Med Surg 3 Exam 2 Immune/ARDs/Hepatic

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot, soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.

1. The classic sign of ARDS is decreased arterial oxygen level (Pao2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? 1. Remove secretions by suctioning. 2. Lower the setting of the tidal volume. 3. Check that tubing connections are secure. 4. Obtain a specimen for arterial blood gases.

1 Secretions in the airway will increase pressure by blocking air flow and must be removed. 2 The nurse must identify/correct the problem so that the set tidal volume can be delivered. 3 Connections that are not intact would cause a low-pressure alarm. 4 Arterial blood gases (ABGs) are used to assess client status, but are not taken each time a pressure alarm is heard.

The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply. 1. Use a sunscreen of SPF 30 or greater when in the sunlight. 2. Notify the HCP immediately when developing a low-grade fever. 3. Some dyspnea is expected and does not need immediate attention. 4. The hands and feet may change color if exposed to cold or heat. 5. Explain the client can be cured with continued therapy.

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The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply. 1. Prepare to administer Solu-Medrol, a glucocorticoid, IV. 2. Request and obtain a STAT chest x-ray. 3. Initiate the rapid response team. 4. Administer epinephrine, an adrenergic blocker, SQ then IV continuous. 5. Assess for the client's pulse and respirations.

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The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

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What is the nurse's primary consideration when caring for a client with rheumatoid arthritis? 1. Surgery 2. Comfort 3. Education 4. Motivation

2 Because pain is an all-encompassing and often demoralizing experience, the client should be kept as pain-free as possible. 1 Surgery is used to correct deformities and facilitate movement; relief of pain is the priority. 3 Concentration is difficult when a client is in severe pain; relief of pain is the priority. 4 Motivation is difficult when a client is in severe pain; relief of pain is the priority.

The nurse is developing a care plan for a client diagnosed with allergic rhinitis. Which independent problem has priority? 1. Ineffective breathing pattern. 2. Knowledge deficit. 3. Anaphylaxis. 4. Ineffective coping.

1. This can be an independent or collaborative nursing problem. It is an airway problem and has priority.

Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? 1. An aminoglycoside antibiotic. 2. A synthetic surfactant. 3. A potassium cation. 4. A nonsteroidal anti-inflammatory drug.

2. Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis.

The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

2. While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.

The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor blood urea nitrogen (BUN) and creatinine level.

3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.

The nurse is discussing autoimmune diseases with a class of nursing students. Which signs and symptoms are shared by rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)? 1. Nodules in the subcutaneous layer and bone deformity. 2. Renal involvement and pleural effusions. 3. Joint stiffness and pain. 4. Raynaud's phenomenon and skin rash

3. Joint stiffness and pain are symptoms occurring in both diseases.

The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client? 1. The client will maintain reproductive ability. 2. The client will verbalize feelings of bodyimage changes. 3. The client will have no deterioration of organ function. 4. The client's skin will remain intact and have no irritation.

3. SLE can invade and destroy any body system or organ. Maintaining organ function is the primary goal of SLE treatment.

For which clinical indicator associated with a complication of portal hypertension should the nurse assess the client? 1. Liver abscess 2. Intestinal obstruction 3. Perforation of the duodenum 4. Hemorrhage from esophageal varices

4 The increased pressure within the portal circulatory system causes increased pressure in areas of portal systemic collateral circulation (most important, in the distal esophagus and proximal stomach). Hemorrhage is a possible complication. 1 Liver abscesses may occur as a complication of intestinal infections, not portal hypertension. 2 This may be caused by manipulation of the bowel during surgery, peritonitis, neurologic disorders, or organic obstruction, not portal hypertension. 3 Perforation of the duodenum usually is caused by peptic ulcers; it is not a direct result of portal hypertension or cirrhosis.

The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal antiinflammatory drugs (NSAIDs)? 1. Take with an over-the-counter medication for the stomach. 2. Drink a full glass of water with each pill. 3. If a dose is missed, double the medication at the next dosing time. 4. Avoid taking the NSAID on an empty stomach.

4. NSAID medications decrease prostaglandin production in the stomach, resulting in less mucus production, which creates a risk for the development of ulcers. The client should take the NSAID with food.

The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority? 1. Altered nutrition, less than body requirements. 2. Anticipatory grieving. 3. Knowledge deficit, procedures and prognosis. 4. Risk for injury.

4. Safety is always an issue with a client with diminished mental capacity.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort

1 Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts. Test-Taking Strategy: Focus on the subject, expected assessment findings. Recalling the function of the liver will direct you to the correct option. Remember that fatigue and malaise are common. Review: The signs and symptoms of h epatitis

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

1. The hepatitis A virus is in the stool of infected people and takes up to two (2) weeks before symptoms develop.

The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with SLE who is complaining of chest pain. 2. The client diagnosed with MS who is complaining of pain at a "10." 3. The client diagnosed with myasthenia gravis who has dysphagia. 4. The client diagnosed with GB syndrome who can barely move his toes.

1. Chest pain should be considered a priority regardless of the admitting diagnosis. Clients diagnosed with SLE can develop cardiac complications.

The client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client? 1. Demonstrate how to use an EpiPen, an adrenergic agonist. 2. Teach the client to never go outdoors in the spring and summer. 3. Have the client buy diphenhydramine over the counter to use when stung. 4. Discuss wearing a Medic Alert bracelet when going outside.

1. Clients who are allergic to bee sting venom should be taught to keep an EpiPen with them at all times and how to use the device. This could save their lives.

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

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The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's position.

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A nurse is planning to provide discharge teaching to the family of a client with AIDS. Which statement should the nurse include in the teaching plan? 1. "Wash used dishes in hot, soapy water." 2. "Let dishes soak in hot water for 24 hours before washing." 3. "You should boil the client's dishes for 30 minutes after use." 4. "Have the client eat from paper plates so they can be discarded."

