NUR 2530 EXAM 2 practice questions

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? A. hairdressers B. the homeless C. children in day care centers D. individuals living in a group home

A - hairdressers Rationale: Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? A. Protecting the client from infection B. Providing emotional support to decrease fear C. Encouraging discussion about lifestyle changes D. Identifying factors that decreased the immune function

A - protecting the client from infection Rationale: The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be infection prevention.

The nurse is conducting allergy skin testing on a client. Which post procedure interventions are most appropriate? Select all that apply. A. Record site, date, and time of the test. B. Give the client a list of potential allergens if identified. C. Estimate the size of the wheal and document the findings. D. Tell the client to return to have the site inspected only if there is a reaction. E. Have the client wait in the waiting room for at least 1 to 2 hours after injection

A, B Rationale: Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at specific date and time for a follow-up site evaluation, even if no reaction is suspected. After injection, clients on need to be monitored for about 30 minutes to assess for any adverse effects

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. A. Administer oxygen B. Quickly assess the clients respiratory status. C. Document the event, interventions, and client's response. D. Leave the client briefly to contact a primary health care provider (HCP). E. Keep the client supine regardless of the blood pressure readings. F. Start an intravenous (IV) infusion of D5W and administer a 500ml bolus.

A, B, C. - administer oxygen, assess respiratory status, and documentation. Rationale: An anaphylactic reaction requires immediate action starting with quickly assessing the clients respiratory status. Although the PHCP and RRT 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 PHCP prescription. Documentation of the event, actions taken, and client outcomes needs to be performed. The HOB should be elevated if the client's blood pressure is normal.

Which interventions apply in the care of a client at high risk for allergic response to a latex allergy? Select all that apply. A. use non latex gloves B. use medications from glass ampules. C. place the client in a private room only D. keep a latex-safe supply cart available in the clients area. E. Avoid the use of medication vials that have rubber stoppers F. Use a blood pressure cuff from an electronic device only to measure the blood pressure

A, B, D, E - use nonlatex gloves, use medications from glass ampules, keep a latex-safe supply cart available in the clients area, and avoid the use of medication vials that have rubber stoppers. Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the clients area. Any supplies or materials that contain latex would be avoided.

The nurse provides home care instructions to a client with systemic lupus erthyematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? A. "I should take hot baths because they are relaxing." B. "I should sit whenever possible to conserve my energy." C. "I should avoid long periods of rest because it causes joint stiffness." D. "I should do some exercises, such as walking, when I am not fatigued."

A. "I should take hot baths because they are relaxing" Rationale: To help reduce fatigue in the client with lupus, the nurse should instruct the client to sit whenever possible, avoid hot baths (they exacerbate fatigue), schedule low-impact exercises when not fatigued, and maintain a balanced diet.

A 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? A. Swelling in the genital area B. Swelling in the lower extremities C. Positive punch biopsy of the cutaneous lesions D. Appearance of reddish-blue lesions noted on the skin

C- positive punch biopsy of the cutaneous lesions. Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macule s on the lower legs that change into plaques. These larger 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 GI tract. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions..

A client 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? A. Advise the client to soak the site in hydrogen peroxide. B. Ask the client if he ever sustained a bee sting in the past. C. Tell the client to call an ambulance for transport to the emergency department. D. Tell the client not to worry about the sting unless difficulty with breathing occurs.

B - Ask the client if he ever sustained a bee sting in the past. Rationale: In some type 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.

A client presents at the primary health care providers office with complaints of a ring-like rash on his upper leg. Which question should the nurse ask first? A. "do you have any cats in your home?" B. "have you been camping in the last month?" C. "have you or close contacts had any flu-like symptoms within the last few weeks?" D. "have you been in physical contact with anyone who has the same type of rash?"

B - have you been camping in the last month? Rationale: The nurse should ask questions to assist in identifying a cause of Lyme disease, which is a multi-system 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, arillate, trunk, and upper arms or legs.

A client 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. A. Tell the client that testing is not necessary unless arthralgia develops. B. Tell the client to avoid any woody, grassy areas that may contain ticks. C. Instruct the client to immediately start to take the antibiotics that are prescribed. D. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. E. Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic.

B, C, D 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. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic.

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

B- administer corticosteroids as prescribed for inflammation Rationale: Scleroderma is a chronic connective tissue disease similar to systemic lupus eryhtematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and temperature needs to be constant.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? A. wearing gloves B. wearing a gown and gloves C. wearing a gown, gloves, and a mask D. wearing a gown and gloves to change the bed linens, and gloves only for the bath

B. wearing a gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Regardless of the amount of wound drainage, a gown and gloves must be worn.

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? A. "My skin will have tiny red vessels" B. "The presence of the skin vesicles is caused by a virus." C. "I have an autoimmune disease that causes blistering in the skin." D. "Red, raised papule and large plaques covered by silvery scales will be present on my skin."

C - "I have an autoimmune disease that causes blistering in the skin." Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of the skin and break easily, leaving denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters.

The nurse is preparing a group of Cub 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? A. "I need to bring a hat to wear during the trip." B. "I should wear long-sleeved tops and long pants." C. "I should not use insect repellents because it will attract the ticks." D. "I need to wear closed shoes and socks that can be pulled up over my pants."

C - I should not use insect repellents because it will attract the ticks. 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 or cat should be worn.

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? A. Eggs B. Milk C. Yogurt D. Bananas

D - Bananas Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen.