EAQ #1 F & E, Acid-Base, Cancer, HIV/AIDS, Hematology
A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan? - "Cover the area with a sterile gauze bandage." - "Put warm compresses on the site once a day." - "Limit lying on the back and unaffected side when sleeping." - "Avoid applying lotions and powders over the area."
"Avoid applying lotions and powders over the area."
A client is admitted to the hospital for surgery for rectosigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with rectosigmoid colon cancer does the nurse expect the client to report? Select all that apply. - Feeling tired - Rectal bleeding - Inability to digest fat - Change in the shape of stools - Feeling of abdominal bloating
Feeling tired Rectal bleeding Change in the shape of stools Feeling of abdominal bloating
A client is seen in the clinic with sickle cell anemia. The primary healthcare provider has prescribed an iron supplement to treat the client's anemia. What is the nurse's primary concern in regard to giving the supplement? - Giving iron with this condition is contraindicated. - Finding a straw is necessary to prevent staining of teeth. - When giving iron, orange juice is needed to improve absorption. - Warning about stools changing to black will prevent undue stress.
Giving iron with this condition is contraindicated
A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. Which locations on the client's body should the nurse assess? Select all that apply. - Sclera - Nail beds - Conjunctivae - Palms of hands - Bony prominences
Nail beds Conjunctivae Palms of hands
The hemoglobin levels of a 30-year-old female client are measured at 8 mg/dL (80 g/L). Which integumentary findings can be noticed in this client? Select all that apply. - Pallor - Clubbing - Café au lait spots - Brittle nails - Koilonychia
Pallor Brittle nails Koilonychia
A client is admitted to the hospital with a diagnosis of intestinal obstruction. The healthcare provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client? - Protein enzymes - Energy carbohydrates - Vitamins and minerals - Water and electrolytes
Water and electrolytes
A client presents with sneezing; lacrimation; swelling with an airway obstruction; and pruritus around the eyes, nose, throat, and mouth. The nurse interprets these findings as a Type I hypersensitivity reaction. Which disease might have occurred in the client? - Angioedema - Allergic rhinitis - Contact dermatitis - Goodpasture syndrome
Allergic rhinitis
What is an example of a type I hypersensitivity reaction? - Anaphylaxis - Serum sickness - Contact dermatitis - blood transfusion reaction
Anaphylaxis
A client presents with cutaneous lesions with swelling in the face, eyelids, and lips from dilation and engorgement of the capillaries. No welts or vesicles are observed. Which condition most likely has occurred in the client? - Urticaria - Angioedema - Atopic dermatitis - Systemic lupus erythematosus (SLE)
Angioedema
The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? - Increase in blood pressure - Decrease in erythropoietin - Increase in serum phosphate levels - Decrease in serum sodium concentration
Decrease in erythropoietin
After providing epinephrine to a client experiencing an anaphylactic reaction, which second-line drugs should the nurse prepare to provide? Select all that apply. - Dopamine - Norepinephrine - Dexamethasone - Diphenhydramine hydrochloride - Hydrocortisone sodium succinate
Dexamethasone Diphenhydramine hydrochloride Hydrocortisone sodium succinate
Which drug can be administered via the intramuscular route to treat anaphylaxis? - Epinephrine - Methdilazine - Phenylephrine - Mycophenolate mofetil
Epinephrine
What information from a client's history should the nurse identify as risk factors for the development of colon cancer? Select all that apply. - Hemorrhoids - Increased age - High-fiber diet - Ulcerative colitis - Low hemoglobin level
Increased age Ulcerative colitis
The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level? - Macrocytic red blood cells (RBCs) - Thrombocytopenia - Decreased folate levels - Increased total iron-binding capacity (TIBC)
Increased total iron-binding capacity (TIBC)
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO 2 60 mm Hg, PCO 2 55 mm Hg, and HCO 3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? - Hypocapnia - Hyperkalemia - Generalized anemia - Respiratory acidosis
Respiratory acidosis
The nurse is caring for a client with a history of atrial fibrillation and a diagnosis of dehydration. What does the nurse anticipate that the plan of care will include? - A glass of water every hour until hydrated - Small, frequent intake of juices, broth, or milk - A short-term nasogastric tube for replacement of fluids and nutrients - A rapid intravenous (IV) infusion of an electrolyte and glucose solution
Small, frequent intake of juices, broth, or milk
The client's laboratory report shows localized vasodilation and transudation of fluid. The nurse interprets these findings as erythema and a wheal. Which condition may be present in the client? - Urticaria - Angioedema - Allergic rhinitis Contact dermatitis
Urticaria
A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what client data or assessment finding? - Skin condition - Fluid and electrolyte balance - Food intake - Fluid intake and output
Fluid and electrolyte balance
The client's laboratory report shows deposits of immunoglobulin G (IgG) along the basement membranes of the lungs. The primary healthcare provider interprets this finding as a sign of Goodpasture's syndrome. What would be the reason for this condition? - Goodpasture's syndrome develops rapidly after exposure to allergens. - Goodpasture's syndrome is caused by dilation and engorgement of the capillaries. - Goodpasture's syndrome occurs when circulating antibodies combine with tissue antigens. - Goodpasture's syndrome is caused by exposure of the skin to substances that combine with epidermal proteins.
