CFCC 211 Final (iggy)

Question 4 of 14 The client who wants to use Truvada for preexposure prophylaxis (PreP) asks the nurse why testing is needed for HIV status before starting this drug. How does the nurse respond? "Although this drug can help prevent HIV infection, it is not enough by itself to control "the disease if you are HIV positive." "The side effects of this drug are worse if you have a detectable HIV viral load." "If you take this drug and are HIV positive, your risk for co-infection with the hepatitis B virus is increased." Some people have a genetic mutation that increases the risk for life-threatening reactions "while taking this drug if they are also HIV positive."

"Although this drug can help prevent HIV infection, it is not enough by itself to control "the disease if you are HIV positive." The drug can help prevent HIV infection, but alone does not adequately suppress viral replication. In addition, taking it when HIV positive often leads to drug resistance. None of the other statements are true.

Question 12 of 18 Which statement by a client who has systemic lupus erythematosus (SLE) indicates to the nurse that more education about the disorder and its management is needed? "My friend and I are going to start walking 2 miles daily." "Taking my temperature every day can help me recognize when a flair is starting." "If I still have a lot of pain after taking an NSAID, I can also take acetaminophen." "At the first sign of a flare, I will begin taking my medication again."

"At the first sign of a flare, I will begin taking my medication again." The client's statement suggests that he or she believes that daily medication is not needed and would be required only during a flare. However, daily drug therapy is essential to slow the progression of the disease and organ damage.Low-impact exercise such as walking is highly recommended to maintain mobility and promote cardiovascular health. Fevers are often associated with a flare. There is no contraindication to taking both NSAIDs and acetaminophen.

Question 13 of 28 What is the nurse's best response when a client with emphysema asks how removing part of the lungs through lung volume reduction surgery will improve breathing? "By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best." "This surgery is preventive, because the parts of the lungs being removed are those that having the highest probability for developing cancer." "Breathing will be improved because diseased lung parts are removed and replaced with healthy parts." "This surgery makes room for the new lungs when a lung transplant is available."

"By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best." Lung volume reduction surgery removes hyperinflated lung areas that contain only stale air and do not contribute to gas exchange. This ensures that respiratory effort results in better gas exchange in the remaining alveoli. Removing some volume also allows respiratory muscle contraction to be more effective.This surgery does not replace any lung tissue and is not performed as a precursor to lung transplantation. The hyperinflated areas are not more susceptible to cancer development than any other lung tissue.

Question 10 of 14 Which statement made by the nurse during an admission assessment for a client who is HIV positive demonstrates a nonjudgmental approach in discussing sexual practices and behaviors? "You must tell me all of your partners' names, so I can let them know about possibly being infected." "I hope you use condoms to protect your partners." "Have you had sex with men or women or both?" "You don't participate in anal intercourse, do you?"

"Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate. "I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. By stating the question about anal intercourse as a negative is very judgmental.

Question 13 of 18 What response by the nurse would be most therapeutic when a client who has systemic lupus erythematosus (SLE) says, "My face has changed so much. I feel really ugly"? "I know what you mean, I feel that way sometimes too." "I bet that was hard to say. Thank you for trusting me with your feelings." "Don't worry, treatment will make everything better." "You look great. It's what is inside that counts."

"I bet that was hard to say. Thank you for trusting me with your feelings." "I bet that was hard to say. Thank you for trusting me with your feelings" is an empathetic response in a hard conversation. It acknowledges the client's bravery for sharing and encourages further therapeutic communication."You look great. It's what is inside that counts" is dismissive of the client's feelings. "Don't worry we will make everything better" is considered false reassurance, this can discount the client's feelings. "I know what you mean, I feel that way sometimes too" is focused on the nurse at a time when the focus should be on the client. All three responses hinder a continued conversation and therapeutic communication.

Question 4 of 28 Which statement made by a client prescribed a reliever drug inhaler for asthma indicates to the nurse correct understanding of this therapy? "If I forget a dose, I will use the inhaler as soon as I remember it." "At night, I will be sure to store the inhaler in a cool, dry place." "I will keep this inhaler with me at all times." "Reliever drugs are needed to prevent asthma attacks."

"I will keep this inhaler with me at all times." The statement by the client that indicates a correct understanding of the instructions is that the emergency inhaler must be with the client at all times because asthma attacks cannot always be predicted.The inhaler is not to be stored at night; it needs to remain with the client for emergency use.Reliever drugs stop an attack and are used when needed, not on a schedule.

Question 7 of 14 Which laboratory test does the nurse analyze to determine the effectiveness of combination antiretroviral drug therapy in an HIV-positive client? Viral load testing Enzyme-linked immunosorbent assay Fourth generation testing Western blot analysis

Viral load testing Only viral load testing directly measures the actual amount of HIV viral RNA particles present in 1 mL of blood. Changes in the number indicate therapy effectiveness. Higher numbers indicate lack of effectiveness and lower numbers indicate the drugs are working. The other tests are used to determine whether the client is infected with HIV and do not change with therapy.

Question 6 of 18 Which client statement about the use and care of an epinephrine autoinjector for a peanut allergy indicates to the nurse that more teaching is needed? "If I inject myself, I will still go immediately to the emergency department." "When needed, I can inject the drug right through my clothing." "My wife and I will both practice putting the device together." "If I keep the injector in the refrigerator, the drug will not expire as quickly."

"If I keep the injector in the refrigerator, the drug will not expire as quickly." Although it is true that the drug may not deteriorate as quickly if refrigerated, the client needs to have the drug with him or her at all times to use as soon as symptoms of anaphylaxis occur in order to prevent death. All other statements for the use and care of an epinephrine autoinjector are correct.

Question 10 of 18 What is the nurse's best response to a client newly diagnosed with systemic lupus erythematosus (SLE) who asks why nicotine use, especially cigarette smoking or vaping, should be avoided? "Nicotine reduces blood flow to your organs and increases the risk for permanent damage." "Using nicotine in any form reduces the effectiveness of drug therapy for lupus." "Nicotine promotes muscle cell loss, increases joint inflammation, and reduces functional mobility." "Smoking or vaping increases your risk for lung cancer development."

"Nicotine reduces blood flow to your organs and increases the risk for permanent damage." Nicotine in any form constricts blood vessels and reduces perfusion. Perfusion is already reduced by the vasculitis that is part of the disease. Thus, use of nicotine greatly increases the risk for necrosis of many tissues and organs. Although smoking or vaping do increase the risk for lung cancer, their effects on blood vessels are a greater issue for the client with SLE. Nicotine neither reduces the effectiveness of drug therapy nor promotes muscle cell loss.

Question 2 of 19 A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." Which nursing response is appropriate? 1-"I will discuss cancelling your medication order with your health care provider." 2-"That sounds like a wonderful idea; and I think it will definitely work!" 3-"That sounds like a great plan; can you tell me more about it?" 4-"Your plan will not work; people with your type of pain need opioids."

"That sounds like a great plan; can you tell me more about it?" Complementary and integrative therapies are most often used to supplement, not replace, medication management. The nurse needs to obtain more data, and will ask for more information about the client's plan.Contacting the health care provider to cancel the medication order is not appropriate. Telling the client that his idea is wonderful and will definitely work is not appropriate, as alternative strategies alone, may not work to relieve the client's pain. Telling the client that his or her plan will not work is dismissive of the client. In addition, the client may not need to be prescribed opioids for the pain.

Question 1 of 18 What is the nurse's best response to a client who had a severe allergic reaction to shrimp states, "I have had shrimp once before and did not have a reaction. Why is this happening now?" "Allergies are tricky, and many reasons for responses are not known." "It is most likely that you didn't eat enough shrimp the first time to cause a reaction." "The first time your body recognized the shrimp as an allergen, and the second time it reacted to it." "This means you may be allergic to something else and not to shrimp."

"The first time your body recognized the shrimp as an allergen, and the second time it reacted to it." Type I reactions have two parts. During the first exposure, the client makes antigen-specific IgE, and becomes sensitized to the allergen. When the sensitized client is re-exposed to the allergen, a more severe reaction occurs.To point out the amount of shrimp eaten is not helpful and could make the client believe that eating only a small amount of shrimp would not cause a reaction. The same is true for option C. Stating that allergies "are tricky" does not help to inform or educate the client about what he or she should do to prevent harm. This response may make the client afraid of everything in his or her environment.

Question 9 of 14 Which statement made to the nurse by an assistive personnel (AP) assigned to care for an HIV-positive client indicates a breach of confidentiality and requires further education by the nurse? "The client's spouse told me she got HIV from a blood transfusion." "The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client." "I told family members they need to wash their hands when they enter and leave the room." "Yes, I understand the reasons why I have don't need to wear gloves when I feed the client."

"The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse. Instruction on handwashing to family members or other visitors is not a breach of confidentiality. Understanding the reasons for when and when not to wear gloves when performing direct client care is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.

