Adult Health Exam 3

A client had abdominal surgery this morning and has been transferred to the medical-surgical unit from the post-anesthesia care unit (PACU). At this point in the client's recovery, what priority nursing intervention is indicated? a. Discharge teaching about dietary restrictions and exercises. b. Performing a sterile dressing change and assessing the surgical incision. c. Monitoring and treating the client's pain, nausea, and vomiting. d. encouraging the client to ambulate in the halls

c. monitoring and treating the client's pain, nausea, and vomiting

thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm3. which client sign/symptom is the most concerning and requires immediate further nursing action? a. current oozing epistaxis b. ecchymosis on leg since yesterday c. new-onset confusion d. reported history of hematuria

c. new-onset of confusion (change in LOC is the most significant finding requiring an emergency response)

A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm3. What information contained in the admission history of this client will need to be addressed during discharge education? a. eats steam vegetables daily b. enjoys eating grilled shrimp weekly c. gardens as a hobby d. takes a bath daily and applies moisturizer

c. gardens as a hobby

A client who is receiving a dose of cefazolin IV develops a diffuse rash, hypotension, and shortness of breath. Place the nurse's actions to take in the correct order. All options must be used. 1.Administer adjunctive therapies. 2.Ensure patent airway then administer oxygen via a high-flow nonrebreather mask. Prepare for intubation, if needed. 3.Give epinephrine intramuscularly. 4.Continue to reassess vital signs for any changes. 5.Stop the infusion that is causing the reaction and call for help.

5. stop the infusion that is causing the reaction and call for help 2. ensure patent airway then administer oxygen via a high-flow nonrebreather mask. prepare for intubation if needed 3. give epinephrine IM 1. administer adjunctive therapies 4. continue to reassess VS for any changes

A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances? a. serosanguineous drainage at this time is a manifestation of possible dehiscence. b. serosanguineous drainage at this time is expected after abd. surgery c. serosanguineous drainage at this time is a manifestation of hemorrhage d. serosanguineous drainage at this time is a manifestation of infection

a. serosaguineous drainage at this time is a manifestation of possible dehiscence (Serosanguineous drainage beyond the fifth postoperative day is a manifestation of possible dehiscence and the provider should be notified.)

When educating a client, which instruction indicates that the nurse understands the nature of a herpes zoster eruption? a. "Anti-viral and steroid medications will kill the virus and prevent the pain and blisters of shingles." b. "Once the blisters and scabs have healed a person with shingles will not have another outbreak." c. "If someone with shingles scratches the lesions they can spread the blisters to other areas on their body." d. "If someone has never had the chicken pox they can get it if they are exposed to open shingles blisters."

d. "If someone has never had the chicken pox they can get it if they are exposed to open shingles blisters."

A nurse is conducting a skin assessment on an older adult who is admitted to the geriatric medical unit. The nurse's examination of the client's integumentary system reveals several notable findings. What finding warrants medical follow-up? a. There are numerous dark-colored, wart-like lesions present on the face, shoulders and back. b. There is dark discoloration of the skin and diminished hair growth on the bilateral lower extremities. c. There is bilateral yellowish, waxy-looking deposits on the upper and lower eyelids. d. There is a flat, multi-colored circular lesion with irregular outer margins on the scalp.

d. There is a flat, multi-colored circular lesion with irregular outer margins on the scalp. (could indicate melanoma)

A client has been living with a diagnosis of anemia for several years and has experienced recent declines in her hemoglobin levels despite active treatment. What assessment finding would signal complications of anemia? a. venous ulcers and visual disturbances b. fever and signs of hyperkalemia c. epistaxis and gastroesophageal reflux d. shortness of breath and peripheral edema

d. shortness of breath and peripheral edema (significant complication of edema is HF--peripheral edema and dyspnea are symptoms of HF)

A nurse working in a health clinic receives 4 telephone messages. What call should the nurse return first? 1. Client who was prescribed azithromycin 3 days ago and is now complaining of "hives". 2. Client with chronic low back pain and is requesting a refill for oxycodone. 3. Client who received an influenza vaccine is reporting a temperature of 100o Fahrenheit (37.7o Celsius), and aching and itching at the injection site 4. Client with newly diagnosed asthma has palpitations after using an albuterol rescue inhaler.

