Nursing Level 4, Test 4: HIV, Organ Transplant, Liver Failure, Cirrhosis, Pancreatitis, FTT
Which of the following is the clearest example of a nurse applying the principles of community-based care? a) A nurse cares for a high-risk pregnant woman from a rural area at a tertiary care hospital in a large urban center. b) A nurse organizes a blood pressure screening clinic at a busy shopping mall. c) A nurse provides wound care for a client's venous ulcer at an ambulatory clinic near the client's home. d) A nurse educates high school students on safer sex practices at a series of in-school workshops.
C - A central component of community-based care is providing care for acute and chronic illnesses in the geographic region near the client's home. Blood pressure screening and health-maintenance education are population-based and community health initiatives distinct from community-based care.
This is the cause of immune dysfunction in HIV infection
Immune dysfunction in HIV is caused by damage and destruction of of CD4+ T cells (also known as T helper cells or CD4+ T lymphocytes
The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1. Client's temperature 2. Expiration date on the bag 3. Time of last dressing change 4. Tightness of tubing connections
1. Client's temp - Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change.
The nurse is analyzing the laboratory report for the client who had a specific gravity determination drawn. The report indicates a value of 1.030. The nurse understands that which condition may potentially be causing this result? 1. renal disease 2. diabetes insipidus 3. decreased renal perfusion 4. inability of the kidneys to concentrate urine
3. decreased renal perfusion. The normal urine specific gravity level is 0.016-1.022. An increase in urine specific gravity can occur as a result of decreased renal perfusion, increased antidiuretic hormone, or insufficient fluid intake. A decrease in urine specific gravity can occur as a result of increased fluid intake, DI, renal disease, or the inability of kidneys to concentrate urine.
The nurse understands that a rise in body temperature is associated with the presence of infection because: 1. Pain activates the sympathetic nervous system 2. Erythema increases the flow of blood throughout the body 3. Leukocyte migration precipitates the inflammatory response 4. Phagocytic cells release pyrogens that stimulate the hypothalamus
4 - Microorganisms or endotoxins stimulate phagocytic cells, which release pyrogens that stimulate the hypothalamic thermoregulatory center causing fever
The nurse understands that a secondary line of defense against infection is the: 1. Mucous membranes of the respiratory tract 2. Urinary tract environment 3. Integumentary system 4. Immune response
4 - The immune response is a specific, secondary line of defense against pathogenic microorganisms. The production of antibodies to neutralize and eliminate pathogens and their toxins (immune response) is activated when phagocytes fail to completely destroy invading microorganisms. The primary, nonspecifi c defenses (anatomical, mechanical, chemical, and infl ammatory) work in harmony with the secondary defense (immune response) to defend the body from pathogenic microorganisms
During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following? a) Metabolic acidosis b) Respiratory alkalosis c) Rebound hyperthermia d) Anaphylaxis
A - When a patient's temperature falls, glucose metabolism is reduced. As a result, metabolic acidosis may develop. Rebound hyperthermia, anaphylaxis, and alkalosis are not associated with hypothermia during surgery.
The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose? a) Reduced peripheral edema and ascites. b) Prevention of hemorrhage. c) Stimulation of peristalsis of the bowel. d) Reduced serum ammonia levels.
D - REDUCED serum ammonia
A client diagnosed with metastatic cancer is preparing for discharge. The physician orders morphine sulfate controlled-release tablets 100 mg every 12 hours as needed after discharge. What legal rights and responsibilities should the nurse address when teaching the client about morphine sulfate use? a) "Morphine sulfate is an opioid and you may develop a tolerance to it. This is an expected response and is not harmful." b) "You must avoid driving or other activities that require alertness while taking controlled-release morphine sulfate." c) "If you no longer require the morphine sulfate controlled-release tablets for your cancer pain, do not take any leftover pills for other disorders." d) "Federal law prevents refills of this medication. Your physician will give you a new prescription when you need more medicine."
D - Federal law prevents the refill of opioids. Therefore, the nurse should tell the client to contact the physician for a new prescription when the current prescription is empty. The client should be instructed to avoid driving or operating hazardous machinery while under the effects of morphine; however, this is a safety issue, not a legal one. Long-term morphine sulfate use may lead to drug tolerance; however, this is not a legal issue surrounding its use. The client with metastatic cancer will most likely require pain medication for the rest of his/her life.
The nurse is volunteering at a camp for children with various medical conditions. In planning for the event, a parent asks, "What causes an acquired immune deficiency?" Which is correct for the nurse to answer? a) Age b) Environment c) Genetics d) Medical treatments
D - Immune deficiencies may result from medical treatments, such as medications, radiation, and transplants. Immune function may decline with age, but it is not considered the cause of acquired immune deficiency. Genetics and environment have not been shown to be factors in acquired immune deficiency.
Pancreatic enzyme replacements are ordered for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? a) Every 4 hours, at specified times. b) In the morning and at bedtime. c) Three times daily between meals. d) With each meal and snack.
