Revised exam 1 nur201

A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories perday. If the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

ANS: 2140 calories

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

ANS: A, D, B, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Apply 100% oxygen using a nonrebreather mask.

ANS: A, E, C, B, D The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last.

The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin? a. The patient recently had an intrauterine device removed. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis.

ANS: A Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The nurse will need to determine whether the patient is using other birth control methods. More information about the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin use.

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a skin biopsy. b. Teach the use of corticosteroid cream. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.

ANS: A Because the appearance of the lesion is suggestive of actinic keratosis or possible squamous cell carcinoma, the appropriate treatment would be excision and biopsy. Over-the-counter corticosteroids, topical antibiotics, and Retin-A would not be used for this lesion.

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for cancers b. Screening for allergies c. Screening for antibody deficiencies d. Screening for autoimmune disorders

ANS: A Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. When planning postoperative interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

ANS: A Elevated blood glucose will impair wound healing in multiple ways. Ensuring adequate nutrition is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact wound healing. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing.

The nurse is advising a patient who was exposed 4 days ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen-antibody test has just been reported as negative for HIV. What information should the nurse give to this patient? a. "You will need to be retested in 2 weeks." b. "You do not need to fear infecting others." c. "We won't know for about 10 years if you have HIV infection." d. "With no symptoms and this negative test, you do not have HIV."

ANS: A HIV screening tests detect HIV-specific antibodies or antigens. However, there may be a delay between infection and the time a screening test is able to detect HIV. The typical "window period" for antigen-antibody combination assays is approximately 2 weeks. It is not known based on this information whether the patient is infected with HIV or can infect others. It would be best practice to have him return for repeat testing in approximately 2 weeks.

A new nurse performs a dressing change on a patient's stage 2 left heel pressure injury. Which action by the new nurse indicates a need for further teaching about pressure injury care? a. The new nurse cleans the injury with half-strength peroxide. b. The new nurse applies a hydrocolloid dressing on the injury. c. The new nurse irrigates the pressure injury with saline using a 30-mL syringe. d. The new nurse inserts a sterile cotton-tipped applicator into the pressure injury.

ANS: A Pressure injuries should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone wound appearance

ANS: A Serum protein levels may decrease with negative pressure therapy, which will adversely affect wound healing. The other findings are expected with wound healing.

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive range of motion (ROM).

ANS: A Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues.

Eight years after seroconversion, a patient with human immunodeficiency virus infection has a CD4+ cell count of 800/µL and an undetectable viral load. What should be included in the plan of care at this time? a. Encourage adequate nutrition, exercise, and sleep. b. Teach about the side effects of antiretroviral agents. c. Explain opportunistic infections and antibiotic prophylaxis. d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

ANS: A The CD4+level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection when the body is able to produce enough CD4+cells to maintain a normal CD4+count. Maintaining healthy lifestyle behaviors is an important goal in this stage. AIDS and increased incidence of opportunistic infections typically develop when the CD4+count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+level would receive ART.

The nurse notes white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time? a. "Are you taking any medications?" b. "Do you have a productive cough?" c. "How often do you brush your teeth?" d. "Have you had an oral herpes infection?"

ANS: A The appearance of the lesions is consistent with an oral candidiasis (thrush) infection, which can occur in patients who are taking medications such as immunosuppressants or antibiotics. Candidiasis is not associated with poor oral hygiene or lower respiratory infections. The lesions do not look like an oral herpes infection.

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? a. Age b. Lifestyle c. Symptoms d. Sexual orientation

ANS: A The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to 64 years. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay

ANS: A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.

ANS: A The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.

An older adult who takes medications for coronary artery disease and hypertension is newly diagnosed with HIV infection and is starting antiretroviral therapy. Which information will the nurse include in patient teaching? a. Many drugs interact with antiretroviral medications. b. HIV infections progress more rapidly in older adults. c. Less frequent CD4+ level monitoring is needed in older adults. d. Hospice care is available for patients with terminal HIV infection.