1. Client who was prescribed azithromycin 3 days ago and is now complaining of "hives". (allergic reaction)

A nurse is admitting a client to the orthopedic unit following a total knee arthroscopy. Which of the following actions by the nurse are appropriate? (select all that apply.) 1.Check continuous passive motion device settings 2.Palpate dorsal pedal pulses. 3.Place a pillow behind the knee. 4.Slightly elevate heels off bed. 5.Apply heat therapy to incision.

1.Check continuous passive motion device settings 3.Place a pillow behind the knee. 4.Slightly elevate heels off bed. 5.Apply heat therapy to incision. (1-assessing color and temp of affected extremity helps identify alterations in circulation) (3/4-elevating leg decreases swelling and pain) (5-assessing pulse and sensation helps identify circulation alterations)

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (select all that apply.) 1.Clean the incision daily with soap and water 2.Turn the toes inward when sitting or lying. 3.Sit in a straight-backed armchair. 4.Bend at the waist when putting on socks. 5.Use a raised toilet seat.

1.Clean the incision daily with soap and water 3.Sit in a straight-backed armchair. 5.Use a raised toilet seat. (1-should wash incision daily) (3/5-decreases chance of bending at an angle greater than 90 degrees)

A female client with severe systemic lupus erythematosus who has been receiving treatment with corticosteroids and immunosuppressants for over 5 years, confides in the nurse that she has a strong desire to have children. Which of the following responses by the nurse is most appropriate? 1 . "Pregnancy is probably not an option for you since you have been taking corticosteroids and immunosuppressants for so long." 1 . "Pregnancy is probably not an option for you since you have been taking corticosteroids and immunosuppressants for so long." 2 . "I recommend that you discuss your options with your primary health provider." 3 . "For the best outcome, you should plan to become pregnant during a period of low disease activity." 4 . "Your child will have a high risk of developing SLE, are you sure you want that?"

2 . "I recommend that you discuss your options with your primary health provider."

A 50-year old female client, presents with fatigue and join pain that has become more and more severe over the last year. She believes that she has osteoarthritis (OA) and requests corticosteroid injections "like my friend Ruth gets." Which of the following findings leads the nurse to suspect that the client has rheumatoid arthritis (RA) rather than OA? 1 . The client has been having difficulty completing her ADL's because of the pain and stiffness. 2 . The client complaints of stiffness in both knees and wrists 3 . Pain and stiffness is worse in the morning and after periods of inactivity 4 . The client suspects that she has not been getting enough calcium

2 . The client complaints of stiffness in both knees and wrists (compare similarities and differences between OA and RA)

A client with systemic lupus erythematosus is admitted to the hospital after having a myocardial infarction. Which of the following are clinical manifestations associated with the autoimmune disease? Select all that apply. 1 . Proteinuria 2 . "Butterfly rash" 3 . Peripheral neuropathy 4 . Joint pain 5. Hypercoagulability

2. "butterfly rash" 4. joint pain 5. hypercoagulability (accumulation of immune complexes in the joints causes arthritis) (interactions with blood causes hypercoagulability)

The nurse receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first? 1 . Alopecia and oral mucositis noted on assessment 2 . Morning hemoglobin result is 8 g/dL 3 . New-onset back pain and weakness in legs 4 . Persistent vomiting and potassium result is 3.4 mEq/L

3 . New-onset back pain and weakness in legs (priority due to risk of spinal cord compression)

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply 1. Avoid annual influenza vaccination 2. Avoid situations that causes physical and emotional stress 3. Avoid sun exposure and ultraviolet light when possible 4. Notify the HCP if you have fever 5. Use antibiotic soap to clean skin rashes

2. Avoid situations that causes physical and emotional stress 3. Avoid sun exposure and ultraviolet light when possible 4. Notify the HCP if you have fever