Question 5 of 14 Which point is most important for the nurse to include when teaching assistive personnel (AP) about protecting themselves from HIV exposure when caring for HIV-positive clients? "Always wear a mask when entering an HIV-positive client's room." "Talk to the employee health nurse about starting preexposure prophylaxis." "Wear gloves when in contact with clients' mucous membranes or nonintact skin." "Wear full protective gear when providing any care to HIV-positive clients."

"Wear gloves when in contact with clients' mucous membranes or nonintact skin." Standard Precautions are all that is needed when caring for any client, including those who have HIV. Masks and full protective gear are not needed. Preexposure prophylaxis is not used for potential occupational exposure.

Question 3 of 19 The nurse is assessing a client for acute or persistent pain. What nursing question allows the nurse to obtain the most data from the client? 1-"Is the pain really that bad?" 2-"Does it feel like sharp pain?" 3-"When does the pain occur?" 4-"Did someone do this to you?"

"When does the pain occur?" Asking when the pain occurs helps determine precipitating factors to identify the source of pain. It is an open-ended question that requires a descriptive response and allows the nurse to obtain the most data.Asking if someone hurt the client may be appropriate in rare circumstances, but typically it is not an appropriately focused question; the question does not relate to the severity or character of the pain. Further, this is not an open-ended question. The nurse should ask the client open-ended questions, not questions requiring a "yes-or-no" answer, such as "Does it feel like sharp pain?" Asking "Is the pain really that bad?" minimizes the client's perception of pain; it is also a closed-ended question requiring a "yes-or-no" answer.

Question 17 of 18 After a client is hospitalized for an anaphylactic reaction to a bee sting, a nurse is teaching the client about the use of an epinephrine autoinjector. Which instruction/ instructions should be included in client education? (Select all that apply.) Select all that apply. 1-Keep the device with you at all times. 2-After administering the device, hospital monitoring is necessary. 3-Use the device before calling 911. 4-If the drug becomes discolored, order a replacement device. 5-The device CANNOT be given through clothing. 6-Inject the device into your arm or your leg.

1, 2, 3, 4 Instruct the client to utilize the device at the first symptom of anaphylactic reaction before calling 911. Hospital monitoring is always necessary after utilizing epinephrine for anaphylaxis. The device should be available at all times, as allergens can be encountered in all life situations. For client safety if the drug becomes discolored, it needs to be replaced.The device CAN be given through a thin layer of clothing. The ideal injection site for an epinephrine automatic injector is in the upper thigh.

Question 18 of 18 Which assessment findings will the nurse expect to see in a client who is suspected to have systemic lupus erythematosus (SLE)? (Select all that apply.) Select all that apply. 1-Anemia 2-Joint pain and swelling 3-Hair loss 4-Fever 5-Fatigue 6-Facial redness

1, 2, 3, 4, 5, 6 Each of these assessment findings has been associated with systemic lupus erythematosus (SLE).

Question 18 of 19 The nursing is using the pain assessment in advanced dementia pain scale to assess a client. What categories of pain indicators will the nurse assess? (Select all that apply.) Select all that apply. 1-Body language 2-Facial expression 3-Breathing pattern 4-Ability to calm the client 5-Ability to distract the client 6-Picking at skin or clothing 7-Vocalizations

1, 2, 3, 4, 7 Pain Assessment in Advanced Dementia (PAINAD) scale has been tested in patients with severe dementia (Herr et al., 2011). The tool groups behavioral indicators into five categories for scoring using a graduated scale of 0 (least intense behaviors) to 2 (most intense behaviors) per category for a maximum behavioral score of 10:· Breathing (independent of vocalization)· Negative vocalization· Facial expression· Body language· Consolability (ability to calm the patient)Picking at the skin or clothing as well as ability to distract the client are not portions of the PAINAD scale.

Question 17 of 19 The nurse is teaching the client about the use of medical marijuana. What teaching will the nurse include? (Select all that apply.) Select all that apply. 1-"Medical cannabis is a controlled substance in the United States". 2-"Federal and state law often vary in the legality of medical cannabis use." 3-"The psychoactive component of medical cannabis is removed." 4-"Your health care provider can prescribe cannabis for you." 5-"Side effects of cannabis can include dizziness and increased appetite."

1, 2, 5 Cannabis is a schedule I controlled substance and has been since 1970. Federal and state law often vary in the legality of cannabis use. A health care provider cannot prescribe cannabis in any state; however, they may assess and determine whether a client has a qualifying condition in accordance with state law. Side effects of cannabis include: increased heart rate, increased appetite, dizziness, decreased blood pressure, dry mouth, hallucinations, paranoia, altered psychomotor function, and impaired attention. The psychoactive component, THC, is not removed from medical cannabis.

Question 16 of 18 Which statement(s) regarding type IV hypersensitivity reactions is/are true? (Select all that apply.) Select all that apply. 1-The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. 2-Type IV responses are usually directed against non-self but the response is excessive. 3-The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema. 4-The secondary phase, when prolonged, is primarily responsible for autoimmune disorders. 5-Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction. 6-Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine.

1, 2, 5, 6 Type IV delayed hypersensitivity reactions have T-lymphocytes (T-cells) as the activated immune system component triggering the excessive responses. A classic example is allergy to poison ivy.Sensitized T-cells (from a previous exposure) respond to an antigen by releasing chemical mediators and triggering macrophages to destroy the antigen; however, histamine is not one of the mediators, making antihistamines of minimal benefit.A type IV response with edema, induration, ischemia, and tissue damage at the site of the exposure typically occurs hours to days after exposure.Angioedema is a type I response, not a type IV response.

Question 19 of 19 The nurse is documenting a pain assessment. Which pain descriptions document location of pain? (Select all that apply.) Select all that apply. 1-Localized pain 2-Sharp pain 3-Negative vocalization 4-Radiating pain 5-Referred pain 6-Pain rated as a 4 on a scale of 0-10.

1, 4, 5 Pain can be described as belonging to one of four categories related to its location: localized, projected, referred, and radiating. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Referred pain is felt in an area distant from the site of painful stimuli. Radiating pain is felt along a specific nerve or nerves.Pain rated as a 4 on a scale of 0-10 describes the intensity of the pain, not the location. Sharp pain describes the quality of the pain, not the location. Negative vocalization is an indicator of the presence of and quality of pain in adults with dementia.

Question 14 of 14 Which conditions or factors will the nurse teach at a community seminar as probable transmission routes for HIV? (Select all that apply.) Select all that apply. 1-Using injection drugs 2-Sitting on public toilets 3-Changing a diaper on an HIV positive child 4-Having unprotected intercourse with multiple partners 5-Breast-feeding 6-Being bitten by mosquitos

1, 4.5 HIV can be transmitted via breast milk from an infected mother to the child. Unprotected intercourse with an HIV positive adult is a major transmission route. HIV is not spread by mosquito bites or by other insects. It is not transmitted by casual contact. Sharing toilet facilities with an HIV-positive adult does not cause transmission of HIV. Use of injection drugs is a common transmission route. Casual contact such as changing a diaper, even with feces and urine (unless there is significant blood in these excretions), is not a probable transmission route.

Question 11 of 14 Which statements about the transmission of HIV are true? (Select all that apply.) Select all that apply. 1-Clients with HIV-III and no drug therapy are very infectious. 2-Even with appropriate drug therapy, most clients infected with HIV live only about 5 years after diagnosis. 3-HIV may be transmitted only during the end stages of the disease. 4-The most common transmission route is casual contact. 5-Newly infected clients with a high viral load are very infectious. 6-HIV-positive clients who have an undetectable viral load appear to not transmit the disease.

1, 5, 6 In the first 4 to 6 weeks after infection, the viral numbers in the bloodstream and genital tract are high and sexual transmission is possible. Clients at the end stage of HIV disease (HIV-III [AIDS]) without drug therapy have a high viral load and are particularly infectious. An undetectable viral load now means noninfectious and therefore, not transmittable. Casual contact does not transmit the infection. With appropriate drug therapy, clients with HIV disease live for decades

Question 16 of 19 A client reports increasing pain during dressing changes to the nurse. Which interventions are recommended for the client? (Select all that apply.) Select all that apply. 1-Music therapy 2-Assistance by the client with the dressing change 3-Epidural analgesic 4-Transcutaneous electrical nerve stimulation (TENS) 5-Distraction 6-Premedication

1, 5, 6 Interventions recommended for the client include distraction, music therapy, and premedication. Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment.Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain, but its use during a dressing change would not be feasible.