ANS: A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic disease.

Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication.

ANS: A The patient should stay out of the sun. If that is not possible, teach the patient to wear sunscreen when taking medications that can cause photosensitivity. The other statements are not accurate

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What should the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.

An older adult patient who is having an annual checkup tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Incidence of cancer-associated infections in older adults d. Impact of poor nutrition on immune function in older adults

ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

Which instructions should the nurse include in the teaching plan for a patient with impetigo? a. Clean the crusted areas with soap and water. b. Spread alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas.

ANS: A The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-and-water removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic ointments, such as mupirocin (Bactroban), may be applied to the lesions.

A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin b. Alopecia of the affected area c. Dryness and scaling in the area d. Reddish-brown skin discoloration

ANS: A Thinning of the skin indicates atrophy, a possible adverse effect of topical corticosteroids. The health care provider should be notified so that the medication can be changed or tapered. Alopecia, red-brown discoloration, and dryness and scaling of the skin are not adverse effects of topical corticosteroid use.

Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who is sneezing after subcutaneous immunotherapy c. Patient who has graft-versus-host disease and severe diarrhea d. Patient with multiple chemical sensitivities with muscle stiffness

ANS: B Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.

The nurse is caring for a patient living with asymptomatic chronic HIV infection (HIV). Which prophylactic measures will the nurse include in the plan of care? (Select all that apply.) a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

ANS: A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are living with HIV, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+counts have dropped or when infection has occurred.

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan? (Select all that apply.) a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections

ANS: A, B, E All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded at once because the number left will not be enough to treat a future infection. Hand washing is considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza.

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse expect for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list

ANS: B Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no sign that the patient will need another transplant or hemodialysis. There is no need to repeat HLA testing.

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Explain potassium hydroxide testing to a patient with a skin infection. e. Teach a patient about site care after a punch biopsy of an upper arm lesion.

ANS: A, C Skills such as administration of patch testing and sterile dressing technique are included in LPN/VN education and scope of practice. Obtaining a health history and patient education require registered nurse (RN) level education and scope of practice.

The registered nurse (RN) is caring for a patient who is living with HIV and admitted with tuberculosis. Which task can the RN delegate to unlicensed assistive personnel (UAP)? a. Teach the patient how to dispose of tissues with respiratory secretions. b. Stock the patient's room with the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.

ANS: B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.

When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next? a. Suggest an appointment with a dermatologist. b. Assess the patient for evidence of liver disease. c. Teach the patient about skin changes with aging. d. Discuss the use of sunscreen to prevent skin cancers.

ANS: B Angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to teach the patient about the effects of aging on the skin and about the effects of sun exposure, but the first action should be further assessment.

Immediately after the nurse administers an intradermal injection of an allergen on the forearm, the patient reports itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b. Place a tourniquet above the site. c. Administer subcutaneous epinephrine. d. Reschedule the patient's other allergen tests.

ANS: B Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. The other actions may occur, but the tourniquet application slows the allergen progress into the patient's system, allowing treatment of the anaphylactic response. A local antiinflammatory cream may be applied to the site of a cutaneous test for persistent itching. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. Other testing may be delayed and rescheduled after development of anaphylaxis.

A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient b. Method of contraception used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patient's face

ANS: B Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable contraception has the most potential for serious adverse medication effects.

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient uses a tanning booth weekly. c. The patient is fair-skinned with blue eyes. d. The patient's mother died of malignant melanoma.

ANS: B Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk for melanoma.

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement by the patient would indicate a need for additional teaching? a. "I need to find a different way to earn extra money." b. "I will take oral antihistamines before going to work." c. "I can get a prescription for epinephrine and learn to self-inject it." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

ANS: B Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.

Which integumentary assessment data from an older patient admitted with bacterial pneumonia should be of concern to the nurse? a. Brown macules on extremities b. Reports a history of allergic rashes c. Skin wrinkled with tenting on both hands d. Longitudinal nail ridges and sparse scalp hair

ANS: B Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data in the other response would be normal for an older patient.