D - In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and should be taken in conjunction with every meal and snack. Specified hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion
How can HIV be transmitted?
HIV can ONLY be transmitted under specific conditions that allow contact with infected body fluids, including blood, semen, vaginal secretions, and breast milk
This is the major concern related to immune suppression in HIV patients
The major concern related to immune suppression is the development of opportunistic diseases (infections and cancers that occur in immunosuppressed patients that can lead to disability, disease, and death).
The nurse is caring for a group of hospitalized patients. What should the nurse do first to prevent patient infections? 1. Provide small bedside bags to dispose of used tissues 2. Encourage staff to avoid coughing near patients 3. Administer antibiotics as ordered 4. Identify patients at risk
4 - This is the most important first step in the prevention of infection. A patient who is at high risk may need to receive special protective precautions as well as transmission-based precautions to protect others.
The nurse notes that a 5-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which landmarks to perform the abdominal thrust maneuver? 1. the umbilicus and the groin 2. the lower abdomen and chest 3. the groin and the xiphoid process 4. the umbilicus and the xiphoid process
4. To perform the abdominal thrust maneuver, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The thumb side of 1 fist is placed against the victim's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped w/ the other hand and upward thrusts are delivered.
A client with cirrhosis should be encouraged to follow which diet? a) Well-balanced normal nutrients, low-sodium diet. b) Bland, low-protein, low-sodium diet. c) High-protein, high-calorie, high-potassium diet. d) High-calorie, restricted protein, low-sodium diet.
A - Cirrhosis is a slowly progressive disease. Inadequate nutrition is the primary ongoing problem. Clients are encouraged to eat normal, well-balanced diets and to restrict sodium to prevent fluid retention. Protein is not restricted until the liver actually fails, which is usually late in the disease. It is not necessary to restrict protein or eat a bland diet
A client is receiving total parenteral nutrition (TPN), and the nurse is concerned about the complication of fluid volume overload. Which of the following nursing actions is most appropriate in the administration of TPN to prevent this complication? a) Use an infusion pump to administer the TPN solution. b) Reduce the ordered flow rate by half. c) Continuously monitor the infusion rate. d) Weigh the client every day.
A - Complications of TPN include fluid overload, electrolyte imbalances, infection, hyperglycemia and hypoglycemia, air embolism, and pneumothorax. A nurse should use an infusion pump to administer TPN to help prevent fluid overload. Although weighing the client every day would alert the nurse to possible fluid overload, it is more appropriate for the nurse to prevent fluid overload by using an infusion pump. The nurse does not need to continuously monitor the infusion rate once the pump is set. The nurse should not decrease the prescribed flow rate, thus preventing the administration of the ordered nutrition.
A 12-month-old child is seen in the neighborhood clinic for a regular checkup. Which statement by the child's mother about the influenza vaccine reflects the need for more teaching? a) "The Haemophilus influenzae vaccine my child has already received helps protect against some forms of the flu." b) "My child is too young to receive the live attenuated intranasal vaccine." c) "The first time a child receives the influenza vaccine, a second dose is recommended in 1 month." d) "Yearly influenza vaccinations are recommended to begin as early as 6 months of age."
A - Haemophilus influenzae is a bacteria that can cause severe disease in children younger than age 5 years, but it does not cause influenza. Yearly vaccination for influenza is recommended to begin at 6 months. The live vaccine is not recommended for children younger than 2 years or with respiratory disease. A second vaccine 4 weeks after the first is recommended the first time a child younger than 9 years receives the flu vaccine.
A nurse is analyzing a client's intake and output. The client has a temperature of 102° F (38.9° C) and is receiving I.V. fluid therapy because of his nothing-by-mouth status due to acute pancreatitis. Before planning nursing actions, the nurse should first consider which of the following? a) Insensible fluid loss through the lungs and skin. b) The number of bags of I.V. fluid for the client. c) The client's body mass index. d) When the client last ate.
A - Insensible fluid loss is invisible vaporization from the lungs and skin, and assists in regulating body temperature. The amount of water loss is increased by accelerated body metabolism, which occurs with increased body temperature. The client's body mass index does not directly influence calculating fluid therapy. When the client's last meal was consumed and the availability of I.V. fluids have no influence on the analysis of intake and output
The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns? a) "Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so he will be able to provide it if you can't tell him yourself." b) "Many people first feel that way when they are admitted into hospice. Although the focus of your care has changed from curative to supportive, your physician will still continue directing it." c) "You don't need to feel that way. Your physician is required by law to sign your orders and the hospice nurses will be contacting him with updates on your condition." d) "It's understandable to feel that way. But clients with end-stage AIDS who have advanced directives generally experience a less painful death that those individuals who don't."
A - Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so he will be able to provide it if you can't tell him yourself." Option 1 provides correct information about advance directives. The advance directive outlines the client's treatment wishes should he be unable to communicate his wishes at any time during his illness. The physician continues to provide care for clients admitted to hospice care. Option 2 invalidates the client's fears and doesn't emphasize the physician's role or the client's role in his care plan. Option 3 doesn't address the purpose of the advance directive, and it discusses treatment options that may not have been discussed with the client. Option 4 doesn't provide evidence-based information about advance directives
A nurse is assigning tasks to the unlicensed assistive personnel and the practical nurse on the client care team. Which of the following tasks will the nurse plan to perform personally? Select all that apply. a) Taking the health history of a newly admitted client b) Assessing a client who just returned from cardiac catheterization c) Assisting a client to the bathroom who uses a walker for mobility d) Administering oral pain medication to a postoperative client e) Providing oral care to a client who had nothing by mouth before surgery
A and B - Although registered nurses perform many tasks that overlap with other caregivers, the nurses perform specific actions within the nursing process. Assessment of new or unstable clients is a part of the nursing process that the RN may not delegate. During the assessment step of the nursing process, the RN obtains the client's health history, measures vital signs, and performs a physical examination to gather data for use in formulating corresponding nursing diagnoses. The other options do not need to be done by the RN.
Which of the following diet instructions are appropriate when teaching a client in the early stages of cirrhosis about nutritional needs? Select all that apply. a) "An adequate intake of protein is important to your health." b) "Limit your alcohol intake to one glass of wine daily." c) "Limit your caloric intake so that you don't become overweight." d) "I encourage you to eat small, frequent meals." e) "Restrict your fluid intake to 1,000 ml/day."
A and D - Appropriate diet instructions for the client in the early stages of cirrhosis include ensuring an adequate intake of protein and eating small, frequent meals. There is no need to limit protein intake unless the patient has evidence of hepatic encephalopathy. Additionally, fluid intake is not restricted unless the client has significant ascites or edema (these typically occur later in the disease). Because of gastrointestinal dysfunction, small, frequent meals are frequently better tolerated than three regular meals. Clients with cirrhosis should be encouraged to increase their caloric intake instead of restricting it. Alcohol intake in any amount is discouraged
Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for: a) high-dose I.V. cyclosporine therapy. b) removal of the transplanted kidney. c) bone marrow transplant. d) intra-abdominal instillation of methylprednisolone sodium succinate.
B - Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given I.V. to treat acute organ rejection, but it's ineffective against hyperacute rejection.
Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation? a) Blood pressure of 100/70 mm Hg b) Urinary output of 20 mL/hr over 2 hours c) Moderate amount of serous drainage on the surgical dressing d) Temperature of 37.6°C (99.7°F)
B - Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the physician. A low-grade fever is expected in healing and is the natural inflammatory response to surgery. Moderate drainage can be observed, and the blood pressure is still within normal parameters.
A nurse is caring for a client with advanced cirrhosis who describes feelings of nausea and dizziness. Upon assessment, the nurse notes pallor with a distended and firm abdomen. What is the most likely cause? a) Ascites increasing significantly due to hypoalbuminemia b) Portal hypertension resulting in a sudden fluid shift and signs of hypovolemia c) Bleeding esophageal varices causing gastric distension d) Development of a paralytic ileus associated with cirrhosis
C - A complication of cirrhosis is esophageal varices. The nurse needs to be alert for signs of internal bleeding. The nausea, dizziness, pallor, and increased pulse rate are all signs or symptoms of hemorrhage. There is usually a gradual fluid shift when ascites presents. Paralytic ileus is not commonly associated with cirrhosis of the liver and would not account for most of the other symptoms
A client with cirrhosis is receiving lactulose. During the assessment the nurse notes increased confusion and asterixis. The nurse should: a) Monitor serum bilirubin levels. b) Hold the lactulose. c) Assess for GI bleeding. d) Increase protein in the diet.
C - Clients with cirrhosis can develop hepatic encephalopathy caused by increased ammonia levels. Asterixis, a flapping tremor, is a characteristic symptom of increased ammonia levels. Bacterial action on increased protein in the bowel will increase ammonia levels and cause the encephalopathy to worsen. GI bleeding and protein consumed in the diet increases protein in the intestine and can elevate ammonia levels. Lactulose is given to reduce ammonia formation in the intestine and should not be held since neurological symptoms are worsening. Bilirubin is associated with jaundice.
A nurse is assessing a client with viral hepatitis. The client reports that the appetite is poor and food causes nausea. The nurse should encourage the client to eat: a) A low-calorie diet with numerous snacks. b) Foods high in protein. c) Most calories in the morning during small frequent snacks. d) High-fat foods at each meal.
C - It is important to explain to the client having nausea that most calories should be eaten in the morning, because nausea is most frequent in the afternoon and evening. Small, frequent portions are best. Clients with viral hepatitis should select a diet high in calories because they require energy for healing. An intake of adequate carbohydrates can spare protein because protein places an increased workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated
A client's nutritional status has been severely compromised through prolonged episodes of nausea and vomiting. Which of the following therapies will be the most effective in correcting nutritional deficits before surgery? a) Continuous enteral feedings at 200 ml/hour. b) I.V. infusion of normal saline solution at 125 ml/hour. c) Total parenteral nutrition (TPN) for several days. d) High-protein between-meal nourishment four times a day.