Question 13 of 14 Which laboratory results does the nurse expect to decrease in a client who has untreated HIV-III (AIDS)? (Select all that apply.) Select all that apply. 1-Total white blood cell count 2-Viral load 3-CD8+ T-cell 4-HIV antibodies 5-CD4+ T-cell 6-Lymphocytes

1, 5, 6 The immune target of HIV is the CD4+ T-cell. With infection of this cell, its circulating levels decline and immune function is reduced over time. As a result, total white blood cell counts decrease and circulating lymphocytes decrease. CD8+ T-cell counts are unaffected. HIV antibodies and viral load increase.

Question 9 of 19 A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What will the nurse say to the visitor? 1-"Please allow the client to push the button when needed." 2-"Please don't touch any equipment in the client's room." 3-"Thank you. I am sure the client appreciated that." 4-"The client is asleep and is not in pain."

1-"Please allow the client to push the button when needed." The nurse will request that the visitor allow the client to push the button for medication when needed. The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues.Telling the family member not to touch any equipment in the client's room is not only nonspecific, but it may also be perceived as disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the client is asleep does not mean that the client is pain-free.

Question 5 of 19 A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical signs of pain. What will the nurse do next? 1-Administer the pain medication as requested. 2-Withhold the pain medication. 3-Decrease the client's standard pain medication dose. 4-Give the client a placebo and monitors the outcome.

1-Administer the pain medication as requested. The nurse will administer the pain medication as requested. Both types of persistent (chronic) pain (chronic cancer pain and chronic noncancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's objective symptoms when managing chronic cancer pain.The nurse would not decrease pain medication under the assumption that, because the client does not exhibit signs of pain, the client must not have any pain. Unless the client is involved in a clinical research trial, giving a placebo in place of medication is never appropriate. It is never appropriate to withhold prescribed pain medication unless the client is medically unstable and the nurse would contact the health care provider.

Question 15 of 19 Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? 1-Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care 2-Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief 3-Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable 4-Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain

1-Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care would be assigned to the LPN/LVN. LPN/LVN education and scope of practice include working within practice parameters to administer pain medication and to perform dressing changes.Assessments and client education are not within the LPN/LVN scope of practice.

Question 14 of 19 The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond? 1-"Yes, this is a valuable way for all of you to make needed adjustments." 2-"Let's ask your father about your request." 3-"No, his pain relief is more important than your concerns." 4-"I will ask his oncologist about your question."

2- "Let's ask your father about your request." The nurse will respond by indicating that the client's desires about analgesia are the most important consideration in this scenario, and so he would be consulted initially about his family's request. This open-ended type of question acknowledges the family, while keeping the client as the major decision maker.Although the health care provider might have an opinion about the family's request, pain is subjective, and the client's desires about analgesia are the most important consideration. Telling the family that the father's pain control is more important than their concerns is a demeaning response, although technically true; it is dismissive of the family and is nontherapeutic. Giving the family control of pain relief for their father is inappropriate in this situation; the subjective nature of pain places decisions about the use of analgesia with the client who is experiencing the pain. The family and the client may need to make adjustments, but reducing pain relief for the client is not an advisable way to accomplish this goal.

Question 12 of 19 The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? 1-3:30 p.m. 2-4:30 p.m. 3-4:00 p.m. 4-7:00 p.m.

2- 4:30 p.m. The nurse will change the dressing at 4:30 p.m. About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a client. At 4:30 p.m., the opioid has had time to take effect and provide relief for the client.It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 p.m.), because the pain medication will be at its lowest concentrations in the client's system. At 4:00 p.m., the analgesic has not had time to enter the client's system, so it is too soon to perform the dressing change. If the client received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 p.m. to facilitate a dressing change with minimal discomfort.

Question 12 of 14 Which practices are generally recommended to prevent sexual transmission of HIV? (Select all that apply.) Select all that apply. 1-Oral contraceptives taken consistently 2-Natural-membrane condoms for genital and anal intercourse 3-Latex gloves for finger or hand contact with the vagina or rectum 4-Latex dental dam genital and anal intercourse 5-Water-based lubricant with a latex condom 6-Latex or polyurethane condoms for genital and anal intercourse

3, 4, 5, 6 Latex or polyurethane condoms, dental dams, and gloves for genital and anal intercourse can prevent HIV from contacting susceptible tissues. Water-based lubricants must be used instead of oil-based or greasy lubricants because these can easily rub holes in the condoms. Oral contraceptives provide no protection against transmission of HIV or any other sexually transmitted infection.

Question 11 of 19 A 44-year-old client with osteoarthritis pain tells the nurse, "I take two extra-strength acetaminophen (500 mg) every 8 hours." How does the nurse respond? 1-"More acetaminophen is needed to provide effective pain relief for you." 2-"You will need to have routine blood draws to monitor clotting time." 3-"That is the appropriate dose of acetaminophen for your pain." 4-"Aspirin would be a better, more effective choice for your pain relief."

3- "That is the appropriate dose of acetaminophen for your pain." In the healthy adult, a maximum daily dose below 4000 mg is rarely associated with liver toxicity. Many experts recommend reducing the daily dose (e.g., 2500 to 3000 mg daily) when used for long-term treatment in older adults. Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice for many people in pain, especially older adults. The dose is appropriate; more is not indicated or advised.Acetaminophen is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding.

Question 13 of 19 The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What is the priority nursing action? 1-Perform a cognitive assessment on the client. 2-Call the care provider for a change in the medication order. 3-Administer a dose of naloxone 0.4 mg slow IV push. 4-Change the order to every 6 hours rather than every 4 hours.

3- Administer a dose of naloxone 0.4 mg slow IV push. The priority nursing action is to administer a dose of naxalone 0.4 mg IV. For an unresponsive client, the nurse would administer naloxone 0.4 mg over a 2-minute time period to reverse the action of the opioid analgesic.The order may need to be altered or changed, but calling for a medication order change is not the first action that the nurse would take in an unresponsive client. Nurses do not change orders in terms of dosage or frequency; the health care provider changes the order. A sedated client will not be able to complete a cognitive assessment, and this action would waste time that should be spent on reversing the effects of hydromorphone.

Question 8 of 19 A postoperative client is vomiting and states, "I am having a lot of pain—a 7 on a scale of 0-10." Which route of administration will the nurse choose to administer an analgesic to the client? 1-PO 2-Rectal 3-IV 4-Transdermal

3- IV The intravenous route is the best choice for fast relief of nausea and pain.Oral pain medication may exacerbate the client's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes.

Question 10 of 19 The charge nurse is working with a new nurse. Which statement by the new nurse requires additional teaching by the charge nurse? 1-"Older adults usually believe that pain is irrelevant and is to be expected." 2-"Older adults are at a very high risk for undertreated pain." 3-"Older adults typically believe that expressing pain is acceptable." 4-"I always assess older adults for present pain."

3-"Older adults typically believe that expressing pain is acceptable." The charge nurse will need to provide further education to the new nurse regarding the statement, "Older adults typically believe that expressing pain is acceptable."Older adults typically do not believe that expressing pain is acceptable. Many older adults believe that pain is irrelevant and is "just part of getting older."As a result, many older adults are at great risk for undertreated pain. In addition, some health care providers have outdated beliefs about older adults' pain sensitivity, tolerance, and ability to take opioids.

Question 1 of 19 The nurse is caring for a client who reports pain. As an advocate for the client, what will the nurse do first for this client? 1-Assess the level of pain. 2-Administer pain medication. 3-Accept the client's report of pain. 4-Call the health care provider for a medication order.

3-Accept the client's report of pain. The nurse's primary role in pain management is to advocate for the client by accepting reports of pain, as such, this is the nurse's first action. This has become the clinical definition of pain worldwide and reflects an understanding that the client is the authority and the only one who can describe the pain experience. In other words, self-report is always the most reliable indication of pain.Administering pain medication, assessing the pain level, and calling the provider are responses to the first response which is accepting that the client is in pain.

Question 4 of 19 A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? 1-Tolerance 2-Pseudoaddiction 3-Physical dependence 4-Addiction

3-Physical dependence The nurse expects the client to have a physical dependence on the opioid. Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms.Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the client's situation. Tolerance is similar to physical dependence, but occurs earlier and consists of a decrease in one or more of the effects of the opioid. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the client's situation.

Question 7 of 19 A client who had a hip replacement 2 days ago, reports having pain rated as a 7 on a pain scale of 0-10. What nursing intervention is the highest priority? 1-Teaching key points of the relaxation response 2-Incorporating activities of daily living as soon as possible 3-Encouraging diversional activities 4-Using preemptive analgesia

4- Using preemptive analgesia The nursing intervention with the highest priority in the client's care plan is the use of preemptive analgesia. This technique is designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay.Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the client to perform activities of daily living is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day.

