imunization, A. Quiz Questions, Evolve Infectious Diseases, Evolve - Med Surg - Integ, 1.1 Infection EAQ, Evolve Immunity Quiz, 1012 Infection, Nutrition Hesi 1, Respiratory Pharmacology

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The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions?

"I must take the medication exactly as prescribed."

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (Select all that apply.)

"I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party.

When evaluating an asthmatic client's knowledge of self-care, the nurse recognizes that additional instruction is needed when the client makes which statement?

"I use my corticosteroid inhaler each time I feel short of breath."

Which statement made by a client taking montelukast indicates the need for further teaching?

"I will take the medication when I first notice I am having trouble breathing."

A client who experiences allergic rhinitis asks the nurse about a nasal corticosteroid. How should the nurse reply?

"The medication works locally and decreases inflammation."

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?

"Wash used dishes in hot, soapy water."

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is:

A 17-year-old adolescent was recently found to have type 2 diabetes mellitus. What information will the nurse include when providing education to the family? 1 "Your teen will need insulin injections for the rest of her life." 2 "The most important interventions are good nutrition and portion control." 3 "This is a condition where the body produces antibodies against its own cells." 4 "This condition causes weight loss and increased appetite, thirst, and urination."

Which patients are at risk of developing health care-associated infections (HAIs)? Select all that apply.

A patient with laryngeal cancer A patient with diabetes mellitus A patient with an indwelling urinary catheter

A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection because it resulted from:

A procedure performed at the hospital

A nurse explains to the parents of a 4-year-old child with chickenpox that immunity by antibody formation during the course of the illness provides what?

Active natural immunity

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. A priority nursing intervention is to:

Administer the prescribed antipyretic and notify the charge nurse or primary health care provider

A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. The priority nursing care is:

Administering prescribed antibiotics

The client has a prescription to receive pirbuterol 2 puffs and beclomethasone dipropionate 2 puffs by metered-dose inhaler. The nurse plans to give these medications in which way to ensure effectiveness?

Administering the pirbuterol before the beclomethasone

What action describes artificial active immunity?

Antibodies are made after an antigen is injected into the body

A client with a documented exposure to tuberculosis is on medication therapy with isoniazid. The nurse is monitoring laboratory results and determines that which laboratory value indicates the need for follow-up?

Aspartate aminotransferase (AST) 55 U/L (55 U/L)

A client arrives at the emergency department after being bitten by a dog. The bite involved tearing of skin and deep soft tissue injury. The first nursing action is to:

Assess the client's injury, vital signs, and past history

A client has a Mantoux test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. The nurse concludes that this response indicates that the client has:

Been exposed to the tubercle bacillus

The health care provider prescribes peak and trough levels of an antibiotic for a client who is receiving the medication intravenous piggyback (IVPB). For peak levels the nurse should have the laboratory obtain a blood sample from the client:

Between 30 and 60 minutes after the IVPB

A client has been given a prescription for benzonatate. Which observation should the nurse look for to evaluate the effectiveness of the medication?

Calming the client's persistent cough

Which are barrier methods of contraception? Select all that apply. Condom Lea's shield Diaphragm Spermicidal foam Coitus interruptus

Condom, Lea's shield, Diaphragm Rationale A condom is considered a barrier method of contraception because it prevents the entrance of sperm into the vagina. Lea's shield is a reusable vaginal contraceptive made of silicone. A diaphragm is a cervical covering used to prevent sperm from reaching the egg. Spermicidal foams are a chemical methods of contraception. Coitus interruptus is a withdrawal contraceptive method.

The health care provider (HCP) has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse should teach the client to monitor for which side effect of the medication?

Constipation

A nurse is caring for a client with a diagnosis of acute salpingitis. Which condition most commonly causing inflammation of the fallopian tubes should the nurse include when planning a teaching program for this client?

Gonorrhea

Which leukocytes should the nurse include when teaching about antibody-mediated immunity?

Memory Cell B-lymphocyte

A client has been taking pyrazinamide for 6 months. The nurse determines that the medication is effective if which cultures yield a negative result?

Sputum

A client has been taking pyrazinamide for 1 month. The client asks the nurse whether the therapy is due to be terminated soon. The nurse determines that the medication probably will be continued based on a positive finding in which report?

Sputum culture

A client is admitted to the hospital with severe burns. What client response should the nurse anticipate when caring for the client during the acute phase of burn recovery?

Stable vital signs

Which stage of HIV would a client with a CD4+ T-cell count of 325 cells/mm 3 be classified? Stage 1 Stage 2 Stage 3 Stage 4

Stage 2 Rationale Stage 2 describes a client with a CD4+ T-cell count between 200 and 499 cells/mm 3. Stage 1 describes a client with a CD4+ T-cell count of greater than 500 cells/mm 3. Stage 3 describes a client with a CD4+ T-cell count of less than 200 cells/mm 3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T-cell counts is available.

Which bacteria causes toxic shock syndrome in female clients? Treponema pallidum Streptococcus faecalis Staphylococcus aureus Neisseria gonorrhoeae

Staphylococcus aureus Rationale Staphylococcus aureus causes toxic shock syndrome. Treponema pallidum causes syphilis. Streptococcus faecalis causes genitourinary tract infections and infection of surgical wounds. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity?

The antigen is neutralized by the antibodies that it supplies.

The nurse has just administered the first dose of omalizumab to a client. Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect?

"My lips and tongue are swollen."

Ampicillin 250 mg by mouth every six hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin?

"The medicine should be taken one hour before or two hours after meals." Ampicillin is a form of penicillin that should be given on an empty stomach; food delays absorption. The response "I should drink a glass of milk with each pill" is incorrect; opaque liquids, such as milk, delay absorption of this drug. The response "I should drink at least six glasses of water every day" is not necessary; however, it is appropriate with sulfonamides. The response "The medicine should be taken with meals and at bedtime" is incorrect; food delays absorption of this drug.

A client with tuberculosis asks the nurse about the communicability of the disease. Which is the best response by the nurse?

"Untreated active tuberculosis is communicable."

A client with tuberculosis asks the nurse about the communicability of the disease. Which is the best response by the nurse?

"Untreated active tuberculosis is communicable." The statement that untreated active tuberculosis is communicable is an accurate statement; treatment is necessary to stop communicability. The statement that tuberculosis is not communicable at this time is false reassurance; untreated active tuberculosis is communicable. Tuberculosis is not communicable when there is no active infection; the primary complex refers to the presence of a primary (Ghon) tubercle and enlarged lymph nodes and is the initial response to exposure; active disease may or may not occur. Tuberculosis is a communicable disease; close contacts should be screened via a skin test.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? "Wear sterile gloves when doing the procedure." "Wash your hands before performing the procedure." "Perform the self-catheterization every 12 hours." "Dispose of the catheter after you have catheterized yourself."

"Wash your hands before performing the procedure." To avoid transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2 to 3 hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.

Fill in the blank An older client who is living in a nursing home is admitted to the hospital to be treated with intravenous antibiotics for sepsis. After the client becomes agitated and attempts to pull out the IV, the healthcare provider prescribes a stat dose of haloperidol 0.5 mg intramuscularly (IM). The haloperidol is available in a vial that contains 2 mg/mL. How much solution will the nurse administer? Record your answer using two decimal places. Include a leading zero if applicable.

0.25 mL Rationale The prescribed dose is 0.5 mg. The available concentration is 2 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse should administer.

A client is to receive an intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride to be administered over 20 minutes. At what rate should the nurse set the infusion pump? Record your answer using a whole number. __________ mL/hr

150 ml/hr

A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling?

45-year-old woman with breast cancer

A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain one week later. What does the nurse identify as the cause of the post therapeutic neuralgia?

Damage to the nerves

A clinic nurse is assessing a client who has been on isoniazid for 6 months. Which client complaint should most concern the nurse?

Difficulty tying shoes

A client taking albuterol by inhalation cannot cough up secretions. What should the nurse suggest that the client do to assist in expectoration of secretions?

Drink increased amounts of fluids every day.

A client is taking cetirizine. The nurse should inform the client of which side effect of this medication?

Drowsiness

Which type of continuing care should a client expect if discharged home with an infusion device to continue treatment for a leg wound? Home care Rehabilitation Skilled nursing care Outpatient therapy

Home care Rationale Clients who are discharged with an infusion device to continue drug therapy at home should expect home care services to teach appropriate administration of drug therapy in the client's home. The client is being discharged to the home and not to rehabilitation or to a skilled nursing facility. Outpatient therapy is not identified as a method for continuing antibiotic therapy with an infusion device.

A construction worker sustains a puncture from a rusty nail. It is unknown when the worker had the last immunization for tetanus, and the primary health care provider prescribes tetanus immune globulin. What protection does this type of immunization offer?

Immediate passive short-term immunity

A client taking theophylline has a serum theophylline level of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this laboratory value?

In the middle of the therapeutic range

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? (Select all that apply.)

Joint pain Facial rash Pericarditis

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed?

Liver enzyme levels

The nurse is preparing to administer albuterol to a client. Which parameters should the nurse assess before and during therapy?

Lung sounds and presence of dyspnea

Which disease is caused by protozoa

Malaria Malaria is caused by sporozoa, which is a type of protozoa, Plasmodium malariae. Leprosy is caused by spirochetes. Fungi cause oral thrush. Varicella zoster virus causes chickenpox.

A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to best prevent malaria?

Mosquito bites

Which type of immunity is acquired through the transfer of colostrum from the mother to the child?

Natural passive immunity

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.

Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client?

Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions Toxins from bacilli invade nervous tissue, causing restlessness. Toxins from bacilli invade nervous tissue, causing muscle spasms and muscular rigidity . Toxins from the bacillus invade nervous tissue; respiratory spasms may result in respiratory failure. Toxins from bacilli invade nervous tissue, causing spastic contraction of voluntary muscles. Tetanus causes spasms of facial muscles, resulting in a grotesque grinning expression (risus sardonicus) and spasms of masticatory muscles (trismus), not atony of facial muscles.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side and adverse effects of the medication should the nurse monitor? Select all that apply.

Signs of hepatitis 2. Flulike syndrome 3. Low neutrophil count Ocular pain or blurred vision

What disease is more commonly seen in preschoolers? Sinusitis Lung cancer Hypertension Angina pectoris

Sinusitis Rationale Toddlers and preschoolers are very prone to developing upper respiratory tract infections such as sinusitis. Lung cancer is seen commonly in young or middle-aged adults due to a smoking habit. Hypertension is commonly seen in middle-aged adults due to an unhealthy diet, lack of exercise, and stress. Angina also tends to affect young and middle-aged adults.

A client with psoriasis asks the nurse what can help this condition. Which should the nurse include in a teaching plan for this client?

Topical application of steroids

A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan?

Two to six weeks

What is the required average daily intake of calories in preschoolers? 1 400 2 700 3 1,000 4 1,800

When assessing the characteristics of an adolescent with anorexia nervosa, how does the nurse expect to describe the adolescent? 1 Manic 2 Rebellious 3 Hypoactive 4 Perfectionistic

D (The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.)

Which nursing process involves delegation and verbal discussion with the healthcare team? A. Planning B. Evaluation C. Assessment D. Implementation

A client diagnosed with osteomyelitis is being discharged. Which statement indicates a need for further teaching? "I will take the antibiotic at the same time every day." "I will take the antibiotic regularly until my symptoms subside." "I will take the antibiotic with food if I develop gastric distress when on the antibiotic." "I will notify my healthcare provider and stop taking the medication if I develop a rash or shortness of breath."

"I will take the antibiotic regularly until my symptoms subside." Rationale The antibiotic should be taken as prescribed for the full length of treatment. The client should not discontinue the medication when symptoms subside. The statements "I will take the antibiotic at the same time every day," "I will take the antibiotic with food if I develop gastric distress when on the antibiotic," and "I will notify my healthcare provider and stop taking the medication if I develop a rash or shortness of breath" demonstrate understanding of the discharge instructions.

A client with a prescription to take theophylline daily has been given medication instructions by the nurse. What statement by the client indicates the need for further education regarding the prescription?

"I will take the daily dose at bedtime."

The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant. The nurse determines that the client needs further instruction if the client makes which statement?

"I will take the medication on an empty stomach."

The nurse determines that a young female client who is being treated for a sexually transmitted infection (STI) understands instructions regarding future sexual contacts. Which client statement confirms the nurse's conclusion? "If I have sex, nothing I do will really prevent me from getting another STI." "If I get another STI, I can take any antibiotic, because I'm not allergic to any of them." "I won't have unprotected sex again, and I'll tell my partners to be tested for STIs." "I have to ask my partners if they have an STI, and if they say no I'll know that I can have sex."

"I won't have unprotected sex again, and I'll tell my partners to be tested for STIs." Rationale The most effective strategies for preventing sexually transmitted infections in one's self and sex partners are the use of condoms and having sex partners tested to determine their status and get treatment if necessary. There are protective measures that can be used to help prevent the transmission of STIs. The emphasis should be on prevention, not treatment; some STIs have no cure. Asking partners whether they have an STI does not always elicit a truthful answer; protection is necessary to help prevent the transmission of STIs.

A client with chronic obstructive pulmonary disease (COPD) is being changed from an oral glucocorticoid to triamcinolone by inhalation. The client asks why this change is necessary. Which statement by the nurse to the client is accurate?

"Inhaled glucocorticoids are preferred because of decreased adverse effects."

A client with acquired immunodeficiency syndrome (AIDS) comments to the nurse, "There are so many rotten people around. Why couldn't one of them get AIDS instead of me?" The nurse's best response is:

"It seems unfair that you should be so ill." Rationale The client is in the anger or "why me" stage; encouraging the expression of feelings will help the client resolve them and move toward acceptance. The response "It may be helpful to speak with a minister" abdicates the responsibility of talking with the client; a suggestion to speak with a minister ignores the client's need for an immediate supportive response. The response "I can understand why you're so afraid of death" does not reflect on what the client said. The judgmental response "I'm sure you really don't wish this on someone else" may precipitate feelings of guilt and block the nurse-client relationship.

A client who has recently been found to be infected with HIV comments to the nurse, "There are so many terrible people around. Why couldn't one of them get HIV instead of me?" What is the best response by the nurse? "It seems unfair that you should have this disease." "I'm sure you really don't wish this on someone else." "It might be good for you to speak with your religious leader." "I'm sure you know that HIV infection is now considered a chronic illness."

"It seems unfair that you should have this disease." The client is in the anger or "why me" stage of grieving; encouraging the client to express feelings will help the client resolve them while moving toward acceptance. "I'm sure you really don't wish this on someone else" is a judgmental response that may create a rift in the nurse-client relationship. Suggesting that the client speak with a religious leader may precipitate guilt feelings and ignores the current concern. "I'm sure you know that HIV infection is now considered a chronic illness" does not reflect what the client said; people with newly diagnosed chronic illnesses grieve for their loss of health.

The nurse instructs the son of an older client about age-related immune system changes and associated care measures. Which statement made by the son during a follow-up visit indicates a need for further instruction?

"My parent comes in for check-ups only whenever he or she has a fever."

Ampicillin 250 mg by mouth every six hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin?

"The medicine should be taken one hour before or two hours after meals."

A health care provider prescribes oral loperamide (Maalox) and intravenous ranitidine (Zantac) for a client with burns and crushing injuries caused by an accident. The client asks how these medications work

"They limit acidity in the gastrointestinal tract."

A client with tuberculosis is to begin Rifater (combination of isoniazid [INH], rifampin [RIF], and pyrazinamide [PZA]), and streptomycin sulfate (streptomycin) therapy. The client says, "I've never had to take so much medication for an infection before." The nurse should explain: "This type of organism is difficult to destroy." "Streptomycin prevents side effects of Rifater." "You'll only need to take the medications for a couple of weeks." "Aggressive therapy is needed because the infection is well advanced."

"This type of organism is difficult to destroy." Multiple drugs are administered because of the concern regarding drug resistance. Streptomycin sulfate is an antibiotic; it does not prevent the side effects of Rifater therapy. Multiple antitubercular drugs are necessary for an extended period, approximately six to eight months depending on the individual. Aggressive therapy may increase anxiety and may not be needed even when the infection is well advanced.

Tuberculosis is confirmed and isoniazid (INH), rifampin (Rifadin), and pyridoxine (vitamin B6) are prescribed for a client. The client says, "I've never had to take so many medicines for an infection before." What is the nurse's best reply? "Rifampin prevents side effects from INH." "This type of organism is difficult to destroy." "You'll need only one medication in a couple of months." "Aggressive therapy is needed because your infection is so advanced."

"This type of organism is difficult to destroy." Organism mutation commonly results in drug resistance when treatment is inadequate. Rifampin decreases the replication of the tubercle bacillus ; pyridoxine is used to prevent neuropathy associated with INH. The response "You'll need only one medication in a couple of months" is an inaccurate statement. High concentrations of at least two antitubercular drugs are necessary for an extended period. The response "Aggressive therapy is needed because your infection is so advanced" may raise anxiety and may not be true; aggressive combination drug therapy always is used for tuberculosis.

A newly hired nurse, during orientation, is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? "Let me get my preceptor." "Wash your hands before and after any client care." "Clean all instruments and work surfaces with an approved disinfectant." "Ensure proper disposal of all items contaminated with blood or body fluids."

"Wash your hands before and after any client care." The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of handwashing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.

A nurse is changing the dressing of a sixth-grader with severe burns. What basic principles of surgical asepsis must the nurse consider? A paper field must remain dry to be considered sterile. Sterile items held below the waist are considered sterile. A 1-inch border around a sterile field is considered contaminated. Sterile objects in contact with clean objects are considered contaminated. A fenestrated drape is not considered sterile.

#1, 3 and 4 Once a sterile paper field becomes wet it allows microorganisms on the surface of the table to contaminate the field. A 1-inch border around the outer edge of a sterile field is considered contaminated because the edges touch the table. Once a sterile object comes into contact with any object that is not sterile, it is no longer considered sterile. Sterile objects below the waist are considered contaminated. A fenestrated drape may be considered sterile as long as it has not been contaminated.

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. What information in the client's history supports the health care provider's diagnosis of pulmonary tuberculosis? (Multiple) Fever Dry cough Night sweats Frothy sputum Engorged neck veins Blood-tinged sputum

#1, 3 and 6 Tuberculosis is an infectious disease in which recurrent fevers are present, usually in the late afternoon. Profuse diaphoresis at night (night sweats) is a classical sign of tuberculosis. Blood-tinged sputum (hemoptysis) results from pathophysiological trauma to mucous membranes. The cough is productive, not dry, because the inflammatory process causes purulent mucus. Frothy sputum is present with pulmonary edema, not tuberculosis. Engorged neck veins are symptomatic of heart failure.

Arrange the sequence of steps required to stimulate antibody-mediated immunity in its correct sequence.

-Exposure of antigen -Antigen recognition -Sensitization -Antibody production -Antibody-antigen binding -Antigen elimination

Arrange the steps required to stimulate antibody-mediated immunity in its correct sequence.