Goodpasture's syndrome occurs when circulating antibodies combine with tissue antigens.
What actions should the nurse take when a client develops an anaphylactic reaction? Select all that apply. - Apply oxygen at 90 to 100% - Call the Rapid Response Team - Elevate the head of the bed to 45 degrees - Assign a nursing assistant to stay with the client - Ensure emergency airway equipment is at the bedside
Apply oxygen at 90 to 100% Call the Rapid Response Team Elevate the head of the bed to 45 degrees Ensure emergency airway equipment is at the bedside
A client comes to the clinic for a physical and asks to be tested for acquired immune deficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for human immunodeficiency virus (HIV)? - CD4 T cell count - Western blot test - Polymerase chain reaction test - Enzyme-linked immunosorbent assay (ELISA)
Enzyme-linked immunosorbent assay (ELISA)
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery? - Infection caused by the excretion of feces - Injury caused by exposed intestinal mucosa - Altered bowel elimination caused by the ostomy - Limited water reabsorption caused by removal of intestine
Limited water reabsorption caused by removal of intestine
What is the priority nursing action in the care of a young child with severe diarrhea? - Measuring daily urine output - Maintaining fluid and electrolyte balance - Replacing the lost calories with high-fiber foods - Promoting perianal skin integrity by bathing often
Maintaining fluid and electrolyte balance
Which statement indicates that a client understands the ways HIV is transmitted? Select all that apply. - "I can contract HIV by participating in oral sex." - "I can contract HIV by eating from used utensils." - "HIV is contracted by using contaminated needles." - "I can contract HIV by using the bathroom of a person who is HIV positive." - "Babies can contract HIV because of contact with maternal blood during birth."
"I can contract HIV by participating in oral sex." "HIV is contracted by using contaminated needles." "Babies can contract HIV because of contact with maternal blood during birth."
The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement? - "Red blood cells appear normal in size and color; however, there is a decreased amount produced." - "The red blood cells have an increased life span with a decrease in normal functioning." - "Administration of vitamins B 12 and folate will help to treat this type of long-term anemia." - "This is the mildest form of anemia and is easily corrected through administration of blood products."
"Red blood cells appear normal in size and color; however, there is a decreased amount produced."
A client who was admitted with severe abdominal pain and vomiting states, "I know I am very sick. Do you think I have cancer?" What is the best response by the nurse? - "You must be upset to think that you have cancer." - "Did you receive information about what therapy will be prescribed?" - "Your primary healthcare provider will need to talk with you about that." - "What are your feelings about the diagnosis of cancer?"
"What are your feelings about the diagnosis of cancer?"
A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected. A test for the human immunodeficiency virus (HIV) is performed and acute retroviral syndrome is diagnosed. Which clinical responses are associated most commonly with this syndrome? Select all that apply. - Malaise - Confusion - Constipation - Swollen lymph glands - Oropharyngeal candidiasis
Malaise Swollen lymph glands
The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history? - Acute gastritis - Diabetes mellitus - Partial gastrectomy - Unhealthy dietary habits
Partial gastrectomy
What does the nurse explain to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is based on? - Performance of high-risk sexual behaviors - Evidence of extreme weight loss and high fever - Identification of an associated opportunistic infection - Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests
Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests
What determines if a client will develop AIDS from an HIV infection? - Level of IgM in the blood - The number of CD4+ T-cells available - Presence of antigen-antibody complexes - Speed with which the virus invades the RNA
The number of CD4+ T-cells available
Which symptoms are observed in a client with Sjögren's syndrome? Select all that apply. - Angioedema - Tooth decay - Corneal ulcers - Vaginal dryness - Pulmonary hemorrhage
Tooth decay Corneal ulcers Vaginal dryness
A postmenopausal woman who has cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she tells the nurse that she does not feel well. The nurse reviews the medical record and notices WBCs 2200/mm 3 (2.2 x 10 9/L), RBCs 4.0 million/mm 3 (4.7 x 10 12/L), hemoglobin 12.0 g/dL (120 mmol/L), hematocrit 38%, platelets 170,000/mm 3 (170 x 10 9/L). Vital signs are heart rate 97 beats/minute, respiration rate 25 breaths/minute, oral temperature 99.1 ºF (37.3 ºC), blood pressure 110/72. Based on this information, what does the nurse conclude is the client's priority need? - Promoting rest - Preventing infection - Avoiding bodily harm - Maintaining fluid balance
Preventing infection