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple leg wounds with eschar to be debrided. b. The patient receiving chemotherapy who has a temperature of 102° F. c. The patient who requires analgesics before a scheduled dressing change. d. The newly admitted patient with a stage 4 pressure injury on the coccyx.

ANS: B Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient.

Which example should the nurse use to explain an infant's "passive immunity" to a new mother? a. Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases

ANS: B Colostrum in breast milk provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy.

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of cancer." b. "After a couple of years, I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."

ANS: B Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patient's leg. b. Press firmly on the lesion. c. Check the temperature of the skin around the lesion. d. Palpate the dorsalis pedis and posterior tibial pulses.

ANS: B If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg but will not be helpful in determining the etiology of the lesion.

A clinic patient reports experiencing an allergic reaction to an unknown allergen several weeks ago. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)? a. Perform a focused physical assessment. b. Administer a cutaneous scratch skin test. c. Obtain the health history from the patient. d. Review diagnostic study results with the patient.

ANS: B LPN/VNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and teaching about study results.

A patient who reports chronic itching of the ankles continuously scratches the area. Which assessment finding should the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles

ANS: B Lichenification is likely to occur in areas where the patient scratches the skin often. It results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo, keloids, and jaundice do not usually occur because of scratching the skin.

The nurse will perform which action for a wet-to-dry dressing change on a patient's stage 3 sacral pressure injury? a. Pour sterile saline onto the new dry dressings after packing the wound. b. Administer a prescribed PRN oral analgesic 30 minutes before the change. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Soak the old dressings with sterile saline 30 minutes before the dressing change.

ANS: B Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound but not soaked after packing. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).

ANS: B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

Which patient would benefit from education about HIV preexposure prophylaxis (PrEP)? a. A 23-yr-old woman living with HIV infection. b. A 52-yr-old recently single woman just diagnosed with chlamydia. c. A 33-yr-old hospice worker who received a needle stick injury 3 hours ago. d. A 60-yr-old male in a monogamous relationship with an HIV-uninfected partner.

ANS: B Preexposure prophylaxis (PrEP) is used to prevent HIV infection. Persons who would be good candidates for PrEP include individuals with a recent diagnosis of an STI and those with more than one partner. Individuals who are not on PrEP but who have a recent high-risk exposure (such as a needle stick) would be better candidates for postexposure prophylaxis (PEP). A person in a monogamous relationship with an HIV-uninfected partner is considered low-risk for HIV infection.

A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse plan to take first? a. Monitor the patient's edema. b. Administer a dose of epinephrine. c. Obtain a prescription for oral antihistamines. d. Assess the patient's use of new skin products.

ANS: B Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and assess for development of more edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin products does not address the immediate concern of a possible anaphylactic reaction.

A patient is being evaluated for possible atopic dermatitis. The nurse should expect elevation of which laboratory value? a. IgA b. IgE c. Basophils d. Neutrophils

ANS: B Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

Which statement by a patient would alert the nurse to a risk for decreased immune function? a. "I had a chest x-ray 6 months ago." b. "I had my spleen removed after a car accident." c. "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."

ANS: B Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function

During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions? a. Confluent b. Symmetric c. Zosteriform d. Generalized

ANS: B The description of the lesions indicates that they are grouped in a bilateral distribution. The other terms are inconsistent with the description of the lesions.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can get dressed as usual." b. "If the medication burns when I apply it, I will wipe it off." c. "I need to minimize time in the sun while using the Elidel." d. "I will rub the medication in gently every morning and night."

ANS: B The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus and that the medication should be left in place. The other statements by the patient are accurate and indicate that patient teaching has been effective

A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b. Document the patient's history and teach about clinical manifestations of a type I latex allergy. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Tell the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

ANS: B The patient's allergy history and occupation indicate a risk of developing a latex allergy. Teach the patient about symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Using latex gloves increases the chance of developing latex sensitivity. Oil-based creams will increase the exposure to latex from latex gloves.