1. Invasion of new antigens in the body 2.Interaction of the macrophage and helper T-cells to recognize the antigen 3.Sensitization of B-lymphocyte to the new antigen 4.Production of antibodies by B-lymphocytes 5.Binding of antibodies to the antigen and formation of immune complex 6.Neutralization or elimination of the antigen

Isoniazid is prescribed for a child with human immunodeficiency virus (HIV) infection who has a positive tuberculin skin test result. The mother of the child asks the nurse how long the child will need to take the medication. For how long should the nurse tell the mother the medication will need to be taken?

12 months

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. Performing an immediate appraisal, using the Rule of Nines, what is the percent of body surface area burned?

22.5%

After surgery a client is to receive an antibiotic by intravenous (IV) piggyback in 50 mL of a diluent. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 15 gtts/mL. The nurse should set the piggyback to flow at how many gtts/min? Record your answer using a whole number. __________ gtts/min

A client who has been receiving theophylline by the intravenous (IV) route has the medication prescription changed to an immediate-release oral form of the medication. After discontinuing the IV medication, when should the nurse schedule the first dose of the oral medication?

4 hours after discontinuing the IV form

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving theophylline. The nurse monitors the serum theophylline level and concludes that the medication dosage may need to be increased if which value is noted?

5 mg/mL (20 mcmol/L)

A 17-year-old client is found to have anorexia nervosa. The psychiatrist, in conjunction with the client and the parents, decides to institute a behavior modification program. What does the nurse recall is a major component of behavior modification? 1 Rewarding positive behavior 2 Reducing necessary restrictions 3 Deconditioning fear of weight gain 4 Reducing anxiety-producing situations

B (Stating that the client feels that she's neglected her health indicates recognition of expressed feelings; a nondirective and reflective response encourages verbalization. Asking the client why she waited so long ignores the client's current emotional needs; direct statements often do not elicit feelings and may cut off communication. Stating that it is never too late to start taking care of her health is a judgmental response, because it implies that the client has been negligent. Although it is true that most clients hate to have Pap smears, this statement ignores the client's current emotional needs.)

A 49-year-old client is admitted with a diagnosis of cervical cancer. As the nurse is obtaining her health history, she says, "I haven't had a Pap smear for more than 5 years. I probably wouldn't be in the hospital today if I'd had those tests more often." What is the nurse's most appropriate response? A. "Please tell me why you waited so long." B. "You feel as though you've neglected your health." C. "It's never too late to start taking care of yourself." D. "Most women hate to have Pap smears done, but they're really important."

A 9-year-old child who has iron-deficiency anemia tells the school nurse, "I get dizzy in gym class." What is the most likely explanation for this symptom? 1 Inflammation of the inner ear 2 Sudden drop in blood pressure 3 Insufficient cerebral oxygenation 4 Decreased level of serum glucose

A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? 1 Lactase 2 Sucrase 3 Maltase 4 Amylase

C (Because the rubella virus is found in the respiratory tract and urine, isolation is necessary; rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated term; the techniques used with this precaution are incorporated under contact precautions, and the techniques used with contact precautions are incorporated under standard precautions. The use of standard precautions alone is unsafe; additional precautions must be implemented to protect the nurse from droplet-transmitted infection.)

A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions should the nurse institute? A. Enteric B. Contact C. Droplet D. Standard

A (Unrelieved chest pain increases anxiety, fatigue, and myocardial oxygen consumption, with the possibility of extending the infarction. The client will not be ready for teaching until the chest pain is relieved. Cardiac monitoring is important, but it does not take priority over relieving the chest pain. Bed rest is necessary to decrease the workload of the heart, but decreasing the cardiac workload will be difficult to achieve unless the chest pain is relieved.)

A client is admitted to the coronary care unit complaining of "viselike" chest pain radiating to the neck. Assessment reveals a blood pressure of 124/64 mm Hg, an irregular apical pulse of 64 beats per minute, and diaphoresis. Cardiac monitoring is instituted, and morphine sulfate 4 mg intravenous (IV) push stat is prescribed. What is the priority nursing care for this client? A. Relief of pain B. Client teaching C. Cardiac monitoring D. Maintenance of bed rest

A client is receiving total parenteral nutrition. The nurse assesses for which client response that indicates hyperglycemia? 1 Paralytic ileus 2 Respiratory rate below 16 3 A fruity odor to the breath 4 Serum glucose of 105 mg/100 mL

A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? 1 Provide low-sodium milk. 2 Provide high-protein drinks. 3 Provide foods that are low in potassium. 4 Provide 10% more calories in the form of fats.

A client who has had recurrent infections before and during pregnancy should be instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. What should the nurse encourage the client to include in her diet? 1 Fat-soluble vitamins 2 Dietary fiber and oat bran 3 Low-fat foods with essential fatty acids 4 Vitamins C and E

A client with arthritis reports receiving several dietary suggestions over the years. Which recommendation for a daily diet should the nurse reinforce? 1 Wheat germ and yeast 2 Yogurt and blackstrap molasses 3 Multiple vitamin supplements in large doses 4 Adequate foods in a variety of different food groups

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? 1 Empty feeding bag stays attached to the tubing. 2 Tube is flushed with air after medication is given. 3 Replacement of the tube is done on a weekly basis. 4 Head of the bed remains elevated after the feeding

A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment? 1 No protein 2 Moderate protein 3 High protein 4 Strict protein restriction

A client with osteoporosis has been receiving dietary information from the nurse. Which food selection by the client indicates that the nurse's dietary instruction was effective? 1 Red meat 2 Soft drinks 3 Turnip greens 4 Enriched grains

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find:

A decrease in CD4 T cells

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find:

A decrease in CD4 T cells The human immunodeficiency virus (HIV) infects helper T-cell lymphocytes; therefore, 300 or fewer CD4 T cells per cubic millimeter of blood or CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS . The thymic hormones necessary for T-cell growth are decreased. An increase in immunoglobulin E is associated with allergies and parasitic infections. A decrease in the serum level of glucose-6-phosphate dehydrogenase is associated with drug induced hemolytic anemia and hemolytic disease of the newborn.

B (For a high colonic enema, the fluid must extend higher in the colon. If the height of the enema fluid container above the anus is increased, the force and rate of flow also increase. 30 cm (12 inches) is too low for a cleansing enema. The heights of 51 cm (20 inches) and 66 cm (26 inches) are too high and may cause mucosal injury.)

A high cleansing enema is prescribed for a client. What is the maximum height at which the container of fluid should be held by the nurse when administering this enema? A. 30 cm (12 inches) B. 37 cm (15 inches) C. 51 cm (20 inches) D. 66 cm (26 inches)

Which supplies should the nurse obtain for the administration of ribavirin to a hospitalized child with respiratory syncytial virus (RSV)?

A mask and pair of goggles

A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal what? 1 Edema 2 Diarrhea 3 Amenorrhea 4 Hypertension

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? 1 Turkey salad, french fries, sherbet 2 Cottage cheese, mixed fruit salad, milkshake 3 Salad, sliced chicken sandwich, gelatin dessert 4 Cheeseburger, tortilla chips, chocolate pudding

A nurse is caring for a client with cholelithiasis. Which clinical manifestation does the nurse expect if the client develops obstructive jaundice? 1 Yellow sclera 2 Pain on urination 3 Dark brown stools 4 Coffee-ground emesis

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? 1 Increase in serotonin 2 Deficiency of thiamine 3 Reduction in iron intake 4 Malabsorption of riboflavin

1,2,5

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply 1 Rye 2 Oats 3 Rice 4 Corn 5 Wheat

A nurse is teaching the parents of a school-aged child with celiac disease about the nutrients that must be avoided in a gluten-free diet. What nutrients should the nurse teach the parents to avoid? 1 Saturated oils and fats 2 Milk and hard cheeses 3 Corn and rice products 4 Wheat and oat products

BDE (Bringing in any change in the preoperative teaching protocol may require the nurse manager to develop new skills and competency required for implementing the change. Modifications should be made in the protocol to implement the change and promote client safety. Late adopters to change may try to negatively influence the change initiatives. Their influence should be minimized on the staff members implementing the change. Support from the clients may not be helpful as they might not have the necessary scientific knowledge. The non-nursing staff can be included in the change initiative for better support.)

A nurse manager wants to change the protocol of preoperative teaching to include aspects of deep breathing and infection control measures. Which strategies should the nurse implement to support this change? Select all that apply. A. Mobilizing positive support from the clients for the change B. Developing new skills and competency required for implementing the change C. Excluding the non-nursing staff from the change initiative to reduce their influence D. Making modifications in preoperative teachings to support the change initiative E. Reducing the negative influences of late adopters from the group implementing the change

A nurse may find that for optimum nutrition a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do? 1 Request that the client's food be pureed. 2 Feed the client to conserve the client's energy. 3 Have a family member assist the client with each meal. 4 Encourage the client to participate in the feeding process

B (Evaluation includes assessing the client's response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the client's needs. Assessment entails collecting and reviewing objective and subjective data about the client's health status. Implementation includes performing specific actions designed to achieve the stated goals.)

A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied? A. Planning B. Evaluation C. Assessment D. Implementation

D (Because clients have the right to know about their health status, the nurse should provide them with all relevant information. This is a therapeutic communication technique that enables clients to understand what is happening and what to expect. Asking for explanations, showing sympathy and asking personal questions of the client are nontherapeutic communication techniques.)

