handed over from the previous shift with stage 3 pressure ulcer? a) reddened skin b) an injury covered by eschar c) damage to muscle and bone d) a deep crater with exposed fat

d

which intervention would the nurse provide a client when vascular changes impair circulation to a wound site? a) proving preventive foot care b) encouraging the client to eat foods rich in iron and folic acid c) encouraging the client to eat adequate amounts of calories and fluids d) encouraging the client to eat foods rich in protein zinc and vitamins a and c

d

which statement is true about active immunity? a) it is also called cell-mediated immunity b) it results when T cells are activated by an antigen c) antivenom given after a snake bite is an example of active immunity d) it develops as the body defends itself from the presence of an active infection

d

The nurse concludes that the teaching regrading vitamin b12 injections to a client with pernicious anemia was understood when the client makes which statement? a) i must take the drug when feeling fatigued b) i must take the drug until my symptoms subside c) i must take the drug monthly for the rest of my life d) i must take the drug during exacerbations of anemia

c

which phase of wound healing involves attachment of blood platelets to the walls of injured vessel? a) maturation b) hemostasis c) reconstruction d) inflammatory phase

b

a nurse explains to the parents of 4 year old child with chickenpox that immunity by antibody formation during the course of the illness provides what? a) active natural immunity b) passive natural immunity c) active artificial immunity d) passive artificial immunity

a

which compensatory mechanism would the nurse expect to observe in a client with acute anemia? a) increase heart rate b)warm reddened skin c) decreased respiratory rate d) increased erythropoietin levels

a

which is the reason for development of erythema, heat, edema, and pain with inflammation? a) increase in the flow of blood elements b) production of thin and watery serum portion of the blood c) production of thin red fluid exudates from the wound d) overgrowth of collagenous scar tissue at the site of the wound

a

which leukocyte value would be assessed to determine the adequacy of client response to inflammation? select all apply a) monocytes b) neutrophils c) plasma cells d) t-helper cells e) macrophages

a,b,e

which statement would the nurse include when teaching lifestyle modifications to a client with iron deficiency anemia? a)calcium blocks the absorption of iron b) coffee and tea block the absorption of iron c) consuming food rich in vitamin c increase the absorption of iron d) distance runners are at increased risk for developing iron deficiency anemia e) the iron in plant foods is not as readily absorbed as the iron in animal based foods

a,b.c.d.e

which function of leukocytes are involved in inflammation? select all apply a) destruction of bacteria and cellular debris b) selective attack and destruction of noncell cells c) release of vocative amines during allergic reactions d) secretion of immunoglobin in response to specific antigen e) enhancement of immune activity through secretion of various factors cytokines and lymphokines

a,c

which instruction would a nurse give an older client to ensure anti-body-mediated immunity? select all apply a) obtain a shingles vaccination b) receive a tetanus booster injection c) obtain the pneumococcal vaccination d) receive annual testing for tuberculosis e) receive an annual influenza vaccination

a.b.c.e

a nurse is discussing immunizations needed to confer active immunity with a pregnant client during her first to prenatal clinic which information would the nurse consider including the client will understand with regard to active immunity? a) protein antigens are formed in the blood to fight invading antibodies b) protein substance are formed by the body to destroy or neutralize antigens c) blood antigens are aided by phagocytes in defending the body against pathogens d) sensitized lymphocytes from an immune donor act antibodies against invading pathogens

b

the nurse identifies that which lab test is part of the complete blood count? a) blood glucose b) hemoglobin c) c-reactive protein d) blood urea nitrogen

b

when performing a sterile dressing change which element of nursing care would the nurse do to maintain sterility? a) put the unopened sterile glove package carefully on the sterile field b) remover the sterile drape from its package by lifting it by the corners c) don sterile gloves before opening the package contain the field drape d) pour irrigation liquid from the height of at least 3 inches above the sterile container

b

which action would the nurse take if specimen for a routine urinalysis cannot be sent immediately to the lab? a) take no special action b) refrigerate the specimen c) store it in the dirty utility room and send it later d) discard the specimen and collet another specimen later

b

which assessment finding would the nurse conclude is an improvement in the underlying condition of the client being treated with erythropoietin? a) 2+ pedal pulses b) decreased pallor c) decreased jaundice d) 2+ deep tendon reflexes

b