Question 1 of 14 Which part of the HIV infection process is disrupted by the antiretroviral drug class of nucleoside reverse transcriptase inhibitors (NRTIs)? 1-Clipping the newly generated viral proteins into smaller functional pieces 2-Activating the viral enzyme "integrase" within the infected host's cells 3-Binding of the virus's gp120 protein to one of the CD4+ coreceptors 4-Forming counterfeit bases that prevent DNA synthesis and viral replication

4-Forming counterfeit bases that prevent DNA synthesis and viral replication The NRTIs have a similar structure to the four bases of DNA, making them "counterfeit" bases. They fool the HIV enzyme reverse transcriptase into using these counterfeit bases so that viral DNA synthesis and replication are suppressed.

Question 8 of 18 Which client with persistent joint and muscle pain will the nurse consider as most likely to have a systemic lupus erythematosus (SLE) diagnosis? A 33-year-old African-American man whose father died from a myocardial infarction. A 33-year-old white woman whose sister has Grave disease. A 33-year-old African-American woman whose mother has psoriasis. A 33-year-old man whose identical twin brother has acute myelogenous leukemia.

A 33-year-old African-American woman whose mother has psoriasis. SLE is an autoimmune disorder that is much more common in women than in men and has a genetic predisposition related to tissue type. A client with SLE is very likely to have another close relative who also has an autoimmune disorder, such as psoriasis (myocardial infarction, type 2 diabetes mellitus, and thrombotic stroke are not autoimmune disorders). In addition, the incidence of SLE is about eight times greater for African-American women than for white women.

Question 3 of 18 For which hypersensitivity situation will the nurse prepare a client for management with plasmapheresis? A 35 year old with drug-induced hemolytic anemia A 30 year old with poison ivy lesions on 60% of the body A 25 year old with penicillin-induced anaphylaxis A 40 year old with angioedema and tongue swelling

A 35 year old with drug-induced hemolytic anemia Drug-induced hemolytic anemia is a type II hypersensitivity reaction in which the body makes autoantibodies directed against red blood cells that have foreign proteins from the drug attached to them. In this type of reaction, the autoantibody binds to red blood cells, forming immune complexes that destroy red blood cells along with the attached protein. Management starts with discontinuing the offending drug and, performing plasmapheresis (filtration of the plasma to remove specific substances) to remove the formed autoantibodies. Plasmapheresis is not beneficial with other types of hypersensitivity reactions.

Question 6 of 19 A postoperative client reports, "I have pain from a mild headache." Which PRN medication will the nurse administer? 1-Oxycodone 2-Hydromorphone 3-Midazolam 4-Acetaminophen

Acetaminophen The nurse will administer acetaminophen as prescribed. Nonopioid analgesics such as acetaminophen are the first line of therapy for mild to moderate pain.Hydromorphone is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Midazolam is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Oxycodone is an opioid and is not needed for a mild headache.

Physiological Integrity Which statement about the genetics of cystic fibrosis is true? A. Recessive disorder affecting chloride transport B. Recessive disorder affecting alpha1-antitrypsin levels C. Dominant disorder inhibiting alveoli formation D. Dominant disorder increasing production of interleukin-5

Answer: A Rationale: Cystic fibrosis is caused by a mutation in both alleles of the CFTR gene, which results in the inhibition of chloride transport in epithelial cells, especially of the lungs, allowing thick, stick mucus to plug the airways. Although alpha1-antitrypsin deficiency is inherited in an autosomal pattern, this problem is associated with emphysema, not CF. Alveolar formation are not affected by CF, nor is interleukin-5 production increased. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

Health Promotion and Maintenance The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane and he missed all of yesterday's dosages. What action does the nurse recommend? A. Take today's dosages as normally prescribed and continue to follow your therapy program. B. Don't worry. Unless you miss your drugs for 4 days consecutively, there is not a problem. C. Take double doses of the drugs for the next 2 days and do not have sex for at least 4 days. D. Go to the nearest emergency department and have an immediate blood test for assessment of viral load.

Answer: A Rationale: One day of missing the drugs is not good but is unlikely to cause drug resistance if 90% of the drugs within any 1 month are taken on time and at proper dosages. The client should not be taught that anything under 4 days of missing drugs is okay. Doubling the next day's doses does not make up for missing doses. The viral load will not change in this short of a time period. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

27-3. Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor in order to prevent harm from this therapy? A. Examine your skin and the whites of your eyes daily for a yellow appearance. B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum. C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination. D. Go to your primary health care provider immediately if you develop a fever or other sign of infection.

Answer: A Rationale: This combination gene therapy drug is an oral medication taken once daily. Both drugs used in the combination can impair liver function. Thus a priority precaution for patients on this drug is to be aware of and report any symptom specific for impaired liver function. Jaundice of the skin or sclera is a major symptom of liver impairment. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

17-3. The client at stage HIV-III (AIDS) reports a large painful "pimple" in the perineal area. How does the nurse respond to this report? A. Inspect the area for indications of infection. B. Ask the client whether this causes pain during intercourse. C. Remind the client to clean the area carefully after every stool. D. Explain that this is a small matter and document the report as the only response.

Answer: A Rationale: With the greatly reduced immunity response of AIDS, even an infected "pimple" can lead to cellulitis and systemic infection. The nurse must determine the degree of infection and inform the immunity health care provider so proper interventions can be initiated to prevent a more serious infection. Cognitive Level: Applying or higher Client needs category: Physiological Integrity Nursing Process Step: Assessment

Physiological Integrity The nurse is teaching a class on pain management strategies. Which client statement requires additional teaching? A. "Persistent pain is a warning in my body that alerts the sympathetic nervous system." B. "Acute pain has a quick onset and is usually isolated to one area of my body." C. "My frozen-shoulder causes musculoskeletal or somatic pain." D. "Nociceptive pain follows a normal and predictable pattern."

Answer: A Rationale: Acute pain, not persistent (chronic) pain serves as a warning signal to alert the sympathetic nervous system. Persistent or chronic pain serves no biologic purpose. The other answer options are all correct and do not require additional teaching. Cognitive Level: Application Integrative Process: Teaching/Learning

1. A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? A. "This is common side effect of gabapentin and will decrease with use." B. "Stop taking the medication and contact the healthcare provider." C. "The dizziness is caused by the neuropathic pain, not the medication." D. "The dizziness is likely from another medication, not the gabapentin."

Answer: A Rationale: Gabapentin is commonly used for neuropathic pain. The most common side effect is dizziness which will generally decrease with use. It is not appropriate to tell the client to stop taking the medication and it is unlikely that the neuropathic pain or another medication is causing the dizziness. Cognitive Level: Application

Physiological Integrity Which documentation will the nurse record for a client who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? A. Reports acute pain at the surgical site. B. Persistent pain reported around the surgical site. C. Experiences neuropathic pain near the surgical site. D. Discomfort has progressed to chronification of pain.

Answer: A Rationale: The nurse will document that the client reports acute pain at the surgical site. Acute pain is commonly associated with surgical procedures and lasts for a short duration. The client does not demonstrate persistent or chronic pain, nor is the pain neuropathic in nature. Acute pain that is poorly controlled and lasts longer than it should can lead to chronification of pain. Cognitive Level: Apply Integrative Process: Nursing Process

17-1. Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

Answer: B Rationale: Entry inhibitors work by binding to and blocking the CCR5 receptors on CD4+ T-cells, the main target of HIV. In order to successfully enter and infect a host cell, the virus must have its gp120 protein attach to the CD4 receptor and have its gp41 bind to the CD4+ T cell's CCR5 receptor. Viral binding to both receptors is required for infection. By blocking the HIV's attachment to the CCR5 receptor, infection is inhibited. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

Health Promotion and Maintenance Which dietary change does the nurse suggest for the client who has esophageal candidiasis? A. Avoid drinking alcoholic beverages. B. Eat soft, cool food such as pudding and smoothies. C. Limit your intake of fluid to no more than 1 liter daily. D. Increase your intake of cooked leafy green vegetables.

Answer: B Rationale: Esophageal candidiasis not only makes food "taste funny" but it is painful and irritating. Eating soft food and liquids is less likely to irritate the esophagus further. Cooler and cold food can reduce discomfort by numbing sensations somewhat. Cognitive Level: Applying or higher Client needs category: Health Promotion and Maintenance Nursing Process Step: Implementation

Health Promotion and Maintenance A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm? A. "This year I will get the pneumonia vaccination in addition to a flu shot." B. "Now I will try to rest as much as possible and avoid any unnecessary exercise." C. "Maybe drinking a supplement will help me retain weight and have more energy." D. "Perhaps using a spacer with my metered dose inhaler will make the drug work better."

Answer: B Rationale: Many clients mistakenly believe that performing no exercise will reduce COPD symptoms. Exercising did not cause the increase in disease severity, but inactivity can by making muscles weaker, including the muscles used in breathing. Exercise for conditioning and pulmonary rehabilitation can improve function and endurance in clients with COPD, even those at a GOLD 3 class. The client should receive the pneumonia vaccination and should have an annual influenza vaccination. Drinking supplements can add calories to the diet and may have a positive effect on both weight and energy levels. Using a spacer with an MDI is the preferred method for this type of drug delivery system and can improve the likelihood that the drug will reach the lower airways. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention

27-5. A client newly diagnosed with Stage I nonsmall cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response? A. "This drug will only work on those lung cancers that have the right target and your tumor does not have it." B. "This drug is approved for use in client's whose lung cancer has metastasized not for early stage cancers." C. "Why would you want to take a drug for months when you may be cured by surgery alone?" D. "You need to talk about this with your oncologist and your surgeon."