A nurse uses therapeutic communication techniques in order to achieve desired client outcomes. Which communication technique is a part of therapeutic communication? A. Asking for explanations B. Showing sympathy to the client C. Asking personal questions of the client D. Providing relevant information to the client

BDE (The content component involves information about the nursing interventions for clients with specific health care problems. When the nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli, this action is an example of the content component. When the nurse understands that many clients practice polypharmacy by purchasing prescribed medications from multiple stores, this understanding is an example of the content component. When the nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent spread of pathogens, this knowledge is an example of the content component. When the nurse assessing a client's medical records before surgery finds that the client is allergic to latex, this discovery is an example of the input component. When the nurse checks the medical records of the client for blood transfusion reaction before administering a blood transfusion, this action is an example of the input component.)

A nursing student is learning about the nursing process, which consists of four components. Which scenarios should the nursing student consider as content components? Select all that apply. A. "A nurse assessing a client's medical records before surgery finds that the client is allergic to latex." B. "The nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli." C. "The nurse checks the client's medical records for any blood transfusion reactions before administering a blood transfusion." D. "The nurse understands that many clients buy prescribed medications from multiple medical stores; this is known as polypharmacy." E. "The nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent the spread of pathogens."

A pregnant client tells the nurse, "I'm sticking to my diet, and I don't eat anything containing salt." How should the nurse respond? 1 "You're doing fine. Just keep up the good work." 2 "A low-salt diet will protect you from getting swollen feet." 3 "We now encourage pregnant women to increase their salt intake because of changes in the circulation." 4 "Salt is necessary in your diet. Use a little when you're cooking, but avoid processed meats and canned foods with salt."

Which prescribed medication should the nurse expect to administer to a female client who exhibits the genital lesions presented in the illustration?

Acyclovir sodium is a treatment for herpes simplex type 2 in a female client. There is no medication that cures this disease; however, an antiviral, such as acyclovir sodium, generally is prescribed to reduce healing time and the severity of clinical findings. Zidovudine is a nucleoside analog reverse transcriptase inhibitor often prescribed to treat acquired immunodeficiency syndrome (AIDS). Metronidazole is an antimicrobial agent generally prescribed to treat gastroenteritis caused by Clostridium difficile. Ceftriaxone is an antimicrobial agent generally prescribed for gonorrhea.

A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions?

Airborne precautions

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs? 1 Low in fat and vitamin D 2 High in calories and fiber 3 Low in residue and bland 4 High in protein and vitamin C

A nurse explains to the mother of a 1-year-old with a history of frequent ear infections that the primary cause of otitis media in young children is: Sinusitis Recurrent tonsillitis An inflamed mastoid process An obstructed eustachian tube

An obstructed eustachian tube A blocked eustachian tube impairs drainage and creates negative pressure; when the tube opens, bacteria are pulled into the middle ear. Sinusitis is not related to otitis media. Recurrent tonsillitis is not the direct cause of otitis media. Mastoiditis is a complication, not a cause, of otitis media.

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) has been on oral glucocorticoids and is currently being weaned to triamcinolone by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change when the client states the need to report which signs and symptoms?

Anorexia, nausea, weakness, and fatigue

The parents of a 6-week-old infant who was born without an immune system ask the nurse why their baby is still so healthy. What is the best response by the nurse?

Antibodies are passively received from the mother through the placenta and breast milk.

A client is diagnosed with psoriasis and the nurse is providing health teaching concerning skin care at home. What recommendation does the nurse include in the teaching?

Apply moisturizing lotion several times a day

A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the most appropriate nursing action? Applying cold compresses to the affected area Ensuring the client keeps the skin clean and dry Monitoring for neurological and cardiac symptoms Advising the client to launder all clothes with bleach

Applying cold compresses to the affected area Rationale A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurologic manifestations. Therefore the nurse has to monitor for these symptoms. Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure that the client's clothes are bleached to prevent the transmission of the infection.

Which type of immunity will clients acquire through immunizations with live or killed vaccines?

Artificial active immunity

The nurse is teaching a client about the effects of diphenhydramine, an ingredient in the cough suppressant prescribed for the client. The nurse should plan to tell the client to take which measure while taking this medication?

Avoid activities requiring mental alertness.

A client receiving chemotherapy takes a steroid daily. The client has a white blood cell count of 12,000/mm3 and a red blood cell count of 4.5 million/mm3. What is the priority instruction that the nurse should teach the client?

Avoid large crowds and persons with infections

Been exposed to the Tubercle Bacillus Induration measuring 10 mm or more in diameter is interpreted as significant; it does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure; infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies; a positive Mantoux indicates the presence of antibodies, not how they were formed. Developing a resistance to the tubercle bacillus reaction indicates exposure, not resistance.

A teenage mother is diagnosed with syphilis. What would be the drug of choice for this client if she wishes to continue breast-feeding? Doxycycline Tetracycline Azithromycin Benzathine penicillin

Benzathine penicillin Rationale Benzathine penicillin is safe to use for syphilis in lactating women. Doxycycline and tetracycline are used in the treatment of syphilis in nonpregnant women. Azithromycin is not the drug of choice for the treatment of syphilis.

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication?

Bronchospasm

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication?

Causes orange discoloration of sweat, tears, urine, and feces

A client taking rifampin reports, "My urine has blood in it." When the nurse assesses the urine, it is brown. Which is the nurse's best action?

Chart the finding as a normal response to the rifampin.

A client who is in labor is admitted 30 hours after her membranes ruptured. For what condition does the nurse anticipate that the client is most at risk? Cord prolapse Placenta previa Chorioamnionitis Abruptio placentae

Chorioamnionitis The risk of developing chorioamnionitis (intra-amniotic infection) is increased with prolonged rupture of the membranes; foul-smelling fluid is a sign of infection. A prolapsed cord usually occurs shortly after the membranes rupture, not 1½ days later. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Premature separation of the placenta is unrelated to ruptured membranes.

A client in the emergency department states, "I was bitten by a raccoon while I was fixing a water pipe in the crawl space of my basement." Which is the most effective first-aid treatment for the nurse to use for this client?

Cleansing the wound with soap and water

A client has begun using a methylxanthine bronchodilator. What beverage should the nurse plan to teach the client to avoid while taking this medication?

Coffee

A client receiving oral theophylline is due to have a theophylline level drawn. The nurse should question the client to ensure that the client has not ingested which substance before the blood sample is drawn?

Coffee

A client has begun therapy with theophylline. The nurse should plan to teach the client to limit the intake of which items while taking this medication?

Coffee, cola, and chocolate

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care?

Cool, moist towels

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? No special precautions are required. Cover the infected site with a dressing. Drape the client with a covering labeled biohazardous. Place a surgical mask on the client.

Cover the infected site with a dressing. Rationale Covering the infected site with a dressing will contain secretions and set up a barrier, thus decreasing the risk for transmission to others. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Draping the client with a sheet marked biohazardous does not protect the client's privacy. A wound infected with MRSA can be transmitted to others via contact, not the airborne route; thus a mask is unnecessary.

A nurse is teaching a client about drug therapy for gonorrhea. Which fact about drug therapy should the nurse emphasize?

Cures the infection Ceftriaxone (Rocephin), followed by doxycycline (Vibramycin), is specific for Neisseria gonorrhoeae and eradicates the microorganism; other treatment regimens are available for resistant strains. If the disease progresses before the diagnosis is made, complications such as sterility, heart valve damage, or joint degeneration may occur. Transmission is not controlled; the organism is eliminated. If tubal structures, heart valves, or joints degenerate, the pathological changes will not be reversed by antibiotic therapy.

A nurse is teaching a client about drug therapy for gonorrhea. Which fact about drug therapy should the nurse emphasize? Cures the infection Prevents complications Controls its transmission Reverses pathological changes

Damage to the nerves After the original infection has healed, the virus remains quiescent, or it may return. Post therapetic neuralgia, which occurs in some individuals, results from damage to the nerves caused by the varicella-zoster virus; the neuralgia may last for months. Untreated major depression and scarring in the area of the rash are unrelated to post therapeutic neuralgia. The rash does not cause post therapeutic neuralgia. .

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution?

Diabetes mellitus

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that he or she will immediately report which finding?

Difficulty in discriminating the color red from green

When assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies areas of white plaque on the client's tongue and palate. What is the nurse's initial response?

Document the presence of the lesions, describing their size, location, and color

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the room. Implement contact precautions and post appropriate signage. After finishing with patient care, remove the gown first and then remove the gloves.

Don an N95 respirator mask before entering the room. A N95 respirator mask is unique to airborne precautions. It is unique for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be non-permeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

The client questions the nurse as to why the health care provider switched the usual prescription from a metered-dose inhaler (MDI) to a dry powder inhaler (DPI). The nurse should respond correctly by providing which facts? Select all that apply.

Dry powder inhalers pose no environmental risks. Dry powder inhalers deliver more medication to the lungs. 5. Dry powder inhalers require less hand-to-lung coordination.

D (Administration of additional fluid when a client reports experiencing abdominal cramps adds to discomfort because of additional pressure. By clamping the tubing a few minutes, the nurse allows the cramps to subside, and the enema can be continued. Cramps are not a reason to discontinue the enema entirely; temporary clamping of the tubing usually relieves the cramps, and the procedure can be continued. Slowing the rate decreases pressure but does not reduce it entirely. Lowering the height of the container will reduce the flow of the solution, which will decrease pressure but not reduce it entirely.)

During administration of an enema, a client reports having intestinal cramps. What should the nurse do? A. Discontinue the procedure. B. Instill the fluid at a slower rate. C. Lower the height of the container. D. Stop the fluid until the cramps subside.