When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient has had the injuries for 6 months. b. The patient takes oral hypoglycemic agents daily. c. The patient states that the injuries are very painful. d. The patient has several incisions that formed keloids

ANS: B The use of oral hypoglycemics indicates diabetes, which can interfere with wound healing. The persistence of the injuries over the past 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's pain will be implemented, but pain does not directly affect wound healing.

The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. Which statement should the nurse include in the patient's instructions? a. "5-FU will shrink the lesion to prepare for surgical excision." b. "Your cheek area will be eroded and take several weeks to heal." c. "You may develop nausea and anorexia, but good nutrition is important during treatment." d. "You will need to avoid crowds because of the risk for infection caused by chemotherapy."

ANS: B Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea.

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose of 136 mg/dL b. Separation of proximal wound edges c. Oral temperature of 101° F (38.3° C) d. Patient reports increased incisional pain

ANS: B Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention by the HCP as rapidly.

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea? (Select all that apply.) a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

ANS: B, C Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan? (Select all that apply.) a. Add oil to your bath water to moisturize the affected skin. b. Cool, wet clothes or compresses can be used to reduce itching. c. Use an over-the-counter (OTC) antihistamine to reduce itching. d. Take cool or tepid baths several times daily to decrease itching. e. Rub yourself dry with a towel after bathing to prevent skin maceration.

ANS: B, C, D Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry.

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

ANS: C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. There is a 2-cm wheal at the site of the injection. d. The patient's symptoms did not improve in 2 months.

ANS: C A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG shows that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months.

A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

ANS: C A stage 3 pressure injury has full-thickness skin damage and extends into the subcutaneous tissue. A stage 1 pressure injury has intact skin with some observable damage such as redness or a boggy feel. Stage 2 pressure injuries have partial-thickness skin loss. Stage 4 pressure injuries have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

A patient informed of a positive rapid screening test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Inform the patient about the available treatments. b. Teach the patient how to manage a possible drug regimen. c. Remind the patient to return for retesting to verify the results. d. Ask the patient to identify those persons who had intimate contact.

ANS: C After an initial positive antibody test result, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about the HIV status of other individuals.

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. Shave biopsy b. Punch biopsy c. Incisional biopsy d. Excisional biopsy

ANS: C An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be cancerous. A shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.

The health care provider asks the nurse to evaluate whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Obtain the patient's blood pressure and heart rate. b. Question the patient about any clear nasal discharge. c. Observe for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Minimizing sun exposure reduces risk for future BCC. d. Low-dose systemic chemotherapy is used to treat BCC.

ANS: C BCC is frequently associated with sun exposure, and preventive measures should be taken for future sun exposure. BCC spreads locally and does not metastasize to distant tissues. Because BCC can cause local tissue destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC.

The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week. b. Administer the scheduled dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Reevaluate the patient's sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

What is the most effective method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Apply antibiotic ointment over the wound. c. Wash hands and properly dispose of soiled dressings. d. Soak the dressing in sterile normal saline before removal.

ANS: C Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of infection to others. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of infection.

The nurse teaches a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. The patient takes a tepid bath before applying the cream. b. The patient spreads the cream using a downward motion. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream.

ANS: C Creams and ointments should be applied in a thin layer to avoid wasting the medication. The other actions by the patient indicate that the teaching has been successful.

A patient with dark skin has been admitted to the hospital with acute decompensated heart failure. How would the nurse assess this patient for cyanosis? a. Assess the skin color of the earlobes. b. Apply pressure to the palms of the hands. c. Check the lips and oral mucous membranes. d. Examine capillary refill time of the nail beds.

ANS: C Cyanosis persons with dark skin is more easily seen in the mucous membranes. Earlobe color may change in persons with light skin, but this change in skin color is hard to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation but not for skin color.