C - TPN bypasses the enteral route and provides total nutrition: protein, carbohydrates, fats, vitamins, minerals, and trace elements. The client is not able to tolerate oral feedings. Enteral feedings would enter the stomach and could increase feelings of fullness, nausea, and vomiting that the client may have had. I.V. isotonic saline, which contains only water, sodium, and chloride, provides incomplete nutrition.
A client is to receive total parental nutrition (TPN) solution. The nurse is aware it will be given via a central line and contains which of the following as the main nutrient? a) Amino acids, including vitamin K b) 10% fat emulsions c) 50% dextrose d) Electrolytes and 10 units of heparin
C - TPN is a hypertonic solution that consists of dextrose, proteins, and electrolytes. High-glucose solutions are better tolerated in a central line based on viscosity. Other answers can be given peripherally and do not require a central line.
The nurse is planning care for a client with human immunodeficiency virus (HIV). Which statement by the nurse indicates understanding of HIV transmission? Select all that apply. a) "I don't need to wear any personal protective equipment due to decreased risk of occupational exposure." b) "I will wear a gown, mask, and gloves with all client contact." c) "I will wash my hands after client care." d) "I will wear a mask if the client has a cough caused by an upper respiratory infection." e) "I will weak a mask, gown, and gloves when splashing bodily fluids is likely."
C and E - Standard precautions include wearing gloves for any known or anticipated contact with blood, body fluids, tissue, mucous membranes, and nonintact skin. If the task or procedure may result in splashing or splattering of blood or body fluids to the face, the nurse should wear a mask and goggles or face shield. If the task or procedure may result in splashing or splattering of blood or body fluids, the nurse should wear a fluid-resistant gown or apron. The nurse should wash hands before and after client care and after removing gloves. A gown, mask, and gloves are not necessary for all client care unless contact with bodily fluids, tissue, mucous membranes, and nonintact skin is expected. Nurses have an increased, not decreased, risk of occupational exposure to blood-borne pathogens. HIV is not transmitted in sputum unless blood is present.
A client with human immunodeficiency virus undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is: a) the client has no previous exposure to the antigens injected. b) the client isn't allergic to the antigens and therefore doesn't react. c) the client has antibodies to the antigens. d) the client is immunodeficient and won't have a skin response.
D - Anergy testing determines the level of immune response an individual has to common microbes. A normal response is a local skin reaction to all the antigens injected intradermally. Absence of a response within 3 days suggests the individual is immunodeficient and can't produce a normal immune response. It doesn't imply nonexposure to the antigens, which are environmentally prevalent. A positive skin reaction demonstrates presence of antibodies to the antigens. An expected reaction to the antigens isn't considered an allergic or hypersensitive reaction.
The ICU nurse is caring for a client who experienced trauma in a workplace accident. The client reports dyspnea and abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3- 23 mEq/L. The nurse should recognize the likelihood of what acid-base disorder? a) Metabolic alkalosis b) Respiratory acidosis c) Respiratory alkalosis d) Mixed acid-base disorder
D - Clients can simultaneously experience two or more independent acid-base disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3- concentration immediately suggests a mixed disorder, making the other options incorrect.
A mother brings her 4-month-old infant to the clinic for a wellness checkup. Which immunizations should the infant receive? a) DTaP, hepatitis B, Hib, and varicella b) Haemophilus influenzae type B (Hib), rotavirus, DTaP, and IPV c) Diphtheria, tetanus toxoids, and acellular pertussis (DTaP), inactivated polio virus (IPV), rotavirus, and measles-mumps-rubella (MMR) d) DTaP, IPV, Hib, hepatitis B, and pneumococcal conjugate vaccine (PCV)
D - DTaP, IPV, Hib, hepatitis B, and PCV are administered at ages 2 and 4 months. The MMR vaccine is typically administered at age 12 to 15 months. Rotavirus vaccine is no longer recommended because of the associated risk of intussusception. The varicella vaccine is commonly administered between ages 12 and 18 months
The nurse understands that which procedure(s) are used to detect the presence of dysrhythmias? Select all that apply. 1. Telemetry 2. Holter monitor 3. Pulse oximetry 4. Electrocardiogram 5. Blood pressure monitoring
1, 2, 4. To detect the presence of dysrhythmias - telemetry, Holter monitors, or electrocardiograms are used. These devices assist in visualizing the trace of the heart beat to determine the presence of and identify the dysrhythmias.
The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
2. An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn
A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? 1. Discard them in the unit trash. 2. Return them to the hospital pharmacy. 3. Send them to the laboratory for culture. 4. Save them for return to the manufacturer.