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first? 1 Suggest that an antiemetic be prescribed 2 Change the feeding schedule to omit nights 3 Request that the type of solution be changed 4 Gather more data from the night nurse about the technique used

A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. The nurse teaches the client that the purpose of the antibiotics is to help: Prevent incisional infection Avoid postoperative pneumonia Limit the risk of a urinary tract infection Eliminate bacteria from the gastrointestinal (GI) tract

Eliminate bacteria from the gastrointestinal (GI) tract The GI tract contains numerous bacteria; antibiotics are given to decrease the number of microorganisms in the bowel before surgery. Preventing incisional infection is a potential complication prevented by the use of sterile technique when changing the dressing. Avoiding postoperative pneumonia is a potential complication prevented by coughing, deep breathing, and early ambulation postoperatively. Limiting the risk of a urinary tract infection is a potential complication prevented by hygiene, meatal care, and increased hydration postoperatively.

A client is diagnosed with gastroenteritis. What does the nurse determine is the basic intention underlying the unique dietary management for this client?

Eliminate chemical, mechanical, and thermal irritation.

A client is diagnosed with gastroenteritis. What does the nurse determine is the basic intention underlying the unique dietary management for this client

Eliminate chemical, mechanical, and thermal irritation. Irritation of the mucosa may cause increased bleeding or perforation and therefore should be avoided. All clients' diets should be nutritionally balanced; this is not specific to this client's problem. Bulk and roughage may irritate the mucosa and should be decreased. Psychological support is not the primary goal; efforts should be made to include foods that are psychologically beneficial but eliminate foods that are irritating to the mucosa.

The nurse is providing care for a client that is on bed rest. The nurse can prevent skin breakdown for this client by:

Encouraging the client to move around as much as possible

What nursing intervention should be implemented routinely after a client has a vacuum aspiration abortion? Giving the client the prescribed oxytocic medication Preparing the client for discharge within 30 minutes Teaching the client about the various methods of birth control Encouraging the client to take the prescribed antibiotic medication

Encouraging the client to take the prescribed antibiotic medication Prophylactic antibiotics after a decrease the incidence of infection. Oxytocics are not used routinely after an abortion unless there is excessive vaginal bleeding. The client is usually observed for 1 to 3 hours before being discharged. Birth control instructions should be given before the abortion; a client is not receptive to teaching immediately after the procedure.

What clinical signs should lead a nurse to suspect that a 1-year-old child has rubella (German measles)? Bulging fontanel and nuchal rigidity Conjunctivitis and sensitivity to light Koplik spots on the soft palate and buccal mucosa Enlarged posterior cervical and postauricular nodes

Enlarged posterior cervical and postauricular nodes Lymphadenopathy and the development of a rash after a day of fever, sneezing, and coughing are characteristics of rubella (German measles). A bulging fontanel and nuchal rigidity are associated with meningitis and encephalitis, not rubella. Conjunctivitis and light sensitivity are associated with rubeola (measles), not rubella. Koplik spots are present with rubeola, not rubella.

The nurse is administering a dose of morphine sulfate to a client via an epidural catheter after nephrectomy. Before administering the medication, what should the nurse plan to do?

Ensure that naloxone is readily available.

A client is admitted for malignant melanoma that was discovered during a routine eye examination. For which preferred treatment does the nurse expect the client to be scheduled?

Enucleation

Which diseases may occur due to rickettsial infections? Select all that apply. Leprosy Lyme disease Epidemic typhus West Nile fever Rocky Mountain spotted fever

Epidemic typhus, Rocky Mountain spotted fever Rationale Typhoid fever and Rocky Mountain spotted fever are caused by rickettsial infections. Spirochetes and Mycobacterium leprae cause leprosy. Borrelia burgdorferi cause Lyme disease. The West Nile virus causes West Nile fever.

An adolescent reports scrotal pain, redness, dysuria, and fever. Which condition does this adolescent have? Varicocele Epididymitis Testicular torsion Testicular cancer

Epididymitis Rationale Epididymitis is a condition associated with scrotal pain, dysuria, redness, and fever. Varicocele can be palpated as a worm-like mass situated above the testicles. Manifestations of testicular torsion include nausea, vomiting, and abdominal pain. The presence of a heavy, hard mass that is palpable accompanied by back pain and shortness of breath is associated with testicular cancer.

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications?

Examining the feet daily, Wearing well-fitting shoes, Performing regular exercise

A primary health care provider prescribes airborne precautions for a client with tuberculosis. After being taught about the details of airborne precautions, the client is seen walking down the hall to get a glass of juice from the kitchen. The most effective nursing intervention is to:

Explore what the precautions mean to the client

A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer because the major precipitating factor associated with skin cancer is:

Exposure to radiation

A client sustains full-thickness and deep partial-thickness burns. The client asks, "What is the difference between my full-thickness and deep partial-thickness burns?" The nurse explains that full-thickness burns:

Extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis

A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16-year-old adolescent. Which should be of most concern to the nurse?

Finding the client's contacts

Nitrofurantoin (Macrobid) 0.1 gm is prescribed for a client with a urinary tract infection. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number.

First convert 0.1 g to its equivalent in mg by multiplying by 1000 (move the decimal 3 places to the right). Use the "Desire over Have" formula of ratio and proportion to solve the problem. Desire 100 mg x tablets ---------------- = --------- Have 50 mg 1 tablet 50x = 100 x = 100 ÷ 50 x = 2 tablets

The bacteria Clostridium botulinum causes which condition in a client? Upper respiratory tract infection Toxic shock syndrome Urinary tract infection Food poisoning with progressive muscle paralysis

Food poisoning with progressive muscle paralysis Rationale Clostridium botulinum bacteria causes food poisoning with progressive muscle paralysis. Toxic shock syndrome is caused by the bacteria Staphylococcus aureus. Many viruses and bacteria can cause upper respiratory tract infection but Clostridium is not one of them. Klebsiella-Enterobacter organisms most likely cause urinary tract infections.

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? Soap Time Water Friction

Friction Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.

Which sexually transmitted disease is treated with antiviral drugs? Syphilis Gonorrhea Genital herpes Chlamydial infection

Genital herpes Rationale Genital herpes is a sexually transmitted disease caused by herpes simplex virus. Therefore antiviral drugs are used to treat this condition. Bacteria cause syphilis, gonorrhea, and chlamydial infections.

A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug?

Give the medication an hour before milk products are ingested.

A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug? Administer the medication with meals or a snack. Provide orange or other citrus fruit juice with the medication. Give the medication an hour before milk products are ingested. Offer antacids 30 minutes after administration if gastrointestinal side effects occur.

Give the medication an hour before milk products are ingested. Any product containing aluminum, magnesium, or calcium ions should not be taken in the hour before or after an oral dose, because it decreases absorption by as much as 25% to 50%. Food interferes with absorption; it should be given one hour before or two hours after meals. Citrus juice has no influence on this drug. Antacids will interfere with absorption.

A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? (Select all that apply.)

Gloves Hand hygiene

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client:

Has a CD4+ T lymphocyte level of less than 200 cells/µL

A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease? Handling a cat litter box Drinking contaminated water Having sex with many partners Eating inadequately cooked meat

Having sex with many partners Cytomegalovirus has been recovered from semen, vaginal secretions, urine, feces, and blood; it is commonly found in clients who are HIV positive. Drug use can decrease sexual inhibitions and judgment. Toxoplasmosis can be contracted from contaminated cat litter. Contaminated water is associated with hepatitis type A. Toxoplasmosis can be contracted from inadequately cooked meat.

When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take? Giving the infant to the mother Having the visitor step outside the room Verifying the infant's and mother's identification bands Asking the visitor whether the coughing and sneezing are caused by a cold

Having the visitor step outside the room Protection of newborns from unnecessary exposure to microorganisms is the priority. Giving the infant to the mother should not be done until the mother and newborn's identification bands have been verified. Verifying the infant's and the mother's identification bands should be done after the visitor leaves the room. Asking the visitor whether the coughing and sneezing are caused by a cold is a discussion that should take place outside the room. The visitor should be asked to leave if indications of an infection are present.

C (The lines of communication in a healthcare organization can be improved by appreciating and valuing each other's cultural perspectives, which balances strengths between the delegator and delegatee and improves client care outcomes. Considering all aspects of client care ensures that all of the client care needs are addressed. Selecting experienced nursing assistants as delegatees increases the chances of the delegatee to adapt to changing situations. Selecting a delegatee having similar strengths as that of the delegator may decrease the lines of communication because the delegatee might do the task of the delegator.)

How can the lines of communication be improved in a healthcare organization during the process of delegation? A. By considering all aspects of client care B. By selecting experienced nursing assistants as delegatees C. By appreciating and valuing each other's cultural perspectives D. By selecting a delegatee having similar strengths as that of the delegator

A client is undergoing highly active antiretroviral therapy (HAART). From what viral disease could the client possibly be suffering? Hepatitis Herpes simplex virus (HSV) Human papillomavirus (HPV) Human immunodeficiency virus (HIV)

Human immunodeficiency virus (HIV) Rationale Highly active antiretroviral therapy (HAART) is a combination of antiretroviral drugs used to treat human immunodeficiency virus (HIV). Because hepatitis, herpes simplex virus (HSV), and human papillomavirus (HPV) are not retroviral, HAART is ineffective for these disorders.

During the first 48 hours after a client has sustained a thermal injury, the nurse should assess for:

Hyperkalemia and hyponatremia

During the first 48 hours after a thermal injury, the nurse should assess the client for

Hyperkalemia and hyponatremia

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? (Select all that apply.)

Hyperthermia Splenomegaly

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client?

Hyperthermia Splenomegaly A high fever (hyperthermia) results from the disease process. Parasites invade the erythrocytes, subsequently dividing and causing the cell to burst. The spleen enlarges from the sloughing of red blood cells. Oliguria, not polyuria, occurs in malaria-induced kidney failure. Leukopenia does not occur. Erythrocytosis does not occur.