1 A person cannot contract HIV by eating from dishes previously used by an individual with AIDS; routine care is adequate. 2, 3, 4 This is unnecessary.

Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis? 1. Aspirin 2. Codeine 3. Meperidine 4. Alprazolam

1 Because of its antiinflammatory effect, aspirin is useful in treating arthritis symptoms. 2, 3 Opioids should be avoided because they promote drug dependency and do not affect the inflammatory process. 4 Alprazolam (Xanax) is an antianxiety, not an antiinflammatory, agent.

A nurse is caring for a client who is HIV positive. For which complication associated with this diagnosis is it most important for the nurse to teach prevention strategies? 1. Infection 2. Depression 3. Social isolation 4. Kaposi sarcoma

1 The client has a weakened immune response. Instructions regarding rest, nutrition, and avoidance of unnecessary exposure to people with infections help reduce the risk for infection. 2 Clients can be taught cognitive strategies to cope with depression, but the strategies will not prevent depression. 3 The client may experience social isolation as a result of society's fears and misconceptions; these are beyond the client's control. 4 Although Kaposi sarcoma is related to HIV infection, there are no specific measures to prevent its occurrence.

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a health care provider (HCP). 5. Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1, 2, 3 Rationa le: An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the HCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per HCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal. Test-Taking Strategy: Focus on the subject, interventions the nurse takes for an anaphylactic reaction. Read each option carefully and remember that this is an emergency. Think about the pathophysiologythat occurs in this reaction to answer correctly. Review: Interventions for a clientwith an anaphylactic reaction

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.

The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? 1. The client who has flushed, warm skin with tented turgor. 2. The client who states the staff ignores the call light. 3. The client whose vital signs are T 99.9˚F, P 101, R 26, and BP 110/68. 4. The client who is unable to provide a sputum specimen.

1. Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified immediately for fluid orders or other orders to correct the reason for the dehydration.

Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke. 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about one (1) month to recuperate.

1. Not smoking is vital to prevent further lung damage

The client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules? 1. The nodules indicate a rapidly progressive destruction of the affected tissue. 2. The nodules are small amounts of synovial fluid that have become crystallized. 3. The nodules are lymph nodes which have proliferated to try to fight the disease. 4. The nodules present a favorable prognosis and mean the client is better.

1. The nodules may appear over bony prominences and resolve simultaneously. They appear in clients with the rheumatoid factor and are associated with rapidly progressive and destructive disease.

The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? 1. Flush the skin with water and try to get the area to bleed. 2. Notify the charge nurse and complete an incident report. 3. Report to the employee health nurse for prophylactic medication. 4. Follow up with the infection control nurse to have laboratory work done.

1. The nurse should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse.

The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP.

1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the nurse should demonstrate the proper way to bathe a client in the bed.

The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one (1) ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

1. These arterial blood gases are within normal limits, and, therefore, the nurse should not take any action except to continue to monitor the client.

Aclient is diagnosed with viral hepatitis, complaining of "no appetite" and "losingmy taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is not as severe. 4. Eat less often, preferably only 3 large meals daily.

2 Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fatmaybe tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast.An adequate fluid intake of2500 to 3000 mL/day that includes nutritional juices is also important. Test-Taking Strategy: Focus on the subject, a diet for viral hepatitis. Think about the pathophysiology associated with hepatitis and focus on the client's complaints to direct you to the correct option.

The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1. "I have had unprotected sex with multiple partners." 2. "I ate shellfish about 2 weeks ago at a local restaurant." 3. "I was an intravenous drug abuser in the past and shared needles." 4. "I had a blood transfusion 30 years ago after major abdominal surgery."

2 Rationale: Hepatitis Ais transmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse, history of blood transfusion, or unprotected sex with multiple partners. Test-Taking Strategy: Focus on the subject, hepatitis A. Recalling the modes of transmission of the various types of hepatitis is required to answer this question. Remember that hepatitis A is transmitted by the fecal-oral route. Review: Method of transmission of h epatitis A

Aclient calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide. 2. Ask the client if he ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency department. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

2 Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry." Test-Taking Strategy: Use the steps of the n ursin g process to answer the question. The correct option is the only one that addresses assessment. Review: Information related to hypersensitivity and allergy

A mother with the diagnosis of 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? 1. If she has kissed the baby 2. If the baby is breastfeeding 3. When the baby last received antibiotics 4. How long she has been caring for the baby

2 Epidemiologic evidence has identified breast milk as a source of HIV transmission. 1 This behavior is not believed to transmit HIV. 3 This is unrelated to transmission of HIV. 4 HIV transmission does not occur from contact associated with caring for a newborn

When preparing an individualized teaching plan for a client with rheumatoid arthritis, which topic should the nurse omit from the generalized teaching plan for clients with arthritis? 1. Ulnar drift 2. Heberden nodes 3. Swan neck deformity 4. Boutonnière deformity

2 Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis. 1, 3, 4 These deformities occur with rheumatoid arthritis.

A nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos should the nurse include in the teaching plan? 1. A 2. C 3. D 4. E

2 Hepatitis C is a bloodborne pathogen that can be transmitted via contaminated tattoo needles. 1 Hepatitis A is not a bloodborne pathogen; it is spread through contaminated food or water. 3 Although hepatitis D is a bloodborne pathogen, it can be produced only when the hepatitis B virus is present. Also, hepatitis D is not the main virus associated with contaminated tattoo needles. 4 Hepatitis E is believed to be transmitted via the fecal-oral route; it is spread through contaminated food or water.

What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of rheumatoid arthritis? 1. Inflammation of the synovial membrane rarely occurs. 2. Bony ankylosis of a joint is irreversible and causes immobility. 3. Complete immobility is desired during the acute phase of inflammation. 4. Redness and swelling of a joint signify irreversible damage has occurred.

2 Ossification of cartilage, particularly of the spine, causes fixation of the involved joints. 1 Inflammation and thickening of the synovial membrane are characteristics of arthritis. 3 Although rest is essential, complete immobility will result in loss of joint motion. 4 Redness and swelling are symptoms of local inflammation; they do not indicate irreversible damage.