Answer: B Rationale: Pembrolizumab is a type of immunotherapy that helps control lung cancer but does not cure it. It is approved only for use in clients whose cancers are positive for PD-L1 or 2 and have metastasized to the extent that they are at Stage IV. Although this client's cancer cells may have been tested for PD-L levels, his cancer stage does not qualify for the therapy. His best chances for cure at a stage I is complete tumor removal by surgery. Although C sounds like a correct response, it sounds very judgmental. The nurse can give accurate information to the client about the immunotherapy drug. It is not necessary to keep the information from him until he speaks to the oncologist or the surgeon. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention

18-3. Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy? A. Avoid injecting it in a site near a cutaneous lesion. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because it causes extreme drowsiness.

Answer: B Rationale: The drug is a monoclonal antibody given parenterally. It is composed of some foreign proteins and has been known to cause anaphylaxis even 2 hours after administration. Thus, it must be given by a health care professional in a setting capable of handling an anaphylactic emergency. It must not be self-administered. The drug is not available in tablet form. Belimumab does not induce drowsiness and can be administered at any time of day. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

Safe and Effective Care Environment The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling. C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system. D. No action is needed because these responses are normal for the first post-op day after lobectomy.

Answer: B Rationale: The tip of the chest tube could be lying against tissue, becoming occluded and causing the burning pain. Repositioning the client can change the position of the chest tube tip, relieving the pain and allowing drainage to continue. A is incorrect because although no bubbling means no drainage and could lead to a tension pneumothorax, troubleshoot quickly before call the rapid response team. If repositioning does not solve the problem, then call the rapid response team. C is incorrect. Identifying the cause of the pain is critical in this situation. Although it is important to relieve pain, wait to see how the repositioning affects the problem. The client needs to be completely alert to report how the sensation has changed (or not changed) as a result of the repositioning. D is incorrect. Neither the burning pain nor the lack of bubbling in the water seal chamber are normal at this stage of postoperative recovery. Cognitive level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation/Evaluation

Integrative Process: Communication and Documentation or Nursing Process 2. A client has been receiving the same dose of an intravenous opioid for two days to manage post-surgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? A. There is likely a history of addiction. B. Tolerance to the opioid is developing. C. Physical dependence is developing. D. The client is opioid-naïve.

Answer: B. Rationale: A client who has been receiving the same dose of an opioid for several days and now reports that the drug is not controlling the pain is likely developing tolerance. This is not the same thing as addiction or physical dependence. Physical dependence is manifested when a drug is stopped and the client shows withdrawal symptoms. Tolerance means the body has adapted to the drug and the client may require an increased dose or switching to a different drug for pain control. An opioid-naïve person has not recently taken enough opioid on a regular basis to become tolerant to the effects of an opioid. Tolerance does not indicate addiction or a history of addiction. Cognitive Level: B Integrative Process: Nursing Process

Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 X 109/L) to 400 cells/mm3 (0.2 X 109/L) indicates to the nurse that more teaching is needed? A. "Now my viral load is also probably lower." B. "I am so relieved that my drug therapy is working." C. "Although I am still HIV positive, at least I no longer have AIDS." D. "This change means I am less likely to develop an opportunistic infection."

Answer: C Rationale: A diagnosis of AIDS (HIV-III) requires that the adult be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 (0.2 X 109/L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3 [0.2 X 109/L]) or an opportunistic infection. Once HIV-III (AIDS) is diagnosed, even if the patient's T-cell count improves or if the percentage rises above 14%, or the infection is successfully treated, the AIDS diagnosis remains. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

18-2. Which action will the nurse perform first for a client in anaphylaxis to prevent harm? A. Applying oxygen by nonrebreather mask B. Administering IV diphenhydramine C. Injecting epinephrine D. Initiating IV access

Answer: C Rationale: All actions are appropriate interventions for the client having an anaphylactic reaction. The first and most important action is to inject the epinephrine to stop the attack. Administering oxygen is helpful in supporting the client but will not stop this extremely rapid response and will take time away from administering the epinephrine. Giving diphenhydramine is a second line therapy for anaphylaxis. Initiating IV access is important but may not even be possible if the blood pressure is too low during anaphylaxis. Time should not be wasted on this action. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation

Safe and Effective Care Environment When performing a medication reconcilliation for a newly admitted client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm? A. Record and display the information in a prominent place within the client's medical record. B. Ask the client how long the drugs have been prescribed and how well the asthma is controlled. C. Collaborate with the surgeon to arrange for continuation of this therapy in the postoperative period. D. Ensure that parenteral forms of these drugs are prescribed for use while the client remains NPO after surgery.

Answer: C Rationale: Asthma is a common disorder and adults admitted to the hospital for other health problems or surgery may also have asthma. For optimal control continuing the asthma drug therapy, is a priority regardless of setting. Although the length and effectiveness of therapy are important for evaluating an asthma treatment plan, the information is not the priority for this situation. Ensuring this information is included in the client's medical record is important but ensuring that the drugs are continued as prescribed during this client's hospitalization has a higher priority. The drugs are administered by inhalation and a parenteral form is not needed for a client who is NPO. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Intervention

Physiological Integrity What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed this drug? A. "Do you have glaucoma or any other problem with your eyes?" B. "Do you take medications for a seizure disorder?" C. "Are you allergic to sulfa drugs?" D. "Are you a diabetic?"

Answer: C Rationale: Fosamprenavir, a protease inhibitor, contains sulfa. A client who is allergic to sulfa drugs is highly likely to also be allergic to fosamprenavir and have a serious or life-threatening reaction to the drug. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment

Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

Answer: C Rationale: HIV particles are made within the infected CD4+ T-cell, using the host cell's protein synthesis processes. The new virus particle is made as one long inactive protein strand. The strand is clipped by the enzyme HIV protease into smaller active pieces. Protease inhibitors block the enzyme from creating active viral pieces that can leave the cell and infect other cells. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

18-3. Which new onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm? A. Increased bruising B. Increased daily output of slightly foamy urine C. Failure to see letters in the middle of a word D. Sensation of nausea within an hour of taking the drug

Answer: C Rationale: Hydoxychloroquine can be toxic to retinal cells, especially near the macula. This would result in decreased or lost central vision such as would be seen as "missing" letters in the center of a word being read. Bruising is an expected side effect of the drug because is decreases clotting. Although foamy urine is an early indicator of protein in the urine and would need to be addressed, it is not as pressing a problem as the decreased central vision, which is irreversible and an indication that the drug must be stopped immediately. Nausea, although unpleasant, does not have a high risk for causing harm. Cognitive Level: Applying or Higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluation

27-2. A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm? A. pH from 7.21 to 7.20 B. HCO3- remains the same at 31 mEq/L C. PaCO2 from 45 mmHg to 68 mmHg D. PaO2 from 88 mmHg to 86 mmHg

Answer: C Rationale: The rise in PaCO2 represents acute hypercapnia that could rapidly lead to respiratory failure. Although the oxygen level has dropped slightly, which is never good, it is the dramatic rise in carbon dioxide level that requires immediate action to determine the cause and intervene to prevent a worsening of the client's condition. The decrease in pH supports the identification of hypercapnia but this change alone does not warrant immediate action. The bicarbonate level is unchanged, which supports that the hypercapnia is an acute problem. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation

17-4. A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient's pregnancy? A. Abacavir B. Darunivir C. Tripanavir D. Raltegravir

Answer: D Rationale: Raltegravir is teratogenic and can cause birth defects. Although most cART drugs are prescribed during pregnancy and significantly reduce the risk for transmitting HIV to the infant, raltegravir is suspended during pregnancy. Cognitive Level: Understanding Client Needs Category: Safe and Effective Care Environment

18-2. A client who is six feet two inches tall and weighs 205 lb is having an anaphylactic reaction. Which dose of epinephrine will the nurse prepare for this client? A. 0.3 mL of a 1:10,000 solution B. 0.5 mL of a 1:10,000 solution C. 0.3 mL of a 1:1000 solution D. 0.5 mL of a 1:1000 solution

Answer: D Rationale: The dosage of epinephrine needed to be of benefit during an anaphylactic reaction is based on size. Adults are prescribed doses ranging from 0.3 mL to 0.5 mL of a 1:1000 solution. A solution of 1:10,000 will be ineffective unless the dose is massive. This client is larger than average and needs a larger dose of the solution. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation

17-2. Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid? A. Caffeinated beverages B. Grapefruit juice C. Dairy products D. St. John's Wort

Answer: D Rationale: Tipranavir is a protease inhibitor. St. John's Wort changes the activity of metabolizing enzymes resulting in more rapid elimination of all the protease inhibitors and reducing their effectiveness. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

27-4. The nurse teaching clients precautions to use with drug therapy for primary pulmonary arterial hypertension (PAH) instructs the female clients to use two reliable forms of contraception while taking which drugs? Select all that apply. A. Ambrisentan B. Bosentan C. Epoprostenol D. Iloprost E. Macitentan F. Riociguat G. Selexipag H. Sildenafil I. Tadalafil J. Treprostinil

Answers: A, B, E, F Rationale: All the endothelin-receptor antagonists, including ambrisentan, bosentan, and macitentan, have been demonstrated to have teratogenic properties that can cause birth defects. Riociguat also has teratogenic properties. These drugs are contraindicated for use in women who are pregnant and when used by women of child-bearing age who are sexually active, two reliable methods of contraception are needed. The prostacyclin agonists (epoprostenol, iloprost, treprostinil, and selexipag), as well as the phosphodiesterase inhibitor-based guanylate cyclase inhibitors (sildenafil and tadalafil), are not associated with an increased risk for birth defects. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation

18-1. Which statement(s) regarding type III hypersensitivity reactions is/are true? Select all that apply. A. Type III responses are usually directed against self cells and tissues. B. Susceptibility for developing a type III hypersensitivity response follows an autosomal dominant pattern of inheritance. C. The hypersensitivity starts as a type II reaction that progresses to a type III reaction. D. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. E. Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity. F. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

Answers: A, E Rationale: Type III reactions are responsible for the generation of autoantibodies that attack self cells and tissues as part of autoimmune disorders. Rheumatoid arthritis is a classic example of a type III response generating autoimmunity. Although this type of reaction results from a genetic susceptibility combined with a triggering event, the pattern of inheritance is not discernable and most likely represents a polygenic effect. A type II response is generated by a foreign cell or protein that attaches to a normal body cell. When the antigen is attacked, the normal cell attached to it also is attacked. It does not progress to a type III autoimmune response. Although macrophages may be involved in some aspect of tissue injury with autoimmune disorders, the main mechanism is the development of autoantibodies from B-cells. Bradykinin and angioedema are features of a type I hypersensitivity and are not associated with type III responses. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

18-1. Which statement(s) regarding type I hypersensitivity reactions is/are true? Select all that apply. A. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine. B. The response is characterized by the five cardinal symptoms of inflammation. C. Type I responses are usually directed against nonself but the response is excessive. D. Susceptibility for developing a type I hypersensitivity response follows an X-linked recessive pattern of inheritance. E. This type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus. F. Responses always occur within minutes of exposure to the allergen. G. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

Answers: B, C, G Rationale: Type I responses Type I reactions result from the increased production of the immunoglobulin E (IgE) antibody class that cause the release of mediators including histamine, bradykinin, leukotriene, and others that result in the five cardinal symptoms of inflammation (pain, swelling, warmth, redness, and loss of function). The reactions are directed against appropriate nonself targets rather than against self cells but the responses are excessive. The second phase of type I reactions are caused by accumulation of bradykinin deep within the skin tissue layers, which is the major mechanism of angioedema. Antihistamines are helpful with a type I hypersensitivity reaction because the major mediator is histamine. Although the susceptibility to type I reactions is genetic, no specific pattern of inheritance has been identified. Many type I reactions do occur rapidly after exposure to the allergen; however, angioedema is a pure type I reaction and may not occur until days, weeks, months, and even years after continual exposure to the allergen. Cognitive Level: Understanding Client Needs Category: Physiological Integrity

Psychosocial Integrity Which activities can the nurse postpone or eliminate for the client who has extreme fatigue today? Select all that apply. A. Administering prescribed drug therapy B. Ambulating in the hall C. Culturing suspected infectious drainage D. Performing pulmonary hygiene E. Performing oral care F. Providing a complete bed bath G. Teaching about nutrition therapy

Answers: B, F, G Rationale: Although the patient is fatigued, some nursing care actions are essential to prevent immediate and potentially lethal complications. Most of these involve infection prevention activities and include administering prescribed drug therapy, culturing body fluids or lesions when infection is suspected, performing pulmonary hygiene to prevent or manage respiratory infections, and performing meticulous oral care to prevent infections. It is not immediately helpful to have the client ambulate in the hall or receive a complete bed bath (just inspect and clean the perineal and axillary areas). Teaching performed when the client is extremely fatigue has little effect or retention. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluating

A client with primary pulmonary arterial hypertension (PAH) receiving treprosinil by continuous IV infusion now has a fever of 101.6 degrees F (38.7 degrees C). Which actions will the nurse perform to prevent harm? Select all that apply. A. Administer the prescribed antipyretic B. Ask the client whether a productive cough is present C. Apply oxygen by nasal cannula D. Culture the IV site E. Determine whether a durable power of attorney has been signed F. Increase the treprostinil flow rate G. Initiate a second IV access and administer prescribed antibiotic H. Place the client in protective isolation

Answers: D, F, G Rationale: Clients with PAH receiving continuous IV drug therapy are at high risk for developing sepsis because of the long-term direct access line. Any client with a fever is considered to have sepsis until proven otherwise, not pneumonia or any other respiratory infection. Also, clients with PAH who develop sepsis are less likely to survive it. The critical actions to prevent harm are to give oxygen to promote better gas exchange, initiate a second IV (only the prostacyclin agonist is administered through the long-term continuous line) and give the prescribed antibiotic immediately, increase the treprostinil flow rate (as prescribed) to prevent the pulmonary pressure from becoming higher. Culturing the IV site instead of the blood is unlikely to provide useable information in a timely manner. Placing the client in protective isolation will not help fight the sepsis. A durable power of attorney is not going to prevent harm. Administering the antipyretic will not prevent harm and is not the priority. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Health Care Environment Nursing Process Step: Implementation

Question 15 of 18 Which type of drug therapy will the nurse prepare a client in the early disseminated stage of Lyme disease to take for control or cure of this disease? Convalescent serum Corticosteroids Biological response modifiers Antibiotics

Antibiotics The goal of therapy during the initial and disseminated stages of Lyme disease is to eradicate the organism causing the infection with antibiotic therapy. Common antibiotics prescribed, sometimes for up to 30 days, include doxycycline, amoxicillin, and erythromycin. None of the other types of therapy listed are focused on this outcome.

Question 4 of 18 Which action is the priority for the nurse to take to prevent harm for the alert 58-year-old client who is admitted to the emergency department with wheezing, dyspnea, angioedema, blood pressure of 70/52 mm Hg, and an irregular apical pulse of 122 beats/min? Asking about exposure to possible allergens Applying oxygen via a high-flow nonrebreather mask at 90% to 100% Reassuring the client that appropriate interventions are being instituted Starting an IV infusion of normal saline

Applying oxygen via a high-flow nonrebreather mask at 90% to 100% The immediate priority is to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.

Question 5 of 28 Which assessment findings in a client with asthma indicate to the nurse that the client's asthma condition is deteriorating and progressing toward respiratory failure? Audible wheezing with use of accessory muscles on inhalation Crackles, rhonchi, and productive cough with yellow sputum Tachypnea, thick and tenacious sputum, and hemoptysis Respiratory alkalosis; slow, shallow respiratory rate

Audible wheezing with use of accessory muscles on inhalation Normal exhalation is passive. When airways narrow, wheezing is first heard on exhalation. Wheezing on inhalation along with the use of accessory muscles for inhalation indicates more severe airway problems and a worsening of asthma.Worsening asthma would cause acidosis, not alkalosis. Hemoptysis is not associated with asthma. Crackles are not present because asthma is an airway problem, not an alveolar problem.

Question 14 of 18 What is the pathophysiologic basis for Lyme disease progression to stage III? Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels Failure of the immune system to recognize the causative organism as non-self, allowing it to become a systemic infection Triggering of antibodies against infected cells that lead to autoimmune disease The special ability of Borrelia burgdorferi to burrow deeply into joint, cardiac, and neurons causing direct damage to these tissues.

Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels The causative organisms can switch out parts of its unique surface proteins, which changes the ability of immune sensitized system cells and antibodies to recognize the existing infecting organism allowing it to "hide." Every time a switch occurs, the immune system treats them like a new infection, and develops new antibodies and inflammatory responses to them, resulting in keeping all general and specific immunity actions in continual but ineffective attack mode through all stages of the disease process. This prolonged and continuous process results in persistent and enhanced damage to a variety of tissues and organs.