3 - Send to the lab for culture. When the client who is receiving PN develops a fever, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms. The other options are incorrect. Because culture for infectious organisms is necessary, the discontinued materials are not discarded or returned to the pharmacy or manufacturer.
A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity? a) Potato chips and chocolate milk shakes b) Fruit salad and mineral water c) Raisins and carrot sticks d) Applesause and dried apricots
A - A diet containing excessive fat, such as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues. Raisins, carrot sticks, fruit, mineral water, applesauce, and dried apricots are snacks containing adequate amounts of vitamin A, zinc, and carotene, which are beneficial for the body.
The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by doing which of the following? a) Observing stools for steatorrhea. b) Performing glucose fingerstick tests twice a day. c) Testing urine for ketones. d) Recording daily fluid intake.
A - If the dosage and administration of pancreatic enzymes are adequate, the client's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would not indicate effectiveness of the therapy.
The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply. a) A client who underwent inguinal hernia repair surgery 3 hours ago. b) A client with diverticulitis who needs teaching about his take-home medications. c) A client with an intestinal obstruction who needs a Cantor tube inserted. d) A client with Crohn's disease who is receiving total parenteral nutrition (TPN). e) A client who is experiencing an exacerbation of his ulcerative colitis.
A and E. • A client who underwent inguinal hernia repair surgery 3 hours ago. • A client who is experiencing an exacerbation of his ulcerative colitis. Explanation: The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of his ulcerative colitis are appropriate clients to assign to a licensed practical nurse as the care they require fall within the scope of practice for a licensed practical nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.
A nurse is caring for a client with the following laboratory values: white blood cell count (WBC) 4,500/mm3, neutrophils 15%, and bands 1%. Based on the client's absolute neutrophil count (ANC), the nurse knows that the clients risk for infection is: a) low risk b) intermediate risk c) No increased risk d) Significant risk
D
A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy? 1. Pulse and weight 2. Temperature and weight 3. Pulse and blood pressure 4. Temperature and blood pressure
2 - Temp and wt. The client receiving PN at home should have her or his temperature monitored as a means of detecting infection, which is a potential complication of this therapy. An infection also could result in sepsis because the catheter is in a blood vessel. The client's weight is monitored as a measure of the effectiveness of this nutritional therapy and to detect hypervolemia. The pulse and blood pressure are important parameters to assess, but they do not relate specifically to the effects of PN.
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition? a) Recording fluid intake and output b) Accelerating the infusion if it falls behind schedule c) Ensuring that the TPN tubing has an in-line filter d) Monitoring the client's weight every day
D - By weighing the client every day, the nurse helps the team evaluate the client's response to TPN. Maintenance of the current weight is one indicator of adequate nutrition; weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. The nurse shouldn't accelerate a TPN infusion that has fallen behind because this can cause wide fluctuations in the blood glucose level. Use of an in-line filter on TPN tubing traps bacteria and particles but has no effect on nutrition. The nurse records intake and output to evaluate fluid replacement — not the nutritional adequacy of TPN.
The nurse is transferring a child who has had open heart surgery from the pediatric intensive care unit (PICU) to the pediatric unit. The child's blood pressure has been fluctuating but stable during the last 2 hours. The nurse from the PICU should include which of the following information in the report to the nurse on the pediatric unit? Select all that apply. a) Medications being used. b) Potential for blood pressure to drop. c) Drip rate for the intravenous infusion. d) Current vital signs. e) Time of the most recent dose of pain medication.
• Medications being used. • Current vital signs. • Potential for blood pressure to drop. • Drip rate for the intravenous infusion. • Time of the most recent dose of pain medication. The report made when nurses are "handing off" a client from one nursing unit to another must include information about the condition of the client, potential for changes in the client's condition, current medications, and care and services received.
The nurse understands that the skin protects the body from infections because the: 1. Cells of the skin are constantly being replaced, thereby eliminating external pathogens 2. Epithelial cells are loosely compacted on skin, providing a barrier against pathogens 3. Moisture on the skin surface prevents colonization of pathogens 4. Alkalinity of the skin limits the growth of pathogens
1 - Epithelial cells of the skin are regularly shed along with potentially dangerous microorganisms that adhere to the skin's outer layers, thereby reducing the risk of infection
The nurse understands which primary (nonspecific) defense protects the body from infection? 1. Tears in the eyes 2. Alkalinity of gastric secretions 3. Bile in the gastrointestinal system 4. Moist environment of the epidermis
1 - Tears flush the eyes of microorganisms and debris and are a primary (nonspecific) defense that protects the body from infection.
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8° F orally from a baseline of 99.2° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction
1. septicemia - Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.
Which nursing action protects the patient as a susceptible host in the chain of infection? 1. Wearing personal protective equipment 2. Administering childhood immunizations 3. Recapping a used needle before discarding 4. Disposing of soiled gloves in a waste container
2 - This is an example of an action designed to interrupt the susceptible host link in the chain of infection by increasing the resistance of the host to an infectious agent.