A client with rheumatoid arthritis asks the nurse why it is necessary to inject hydrocortisone into the knee joint. What reason should the nurse include in a response to this question? 1. Lubricate the joint 2. Reduce inflammation 3. Provide physiotherapy 4. Prevent ankylosis of the joint

2 Steroids have an antiinflammatory effect that can reduce arthritic pannus formation. 1 This will not provide lubrication. 3 Injection of a drug into a joint is not physiotherapy. 4 Ankylosis refers to fusion of joints. It is only indirectly influenced by steroids, which exert their major effect on the inflammatory process.

Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

2. Adequate rest is needed for maintaining optimal immune function.

The client diagnosed with liver problems asks the nurse, "Why are my stools clay-colored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins

2. Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin.

The nurse identifies the client problem "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.

The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client's lung sounds.

2. If the ventilator system malfunctions, the nurse must ventilate the client with a manual resuscitation (Ambu) bag until the problem is resolved.

The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?" Which statement is the nurse's best response? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

2. Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth.

The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach? 1. Explain the medication loses its efficacy after a few months. 2. Continue to have checkups and laboratory work while taking the medication. 3. Have yearly magnetic resonance imaging to follow the progress. 4. Discuss the drug is taken for three (3) weeks and then stopped for a week.

2. The drug requires close monitoring to prevent organ damage.

The client in the HCP's office is complaining of allergic rhinitis. Which assessment question is important for the nurse to ask the client? 1. "What time of year do the symptoms occur?" 2. "Which over-the-counter medications have you tried?" 3. "Do other members of your family have allergies to animals?" 4. "Why do you think you have allergies?"

2. There are many over-the-counter remedies available. Therefore, the nurse should assess which medications the client has tried and what medications the client is currently taking.

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

2. There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3 Rationa le: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions. Test-Taking Strategy: Focus on the subject, diagnosing Kaposi's sarcoma. Eliminate options 1 and 2 first because these symptoms occur late in the development of Kaposi's sarcoma. Then, note the word confirmed in the question. This word will assist in directing you to the option that will confirm the diagnosis, the biopsy of the lesions. Review: Diagnostic measures for Kaposi's sarcoma

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen 2. Check the client's vital signs 3. Ventilate the client manually 4. Start cardiopulmonary resuscitation

3 Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client. Test-Taking Strategy: Note the strategic word, initial, and note that the subject relates to adequate ventilation of the client. Also, note that the nurse is unsuccessful in determining the cause of the alarm. This will direct you to the correct option. Review: Management of ventilators and alarms

The nurse is preparing a group ofCub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease.Which statement by one of the Scouts indicates a need for further instruction? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and longpants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."

3 Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat orcap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

A nurse is caring for a client with rheumatoid arthritis. Based on the client's diagnosis, the nurse should review the result of which laboratory test? 1. Pancreatic lipase 2. Bence Jones protein 3. Antinuclear antibody 4. Alkaline phosphatase

3 An antinuclear antibody test (ANA) may be positive in clients with autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. 1 Pancreatic lipase is an enzyme that catalyzes the breakdown of lipids; this is a test used to diagnose pancreatic problems. 2 Bence Jones protein is a urine test helpful in diagnosing multiple myeloma. 4 Alkaline phosphatase is a blood test that determines phosphorus activity; it is used in diagnosing liver and biliary tract disorders and identifying periods of active bone growth or metastasis of cancer to bone.

The nurse is caring for clients on a medical floor. Which client should the nurse assess first? 1. The client diagnosed with RA complaining of pain at a "3" on a 1-to-10 scale. 2. The client diagnosed with SLE who has a rash across the bridge of the nose. 3. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV. 4. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.

3. Antineoplastic drugs can be caustic to tissues; therefore, the client's IV site should be assessed. The client should be assessed for any untoward reactions to the medications first.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

3. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator.

Which client problem is priority for a client diagnosed with RA? 1. Activity intolerance. 2. Fluid and electrolyte imbalance. 3. Alteration in comfort. 4. Excessive nutritional intake.

3. The client diagnosed with RA has chronic pain; therefore, alteration in comfort is a priority problem. 4. Clients diagnosed with

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

3. This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate for the client.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4 Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. Test-Taking Strategy: Note the strategic word, earliest. Eliminate option 3 first because intercostal retraction is a later sign of respiratory distress. Of the remaining options, recall that adventitious breath sounds (options 1 and 2) would occur later than an increased respiratory rate.

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: 1. contracts HIV-specific antibodies. 2. develops an acute retroviral syndrome. 3. is capable of transmitting the virus to others. 4. has a CD4+ T lymphocyte level of less than 200 cells/μL.

4 AIDS is diagnosed when an individual with HIV develops one of the following: a CD4+ T lymphocyte level of less than 200 cells/μL, wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, M. tuberculosis). 1, 2 The development of HIV-specific antibodies (seroconversion) accompanied by acute retroviral syndrome (flu-like syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain) 1 to 3 weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. 3 A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.

A client with hepatitis B asks the nurse, "Are there any medications to help me get rid of this problem?" Which is the best response by the nurse? 1. "Sedatives can be given to help you relax." 2. "We can give you immune serum globulin." 3. "Vitamin supplements are frequently helpful and hasten recovery." 4. "There are medications to help reduce viral load and liver inflammation."

4 Drugs are available to help reduce the viral load (antivirals), including lamivudine (Epivir-HBV), ribavirin (Rebetol), and adefovir dipivoxil (Hepsera). 1 Although this is a true statement, sedatives are given only prn and do not treat the hepatitis. 2 This is used only during the incubation period. 3 Vitamins are used as adjunctive therapy and will not eliminate the hepatitis.