Question 6 of 14 Which concept is the highest priority for the nurse to consider in planning care for the client with HIV-III who has candidial stomatitis? Cellular regulation Gas exchange Comfort Nutrition

Comfort Candidial stomatitis causes considerable oral discomfort and difficulty eating and swallowing. Ice chips and cool liquids can help reduce the discomfort until prescribed antifungal agents have reduced the infection symptoms. Some clients may have pain to the point that opioid analgesics are needed. Gas exchange and cellular regulation are not directly affected by the problem. Although nutrition is negatively affected, it is the pain that interferes most with nutrition.

Question 11 of 28 Which complication does the nurse suspect when a client with severe chronic obstructive pulmonary disease COPD has new-onset increased fatigue, dependent edema, neck vein distension, and oral cyanosis? Lung cancer Cor pulmonale Pneumonia Asthma

Cor pulmonale The client with long-term COPD develops higher pressures in pulmonary blood vessels making the right ventricle of the heart work harder to generate pressures that are high enough to perfuse the lungs. This persistent over-working of the right ventricle leads to right-sided heart failure that is not related to independent cardiac damage (cor pulmonale). This complication remains a constant risk for anyone with COPD.These symptoms are not related to asthma or pneumonia. Although some are also associated the lung cancer, they would appear slowly over time.

27-1. Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy? A. Avoid breathing into the inhaler or getting it wet. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because of the extreme drowsiness it causes.

Correct Answer: B Rationale: The drug is a monoclonal antibody given parenterally. It is composed of some foreign proteins and has been known to cause anaphylaxis even 2 hours after administration. Thus it must be given by a health care professional in a setting capable of handling an anaphylactic emergency. It must not be self administered. The drug is not in an inhaled or tablet form. Benralizumab does not induce drowsiness and can be administered at any time of day. Cognitive Level: Applying or higher Client needs category: Health Promotion and Maintenance Nursing Process Step: Implementation

Question 10 of 28 Which changes in arterial blood gas (ABG) values will the nurse expect in a client with long-term chronic obstructive pulmonary disease (COPD)? Decreased pH; Decreased PaO2; Increased PaCO2; Increased bicarbonate level Increased pH; increased PaO2; increased PaCO2; Increased bicarbonate level Increased pH; increased PaO2; increased PaCO2; decreased bicarbonate level Decreased pH; decreased PaO2; decreased PaCO2; decreased bicarbonate level

Decreased pH; Decreased PaO2; Increased PaCO2; Increased bicarbonate level Hallmark changes in ABGs for long-term COPD is respiratory acidosis (increased arterial carbon dioxide [Paco2]); metabolic alkalosis (increased arterial bicarbonate) as compensation by kidney retention of bicarbonate (seen as an elevation of HCO3− although pH remains lower than normal); and lower-than-normal PaO2 from poor gas exchange.

Question 9 of 18 What precaution is most important for the nurse to teach the client with systemic lupus erythematosus (SLE) prescribed to take 45 mg of a corticosteroid daily for 2 weeks to manage an SLE flare? Check all your stools for the presence of blood or a black, tarry appearance. Do not suddenly stop taking the drug when your flare is over. Be sure to take this drug with food. Take 30 mg in the morning and 15 mg at night.

Do not suddenly stop taking the drug when your flare is over. All of the precautions are correct and important. However, the most critical precaution is to not suddenly stop taking the drug, which could lead to acute adrenal insufficiency and even death. This dose of the drug (45 mg daily) would need to be tapered down over a period of weeks to prevent adrenal insufficiency.

Question 7 of 28 Which action will the nurse teach a client with chronic bronchitis to use to mobilize secretions? Drinking at least 2 L of fluid daily Avoiding triggers that cause coughing Elevating the head of the bed 45 degrees Assuming the tripod position as often as possible

Drinking at least 2 L of fluid daily Clients with chronic bronchitis tend to have thick secretions. Hydration with at least 2 L of fluid daily thins tenacious (sticky) secretions, making them easier to expectorate. If health issues require fluid restriction, the client would attempt to consume the total amount permitted.Head of bed elevation may promote oxygenation and lung expansion, but does not promote secretion mobilization. Clients need to sit with both feet on the floor when performing controlled coughing. The tripod position is assumed during episodes of hypoxemia, but will not facilitate mobilization of fluid.

Question 2 of 14 Which signs and symptoms does the nurse expect to find in a client diagnosed with Pneumocystis jiroveci infection? Dyspnea, tachypnea, persistent dry cough, and fever Substernal chest pain and difficulty swallowing Fever, persistent cough, and vomiting blood Cough with copious thick sputum, fever, and dyspnea

Dyspnea, tachypnea, persistent dry cough, and fever P. jiroveci causes pneumonia with dry cough, shortness of breath, breathlessness, and fever. Thick sputum and vomiting blood are not present. Substernal chest pain and difficulty swallowing are associated with an oral and esophageal candida infection. Vomiting blood is not associated with any type of pneumonia.

Question 7 of 18 Which of the drugs or supplements taken daily taken by a client who is newly diagnosed with drug-induced systemic lupus erythematosus (SLE) does the nurse suspect is most likely to have caused this problem? Vitamin D Lisonopril Aspirin Hydralazine

Hydralazine Hydralazine is a blood pressure medication that has been found to cause drug-induced SLE. None of the other drugs are associated with drug-induced SLE, although lisinopril, an angiotensin-converting enzyme inhibitor, is associated with development of angioedema.

Question 17 of 28 For which side effect will the nurse monitor a client with pulmonary arterial hypertension (PAH) who is receiving endothelin receptor antagonist therapy? Hypotension Increased clot formation Sepsis Decreased urine output

Hypotension Endothelin receptor antagonists cause vasodilation of systemic as well as pulmonary blood vessels, which can lead to severe hypotension.These oral drugs do not increase clot formation or lead to sepsis. Urine output is only affected when hypotension becomes profound.

Question 8 of 14 With which antiretroviral drug class will the nurse teach clients to prevent harm by reporting any new onset muscle weakness and muscle pain to the immunity health care provider? Fusion inhibitors Integrase inhibitors Nucleoside reverse transcriptase inhibitors Protease inhibitors

Integrase inhibitors The integrase inhibitor class of drugs can cause muscle breakdown (rhabdomyolysis) especially in adults taking a "statin" (type of lipid-lowering drug). The first symptoms of rhabdomyolysis are muscle pain and weakness. None of the other classes of antiretroviral drugs have this side effect.

Question 8 of 28 Which action is most important for a nurse to take to prevent complications for a client with a history of chronic obstructive pulmonary disease (COPD) is admitted for a surgical procedure that is unrelated to the respiratory system? Assessing the client's respiratory system every 8 hours Instructing the client to use a tissue when coughing or sneezing Monitoring for signs and symptoms of pneumonia Ensuring the client remains in bed for a full 24 hours after surgery

Monitoring for signs and symptoms of pneumonia The client with COPD is always at greater risk for development of a respiratory infection, especially after any surgery requiring anesthesia. The nurse would assess the client's respiratory system at least every 2 hours. The client with COPD alone does not pose an infection risk to others, although everyone is urged to use a tissue to cover the mouth and nose when sneezing or coughing. Remaining in bed is avoided because it promotes atelectasis and pneumonia.

Question 5 of 18 What is the most important action to prevent harm for the nurse to perform after a client's oral and facial swelling from an angiotensin-converting enzyme inhibitor (ACEI) have resolved? Teaching the client about symptoms to report immediately to the primary health care provider Instructing the client to discard the offending drug after being discharged Monitoring the client for return of symptoms for at least the next 2 to 4 hours Assessing the vein above the IV infusion site for a firm, cordlike texture

Monitoring the client for return of symptoms for at least the next 2 to 4 hours All actions are important, although phlebitis is not likely to occur from IV therapy for angioedema. The ACEI class of drugs have a longer half-life and remain in the body longer than does the corticosteroid infusion used to treat the angioedema. As a result, symptoms can recur after first resolving when corticosteroid therapy is stopped. The client remains at risk and must be monitored for at least 2 to 4 hours for return of angioedema.

Question 1 of 28 Which action will the nurse teach an older client with a respiratory problem to make as an accommodation to promote adequate gas exchange? Notify your primary health care provider at the first sign of respiratory infection. If you must walk any distance in cool weather move quickly to keep warm. Replace at least one meal each day with a high-calorie liquid food supplement. Avoid any nonessential physical activity or exercise.

Notify your primary health care provider at the first sign of respiratory infection. A respiratory infection can become serious very quickly in an older client with a pre-existing respiratory problem and must be addressed as early as possible before complications occur.Older clients with respiratory problems are encouraged to perform low-impact exercises, such as walking, daily but should not rush through it. The client is taught to pace the exercise and stop and rest as often as needed. High-calorie liquid food drinks are meant to supplement meals, not replace them.