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? Select all that apply 1. Bitter almond smell on breath 2. Fever and raised skin pustules 3. Low blood cell counts 4. Oral mucosal ulcerations 5. Vomiting and diarrhea

2. Fever and raised skin pustules 3. Low blood cell counts 4. Oral mucosal ulcerations

When caring for a client with an internal radiation implant, the nurse should follow which safety principles? Select all that apply. 1.Limit time with the client to 1 hour per shift. 2.Do not allow pregnant individuals to go into the client's room. 3.Place the client in a private room with a private bath. 4.Wear a lead shield when providing care for the client. 5.Allow children under 16 in the room as long as they stay 6 feet from the client.

2.Do not allow pregnant individuals to go into the client's room. 3.Place the client in a private room with a private bath. 4.Wear a lead shield when providing care for the client. (protects from harmful radiation)

A nurse is caring for a client who just underwent bilateral total knee arthroplasties to treat the joint damage caused by rheumatoid arthritis. Which of the following interventions should the nurse perform first? 1 . Turn and reposition the client 2 . Perform a neurovascular assessment 3 . Assess the client's vital signs 4 . Hang the client's scheduled ceftriaxone IV

3. assess client's vital signs (VS should be monitored regularly after surgery)

In an effort to manage a patient's lower back pain, the nurse should recommend which of the following measures? 1.Bed rest whenever possible 2.Activity reduction 3.Weight loss 4.Avoidance of over-the-counter analgesics

3. weight loss

A nurse is providing health teaching for a client with moderate rheumatoid arthritis. Which statement by the client indicates to the nurse that he understood the health teaching? 1 . "Exercise could cause additional damage to my joints and should be avoided." 2 . "The nodules that have appeared on my elbows will go away on their own." 3 . "Corticosteroid therapy increases my metabolism so I should eat high-calorie meals." 4 . "I have been prescribed methotrexate, so I need to avoid people with colds."

4 . "I have been prescribed methotrexate, so I need to avoid people with colds." (methotrexate treats RA and is an immunosuppressant)

The nurse is caring for several clients with autoimmune diseases. Which of the following clients should the nurse see first? 1 . A client with celiac disease with hemoglobin of 12 g/dL 2 . A client with systemic lupus erythematosus who is scheduled to receive ciprofloxacin 3 . A client with myasthenia gravis who has been having difficulty speaking 4 . A client with myasthenia gravis who just had a thymectomy is in 8/10 pain

4 . A client with myasthenia gravis who just had a thymectomy is in 8/10 pain

A client with systemic lupus erythematosus is being treated for s streptococcal pneumonia. Which of the following precautions are required to prevent transmission of the disease? 1 . No precautions are required when caring for this client 2 . This client can only be placed in a room with other immunocompromised clients 3 . Standard precautions should be used in caring for this client 4 . Droplet precautions are required when caring for this client

4 . Droplet precautions are required when caring for this client (high risk of pneumonia-droplet precautions prevent neumonia)

Cutaneous lesions are a common symptom of systemic lupus erythematosus. Which of the following statements by the client indicates that she understands the health teaching provided by the nurse regarding lesion prevention and treatment? a. "I should avoid going outside between 10 a.m. and 3 p.m." b. "Sunscreen should be avoided, as it may cause irritation and infection of my lesions." c. "Corticosteroid cream should be applied generously to affected areas." d. "I should stop taking my multivitamin because it can increase photosensitivity."

a. "I should avoid going outside between 10 a.m. and 3 p.m." (helps decrease sun exposure)

Which IV fluid would be most appropriate for a client with a serum sodium level of 153 mEq/L? a. 0.45% saline b. 3% saline c. 0.9 % saline d. lactated ringer

a. 0.45% saline (free water and hypotonic solutions would be used for a patient with hypernatremia)(use 3% saline for hypernatremia) normal sodium levels are 135-145(hypernatremia=hypotonic)(hyponatremia=hypertonic)