The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? 1. Females taking birth control pills are protected from becoming infected with HIV. 2. Protected sex is no longer an issue because there is a vaccine for the HIV virus. 3. Adolescents with a normal immune system are not at risk for developing AIDS. 4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.

4. Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship.

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? Select all that apply. 1. Mental confusion 2. Increased cholesterol 3. Brown-colored stools 4. Flapping hand tremors 5. Hyperactive deep tendon reflexes

Answer: 1, 4. 1 An accumulation of nitrogenous wastes affects the central nervous system, causing mental confusion. 2 Increased cholesterol levels are not necessarily present. 3 Stool is often clay-colored because of lack of bile caused by biliary obstruction. 4 An accumulation of nitrogenous wastes in hepatic coma affects the nervous system. Flapping tremors and generalized twitching occur in the second stage of this disease. 5 As encephalopathy progresses to coma, all reflexes are absent.

Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further in struction? 1. "Ishould takehot bathsbecause theyare relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1 Rationa le: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a n egative event query and the need to select the incorrect client statement. Also, focus on the subject, fatigue. This will assist in directing you to the correct option as the action that would exacerbate fatigue. Review: Measures to prevent fatigue in a client with systemic lupus erythematosus

A nurse plans care to prevent deformities in a client with rheumatoid arthritis. Which intervention should be alternated with periods of rest? 1. Active exercise 2. Passive massage 3. Bracing of joints 4. Isometric exercises

1 Active exercises, alternated with periods of rest, offer the best chance at avoiding the joint deformities associated with rheumatoid arthritis because they can move each involved joint through its full range of motion. 2 Massage affects the muscles, not the joints, and will do little to prevent deformities. 3 Immobilization of joints by bracing will promote the formation of contractures and deformities. 4 Isometric exercise will promote muscle, not joint, function.

A nurse is concerned that a client with a diagnosis of cirrhosis of the liver may experience the complication of hepatic coma. For which clinical indicator should the nurse assess this client? 1. Icterus 2. Urticaria 3. Uremic frost 4. Hemangioma

1 Bile deposits will impart a yellowish tinge (jaundice or icterus) to the skin, often first observed in the sclerae. 2 Urticaria (or hives) generally is characteristic of an allergic response. 3 Uremic frost is characteristic of kidney failure. 4 Hemangioma is a benign lesion composed of blood vessels.

A client with chronic hepatic failure is soon to be discharged from the hospital. Which diet should the nurse encourage the client to follow based on the health care provider's order? 1. High-fat 2. Low-calorie 3. Low-protein 4. High-sodium

3 With liver failure, the protein intake is limited to 20 g daily to decrease the possibility of hepatic encephalopathy. 1 A high-fat diet is avoided because of the related cardiovascular risks and the related demand for bile. 2 Regeneration of tissue requires a high-calorie, high-carbohydrate diet. 4 Sodium usually is restricted to decrease the accumulation of fluid and help limit ascites and edema.

A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk for spreading the disease when the client states, "I should: 1. wash my hands frequently." 2. launder my clothes separately." 3. put used tissues in the garbage." 4. wear a mask when leaving the house."

1 Hepatitis A microorganisms are transmitted via the anal-oral route; handwashing, particularly after toileting, is the most important precaution. 2 This will not deter the spread of the virus; handwashing is necessary. 3, 4 Hepatitis A microorganisms exit through the rectum, not the respiratory tract.

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? 1. Ammonia level 2. Culture and sensitivity 3. White blood cell count 4. Alanine aminotransferase level

1 Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines. 2 Culture and sensitivity testing is unnecessary; cirrhosis is an inflammatory, not infectious, process. 3 Increased white blood cell count may indicate infection; however, this will have no relationship to the need for neomycin enemas. 4 Alanine aminotransferase (ALT), also called serum glutamic-pyruvic transaminase (SGPT), assesses for liver disease but has no relationship to the need for neomycin enema

A client newly diagnosed with scleroderma states, "Where did I get this from?" The nurse's best response is "Although no cause has been determined for scleroderma, it is thought to be the result of: 1. autoimmunity." 2. ocular motility." 3. increased amino acid metabolism." 4. defective sebaceous gland formation."

1 Scleroderma is an immunologic disorder characterized by inflammatory, fibrotic, and degenerative changes. 2, 3, 4 This is not involved in the development of scleroderma.

The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications? 1. "Are you sexually active, and, if so, are you using birth control?" 2. "Have you discussed taking these drugs with your parents?" 3. "Which arm do you prefer to have an IV in for four (4) days?" 4. "Have you signed an informed consent for investigational drugs?"

1. Immunosuppressive medications are considered class C drugs and should not be taken while pregnant. These drugs are teratogenic and carcinogenic, and the client is only 20 years old.

The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment? 1. Immunotherapy is effective in preventing anaphylaxis following a future sting. 2. Immunotherapy will prevent all future insect stings from harming the client. 3. This therapy will cure the client from having any allergic reactions in the future. 4. This therapy is experimental and should not be undertaken by the client.

1. Immunotherapy does not cure the problem. However, if immunotherapy is done following a reaction, it provides passive immunity to the insect venom (similar to the way RhoGAM prevents a mother who is Rh negative from building antibodies to the blood of a baby who is Rh positive). This is the purpose for immunotherapy in clients who are allergic

The nurse is preparing to administer morning medications. Which medication should the nurse administer first? 1. The pain medication to a client diagnosed with RA. 2. The diuretic medication to a client diagnosed with SLE. 3. The steroid to a client diagnosed with polymyositis. 4. The appetite stimulant to a client diagnosed with OA.

1. Pain medication is important and should be given before the client's pain becomes worse.

The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? 1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. 2. The HIV virus can be eradicated from the host body with the correct medical regimen. 3. It is difficult for the HIV virus to replicate in humans because it is a monkey virus. 4. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.

1. Retroviruses never die; the virus may become dormant, only to be reactivated at a later time.

The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE? 1. Pericardial friction rub and crackles in the lungs. 2. Muscle spasticity and bradykinesia. 3. Hirsutism and clubbing of the fingers. 4. Somnolence and weight gain.