Before the nurse can be an advocate for a client who is homosexual who has acquired immunodeficiency syndrome (AIDS), the nurse needs to do what?

Identify personal attitudes and feelings about homosexuality

Before the nurse can be an advocate for a client who is homosexual who has acquired immunodeficiency syndrome (AIDS), the nurse needs to do what?

Identify personal attitudes and feelings about homosexuality Before nurses can be client advocates, they must understand themselves, particularly regarding issues that may affect clients; this is the first step toward providing nonjudgmental care. It is not necessary for the nurse to discuss the nurse's sexual identity to clients. Although it is beneficial for nurses to examine themselves, this does not mean that the care will be nonjudgmental. Although having a commitment to treat all patients equally is important, the nurse should first thoroughly self assess attitudes, values, and beliefs. Although truthfulness is important in a therapeutic relationship, the nurse should attempt to be nonjudgmental.

A mother with the diagnosis of acquired immunodeficiency disease (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine?

If the baby is breastfeeding

If the baby is breastfeeding Epidemiological evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn.

During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement?

Ignorance related to correct condom use

While on a hike, a rusty nail pierces the sole of an adolescent's foot and the adolescent is brought to the emergency department of a local hospital. Tetanus immune globulin is prescribed because the adolescent does not know when the last tetanus immunization was received. The nurse administers the prescribed dose of tetanus immune globulin and explains that it provides:

Immediate passive short-term immunity

A postpartum nurse is caring for a client with an epidural catheter in place for opioid analgesic administration following cesarean birth. The client develops respiratory depression and requires naloxone administration. Which finding should the nurse anticipate as a result of the naloxone administration?

Increase in pain level

The nurse is administering a dose of pirbuterol to a client. The nurse should monitor for which side or adverse effect of this medication?

Increased pulse

Cromolyn sodium is prescribed for the client with allergic asthma. What goal does the nurse expect to achieve by administration of this medication?

Inhibition of the release of mediators from mast cells after exposure to an antigen

A 16-year-old client has a steady boyfriend with whom she is having sexual relations. She asks the nurse how she can protect herself from contracting human immunodeficiency virus (HIV). Which guidance is most appropriate for the nurse to provide? Ask her partner to withdraw before ejaculating. Make certain their relationship is monogamous. Insist that her partner use a condom when having sex. Seek counseling about various contraceptive methods.

Insist that her partner use a condom when having sex. Rationale A condom covers the penis and contains the semen when it is ejaculated; semen contains a high percentage of HIV in infected individuals. Preejaculatory fluid carries HIV in an infected individual, so withdrawing before ejaculation is not effective. Although a monogamous relationship is less risky than having multiple sexual partners, if one partner is HIV positive, the other person is at risk for acquiring HIV. The client is not asking about various contraceptive methods. Most contraceptives do not provide protection from HIV.

When planning nursing care for a 5-year-old child with acute poststreptococcal glomerulonephritis, what should the nurse emphasize that the child and family must maintain? A bland diet high in protein Bedrest lasting at least 4 weeks Isolation from children with infections A daily intramuscular dose of penicillin

Isolation from children with infections During the acute stage, anorexia and general malaise lower the child's resistance to infection. A bland diet is not necessary, but high protein and high-sodium foods should be avoided. Bedrest is not a necessary restriction. It is encouraged when the child is easily fatigued. Antibiotics are not necessary for all children with acute glomerulonephritis, only those with persistent streptococcal infections. The intramuscular route is not used.

A child with a diagnosis of tuberculosis is admitted to the pediatric unit. Which location should the nurse select as the best placement for the child? Private room Isolation room Four-bed room Semiprivate room

Isolation room Rationale An isolation room is a private room fitted with special air handling and ventilation to prevent the transmission of airborne droplet nuclei 5 micrometers or smaller. It has monitored negative pressure to prevent air from moving from the room into the corridor of the facility. Room air is exchanged 6 to 12 times an hour to the outdoors or through a monitored high-efficiency filtration system. Mycobacterium tuberculosis remains suspended in the air for prolonged periods and is transmitted in air currents. A private room does not have the technical equipment to manage airborne droplet nuclei of 5 micrometers or smaller. Other children and people on the unit will be exposed to the infected individual's pathogens that travel through air currents. A four-bed room or semiprivate room will expose the children and other people on the unit to the infected individual's pathogens.

A nurse is counseling a client who has gonorrhea. What additional fact about gonorrhea, besides the fact that it is highly infectious, should the nurse teach this client?

It can produce sterility.

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit?

Joint pain Facial rash Pericarditis SLE is a chronic, autoimmune disease that affects connective tissue; joint pain is common. A butterfly rash is characteristic of SLE. Pericarditis is the most common cardiac indicator of SLE. Weight loss, not gain, is a classic sign of SLE because of gastrointestinal effects. Renal impairment with SLE may cause hypertension, not hypotension. pg 87-88

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care?

Keep skin lubricated with lotion

A client with scleroderma complains of numbness and tingling in the hands followed by blanching of the fingers. The nurse concludes that the client has Raynaud's phenomenon, a condition commonly associated with scleroderma. The nurse plans to advise the client to:

Keep the hands warm by wearing gloves

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?

Liver function tests

A school nurse is teaching a group of parents about the early signs of rubeola (measles). What sign related to rubeola should alert the parents to seek medical help? Macular rashes Scaly skin patches Bald patches on the scalp Generalized vesicular skin lesions

Macular rashes Rationale Rubeola (measles) starts with a discrete maculopapular rash on the face and spreads downward, eventually becoming confluent. Scaly skin occurs with eczema or dermatitis. Bald patches occur with tinea capitis (ringworm). Vesicular skin lesions occur with varicella (chickenpox).

The nursing staff has a team conference on acquired immunodeficiency syndrome (AIDS) and discusses the routes of transmission of the human immunodeficiency virus (HIV). The discussion reveals that there is no risk of exposure to HIV when an individual:

Makes a donation of a pint of whole blood Equipment used in blood donation is disposable; the donor does not come into contact with anyone else's blood. The risk depends on the spouse's previous behavior. Although condoms do offer protection, they are subject to failure because of condom rupture or improper use; risks of infection are present with any sexual contact. An individual may be infected before testing positive for the antibodies; the individual can still transmit the virus.

The mother of a 3-year-old child with rubeola states that she once heard that it was called by another name. The nurse tells the mother that rubeola commonly is known as: Measles Chickenpox German measles Whooping cough

Measles Measles is another name for rubeola. Chickenpox is also known as varicella. German measles is also known as rubella. Whooping cough is also known as pertussis.

A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to best prevent malaria?

Mosquito bites Malaria is caused by the protozoan Plasmodium falciparum, which is carried by mosquitoes. Avoiding untreated water, undercooked food, and overpopulated areas will not prevent protozoa from entering the bloodstream.

Which nursing intervention prevents footdrop in a client with osteomyelitis? Elevating the foot with the use of pillows Consistently flexing the affected extremity Encouraging the client to change positions Neutral positioning of the foot with the use of a splint

Neutral positioning of the foot with the use of a splint Rationale A client with osteomyelitis is at an increased risk for footdrop, which results in an abnormal gait. Neutral positioning of the foot with the use of a splint can reduce the risk of footdrop in the client with osteomyelitis. Elevating the client's foot on pillows can reduce the risk of edema. Asking the client with osteomyelitis to flex the affected extremity can result in flexion contracture. Encouraging the client with osteomyelitis to change positions helps prevent complications associated with immobility and promotes comfort; carefully handle the involved limb and avoid excessive manipulation which may lead to a pathologic fracture.

A client scheduled for surgery has a history of methicillin-resistant Staphylococcus aureus (MRSA) since developing an infection in a surgical site nine months ago. The site is healed and the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present?

Obtain a prescription to culture the client's blood

What should an older client be instructed to do to ensure antibody-mediated immunity? Select all that apply.

Obtain a shingles vaccination Receive a tetanus booster injection Obtain the pneumococcal vaccination Receive an annual influenza vaccination

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?

Occurred in conjunction with treatment for an illness

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?

Occurred in conjunction with treatment for an illness. Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a drug-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a drug-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis. The client states that a roommate at the extended care facility where the client resides sleeps a lot, coughs a great deal, and sometimes spits up blood. The primary reason that the nurse pursues more information about the roommate is because:

Older adults with chronic illness are affected adversely by tuberculosis

A chronically ill, older client tells the home care nurse that the daughter with whom the client lives seems run-down and disinterested in her own health, as well as the health of her children, who are 5, 7, and 12 years old. The client tells the nurse that the daughter coughs a good deal and sleeps a lot. Why is it important that the nurse pursue the daughter's condition for potential case finding?

Older adults with chronic illness are more susceptible to tuberculosis

Ribavirin is prescribed for a hospitalized child with severe respiratory syncytial virus (RSV). The nurse prepares to administer this medication via which route?

Oxygen tent

Which viral infection will cause the nurse to observe for warts? Pox virus Rhabdovirus Epstein-Barr virus Papillomavirus

Papillomavirus Rationale Warts are caused by papillomavirus. Pox viruses cause smallpox. Rhabdovirus causes rabies. Epstein-Barr causes mononucleosis and Burkitt's lymphoma.

A home care nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. The nurse understands that this is the result of which occurrence?

Paradoxical bronchospasm, which must be reported to the health care provider (HCP)

A school-aged child who has just arrived from Africa has been exposed to diphtheria, and a nurse in the pediatric clinic is to administer the antitoxin. Which type of immunity does the antitoxin confer?