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. Sterile gloves b. Patch test instruments c. Cotton-tipped applicators d. Syringe and intradermal needle

ANS: C Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators. Sterile gloves are not needed because it is not a sterile procedure. Local injection or aspiration is not involved in the procedure. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens.

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the safe use of cyclosporine? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day

ANS: C Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function.

A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). The patient denies any discomfort. Which action by the nurse is appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Check the patient's temperature again in 4 hours. d. Give acetaminophen prescribed as-needed for pain.

ANS: C Mild to moderate temperature elevations (less than 103° F) do not harm young adult patients and may benefit host defense mechanisms. Continue to monitor the temperature. Antipyretics are not indicated unless the patient has fever-related symptoms, and the patient does not require analgesics if not reporting discomfort. There is no need to notify the patient's health care provider of a fever in a patient who is already being treated for the infection or to use a cooling blanket for a moderate temperature elevation.

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? a. "Thinking about dying will not improve the course of AIDS." b. "Do you think that taking an antidepressant might be helpful?" c. "Can you tell me more about the thoughts that you are having?" d. "It is important to focus on the good things about your life now."

ANS: C More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" or suggesting an antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient.

The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. The patient reports incisional pain. b. The patient's heart rate is 100 beats/min. c. The skin around the incision is pale and cold. d. The patient is unable to sense touch on the eyelids.

ANS: C Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 100 beats/min may be related to the stress associated with surgery. Assessment of other vital signs and continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.

A patient who uses injectable illegal drugs asks the nurse how to prevent acquired immunodeficiency syndrome (AIDS). Which response by the nurse is most accurate? a. "Clean drug injection equipment before each use." b. "Ask those who share equipment to be tested for HIV." c. "Consider participating in a needle-exchange program." d. "Avoid sexual intercourse when using injectable drugs."

ANS: C Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. HIV can be transmitted through both intercourse and injection.

A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. Ringlike rashes with red, scaly borders over the entire scalp b. Red, hivelike papules and plaques with circumscribed borders c. Papular, wheal-like lesions with white deposits on the hair shaft d. Patchy areas of alopecia with small vesicles and excoriated areas

ANS: C Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Tell the patient a secondary infection is present. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.

ANS: C Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Lymphadenopathy is common with acute HIV infection and is therefore not likely to represent an additional infection. Ice will not decrease the swelling in persistent generalized lymphadenopathy

Which abnormality on the skin of an older patient is the priority for the nurse to discuss with the health care provider? a. Dry, scaly patches on the face b. Numerous varicosities on both legs c. Petechiae on the chest and abdomen d. Small dilated blood vessels on the face

ANS: C Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patient's health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative. b. Six antigen matches are present in HLA typing. c. Results of patient-donor crossmatching are positive. d. Panel of reactive antibodies (PRA) percentage is low.

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the transplant. The other information shows that the tissue match between the patient and potential donor is acceptable.

After the home health nurse teaches a patient's family member about how to care for a sacral pressure injury, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag.

ANS: C Pressure injuries need to be moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care. The use of lift sheets prevents shearing forces. Clean tap water is acceptable for home use on chronic pressure wounds. Proper disposal of contaminated dressings prevents the spread of infection.

Which exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Bite to the arm that does not result in open skin b. Splash into the eyes while emptying a bedpan containing stool c. Needle stick with a needle and syringe used for a venipuncture d. Contamination of open skin lesions with patient vaginal secretions

ANS: C Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission. b. Ways to sterilize needles used by injectable drug users. c. Prevention of HIV transmission between sexual partners. d. Means to prevent transmission through blood transfusions

ANS: C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

Which nursing action will be most useful in assisting a young adult to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Help the patient develop a schedule to decide when the drugs should be taken. d. Encourage the patient to join a support group for adults who are HIV positive.

ANS: C The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions are also useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.