1. SLE can affect any organ. It can cause pericarditis and myocardial ischemia as well as pneumonia or pleural effusions.

The nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake

1. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily

The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? 1. Assess the client's body weight and ask what the client has been able to eat. 2. Place in contact isolation and don a mask and gown before entering the room. 3. Check the HCP's orders and determine what laboratory tests will be done. 4. Teach the client about total parenteral nutrition and monitor the subclavian IV site.

1. The client has a malnutrition syndrome. The nurse assesses the body and what the client has been able to eat.

The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

1. When peak airway pressure is increased, the nurse should implement the intervention least invasive for the client. This alarm goes off with a plugged airway, "bucking" in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.

Aclient is diagnosed with scleroderma.Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

2 Rationale: Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours aftermeals if esophageal involvement is present. Test-Taking Strategy: Focus on the subject, scleroderma.Think about the pathophysiology associated with this condition and read each option carefully to assist in answering correctly. Review: Nursing interventions for the client with scleroderma

A client presents at the health care provider's office with complaints of a ring-like rash on his upper leg. Which question should the nurse ask first? 1. "Do you have any cats in your home?" 2. "Have you been camping in the last month?" 3. "Have you or close contacts had any flu-like symptoms within the last few weeks?" 4. "Have you been in physical contact with anyone who has the same type of rash?"

2 Rationale: The nurse should ask questions to assist in identifying a cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ring-like rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

Aclient arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply. 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic.

2, 3, 4 Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the followingmanner. Immunoglobulin Mis detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect

The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected? 1. Complete metabolic panel and liver function tests. 2. Complete blood count and antinuclear antibody tests. 3. Cholesterol and lipid profile tests. 4. Blood urea nitrogen and glomerular filtration tests.

2. No single laboratory test diagnoses SLE, but the client usually presents with moderate to severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear antibody.

The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit.Which HCP's order should the nurse implement first? 1. Draw a serum for CD4 and complete blood count STAT. 2. Administer oxygen to the client via nasal cannula. 3. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB. 4. Obtain a sputum specimen for culture and sensitivity.

2. Oxygen is a priority, especially with a client diagnosed with a respiratory illness.

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions. 2. Standard Precautions. 3. Droplet Precautions. 4. Exposure Precautions.

2. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood.

The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP washes her hands before and after performing vital signs on a client. 2. The UAP dons sterile gloves prior to removing an indwelling catheter from a client. 3. The UAP raises the head of the bed to a high Fowler's position for a client about to eat. 4. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.

2. The UAP can remove an indwelling catheter with nonsterile gloves. This is a waste of expensive equipment. The nurse is responsible for teaching UAPs appropriate use of equipment and supplies and cost containment.

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request postexposure prophylaxis. 4. Check the hepatitis status of the client.

2. The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin.

The client diagnosed with RA has developed swan-neck fingers. Which referral is most appropriate for the client? 1. Physical therapy. 2. Occupational therapy. 3. Psychiatric counselor. 4. Home health nurse.

2. The occupational therapist assists the client in the use of the upper half of the body, fine motor skills, and activities of daily living. This is needed for the client with abnormal fingers.

The nurse on a medical unit has received the morning shift report. Which client should the nurse assess first? 1. The client who has a 0730 sliding-scale insulin order. 2. The client who received an initial dose of IV antibiotic at 0645. 3. The client who is having back pain at a "4" on a 1-to-10 scale. 4. The client who has dysphagia and needs to be fed.

2. This client has received an initial dose of antibiotic IV and should be assessed for tolerance to the medication within 30 minutes.

The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? 1. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush. 2. Notify the HCP for an order for an antifungal swish-and-swallow medication. 3. Have the client gargle with an antisepticbased mouthwash several times a day. 4. Determine what types of food the client has been eating for the last 24 hours.

2. This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition.

A client with rheumatoid arthritis has severe pain and swelling of the joints in both hands. Range-of-motion exercises for this client should be: 1. passively performed by the nurse. 2. avoided if the client reports discomfort. 3. preceded by the application of heat or cold. 4. gradually increased to improve mobility and independence.

3 Heat and cold applications reduce inflammation and discomfort. 1 This will depend on the client's tolerance. 2 Avoiding exercise will increase the destructive effects of immobility. 4 Exercises are necessary to prevent contractures and permanent joint damage, but cannot be gradually increased unless the client is able to tolerate them.

A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted by transfusions?" The nurse should respond, "Although the risk is minimal, the type of hepatitis associated with blood transfusions is hepatitis: 1. A." 2. B." 3. C." 4. D."

3 Hepatitis C is caused by an RNA virus that is transmitted parenterally. More effective blood screening for hepatitis C was introduced in June 1992; this brought about a dramatic decrease in hepatitis C infection caused by blood transfusions; recent studies document that the risk of contracting hepatitis C from a blood transfusion is 1 in 103,000 transfusions. The incubation period is 5 to 10 weeks. 1 Hepatitis A, also known as infectious hepatitis, is caused by an RNA virus that is transmitted via the fecal-oral route. The incubation period is 2 to 6 weeks. 2 Hepatitis B is transmitted parenterally, sexually, and by direct contact with infected body secretions. The incubation period is 1 to 6 months. It is not the major cause of posttransfusion hepatitis. 4 Hepatitis D is a complication of hepatitis B.

The nurse questions a client with rheumatoid arthritis about pain. When should the nurse expect the client to experience increased pain and limited movement of the joints? 1. After assistive exercise 2. When the room is cool 3. In the morning on awakening 4. When the latex fixation test is positive

3 Inactivity over an extended time increases stiffness and pain in joints. 1 Assistive exercises help maintain joint mobility. 2 This is not a factor; cold applications may decrease joint discomfort. 4 The latex fixation test is positive when the rheumatoid factor is found in blood serum; this factor is present in many conditions, including rheumatoid arthritis, aging, narcotic addiction, and SLE.