A client has returned to the medical-surgical unit following a video assisted thoracic surgery to treat a small lung nodule. The client is refusing to get out of bed. Which common complication is the client at the highest risk for developing by refusing to ambulate? a. DVT b. sepsis c. infection d. hemorrhage

a. DVT (early ambulation and leg exercises are highly recommended for all clients to prevent venous thromobembolism complications such as PE and DVT)

A client is being treated in the health clinic for an exacerbation of psoriasis. The nurse includes what information when providing teaching about disease management? Select all that apply. a. Emotional stress, trauma, infection, or seasonal and hormonal changes can cause psoriatic flare-ups. b. Take a photosensitizing agent before exposing the skin to direct sunlight to lessen the potential for complications c. Establish routine skin care including hot showers and/or baths to soften skin. d. Reassure the client that the disease is not infectious or a reflection of poor personal hygiene. e. Intravenous or oral systemic corticosteroids, such as prednisone, are needed to reverse flare-ups.

a. Emotional stress, trauma, infection, or seasonal and hormonal changes can cause psoriatic flare-ups. d. Reassure the client that the disease is not infectious or a reflection of poor personal hygiene.

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client? a. Stress on the weakened bone must be avoided. b. Increased heart rate enhances perfusion and bone healing. c. Bed rest results in improved outcomes in clients with osteomyelitis. d. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

a. Stress on the weakened bone must be avoided.

The nurse is working in a health clinic and has completed an administration of an antibiotic intravenously to a client. The client complains of "itching" and feeling "nauseous". Assessment reveals: blood pressure 86/46 millimeters of mercury (mmHg), heart rate 110 beats per minute; respiratory rate 28 breaths per minute; oxygen saturation 90%; and emesis of 200 milliliters (mL). What priority action is indicated? a. begin oxygen therapy at 2 L/nasal cannula b. begin cardiopulmonary resuscitation (CPR) c. start IV infusion of normal saline d. administer diphyendramine IV

a. begin oxygen therapy at 2 L/nasal cannula (An anaphylactic reaction requires immediate reaction-starting with the clients airway, oxygen should be administered)

The nurse is providing care for a client who has undergone total knee arthroplasty. What should the nurse include in the neurovascular assessment? Select all that apply. a. color of extremity b. presence of sensation on the foot c. presence of pedal pulses d. presence of movement of the toes e. presence of hair on the extremity

a. color of extremity b. presence of sensation on the foot c. presence of pedal pulses d. presence of movement of the toes

A nurse is discussing informed consent with a client prior to a surgical procedure. The client has not signed the informed consent and tells the nurse "I'm not sure I understand what is going to happen during my surgery." What is the nurse's priority intervention? a. contact the physician to answer the client's questions b. ask the client to sign informed consent c. prepare to administer sedative drugs d. allow the client's spouse to sign the informed consent

a. contact the physician to answer the clients questions

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first? a. cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation b. assess the client for manifestations of shock c. place the client supine with knees bent d. raise the head of the clients bed 15 degrees to 20 degrees

a. cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation (protects the client's internal organs. Nurse should not attempt to reinsert organs or viscera)

A client allergic to bee sting was stung about 20 minutes ago at a picnic. Based on the assessment data, the nurse anticipates which immediate action? Select all that apply. BP: 92/40 mmHg Apical pulse: 140/min and regular respirations: 36/min and labored oxygen sat: 89% a. inhaled albuterol b. intramuscular epinephrine c. IV methylprednisolone d. IV metoprolol e. IV nitroglycerine

a. inhaled albuterol b. IM epinephrine c. IV methylprednisolone (anaphylactic shock treatment)

A nurse is caring for a client admitted to the unit following a total hip arthroplasty. When providing education, which precautions will the nurse include about mobility of the affected hip? Select all that apply. a. the hip should not bend more than 90 degrees b. the affected leg should not turn outward c. the affected leg should not turn inward d. the affected hip should not cross over the center of the body e. the client should not put any weight on the affected leg

a. the hip should not bend more than 90 degrees c. the affected leg should not turn inward d. the affected hip should not cross over the center of the body