Passive artificial

A mother is concerned that her newborn will be exposed to communicable diseases after she is discharged. While teaching the mother ways to decrease the risk of infection, what type of immunity should the nurse explain was transferred to her baby through the placenta?

Passive natural

Which is the preferred drug of choice for the treatment of syphilis in a pregnant adolescent? Penicillin G Doxycycline Tetracycline Erythromycin

Penicillin G Rationale According to the Center for Disease Control and Prevention, penicillin G is the preferred drug of choice for any stage of syphilis in pregnant women. Both doxycycline and tetracycline are contraindicated during pregnancy. Erythromycin may not be able to cure a fetal infection.

A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client?

Penicillin therapy

A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client?

Penicillin therapy parental benzyl-penicillin (Penicillin G) remain the treatment of choice for all stages of syphilis

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

Peripheral neuritis

A nurse is caring for a client with severe burns. The nurse determines that this type of client is at risk for hypovolemic shock because of the:

Plasma proteins moving out of the intravascular compartment

The nurse explains to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is made based on:

Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests pg 764 Positive ELISA and Western blot tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus. Performance of high-risk sexual behaviors places someone at risk but does not constitute a positive diagnosis. Evidence of extreme weight loss and high fever do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the Center for Disease Control surveillance case definition for acquired immunodeficiency syndrome [AIDS]) in the presence of HIV antibodies indicates that the individual has AIDS.

A nurse is discussing immunizations needed to confer active immunity with a pregnant client during her first visit to the prenatal clinic. What information should the nurse consider including to ensure that the client understands the process of active immunity?

Protein substances are formed by the body to destroy or neutralize antigens.

A client who has been living in another country for 10 years is undergoing diagnostic testing to identify the causative organisms of the infection that has been acquired. When caring for this client, what should the nurse recall about active immunity?

Protein substances are formed within the body to neutralize antigens.

The nurse would anticipate that the health care provider (HCP) would add which medication to the regimen of the client receiving isoniazid?

Pyridoxine

Which actions contribute to the transmission of human immunodeficiency virus (HIV) infection from an infected to a healthy person? Select all that apply.

Receiving blood transfusions Having sexual intercourse

Which are examples of actively acquired specific immunity?

Recovery from measles Recovery from chickenpox Immunization with live or killed vaccines

After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis? Nodules on the pinna Redness of the eardrum Lesions in the external canal Excessive soft cerumen in the external canal

Redness of the eardrum Rationale Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity but not the manifestation of otitis media. Excessive soft cerumen in the external canal impacts the hearing acuity but not the manifestation of otitis media.

After a basal cell carcinoma is removed by fulguration, a client is given a topical steroid to apply to the surgical site. The nurse evaluates that the teaching regarding steroids and skin lesions is effective when the client states that the primary purpose of the medication is to:

Reduce inflammation at the surgical site

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action?

Report yellow eyes or skin immediately.

A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should:

Reschedule administration of the vaccine for the next month

An infant with cardiopulmonary disease who displays signs and symptoms of bronchiolitis and pneumonia was admitted to the hospital. What condition is the infant likely to have? Poliomyelitis Pneumococcal infection Meningococcal infection Respiratory syncytial virus infection

Respiratory syncytial virus infection Rationale Respiratory syncytial virus infections are the most common cause for hospitalization of infants younger than 1 year of age; this disease especially affects premature infants and infants with cardiopulmonary disease. Poliomyelitis is caused by the poliovirus. Streptococcus pneumonia infections cause meningitis, sepsis, pneumonia, and otitis media. Neisseria meningitidis causes meningitis.

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.)

Restlessness Muscular rigidity Respiratory tract spasms Spastic voluntary muscle contractions

The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if needed?

Resuscitation equipment

A nurse observes that an unlicensed assistive personnel (UAP) did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. The nurse's best way to handle this situation is to:

Review transmission-based precautions with the UAP

Which diseased condition associated with the client's heart is an example of an autoimmune disease? Uveitis Rheumatic fever Myasthenia gravis Graves' disease

Rheumatic fever Rationale Rheumatic fever is a heart disorder that is an example of an autoimmune disease. Uveitis is an eye disorder that is an example of an autoimmune disease. Myasthenia gravis is a muscle disorder that is an example of an autoimmune disease. Graves' disease is an endocrine disorder that is an example of an autoimmune disease.

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure?

Salmeterol first and then the beclomethasone

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe?

Scaly lesions, Pruritic lesions, Reddened papules

A nurse is caring for a client with glomerulonephritis. What should the nurse instruct the client to do to prevent recurrent attacks? Take showers instead of tub baths. Continue the same restrictions on fluid intake. Avoid situations that involve physical activity. Seek early treatment for respiratory tract infections.

Seek early treatment for respiratory tract infections. Hemolytic streptococci, common in throat infections, can initiate an immune reaction that damages the glomeruli. Baths may be linked to urethritis, not glomerulonephritis. Fluid restriction is moderated as the client improves; fluid helps prevent urinary stasis. Activity helps prevent urinary stasis.

Which test result should a nurse review to determine if the antibiotic prescribed for the client will be effective?

Sensitivity test

A nurse is caring for a client with the diagnosis of pemphigus vulgaris. Which expected response does the nurse need to address in the client's plan of care?

Skin lesions

The health care provider prescribes cromolyn for the client with asthma. The nurse identifies that the client correctly understands the purpose of this medication when the client states that the medication will produce which effect?

Suppress an allergic response

The nurse should monitor the client receiving the first dose of albuterol for which side or adverse effect of this medication?

Tachycardia

The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia?

Tachypnea Increased pulse rate Fever causes an increase in the body's metabolism, which results in an increase in oxygen consumption, causing tachypnea. Fever causes an increase in the body's metabolism, which results in an increase in oxygen consumption; this need for oxygen is met by an increased heart rate, which is reflected in an increased pulse rate. Although the respiratory rate may increase slightly, fever will not cause dyspnea. Chest pain is not related to the fever unless its cause is respiratory in nature. An increase in blood pressure does not accompany necessarily a fever.

The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? (Select all that apply.)

Tachypnea Increased pulse rate

A client diagnosed with active tuberculosis has been prescribed a combination of isoniazid and rifampin for treatment. The nurse teaches the client to perform which action?

Take both medications together once a day.

A client with tuberculosis receiving cycloserine orally twice daily must have blood drawn in 1 week to measure the serum concentration of the medication. The nurse prepares the client for this test by providing which information to the client?

Take the morning dose and have the blood drawn 2 hours after taking the dose.

A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that he or she will perform which action?

Take the tablet with a full glass of water.

A client has a prescription to take guaifenesin. The nurse should conclude that the client understands the most effective use of this medication if the client states that they need to take which action?

Take the tablet with a full glass of water.

An 11-year-old boy who has stepped on a rusty nail is given tetanus immune globulin in the emergency department. The nurse knows that the immune globulin injection will confer what type of immunity?

Temporary passive acquired immunity

A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should:

The appropriate response is to delay the administration of the vaccine until the client is healthy. Vaccines should not be administered during a febrile illness. Administering an aspirin is a dependent function of the nurse and requires a health care provider's prescription. Although holding the vaccine and administering it after the fever and cough are resolved is appropriate, notifying the health care provider is not necessary.

A client has a tuberculin purified protein derivative test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. What does the nurse conclude about the client based on this response? The client has contracted clinical tuberculosis. The client has passive immunity to tuberculosis. The client has been exposed to the tubercle bacillus. The client has developed a resistance to the tubercle bacillus.

The client has been exposed to the tubercle bacillus. Rationale Induration measuring 10 mm or more in diameter is interpreted as significant; it does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure; infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies; a positive tuberculin purified protein derivative indicates the presence of antibodies, not how they were formed. Developing a resistance to the tubercle bacillus reaction indicates exposure, not resistance.

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? All nursing functions will be completed by discharge. All invasive intravenous lines will remain patent. The client will remain awake, alert, and oriented at all times. The client will be free of signs and symptoms of infection by discharge.

The client will be free of signs and symptoms of infection by discharge. Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.

What is the incubation period for an infectious disease?

The interval between entrance of pathogen into body and appearance of first symptoms

The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history? 1 Acute gastritis 2 Diabetes mellitus 3 Partial gastrectomy 4 Unhealthy dietary habits

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? 1 Apples 2 Broccoli 3 Cherries 4 Cauliflower

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder? 1 Ham sandwich with cheese, whole milk, and potato chips 2 Penne pasta, spinach, banana, and decaffeinated iced tea 3 Baked lasagna with sausage, salad, and milkshake 4 Hamburger, french fries, and cola

The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms? 1 Nervous and weak 2 Thirsty with a headache 3 Flushed and short of breath 4 Nausea and abdominal cramps

The parents of a 6-month-old ask a nurse how to introduce their infant to pureed foods. How should the nurse respond? 1 "Introduce one food at a time every 4 to 7 days." 2 "Mix the pureed food with the formula two or three times a day." 3 "Try to maintain the formula intake regardless of solid food intake." 4 "Offer pureed foods by spoon after the bottle of formula is finished."

C (The licensed practical nurse provides tracheostomy care using sterile techniques. Developing a plan to avoid aspiration in a client with tracheostomy is done by the registered nurse. Assessing the client's condition after tracheostomy is done by the registered nurse. Teaching a client and caregiver about home tracheostomy care is done by the registered nurse.)