Question 2 of 28 How will the nurse categorize the level of asthma control for a client who reports usually waking at night with wheezing once weekly and needing to use the prescribed reliever inhaler to stop the episode? Minimally controlled Partly controlled Controlled Uncontrolled

Partly controlled The client meets the criteria for partly controlled asthma, which are that any of these symptoms occur one to two times per week:Daytime symptoms of wheezing, dyspnea, coughingWaking from night sleep with symptoms of wheezing, dyspnea, coughingReliever (rescue) drug needed no more than twice weekly

Question 3 of 28 What is the priority action for the nurse to take when a client comes to the emergency department with extremely labored breathing and a history of asthma that is unresponsive to prescribed inhalers? Establishing IV access to give emergency medications. Asking the client how long he or she has had asthma and what triggered this attack Preparing the client for intubation Placing the client in a high-Fowler position, and starting oxygen

Placing the client in a high-Fowler position, and starting oxygen With labored breathing, the client is most likely hypoxemic and the first priority is ensuring gas exchange by placing the client in a high-Fowler position and starting oxygen.The length of time the client has had asthma and the probably trigger for this attack are not important and will not affect how this attack is managed. Establishing IV access is important but not the first priority. Preparing a client for intubation is not needed unless all other methods to improve gas exchange are not effective.

Question 9 of 28 Which point is most important to prevent harm for the nurse to teach a client with chronic obstructive pulmonary disease (COPD) who is being discharged on home oxygen th Correct performance when setting up the oxygen delivery system Understanding the signs and symptoms of hypoxemia Demonstrating how to use a pulse oximetry device Removing combustion hazards present in the home

Removing combustion hazards present in the home The highest priority of education is that oxygen is highly combustible. The nurse must ensure that no open flames or combustion hazards will be present in a room where oxygen is in use.The oxygen delivery system in the home will be different than in the hospital. Therefore, this skill may be verified by the visiting nurse or company providing the oxygen. The client must be able to state signs and symptoms of hypoxemia, although safety is the priority. Pulse oximetry may be useful for monitoring the client's oxygenation status and the visiting nurse or respiratory therapy partner can assess this.

Question 12 of 28 Which action is most important for the nurse to take when a client with chronic obstructive pulmonary disease who is taking a cholinergic antagonist now reports nausea, blurred vision, headache, and inability to sleep? Reporting the symptoms to the primary health care provider immediately Asking the client to explain the exact techniques he or she uses when taking the drug Requesting an order to draw blood to determine the drug level Reminding the client that these side effects are normal and not to worry

Reporting the symptoms to the primary health care provider immediately The symptoms the client describes represent a drug overdose placing the client in danger of even more adverse effects.It is possible that the client is taking the drug more frequently or at higher doses than prescribed; however, the first priority is to notify the primary health care provider. The drug is only taken as an inhalation and blood levels will not provide any useful information.

Question 14 of 28 Which complication will the nurse assess for first in any client with cystic fibrosis (CF)? Respiratory infection Pneumothorax Weight loss Osteoporosis

Respiratory infection In addition to respiratory failure, the most common cause of death for any client with CF is respiratory infection. Recognizing infections early and initiating appropriate therapy are essential life-saving strategies.Although weight loss and osteoporosis are complications of CF, they are not immediately life threatening. Pneumothorax is not a common complication of CF.

Question 11 of 18 Which precaution is a priority to prevent harm for the nurse to teach a client with systemic lupus erythematosus (SLE) who is newly prescribed to take hydroxychloroquine for disease management? See your ophthalmologist for visual field testing every 6 months. Report a reduction of joint swelling to your rheumatology health care provider immediately. Report a worsening of joint swelling to your rheumatology health care provider immediately. See your ophthalmologist for intraocular pressure measurement every 6 months.

See your ophthalmologist for visual field testing every 6 months. Hydroxychloroquine has both immunomodulating and anticlotting effects that can be beneficial to clients with SLE. A major complication of this drug is its toxicity to retinal cells causing retinitis that can lead to an irreversible loss of central vision. Clients prescribed hydroxychloroquine are instructed to have frequent eye examinations with visual field testing (before starting the drug and every 6 months thereafter). If retinal toxicity is suspected, the drug is discontinued to preserve the remaining vision.

Question 6 of 28 Which outcome indicates to the nurse that oxygen therapy for the client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia is effective? PCO2 is within normal range. Finger clubbing has resolved. Client reports decreased distress. SpO2 is between 88% and 90%.

SpO2 is between 88% and 90%. Clients with hypoxemia, even those with COPD and hypercarbia, need to receive oxygen therapy at rates appropriate to reduce hypoxia and maintain SpO2 levels between 88% and 92%.Gases diffuse independently, therefore applying oxygen will not decrease the carbon dioxide level and hypoxemia may still be present. A report of less distress is appropriate but not an objective indicator of therapy effectiveness. Finger clubbing in a client with long-term COPD does not resolve.

Question 18 of 28 Which action with the nurse take to prevent harm when prescribed to administer an IV antibiotic to a client with pulmonary artery hypertension (PAH) who is being managed with a continuous prostacyclin agonist infusion? Requesting a prescription for an oral antibiotic Starting a peripheral IV access to use for administering the antibiotic Stopping the prostacyclin agonist infusion for 15 minutes to administer the IV antibiotic Administering the IV antibiotic through the continuous infusion's side port

Starting a peripheral IV access to use for administering the antibiotic The prostacyclin agonist infusion cannot be stopped for even 15 minutes without endangering the client's life. The drug also cannot be mixed with any other drug. Clients with PAH are at high risk for sepsis. Thus, the antibiotic must be administered intravenously and the safest action is to insert a separate peripheral IV access for this purpose.

Question 15 of 28 Why will the nurse administer vitamin supplements to a client who has cystic fibrosis (CF)? Clients are too fatigued to ingest sufficient vitamins and nutrients. Steatorrhea causes a deficiency of fat-soluble vitamins. Increased blood levels of vitamins enhance chloride transport activity. High doses of vitamins can slow the progression of the disease.

Steatorrhea causes a deficiency of fat-soluble vitamins. The stool of clients with CF contains large amounts of fat (steatorrhea), which promotes loss of fat-soluble vitamins, leaving the client deficient of such vitamins and malnourished.Vitamins are important for general health and nutrition and play no role in the disease or its progression.

Question 16 of 28 Which action is most important for the nurse to take when preparing a client with cystic fibrosis (CF) for a lung transplantation procedure? Teaching the client how to perform pulmonary muscle strengthening exercises Collaborating with the registered dietitian nutritionist to provide high-calorie, high-protein meals Reminding the client to continue taking prescribed vitamin supplementation Using aseptic technique when assisting the client to perform pulmonary hygiene

Teaching the client how to perform pulmonary muscle strengthening exercises Surgery for lung transplantation involves large "clam-shell" incisions that cut through ribs and muscle. This procedure is very painful and clients have a difficult time breathing deeply enough to wean from the ventilator. A critical factor in the outcome of the surgery and prevention of atelectasis and pneumonia in the new lungs is the strength of the muscles used for ventilation. These muscles must be strengthened before the transplantation.

Question 19 of 28 What is the primary indication for the nurse to apply supplemental oxygen to the client with pulmonary artery hypertension (PAH)? Oxygen therapy is part of the client's ongoing clinical management and is applied continuously. The client determines when oxygen supplementation is needed. The nurse applies oxygen when the client's respiratory rate is decreased. The nurse applies oxygen when the client's respiratory rate is increased.

The client determines when oxygen supplementation is needed. The nurse applies supplemental oxygen when the client finds the dyspnea to be uncomfortable. This action is not dependent on a particular respiratory rate. It is also not a continuous therapy.

Question 3 of 14 What is the first action a nurse should take after sustaining a needlestick injury after injecting a client who is known to be HIV positive? Send the syringe and needle to the laboratory for analysis of viral load. Inform the charge nurse. Thoroughly scrub and flush the puncture site. Go to the employee clinic for postexposure prophylaxis.

Thoroughly scrub and flush the puncture site. Although the nurse would also inform the charge nurse and go to the employee clinic to initiate postexposure prophylaxis, the first action is to clean the puncture site by washing it thoroughly with soap and water for at least 1 minute as recommended by the CDC. Viral load cannot be determined by analyzing the syringe and needle.

Question 2 of 18 Which type of hypersensitivity reaction will the nurse suspect in a client who develops as circular rash on the skin underneath a new necklace worn for 3 days? Type IV Type I Type II Type III

Type IV A type IV delayed hypersensitivity reaction occurs when sensitized T-cells respond to an antigen by releasing chemical mediators and triggering macrophages. This reaction causes a rash as seen in a metal allergy exposure.A type I reaction occurs rapidly after exposure and is mediated by immunoglobulin E (IgE). Type II reactions occur when the body makes autoantibodies directed against self-cells and attack those cells. Type III reactions occur when an abundance of immune complexes are made and they get stuck in small vessels causing inflammation.