A regimen of rest, exercise, and physical therapy is ordered for a client with rheumatoid arthritis. What should the nurse explain is the intended purpose of this regimen? 1. Prevent arthritic pain 2. Halt the inflammatory process 3. Help prevent the crippling effects of the disease 4. Provide for the return of joint motion after prolonged loss

3 Range-of-motion exercises are instituted to maintain mobility of joints. Balanced activity and rest will promote resolution of the inflammation. 1 Pain may persist but cannot be allowed to legitimize inactivity. 2 Activity will not prevent the inflammatory process; it may aggravate it. 4 Severely damaged joints may require prosthetic replacement.

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

3 The diet should be high in carbohydrates with moderate to high protein and low fat content. 1, 4 This is too high in fat. 2 This is too low in carbohydrates.

A nurse is caring for a client who is positive for hepatitis A. What should the nurse do? 1. Wear a gown when entering the client's room. 2. Use caution when bringing in the client's food. 3. Use gloves when removing the client's bedpan. 4. Wear a protective mask when entering the client's room.

3 The virus is present in the stool of clients with hepatitis A; therefore, standard precautions should be followed when handling excretions. The virus may also be present in urine and nasotracheal secretions. 1 The Centers for Disease Control and Prevention (CDC) indicate that only standard precautions are necessary when caring for a client who is positive for the presence of hepatitis A; if a client is incontinent or using an incontinence device, the CDC recommends contact precautions be implemented. 2 Bringing food to a client requires no precautions; however, disposable utensils should be used and utensils discarded following standard precautions because the client's nasotracheal secretions contain the virus. 4 Hepatitis A usually is not transmitted via the air.

During an 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? 1. An understanding of safer sex 2. An ability to assume self-responsibility 3. Ignorance related to correct condom use 4. Ignorance concerning the transmission of HIV

3 Vaseline (petroleum jelly) breaks down condom integrity and will increase the risk for condom failure. 1 Using Vaseline instead of a water-soluble lubricant shows a lack of knowledge about condom use, a form of safer sex. 2 Although the person is attempting to be responsible, there is a lack of knowledge and the behavior is unsafe. 4 Condom use shows the client has some understanding about the transmission of HIV.

The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse? 1. The nurse explains the IVP diuretic will make the client urinate. 2. The nurse dons nonsterile gloves to remove the client's dressing. 3. The nurse administers a medication without checking for allergies. 4. The nurse asks the UAP for help moving a client up in bed.

3. Checking for allergies is one (1) of the five (5) rights of medication. Is it the right drug? Even if the drug is the one the HCP ordered, it is not the right drug if the client is allergic to it. The nurse should always assess a client's allergies prior to administering any medication.

Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure

Which intervention is an important psychosocial consideration for the client diagnosed with AIDS? 1. Perform a thorough head-to-toe assessment. 2. Maintain the client's ideal body weight. 3. Complete an advance directive. 4. Increase the client's activity tolerance.

3. Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS.

The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach? 1. Tell the client never to scratch the rash. 2. Instruct the client in administering IM Benadryl. 3. Explain how to take a steroid dose pack. 4. Have the client wear shirts with long sleeves and high necks.

3. Clients with poison ivy are frequently prescribed a steroid dose pack. The dose pack has the steroid provided in descending doses to help prevent adrenal insufficiency.

The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse? 1. The client is able to mark the correct site for the surgery. 2. The client can only tell the nurse about the surgery in lay terms. 3. The client is allergic to iodine and does not have an allergy bracelet. 4. The client has signed a consent form for surgery and anesthesia.

3. Iodine is the basic ingredient in Betadine (povidone-iodine), which is a common skin prep used for surgeries. Therefore, the nurse should notify the surgeon if the client has an allergy to iodine.

The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits? 1. Perform joint x-rays to determine progression of the disease. 2. Send blood to the laboratory for an erythrocyte sedimentation rate. 3. Recommend the flu and pneumonia vaccines. 4. Assess the client for increasing joint involvement.

3. RA is a disease with many immunological abnormalities. The clients have increased susceptibility to infectious disease, such as the flu or pneumonia, and, therefore, vaccines, which are preventive, should be recommended.

The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing? 1. Tapering the medication prevents the client from having withdrawal symptoms. 2. So the thyroid gland starts working, because this medication stops it from working. 3. Tapering the dose allows the adrenal glands to begin to produce cortisol again. 4. This is the health-care provider's personal choice in prescribing the medication.

3. Tapering steroids is important because the adrenal gland stops producing cortisol, a glucocorticosteroid, when the exogenous administration of steroids exceeds what normally is produced. The functions of cortisol in the body are to regulate glucose metabolism and maintain blood pressure.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

3. The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed.

The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.

The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first? 1. Initiate an IV with normal saline. 2. Prepare to intubate the client. 3. Administer oxygen at 100%. 4. Ask the client about an iodine allergy.

3. The client is cyanotic with dyspnea and wheezing. The nurse should administer oxygen first.

The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation? 1. Assign a different nurse every shift to the client. 2. Ask the HCP to tell the client not to yell at the staff. 3. Call a team meeting and discuss options with the staff. 4. Tell one (1) staff member to care for the client a week at a time.

3. The health-care team should meet to discuss ways to best help the client deal with the anger being expressed, and the staff should be consistent in working with the client.

The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse? 1. Administer methotrexate, an antineoplastic medication, IV. 2. Assess the lung sounds of a client with RA who is coughing. 3. Demonstrate how to use clothing equipped with Velcro fasteners. 4. Discuss methods of birth control compatible with treatment medications.

3. The licensed practical nurse (LPN) can demonstrate how to use adaptive clothing.

The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE? 1. The steroids will increase the body's ability to fight the infection. 2. The steroids will decrease the chance of the SLE spreading to other organs. 3. The steroids will suppress tissue inflammation, which reduces damage to organs. 4. The steroids will prevent scarring of skin tissues associated with SLE.