There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 42-yr-old with itching after using topical fluorouracil on the nose b. 50-yr-old with skin redness after having a chemical peel 3 days ago c. 38-year old with a 7-mm nevus on the face that has recently become darker d. 62-yr-old with multiple small, soft, pedunculated papules in both axillary areas

ANS: C The description of the lesion is consistent with possible malignant melanoma. The health care provider should assess this patient as soon as possible. Itching is common after using topical fluorouracil, and redness is an expected finding a few days after a chemical peel. Skin tags are common, benign lesions after midlife.

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? a. Provide high-flow oxygen. b. Administer antihistamines. c. Assess the patient's airway. d. Remove the stinger from the site.

ANS: C The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient's symptoms of anxiety and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part of the emergency management protocol for anaphylaxis, but the priority is airway assessment and maintenance.

A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? a. Change the patient's bedding frequently. b. Apply a hydrocolloid dressing over the injury. c. Change the patient's position every 1 to 2 hours. d. Record the size and appearance of the injury weekly.

ANS: C The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching.

Which patient who has arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose rapid HIV-antibody test is positive. b. Patient whose latest CD4+ count has dropped to 250/µL. c. Patient who has had 10 liquid stools in the last 24 hours. d. Patient who has nausea from prescribed antiretroviral drugs.

ANS: C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.

The home health nurse notices irregular patterns of bruising at different stages of healing on an older patient's body. Which action should the nurse take first? a. Ensure the patient wears shoes with nonslip soles. b. Discourage using throw rugs throughout the house. c. Talk with the patient alone and ask about the bruising. d. Suggest that the health care provider prescribe radiographs.

ANS: C The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. Radiographs may be needed if the patient has fallen recently and reports pain or decreased mobility. However, the nurse's first nursing action is to further assess the patient's safety

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's most important action? a. Instruct the patient about the importance of nutrition for skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin

ANS: C The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

ANS: C The patient's report of feeling cold and shivering indicate that the hypothalamic set point for temperature has increased and the temperature will be increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature.

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 10 for adequate protection. b. Water-resistant sunscreens provide good protection when swimming. c. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage

ANS: C The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. No sunscreen is completely water resistant. Sunscreens classified as water resistant still need to be reapplied after swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased

A patient's 4 ⋅ 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing b. Nonadherent dressing c. Hydrocolloid dressing d. Transparent film dressing

ANS: C The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing, such as DuoDerm, would accomplish these goals. Transparent film dressings are used for clean wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient with an anaphylactic reaction d. A patient with graft-versus-host disease

ANS: C There is no increased exposure to infection from a patient who had an anaphylactic reaction. Treatment for a patient with acute rejection includes administration of additional immunosuppressants and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns.

Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection.

ANS: C Warm water and moisturizing soap will avoid over drying the skin. Because older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in.

An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. Schedule daily appointments for dressing changes. b. Describe the use of topical fluorouracil on the incision. c. Instruct how to use sterile technique to clean the suture line. d. Teach the use of cold packs to reduce bruising and swelling.

ANS: D Application of cold packs to the incision after the surgery will help decrease bruising and swelling at the site. Because the Mohs procedure results in complete excision of the lesion, topical fluorouracil is not needed after surgery. After the Mohs procedure, the edges of the wound can be left open to heal, or the edges can be approximated and sutured together. The suture line can be cleaned with tap water. No daily dressing changes are indicated after the first dressing is removed.

The nurse is caring for a patient who is living with human immunodeficiency virus (HIV) and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient reports feeling "constantly tired." b. The patient reports having no side effects from the medications. c. The patient is unable to explain the effects of atorvastatin (Lipitor). d. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

ANS: D Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of Descovy.

The nurse is caring for a patient diagnosed with furunculosis. Which action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Applying antibiotic cream to the groin b. Obtaining cultures from ruptured lesions c. Evaluating the patient's personal hygiene d. Cleaning the skin with antimicrobial soap

ANS: D Cleaning the skin is within the education and scope of practice for UAP. Administering medication, obtaining cultures, and evaluation are higher level skills that require the education and scope of practice of licensed nursing personnel.

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ count of less than 200 cells/μL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient meets the criteria for a diagnosis of acute HIV infection." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient will likely develop symptomatic HIV infection within 1 year." d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."

ANS: D Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count b. How the patient obtained HIV c. Patient's tolerance for potential medication side effects d. Patient's ability to follow a complex medication regimen

ANS: D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? a. Nystatin tablet b. Oral acyclovir (Zovirax) c. Aerosolized pentamidine (NebuPent) d. Oral tenofovir AF/emtricitabine/bictegravir (Biktarvy)

ANS: D It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/VN)? a. The patient who was just admitted after suturing of a full-thickness arm wound. b. The patient who just reported increased tenderness and swelling in a leg wound. c. The patient who requires teaching about home care for an open draining abdominal wound. d. The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury.

ANS: D LPN/VN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN).

15. The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient adds oilated oatmeal to the bath water every day. c. The patient takes diphenhydramine at night for persistent itching. d. The patient uses bacitracin-neomycin-polymyxin on minor abrasions.

ANS: D Neosporin can cause contact dermatitis. The patient is appropriately using the other medications.

The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Extremity numbness

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a. Plasmapheresis counteracts recovery of IgG production. b. Plasmapheresis removes eosinophils and basophils from the blood. c. Plasmapheresis decreases the damage to organs from T lymphocytes. d. Plasmapheresis prevents inflammatory mediators from injuring tissues.

ANS: D Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and inflammatory mediators, such as complement, from the blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE. Immunosuppressive therapy is used to prevent recovery of IgG production.

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage b. Cryosurgery c. Punch biopsy d. Surgical excision

ANS: D The description of the mole is consistent with cancer, so excision and biopsy are indicated. Curettage and cryosurgery are not used if cancer is suspected. A punch biopsy would not be done for a lesion greater than 5 mm in diameter.

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise.

ANS: D The earliest manifestation of an infection may be "just not feeling well." Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications.

A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Shield any unaffected areas with lead-lined drapes. b. Apply petroleum jelly to the areas around the lesions. c. Cleanse the skin carefully with antiseptic soap prior to PUVA. d. Have the patient use protective eyewear while receiving PUVA.

ANS: D The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum jelly are not used to prevent skin damage.

A patient with human immunodeficiency virus (HIV) infection has developed Cryptosporidium parvum infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.

ANS: D The major manifestation of C. pravum infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (e.g., pneumonia, dementia, influenza) associated with HIV infection

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of taking part in an online support group. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life.

ANS: D The nurse's initial actions should be to assess the impact of the disease on the patient's life and to allow the patient to verbalize feelings about the psoriasis. Depending on the assessment findings, other actions may be appropriate.

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's appropriate action? a. Discuss the use of drying agents to minimize infection risk. b. Instruct the patient about the use of mild soap to clean skinfolds. c. Teach the patient about treating fungal infections in the skinfolds. d. Ask the patient about a personal or family history of type 2 diabetes.

ANS: D The presence of acanthosis nigricans in skinfolds suggests either having type 2 diabetes or being at an increased risk for it. The description of the patient's skin does not indicate problems with fungal infection, poor hygiene, or the need to dry the skinfolds better.

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a. Eschar b. Slough c. Maceration d. Undermining

ANS: D Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narrower "lip" around the wound, which widens as the wound deepens. Eschar is a crusted cover over a wound. Slough and maceration refer to loosening friable tissue.

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure injury with pink granulation tissue. b. A patient who has a surgical incision with pink, approximated edges. c. A patient who has a full-thickness burn filled with dry, black material. d. A patient who has a wound with purulent drainage and dry brown areas

ANS: D Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations? (Select all that apply.) a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis

ANS: D, E A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis. Vitiligo, alopecia, and intertrigo are not associated with excessive sun exposure.