A client is recovering in the hospital following a total hip replacement that was performed 2 days ago. In an effort to prevent the common complications associated with the surgical procedure, the nurse should implement which of the following interventions? a. Passive range-of-motion (ROM) exercises with the affected leg b. Application of sequential compression devices (SCD) c. Indwelling urinary catheterization to prevent urinary retention d. Provision of a low-fiber, high-calorie diet

b. Application of sequential compression devices (SCD)

When administering a bisphosphonate medication for the management of osteoporosis, which intervention by the nurse is most appropriate? a. Administer the drug with food b. Assist the client to sit upright after administering the drug c. Administer the drug at bedtime d. Restrict fluid intake after administering the drug

b. Assist the client to sit upright after administering the drug

an elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission lab results and identifies which value as the most likely cause of the client's symptoms? a. brain natriuretic peptide 70 pg/ml b. hematocrit 21% c. leukocytes 3,500/mm3 d. platelets 105,000/mm3

b. hematocrit 21% (low Hct levels mean low Hgb levels, which can cause decrease O2 levels which ultimately leads to shortness of breath)

A nurse is discussing meal plans with an immunosuppressed patient. Which of the following foods is inappropriate for the nurse to recommend? a. pasteurized milk b. over easy eggs c. cooked pasta d. canned fish

b. over easy eggs (avoid because increased infection risk)

The nurse is providing client education for a client with iron deficiency anemia. what information should the nurse include regarding oral iron supplements? Select all that apply a. take iron with milk to reduce gastric distress b. taking the iron with foods high in vitamin C may enhance absorption c. eat foods high in fiber to minimize problems with constipation d. immediately notify provider if your stools become dark in color e. use a straw to take liquid formulation to prevent discoloration of teeth.

b. taking the iron with foods high in vitamin C may enhance absorption. c. eat foods high in fiber to minimize problems with constipation e. use a straw to take liquid formulation to prevent discoloration of teeth (Oral iron supplements should be taken on an empty stomach and with foods high in Vitamin C. Fiber should be taken to minimize constipation. Darker stools are expected and therefore do not need to be reported. Patient should drink the liquid formulation through a straw to prevent discoloration of the teeth.)

The nurse is providing health promotion for adults attending a community health fair. What health education about the ways to prevent skin cancer will the nurse include? a. "If you like to tan, it is important that you do so for less than 60 minutes at a time." b. "Any form of clothing will effectively block the sun's rays from damaging your skin." c."Even if it is cloudy outside, sunrays can still cause harm and contribute to skin cancer." d. "Sunscreens have been shown to have little effect on the ultraviolet damage that is caused by the sun."

c."Even if it is cloudy outside, sunrays can still cause harm and contribute to skin cancer."

A nurse is teaching a client who has received a new diagnosis of systemic lupus erythematosus (SLE) about ways to best manage the disorder. What client statement indicates a need for further information? a. "I will call if I have a temp above 100 degrees F (37.8 C)" b. "I will wear sunscreen and clothing to shield me from the sun" c. "I will limit my time spent under fluorescent lights" d. "I will cleanse my face and rashes with alcohol-based cleansers

d. "I will cleanse my face and rashes with alcohol-based cleansers (The face should be cleansed with antibiotic soap; alcohol-based cleansers should be avoided because they are too drying.)

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL. The nurse should anticipate which findings? a. course crackles b. dyspnea c. pallor d. respiratory depression e. tachycardia

dyspnea, pallor, and tachycardia (all symptoms of anemia)

after receiving report, which client should the nurse assess first? a. the client whose partial thromboplastin time (PTT) is 32 seconds b. the client whose hemoglobin is 14 gm/dL and hematocrit is 45% c. the client whose platelet count is 45,000 per mL of blood d. the client whose RBC count is 48 X 10^6 mm

the client whose platelet count is 45,000 per ML of blood (a platelet count less than 50,000 needs to be under bleeding precaution--all other labs are normal)