The nurse is caring for a patient with a high fever secondary to septicemia. When the physician orders a cooling blanket, the nurse understands that it is used to achieve heat loss via: 1. Radiation 2. Convection 3. Conduction 4. Evaporation
3 - Conduction is the transfer of heat from a warm object (skin) to a cooler object (cooling blanket) during direct contact.
A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? a) Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. b) Put on gloves, a mask, and eye protection. c) Take no special precautions for this client. d) Use standard precautions, which require gloves for suctioning.
A - Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis
Which of the following dietary instructions would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? a) Avoid crash dieting. b) Restrict carbohydrate intake. c) Decrease sodium in the diet. d) Eat six small meals a day.
A - Crash dieting or bingeing may cause an acute attack of pancreatitis and should be avoided. Carbohydrate intake should be increased because carbohydrates are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six meals a day; the client can eat whenever desired. There is no need to place the client on a sodium-restricted diet because pancreatitis does not promote fluid retention.
The nurse is caring for a client who is receiving parenteral nutrition. Which of the following assessments is most important for the nurse to make in order to detect early signs of metabolic complications? a) Urine output b) Lung sounds c) Daily weights d) Vital signs
A - Monitor urine output to detect signs of hyperosmolar hyperglycemia. Hyperosmolar hyperglycemia is a metabolic complication of parenteral nutrition. Expansion of the blood volume combined with hyperglycemia can cause osmotic diuresis, presenting as increased urine output. Intake and output should be recorded so that a fluid imbalance can be readily detected. Urine can also be tested for hyperosmolar diuresis. Each of the assessments is important, but does not indicate metabolic complications.
A client with a history of alcohol abuse was admitted with bleeding esophageal varices. After several days of treatment, the client is ready for discharge. The nurse enters the client's room to review discharge instructions with the client when he tells the nurse that he wants help to quit drinking. How should the nurse respond? a) "I'll tell your family so they can make arrangements for you to enter an alcohol rehabilitation center." b) "I hope it isn't too late; you've already done a lot of damage to your liver." c) "Let me finish reviewing your discharge instructions, then we can discuss your concerns." d) "I'll notify your physician and call the social worker so she can discuss treatment options with you."
D - The nurse should notify the physician and call the social worker so the social worker can discuss treatment options with the client. The social worker may be able to arrange inpatient treatment for the client immediately after discharge if the client wishes. Telling the client to wait to discuss his concerns minimizes his feelings. Telling the family about the client's wishes breaches client confidentiality
Which nursing action protects the patient from infection at the portal of entry? 1. Positioning an indwelling urine collection bag below the level of the patient's pelvis 2. Enclosing a urine specimen in a biohazardous transport bag 3. Wearing clean gloves when handling a patient's excretions 4. Handwashing after removal of soiled protective gloves
1 - This is an action designed to interrupt the portal of entry link in the chain of infection. By keeping the collection bag below the level of the patient's pelvis backflow is prevented, which reduces the risk of introducing pathogens into the bladder.
The nurse is analyzing laboratory values that were prescribed to determine nutrition status for the older adult client. Which laboratory value(s) would be of concern to the nurse? Select all that apply. 1. Hematocrit 30% 2. Albumin 3.0 g/dL 3. Calcium 10 mg/dL 4. Hemoglobin 8 g/dL 5. Creatinine 0.6 mg/dL 6. Blood urea nitrogen 20 mg/dL
1, 2, 4. Expected lab values for the older adult may very slightly when compared to that of the adult client. Lab values of concern to the nurse would be the hematocrit, albumin, and hemoglobin. For the older adult client, the normal hematocrit range is approx. 38-44%; normal albumin is 3.5-5; and normal hemoglobin is 12-16. Options 3, 5, and 6 are within normal ranges. The normal calcium level ranges from approx 9-11 mg/dL; creatinin e0.5-1.0 mg/dL; and BUN 10-20.
The nurse is caring for a client who is retaining carbon dioxide (CO2) due to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the pH will most likely be which value? 1. 7.30 2. 7.50 3. 7.70 4. 7.88
1. 7.30 - CO2 acts as an acid in the body. Therefore, with a rise in CO2, there is a corresponding fall in pH ("opposite effect").
The nurse understands that which are examples of a nosocomial infection occurring in a health care facility? Select all that apply. 1. A common cold noted on day 1 of hospitalization 2. Sepsis that results from contaminated intravenous fluid 3. A urinary tract infection that develops after catheter insertion 4. A streptococci wound infection that develops in a postoperative client 5. The development of Clostridium difficile in an immunocompromised client 6. A respiratory tract infection that develops in a client receiving frequent respiratory treatments and requiring frequent suctioning
2, 3, 4, 5, 6. Nosocomial infections occur in a health care facility and result from the delivery of care. A hospital is a likely setting for acquiring an infection because it harbors a high population of virulent organisms that may be resistant to antibiotics. These infections may be exogenous or endogenous. An exogenous infection arises from microorganisms external to the client that does not exist as normal flora. An endogenous infection occurs when part of the client's flora becomes altered and overgrowth results.