3. The main function of steroid medications is to suppress the inflammatory response of the body

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.

The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves? 1. Use only sterile, nonlatex gloves for any procedure requiring gloves. 2. Do not use gloves when starting an IV or performing a procedure. 3. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform. 4. Wear white cotton gloves at all times to protect the hands.

3. The nurse should be prepared to care for a client at all times and should not place himself or herself at risk because the facility does not keep nonlatex gloves available in the rooms. The nurse should carry the needed equipment (nonlatex gloves) with him or her.

The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? 1. The client is fortunate not to have contracted HIV from an infected needle. 2. The client must be repeatedly exposed to HIV before becoming infected. 3. The client may be in the primary infection phase of an HIV infection. 4. The antibody test is negative because the client has a different flu virus.

3. The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV

The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented? 1. Use astringent lotion on the face and skin. 2. Inspect the skin weekly for open areas or rashes. 3. Dry the skin thoroughly by patting. 4. Apply anti-itch medication between the toes.

3. The skin should be washed with mild soap, rinsed, and patted dry. Rubbing can cause abrasions and skin breakdown.

The client who smokes two (2) packs of cigarettes a day develops ARDS after a neardrowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people who almost drown end up developing ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. "Smoking has caused your lungs to become weakened, so you got ARDS."

3. This is a basic layperson's terms explanation of ARDS and explains why the client is having trouble breathing.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1. Chest tube insertion 2. Aggressive diuretic therapy 3. Administration of beta blockers 4. Positive end-expiratory pressure

4 Mechanical ventilation with positive end-expiratory pressure (PEEP) will help prevent alveolar collapse and improve oxygenation. 1 Fluid is not in the pleural space, so this is not indicated. 2, 3 This is contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.

A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain will most likely remain contaminated with the hepatitis A virus after being cooked? 1. Canned tuna 2. Broiled shrimp 3. Baked haddock 4. Steamed lobster

4 The temperature during steaming is never high enough or sustained long enough to kill microorganisms. 1 Processing destroys the virus. 2 Because of the extremely high temperature, broiling sufficiently destroys the virus. 3 Baking will destroy the virus.

A client who has intermittently been having painful, swollen knee and wrist joints during the past 3 months is diagnosed with rheumatoid arthritis. What type of diet should the nurse expect the health care provider to order? 1. Salt-free, low-fiber diet 2. High-calorie, low-cholesterol diet 3. High-protein diet with minimal calcium 4. Regular diet with vitamins and minerals

4 There are no dietary restrictions, but iron and vitamins should be encouraged to treat any underlying nutritional deficiencies. 1 These nutritional restrictions are not indicated. 2 A high-calorie diet will increase the client's weight; this is contraindicated because it will increase the strain on weight-bearing joints. 3 A balanced diet should fulfill nutritional needs; there is no need to increase protein or restrict calcium.

A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube should the nurse anticipate will most likely be used to meet the needs of this client? 1. Levin 2. Salem sump 3. Miller-Abbott 4. Blakemore-Sengstaken

4 This tube includes an esophageal balloon that exerts pressure on inflation, which retards hemorrhage. 1 A Levin tube is used for gastric decompression, gavage, or lavage; it has one lumen. 2 A Salem sump tube is used for gastric decompression; it has two lumens, one for decompression and one for an air vent. 3 A Miller- Abbott tube is used for intestinal decompression.

The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea.

4. "Flu-like" symptoms are the first complaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day

4. Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels.

The client asks the nurse, "Which time of the year is allergic rhinitis least likely to occur?" Which statement is the nurse's best response? 1. "It is least likely to occur during the springtime." 2. "Allergic rhinitis is not likely to occur during the summer." 3. "It is least likely to occur in the early fall." 4. "Allergic rhinitis is least likely to occur in early winter."

4. Early winter is the beginning of deciduous plants becoming dormant. Therefore, allergic rhinitis is least prevalent during this time of year.

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

4. Hepatitis A is transmitted via the fecal- oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands.

The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented? 1. Plan a strenuous exercise program. 2. Order a mechanical soft diet. 3. Maintain a keep-open IV. 4. Obtain an order for a sedative.

4. Sleep deprivation resulting from pain is common in clients diagnosed with RA. A mild sedative can increase the client's ability to sleep, promote rest, and increase the client's tolerance of pain.

Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections? 1. Contact Precautions. 2. Airborne Precautions 3. Droplet Precautions. 4. Standard Precautions.

4. Standard Precautions are used for all contact with blood and body secretions.

The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.

4. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one (1) inch above the bifurcation of the bronchi.

The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention? 1. The client complains of joint stiffness and the knees feel warm to the touch. 2. The client has experienced one (1)-kg weight loss and is very tired. 3. The client requires a heating pad applied to the hips and back to sleep. 4. The client is crying, has a flat facial affect, and refuses to speak to the nurse.

4. The client has the signs and symptoms of depression. The nurse should attempt to intervene with therapeutic conversation and discuss these findings with the HCP.

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

4. The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention.

The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response? 1. "I know you are upset, but stress makes the SLE worse." 2. "Please explain to me why you are crying." 3. "I recommend going to an SLE support group." 4. "I see you are crying. We can talk if you would like."

4. The nurse stated a fact, "You are crying," and then offered self by saying "Would you like to talk?" This addresses the nonverbal cue, crying, and is a therapeutic response.

The client recently diagnosed with SLE asks the nurse, "What is SLE and how did I get it?" Which statement best explains the scientific rationale for the nurse's response? 1. SLE occurs because the kidneys do not filter antibodies from the blood. 2. SLE occurs after a viral illness as a result of damage to the endocrine system. 3. There is no known identifiable reason for a client to develop SLE. 4. This is an autoimmune disease that may have a genetic or hormonal component.

