PN1 exam 3

Which client is at greatest risk for dehydration?

Older adult client with cognitive impairment

An older adult client tells the nurse that her granddaughter has chickenpox. The client is afraid to visit because she is afraid of getting shingles from her granddaughter. What is the nurse's best response?

"If you already had chickenpox, you can safely visit your granddaughter."

A mother overhears two nurses discussing the incubation period for a measles outbreak. The mother asks the nurses why it is important to know this. The nurses' reply would include which statement about the incubation period?

"It describes a period when the child might be contagious."

The nurse is caring for a client who has undergone a kidney transplant. The client asks the nurse what will happen when his body realizes that the kidney is not "his." What is the nurse's best response?

"The immune system will try to destroy the kidney if we don't suppress it."

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she states which of the following?

"The medications that I take will help prevent my body from attacking my new kidney."

The physician is going to order a hypotonic intravenous solution for a client with cellular dehydration. The nurse would expect which fluid to be administered?

0.45% sodium chloride

During a routine screening, a client has a positive response to intradermal injection of purified protein derivative (PPD or Mantoux test). The nurse draws which conclusion about this result?

The client has been infected with tuberculosis, and has developed a cellular (T cell) response to the tubercle bacillus

A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. The nurse plans to teach the patient to

avoid sharing razors and other personal items

The mother of a newborn baby is concerned that the baby will develop illnesses from being around so many people. The nurse should explain that the baby has immunity that is present at birth or:

innate immunity

The nurse would suspect that a client who frequently uses which medication is at risk for developing metabolic alkalosis?

Calcium carbonate (Tums)

A client with hypocalcemia is taking supplemental vitamin D. When the client asks the purpose of this therapy, what explanation should the nurse give?

Calcium is absorbed in the intestines only under the influence of activated vitamin D.

A client presents with dyspnea, pruritus, and localized swelling of the forearm after being stung by a bee. What is the priority nursing intervention?

Check the tongue for swelling and listen for stridor

When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area?

Clean the area with mild soap, dry, and add a protective moisturizer

A client is demonstrating signs of the inflammatory response. The nurse would assess which of the following in this client? (Select all that apply.)

Edema Heat Erythema Pain

The nurse is caring for a client with fluid volume excess who has edematous skin. Which of the following is an appropriate nursing consideration for this client?

Elevate an edematous part to a position higher than the heart's level

The nurse is using the Braden Scale to determine a client's risk for developing a pressure ulcer. Which of the following areas are assessed with this scale?

Friction and shear

The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.)

Help protect individuals and communities Are recommended by the Centers for Disease Control and Prevention (CDC) Are part of primary prevention for system disorders

A nurse is reviewing a metabolic panel laboratory report of a client on diuretic therapy for congestive heart failure. The report is as follows: sodium, 142 mEq/L; potassium, 2.5 mEq/L; calcium, 8.5 mEq/L; and chloride, 98 mEq/L. Which of the following electrolyte disturbances should the nurse report to the physician?

Hypokalemia

The nurse is reviewing the results of a laboratory test to measure the amount of immunoglobulins in a client's blood. Which of the following should have the highest value?

IgG

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?

Institute fall precautions due to potential postural hypotension and weak leg muscles

Which body fluid lies in the spaces between the body cells?

Interstitial

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order?

Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr

The nurse is completing a physical assessment with a client. Which of the following findings could be caused by impaired immune function in the client?

Leg rash

Arterial blood gas levels are obtained for the client. If the client's results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances?

Metabolic alkalosis

Identify the appropriate intervention(s) for a patient with hypovolemia. Choose all that apply.

Monitor I&O daily Encourage fluid intake . Monitor electrolyte balance.

When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?

Neurological

The nurse is concerned that a client will develop an overwhelming infection because which of the following laboratory values is low?

Neutrophils

What type of immunity is provided by intravenous (IV) administration of immunoglobulin G?

Passive

A patient is receiving an IV infusion of lactated Ringer's solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following?

Phlebitis

A 5-year-old child is brought into the clinic after being stung by an insect. The child appears to be going into anaphylactic shock. Which nursing action is of highest priority?

Position the child's head to maintain an open airway

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report most urgently to the physician?

Positive Chvostek's sign in patient with acute pancreatitis

To enhance meeting the psychosocial needs of a client on transmission-based precautions, the nurse should place highest priority on which of the following?

Providing the client with diversional activities to enhance sensory input

Which of the following is the principal site for regulation of fluid and electrolyte balance?

Renal system

The nurse, after reviewing a client's immunization history, realizes that which of the following pathogen toxoids would not be given to an individual to develop an immune response?

Snake toxin

A client is being admitted to a health care facility. Which type of precautions will the nurse implement at this time?

Standard

A nurse is teaching a group of businesspeople about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following?

"If I don't feel sick, then I don't have to worry about transmitted diseases."

Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.)

"I shall take my insulin on time every day." "My aspirin is on a high shelf away from children." "I have reliable transportation to dialysis sessions."

The nurse is providing discharge teaching for a client following a liver transplant. Which statement by the client indicates that additional teaching is needed?

"If I develop an infection, I should stop taking the steroid preparation."

Which client is at highest risk of compromised immunity?

Client who has just had surgery

The nurse instructs a client to use good hand washing and cover her nose and mouth when sneezing. These efforts will reduce others' exposure to molecules that can elicit an immune response or

immunogens

A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient?

Airborne transmission

Which of the following would the nurse identify as age-related changes in immunologic function that occur in the older adult? (Select all that apply.)

Altered nutrition intake Failure of immune system to differentiate self from nonself Increased hematuria

Which set of assessment data is consistent for a patient with severe infection that could lead to system failure?

BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning?

Basic infection control techniques

A client is admitted with severe diarrhea. Arterial blood gas (ABG) results are pH 7.33; PaCO 2 42; HCO 3 - 20. The nurse concludes this client has which acid-base imbalance?

Uncompensated metabolic acidosis

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?

Unstageable pressure ulcer

A client has a reduction in immune function. What is the nurse's priority action for this client?

Wash hands before entering the room

The nurse records a patient's hourly urine output from an indwelling catheter as follows:0700: 36 mL0800: 45 mL0900: 85 mL1000: 62 mL1100: 50 mL1200: 48 mL1300: 94 mL1400: 78 mL1500: 60 mL The nurse can conclude that the patient's urine output should be described as which of the following?

Within normal limits

A client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse recognizes that the client's nutritional history is of primary importance since:

Wound healing and infection prevention are negatively impacted by poor nutrition

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse explains to the patient that the goal of medication treatments for RA is to

control inflammation