The nurse understands that a primary (nonspecific) defense that protects the body from infection is: 1. Antibiotic therapy 2. The high pH of the skin 3. Cilia in the respiratory tract 4. The alkaline environment of the vagina
3 - Cilia in the respiratory tract are a primary (nonspecific) defense mechanism that protects the body from infection. Mucus, produced by the respiratory tract, traps microorganisms, which are then propelled away from the lungs by cilia.
Four clients in a critical care unit have been diagnosed with Psuedomonas aeruginosa. The Infection Prevention Department (Infection Prevention and Control Department) has determined that this is probably a nosocomial infection. Select the most appropriate intervention by the nurse. a) Wear an N-95 mask when caring for the four clients. b) Initiate contact precautions. c) Initiate transmission-based precautions. d) Ensure that staff members do not have artificial fingernails.
D - It is well documented that the subungal areas of the hand harbor bacteria that can be transmitted to others despite aggressive handwashing procedures. Therefore, it is important that staff on this unit do not have artificial fingernails that could be the source of the infection on this unit. The Joint Commission and Health Canada follow the hand cleaning guidelines from the Centers for Disease Control and Prevention, World Health Organization, and Public Health Agency of Canada to prevent infection. There is no need to institute transmission-based or contact precautions. It is not necessary to wear a mask when caring for these clients
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with the most recent temperature 37 degrees Celsius (98.6 F), blood pressure (BP) 118/76, respiratory rate (RR) 16 per minute, and heart rate (HR) 78 beats per minute. Now, however, the vital signs are changing. Which of the following indicates that the nurse should contact the physician? a) Temperature 38.8 degrees Celsius (101.8 F), BP 140/86, HR 94 beats per minute, RR 24 per minute. b) Temperature 37.5 degrees Celsius (99.5 F), BP 126/80, HR 58 beats per minute, RR 16 per minute. c) Temperature 38.2 degrees Celsius (100.7 F), BP 118/68, HR 84 beats per minute, RR 20 per minute. d) Temperature 36.4 degrees Celsius (97.5 F), BP 98/64, HR 98 beats per minute, RR 18 per minute.
D - This client is exhibiting three of four signs of systemic inflammatory response syndrome (SIRS): temperature greater than 38 degrees Celsius (or less than 36 degrees Celsius), heart rate greater than 90 beats per minute, and respiratory rate greater than 20 breaths per minute. The fourth indicator is an abnormal white blood cell count (> 12,000 [12 X 109/L], < 4000 [4 X 109/L] or >10% [0.1 X 109/L] bands). At least two of these variables are required to define SIRS.
What is the most common mode of transmission for Human Immunodeficiency Virus?
Sexual contact with an HIV-infected partner
A registered nurse (RN) and licensed practical nurse (LPN) are working on the same team and reviewing the charts of their assigned clients. When asked by the LPN, which assigned clients would the RN identify as clients that may qualify for hospice care? Select all that apply. a) A client who had coronary artery bypass surgery 2 weeks previously b) A client with cirrhosis/liver failure and encephalopathy c) A client who's undergoing treatment for heroin addiction d) A client with left-sided paralysis resulting from a stroke e) A client with late-stage acquired immunodeficiency syndrome (AIDS)
• A client with cirrhosis/liver failure and encephalopathy • A client with late-stage acquired immunodeficiency syndrome (AIDS) Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS and liver failure with co-morbidity, such as hepatorenal syndrome or encephalopathy, as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's undergoing treatment for heroin addiction, or one who has recently undergone coronary artery bypass surgery because these health problems are not necessarily terminal.
The nurse is concerned about a patient's ability to withstand exposure to pathogens. What blood component should the nurse monitor? 1. Platelets 2. Neutrophils 3. Hemoglobin 4. Erythrocytes
2 - Neutrophils, the most numerous leukocytes (white blood cells), are a primary defense against infection because they ingest and destroy microorganisms (phagocytosis). When the leukocyte count is low, it indicates a compromised ability to fight infection
The nurse understands that subclinical infections most commonly occur in: 1. Infants 2. Adolescents 3. Older adults 4. Children of school age
3 - Older adults Infections are more difficult to identify in the older adult because the symptoms are not as acute and obvious as in other age groups because of the decline in all body systems related to aging.
The client with cirrhosis receives 100 ml of 25% serum albumin I.V. Which finding would best indicate that the albumin is having its desired effect? a) Increased urine output. b) Decreased anorexia. c) Increased serum albumin level. d) Increased ease of breathing.