The registered nurse (RN) delegates a task to a licensed practical nurse (LPN) to take care of the client who underwent a tracheostomy. Which task should be performed by the LPN in this situation? A. Developing a plan to avoid aspiration B. Assessing the client's condition after tracheostomy C. Providing tracheostomy care using sterile techniques D. Teaching a client and caregiver about home tracheostomy care

A client is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. Which outcome would the nurse expect as a result of the administration of this medication?

Thinning of respiratory secretions

A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?

Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine

Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine.

Two to six weeks Although the usual incubation period of syphilis is about three weeks, clinical symptoms may appear as early as nine days or as long as three months after exposure. The usual incubation period is 21 days.

Which is the nurse's priority assessment for monitoring for adverse effects for the client taking isoniazid?

Urine color

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?

Use standard precautions.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?

Use standard precautions. The Centers for Disease Control states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact and discouraging long visits from family members will unnecessarily isolate the client.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client? Use standard precautions. Employ airborne precautions. Plan interventions to limit direct contact. Discourage long visits from family members.

Use standard precautions. Rationale The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact and discouraging long visits from family members will unnecessarily isolate the client.

A client arrives at the clinic after being bitten by a raccoon in an area in the woods where rabies is endemic. When considering the client's needs, the nurse recalls that rabies is a:

Viral infection characterized by convulsions and difficulty swallowing

A client is taking a prescribed course of therapy with ethambutol. The home health nurse assesses the client at each home visit for which adverse effect of this medication?

Visual disturbances

The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in:

Vitamins A, C, E, and selenium

When taking the blood pressure of a client who has acquired immunodeficiency syndrome (AIDS), the nurse must:

Wash the hands thoroughly

When taking the blood pressure of a client who has acquired immunodeficiency syndrome (AIDS), the nurse must: Don clean gloves Use barrier techniques Put on a mask and gown Wash the hands thoroughly

Wash the hands thoroughly Because this procedure does not involve contact with blood or secretions, additional protection to washing the hands thoroughly is not indicated. Donning clean gloves and using barrier techniques are necessary only when there is risk of contact with blood or body fluid. A mask and gown are indicated only if there is a danger of secretions or blood splattering on the nurse (for example, during suctioning).

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?

Wash used dishes in hot, soapy water."

A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, the nurse anticipates a prescription for:

Water-soluble forms of vitamins A and E

Water-soluble forms of vitamins A and E Vitamins A, D, E, and K are known as fat-soluble vitamins because bile salts and other fat-related compounds aid their absorption. A high fat diet will not achieve the uptake of fat-soluble vitamins in this client. Supplemental cod liver oil will not achieve the uptake of fat-soluble vitamins in this client. TPN is unnecessary; a well-balanced diet is preferred. Water-miscible forms of vitamins A and E can be absorbed with water-soluble nutrients.

A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do?

Wear a particulate respirator mask

A client has begun a course of therapy with rifampin. The home care nurse instructs the client on which measure due to an anticipated side effect?

Wear dark clothing to avoid staining.

A client with tuberculosis (TB) has a prescription for rifampin. What instruction should the nurse include in the client's teaching plan?

Wearing glasses instead of soft contact lenses will be necessary.

Which virus can cause encephalitis in adults and children? Rubella virus Parvovirus Rotaviruses West Nile virus

West Nile virus Rationale The West Nile virus causes encephalitis. German measles is caused by rubella. Gastroenteritis is caused by parvovirus. Rotavirus also causes gastroenteritis.

1 year old (The use of whole cow's milk, 2% cow's milk, or alternate milk products before the age of 12 months is not recommended)

What would the nurse explain is the recommended age when a child can start having whole cow's milk? Record your answer using a whole number. _____ year(s) old

A (Inflating or deflating the cuff too slowly will yield false high diastolic readings. Wrapping the cuff too loosely will result in false high systolic and diastolic values. Applying the stethoscope too firmly will result in false low diastolic readings. Repeating the assessment too quickly will result in false high systolic readings.)

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? A. Inflating the cuff too slowly B. Wrapping the cuff too loosely C. Applying the stethoscope too firmly D. Repeating the assessment too quickly

C (The licensed practical nurse can insert an indwelling urinary catheter for clients after a hysterectomy or any other surgery. A registered nurse can insert an indwelling urinary catheter, but the task can also be performed by the licensed practical nurse. A patient care associate can only monitor and assist the client. Unlicensed nursing personnel are not qualified to insert an indwelling urinary catheter.)

Which healthcare team member is considered the priority person to insert an indwelling urinary catheter for a client who underwent a hysterectomy? A. Registered nurse B. Patient care associate C. Licensed practical nurse D. Unlicensed assistive personnel

D (The expected value of a pulse oximetry reading is 95% to 100%. Nonrebreather mask will deliver high oxygen concentrations (95% to 100%) at a liter flow of 10 to 15 L/min. When using a nonrebreather mask, the client breathes only the oxygen source from the bag. A face tent delivers 30% to 50% oxygen when set at a flow rate of 4 to 8 L/min. A Venturi mask delivers 24% to 50% oxygen when set at a flow rate of 4 to 10 L/min. A nasal cannula delivers 24% to 45% oxygen when set at a flow rate of 2 to 6 L/min.)

Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? A. Face tent B. Venturi mask C. Nasal cannula D. Nonrebreather mask

Which nutrient deficiency in the pregnant adolescent may result in decreased birth weight as a consequence of low bone mineral density in the fetus? 1 Zinc 2 Iron 3 Calcium 4 Folic acid

D (Identifying the problem, which includes reviewing literature, formulating a theoretical framework, and identifying the study variables is similar to assessment in the nursing process. Analyzing the results of research is similar to the evaluation phase of the nursing process. Conducting the study is similar to the implementation phase of the nursing process. Developing the hypothesis coincides with the diagnosis phase of the nursing process.)

Which step in the research process is similar to the assessment step of the nursing process? A. Analyzing the results B. Conducting the study C. Developing hypothesis D. Identifying the problem

D (In the acute phase, wound care is given by assessing the wound daily and adjusting the dressing if necessary according to the protocols. Assessing the extent and depth of burns is performed in the emergent phase. Providing a daily shower and removing the dead and contaminated tissue (debride) is performed in the emergent phase.)

Which wound care is given to a client with severe burn injuries during the acute phase? A. Assess extent and depth of burns B. Provide daily shower and wound care C. Remove dead and contaminated tissue D. Assess the wound daily and adjust the dressing

B (Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps. ***Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.)

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? A. Immediately stop the infusion. B. Lower the height of the enema bag. C. Advance the enema tubing 2 to 3 inches (5 to 7.5 cm). D. Clamp the tube for 2 minutes and then restart the infusion.

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care?

With scleroderma, the skin becomes dry because of interference with the underlying sweat glands. Pruritus, inflamed areas, and skin lesions are not associated with scleroderma. Answer: Keep skin lubricated with lotion

Which is a leukotriene modifier used to manage and prevent allergic rhinitis? Zileuton Ephedrine Scopolamine Cromolyn sodium

Zileuton Rationale Zileuton is a leukotriene modifier used to manage and prevent allergic rhinitis. Ephedrine is an ingredient in decongestants used to treat allergic rhinitis. Scopolamine is an anticholinergic used to reduce secretions. Cromolyn sodium is a mast cell stabilizing drug used to prevent mast cell membranes from opening when an allergen binds to IgE.

Which drug treats hay fever by preventing leukotriene synthesis? Zileuton Cromolyn sodium Chlorpheniramine Diphenhydramine

Zileuton Rationale Zileuton[1][2] is a leukotriene antagonist drug; this substance prevents the synthesis of leukotrienes and helps in managing and preventing hay fever. Cromolyn sodium stabilizes mast cells and prevents the opening of mast cell membranes in response to allergens binding to immunoglobulin E. Chlorpheniramine and diphenhydramine are antihistamines and prevent the binding of histamine to receptor cells and decrease allergic manifestations.

A client has begun therapy with a xanthine bronchodilator. The nurse determines that the client understands dietary alterations if the client states to limit which items while taking this medication? Select all that apply.

coffee chocolate

What is the primary focus of nursing care for a client admitted with tetanus caused by a puncture wound?

decrease external stimuli The slightest stimulation can set off a wave of severe, painful muscle spasms involving the whole body. Nerve impulses cross the myoneural junction and stimulate muscle contraction caused by exotoxins produced by Clostridium tetani. Monitoring urinary output is not a major nursing concern for clients with tetanus. Body alignment is not an important consideration for clients with tetanus. Oral intake of fluids may not be possible because of excessive secretions and laryngospasms.

A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug?

give an hour before milk product are ingested Any product containing aluminum, magnesium, or calcium ions should not be taken in the hour before or after an oral dose, because it decreases absorption by as much as 25% to 50%. Food interferes with absorption; it should be given one hour before or two hours after meals. Citrus juice has no influence on this drug. Antacids will interfere with absorption

gloves and hand hygiene Wearing gloves protects the nurse from potential contamination. Gloves are appropriate when there is a risk of the hands coming into contact with a client's blood or body fluids. Hand hygiene is the most effective way to prevent the spread of microorganisms. Wearing a mask is necessary for procedures where splashing of body fluids is anticipated or a risk. Wearing a gown is necessary for procedures where splashing of body fluids is anticipated or a risk. Wearing a face shield is necessary for procedures where splashing of body fluids is anticipated.

A female client is upset with her diagnosis of gonorrhea and asks the nurse, "What can I do to prevent getting another infection in the future?" The nurse evaluates that the teaching is understood when the client states, "My best protection is to:

imunization, A. Quiz Questions, Evolve Infectious Diseases, Evolve - Med Surg - Integ, 1.1 Infection EAQ, Evolve Immunity Quiz, 1012 Infection, Nutrition Hesi 1, Respiratory Pharmacology

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