4. There is evidence for familial and hormonal components to the development SLE. SLE is an autoimmune disease process in which there is an exaggerated production of autoantibodies.

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Select all that apply. 1. Eat foods high in vitamin C. 2. Take your temperature daily. 3. Balance periods of rest and activity. 4. Use a strong soap when washing the skin. 5. Expose the skin to the sun as often as possible.

Answer: 1, 2, 3. 1 Vitamin C should be encouraged because it is essential for the biosynthesis of collagen. 2 A fever is the major sign of an exacerbation. 3 A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. 4 Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion applied. 5 This is not necessary. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. Which joints does the nurse expect the client to report were initially involved? Select all that apply. 1. Hips 2. Knees 3. Ankles 4. Shoulders 5. Metacarpals

Answer: 1, 2. 1 Osteoarthritis affects the weight-bearing joints (e.g., hips and knees) first because they bear the most body weight. The resulting joint damage causes a series of physiologic responses (e.g., release of cytokines and proteolytic enzymes) that lead to more damage. 2 Osteoarthritis affects the weight-bearing joints (e.g., hips and knees) first because they bear the most body weight. 3 Although the ankles are weight-bearing joints and eventually are affected, the motion in the ankles is not as great as in the hips and knees; thus, there is less degeneration. 4 Shoulder joints are not the most likely to be involved first because these are not weight-bearing joints. 5 Although the distal interphalangeal joints are frequently affected, the remaining interphalangeal joints and metacarpals are not.

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply. 1. Butterfly facial rash 2. Firm skin fixed to tissue 3. Inflammation of the joints 4. Muscle mass degeneration 5. Inflammation of small arteries

Answer: 1, 3. 1 The connective tissue degeneration of systemic lupus erythematosus (SLE) leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the malar region. 2 This occurs in scleroderma; in an advanced stage the client has the appearance of a living mummy. 3 Polyarthritis occurs in most clients, with joint changes similar to those seen in rheumatoid arthritis. 4 This occurs in muscular dystrophy; it is characterized by muscle wasting and weakness. 5 This occurs in polyarteritis nodosa, a collagen disease affecting the arteries and nervous system.

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? Select all that apply. 1. Encourage motion of the joint. 2. Maintain a knee brace on the leg. 3. Keep the client on a regimen of bed rest. 4. Maintain joints in functional alignment when resting. 5. Immobilize the joint with pillows until pain subsides.

Answer: 1, 4. 1 Exercise of involved joints is important to maintain optimal mobility and prevent buildup of calcium deposits. 2 Immobilization causes loss of joint mobility and contractures. 3 Immobility promotes the development of contractures. 4 Functional alignment places the least strain on joints, muscles, and tendons. 5 Immobilization with pillows promotes the development of contractures.

A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? Select all that apply. 1. Preventing constipation 2. Screening of blood donors 3. Avoiding shellfish in the diet 4. Limiting hepatotoxic drug therapy 5. Maintaining a monogamous sexual relationship

Answer: 2, 5. 1 Preventing constipation is not related to limiting the risk for contracting hepatitis B. 2 Contracting hepatitis B through blood transfusions can be prevented by screening donors and testing the blood. 3 Avoiding shellfish in the diet limits the risk for contracting hepatitis A. 4 This does not prevent transmission of hepatitis B. 5 Hepatitis B can be transmitted via contaminated body fluids such as semen, saliva, and urine. Multiple sexual partners increase the risk. A monogamous sexual relationship with an infection-free individual eliminates the risk.

A nurse is assessing a client with the diagnosis of scleroderma for the signs of CREST syndrome. What clinical indicators should the nurse expect to identify? Select all that apply. 1. Joint pain 2. Mask-like facies 3. Esophageal reflux 4. Spider-like hemangiomas 5. Episodic blanching of the fingers

Answer: 3, 4, 5. 1 Joint pain, caused by inflammation, is a symptom associated with scleroderma, not CREST syndrome. 2 Mask-like facies is a sign associated with scleroderma, not CREST syndrome; it is caused by fibrotic tissue changes. 3 Esophageal dysmotility is associated with CREST syndrome; it results in dysphagia and esophageal reflux. CREST: Calcium deposits in organs; Raynaud phenomenon; Esophageal dysfunction; Sclerodactyly (scleroderma of the digits); Telangiectasia (vascular lesions formed by dilation of a group of small blood vessels). 4 Spider-like hemangiomas (telangiectasia) is associated with CREST syndrome. 5 Episodic blanching of the fingers (Raynaud phenomenon), caused by vasospasms of the arterioles, is a sign associated with CREST syndrome.

A nurse is caring for a client with a diagnosis of AIDS. The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? Select all that apply. 1. Mask 2. Gown 3. Gloves 4. Face shield 5. Hand hygiene

Answer: 3, 5. 1 Wearing a mask is necessary for procedures where splashing of body fluids is anticipated or a risk. 2 Wearing a gown is necessary for procedures where splashing of body fluids is anticipated or a risk. 3 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. 4 Wearing a face shield is necessary for procedures where splashing of body fluids is anticipated. 5 Hand hygiene is the most effective way to prevent the spread of microorganisms.

A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is ordered. What should the nurse instruct the client to do considering the client's condition? 1. Avoid foods high in vitamin K. 2. Check the pulse several times a day. 3. Drink a glass of milk when taking aspirin. 4. Report signs of bleeding no matter how slight.

One of the many functions of the liver is the manufacture of clotting factors; there is interference in this process with cirrhosis of the liver, resulting in bleeding tendencies. 1 The storage of fat-soluble vitamins (A, D, E, and K), water-soluble vitamins (B1, B2, folic acid, and cobalamin), and minerals (including iron) is compromised in cirrhosis; therefore, these nutrients, including vitamin K, should not be limited. 2 Should the client bleed, the pulse rate may be increased, but it is not necessary for the client to check the pulse rate several times daily. 3 A client whose prothrombin time is prolonged and platelet count is low should not be taking aspirin, even with milk.