A - Normal serum albumin is administered to reduce ascites. Hypoalbuminemia, a mechanism underlying ascites formation, results in decreased colloid osmotic pressure. Administering serum albumin increases the plasma colloid osmotic pressure, which causes fluid to flow from the tissue space into the plasma. Increased urine output is the best indication that the albumin is having the desired effect. An increased serum albumin level and increased ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites. However, it is not as direct an indicator as increased urine output. Anorexia is not affected by the administration of albumin.
The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant? a) Reporting the parents to social services for suspected abuse b) Weighing the unclothed infant at the same time every day c) Requiring the parents to attend a community support group prior to discharge d) Suggesting to the infant's mother to continue to try to feed the infant even when the infant is crying
B - Daily weights are an appropriate intervention for an infant with failure to thrive. It would be inappropriate for the nurse to encourage the mother to continue to try to feed the infant when crying because the infant may develop further aversion to eating. It is also inappropriate to assume that abuse has taken place; there is no information in the stem to suggest this. The parents would benefit from a community support group; however, the nurse cannot require the parents to attend a community support group prior to discharge.
Which of the following medications would the nurse question for a client with acute pancreatitis? a) Imipenem 500 mg IV. b) Furosemide 20 mg IV push. c) Famotidine 20 mg IV push. d) Morphine sulfate 2mg IV push.
B - Furosemide can cause pancreatitis. Additionally, hypovolemia can develop with acute pancreatitis and furosemide will further delete fluid volume. Imipenem is indicated in the treatment of acute pancreatitis with necrosis and infection. Research no longer supports meperidine over other opiates. Morphine and dilaudid are opiates of choice in acute pancreatitis to get pain under control. Famotidine is a Histamine 2 receptor antagonist used to decrease acid secretion and prevent stress or peptic ulcers.
What diet should be implemented for a client who is in the early stages of cirrhosis? a) Low-fat, low-protein. b) High-protein, low-fat. c) High-calorie, high-carbohydrate. d) High-carbohydrate, low-sodium.
C - For clients who have cirrhosis without complications, a high-calorie, high-carbohydrate diet is preferred to provide an adequate supply of nutrients. In the early stages of cirrhosis, there is no need to restrict fat, protein, or sodium.
The nurse in the emergency department reports that there is a possibility of having had direct contact with blood from a client suspected of having HIV/AIDS. The nurse requests that the client have a blood test. Consent for HIV testing can be completed only when which of the following circumstances are present? Select all that apply. a) Testing is done on blood collected anonymously in an epidemiologic survey. b) Testing is ordered by a court, based on evidence that the client poses a threat to others. c) Testing is ordered by a physician under emergency circumstances. d) A health care provider taking care of a client who is suspected of having HIV/AIDS requests a blood test. e) An emergency medical provider has been exposed to the client's blood or body fluids
a, b, c, and e. • An emergency medical provider has been exposed to the client's blood or body fluids. • Testing is ordered by a physician under emergency circumstances. • Testing is ordered by a court, based on evidence that the client poses a threat to others. • Testing is done on blood collected anonymously in an epidemiologic survey. Upon a physician's written order requesting an HIV test for a client, consent for HIV testing must be obtained. Consent exceptions include testing is ordered by a physician under emergency circumstances, and the test is medically necessary to diagnose or treat the client's condition; testing is ordered by a court, based on clear and convincing evidence of a serious and present health threat to others posed by an individual; testing is done on blood collected or tested anonymously as part of an epidemiologic survey; or an emergency medical provider has been exposed to the client's blood or body fluids.
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply. a) Administering lactulose. b) Providing food and fluids high in carbohydrate. c) Preventing constipation. d) Checking the pupil reaction. e) Monitoring coordination while walking. f) Encouraging physical activity.
a, b, c, d, and e. • Preventing constipation. • Administering lactulose. • Monitoring coordination while walking. • Checking the pupil reaction. • Providing food and fluids high in carbohydrate. Constipation leads to increased ammonia production. Lactulose is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination and pupil reaction to light and accommodation. Food and fluids high in carbohydrates should be given because the liver is not synthesizing and storing glucose. Because exercise produces ammonia as a byproduct of metabolism, physical activity should be limited, not encouraged.
A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate? a) Limiting I.V. fluid intake according to the physician's order b) Providing the client with plenty of P.O. fluids c) Reserving an antecubital site for a peripherally inserted central catheter (PICC) d) Providing generous servings at mealtime
C - Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve the antecubital site for a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss.
The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse anticipates the client's serum amylase level to be which value? 1. 45 units/L 2. 100 units/L 3. 300 units/L 4. 500 units/L
300 - The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. The options of 45 units/L and 100 units/L are within normal limits. The option of 500 units/L is an extremely elevated level seen in acute pancreatitis.
The nurse identifies that a patient condition unrelated to infection is: 1. Catabolism 2. Hyperglycemia 3. Ketones in the urine 4. Decreased metabolic activity
4 - Metabolic activity increases, not decreases, with an infection as the body increases its activity and mounts a defense to fight invading pathogenic microorganisms.
