Exam 3: Nursing I: Module 6, 7, 8

The nurse looks for results of which laboratory measurement that provides a reliable indicator of lymphocyte status in a client with HIV infection?

1. B lymphocytes 2. T-helper cells (CD4) 3. Natural killer cells (NK) 4. T-cytotoxic cells Answer: 2 Rationale: CD4 cells are indicative of a client's HIV status. As the disease progresses, the T-helper cells decrease in number and lose their ability to function effectively. B lymphocytes indicate the status of humoral immunity and are not directly associated with HIV infection. NK cells are not directly related to HIV infection. T-cytotoxic cells are not directly related to HIV infection. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge of which laboratory measure will provide information about the status of the immune system of a client with HIV. Use nursing knowledge and the process of elimination to make a selection.

MOnoclonal antibodies are:

1. B-cell antibodies developed against a foreign antigen 2. Defective T-cell antibodies that do not recognize self tissue 3. Genetically engineered immunosupressant drugs. 4. Used in vaccines to assist in preventing infections (3) "Rationale: Monoclonal antibodies are genetically engineered immunosuppressant drugs"

The reversible form of SLE is due to reaction to drugs that are known to bind with the individuals DNA such as

1. Beta blockers, Inderal 2. Oral contraceptives, Levora 3. Antibiotics, Tetracycline 4. Antimalarials, Plaquenil (2) "Rationale: The reversible form of SLE is because of a reaction to drugs, such as oral contraceptives (e.g., Levora)."

The assessment of a client with hypokalemia should focus on:

1. Blood pressure 2. Edema 3. Chvostek's sign 4. Heart rhythm (4) Rationale: The major risk associated with a low po- tassium level is cardiac dysrhythmia. Chvostek's sign is associated with hypocalcemia. Although blood pres- sure may be affected by cardiac dysrhythmia, it is not specific to potassium balance. Edema is associated with fluid balance.

1 A 10-month-old infant is admitted to the emergency department with a 102°F rectal temperature and a history of vomiting and diarrhea for 48 hours. For what signs should the nurse look related to this client's likely fluid imbalance?

1. Bulging fontanels, tearless cry, and low urine output 2. Sunken eyes, lethargy, and dry, furrowed tongue 3. Weight loss, dilute urine, and peripheral edema 4. Dry skin, thready pulse, and neck vein distention Answer: 2 Rationale: The client's history suggests Fluid Volume Deficit and dehydration. Sunken eyes, altered mental status and behavior, and dry, furrowed tongue are reliable signs of Fluid Volume Deficit in infants. Bulging fontanels, peripheral edema, and neck vein distention are seen with Fluid Volume Excess. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment 4 Content Area: Adult Health : Endocrine and Metabolic Strategy: The core issue of the question is the ability to correlate a clinical picture with risk for hypovolemia. Use nursing knowledge of signs of dehydration and the process of elimination to make a selection.

Criteria used to diagnose AIDS in an individual with HIV include at least one of the following conditions?

1. CD4+ cell count above 200cells/ml 2. Anemia due to diminished RBC count 3. Dysfunction of one or more organs 4. Development of an opportunistic cancer (4) "Rationale: Criteria used to diagnose AIDS in an individual with HIV includes development of an opportunistic cancer."

Too much of which electrolyte can lead to respiratory depression and arrest?

1. Calcium 2. Magnesium 3. Potassium 4. Chloride (2) "Rationale: Magnesium is important in the transmis- sion of neuromuscular impulses. Too much magne- sium may cause respiratory muscle depression leading to respiratory depression and arrest. Calcium is found mostly in teeth and bones and is involved in blood coagulation. It is also involved in muscle con- traction and nerve impulse transmission. Potassium is necessary for the transmission of nerve impulses, car- diac rhythms, and muscle contraction. Chloride is found in the blood and in the stomach combined with other substances."

A child who must undergo skin testing for allergies takes an antihistamine to control symptoms. The nurse explains that the client must discontinue use of the antihistamine for _____ days before the skin testing to avoid false negative results. Provide a numerical answer.

"_____ days" Answer: 3 Rationale: The client needs to discontinue use of antihistamines for 72 hours (3 days) prior to allergy testing to avoid false negative readings. Cognitive Level: Applying Client Need: Reduction of Risk Potential Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge of the time frame that antihistamine drugs need to be withheld so as not to interfere with the results of allergy testing. Use specific nursing knowledge to determine the correct answer.

A nurse is caring for a patient who is about to begin taking imatinib (Gleevec) to treat chronic myeloid leukemia. Which of the following instructions should the nurse include when talking to the patient about taking this drug? Select all that apply...

-Clean fruits and veggies thoroughly -Increase calcium intake -Weigh daily (SE: Fluid retention) -Perform hand hygiene frequently -Avoid herbal supplements Answer: 1345

A nurse is about to administer IV paclitaxel (Taxol) to a patient who has ovarian cancer. Which of the following actions should the nurse take? Select all that apply...

-Give the patient an antihistamine -Infuse over 1 hour -Administer the drug through non-PVC tubing -Use an in-line filter -Add heparin to the paclitaxel solution Answer: 1,3,4

A nurse is caring for a patient who is about to begin receiving cisplatin to treat testicular cancer. The nurse should tell the patient to report which of the following adverse reactions? Select all that apply...

-Parasthesias -Sore Throat -Flank pain -Tinnitus Answer: 1,2,3,4

Elements of nursing history

-Past medical history -Family history -Genetic history -Current meds -Allergies -Lifestyle behaviors -Occupation -Social environment

A nurse is assessing a patient following trastuzumab (herceptin) infusion to treat metastatic breast cancer. Which of the following findings indicates an adverse reaction to the drug? Select all that apply...

-Wheezing -Dysrythmias -Hypotension -Fever -Ascites Answer: 1234

A nurse is caring for a patient who is about to begin maraviroc (selzentry) therapy. The nurse should tell the patient to report which of the following adverse reactions? Select all that apply...

-parasthesias -cough -tinnitus -jaundice -fever Answer: 1,2,4,5

The nurse is evaluating a client using a cane. Which assessment made by the nurse would indicate that the client is using the cane appropriately?

1. Client holds the cane with the hand on the stronger side. 2. Client holds the cane with the hand on the affected side. 3. Client moves the cane and the affected leg together. 4. The cane tip is made of aluminum to prevent slippage. Answer: 1 Rationale: To provide maximum support and appro- priate body alignment while walking, the cane is held in the hand on the stronger side. The cane and the strongest leg should be advanced together in order to provide a stable stance when the weak leg is advanced. The tip of the cane should have rubber tip to prevent slipping. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: The core issue of the question is the proper use of a cane as an assistive aid. Use the process of elimination and basic nursing knowledge to make a selection.

14 A client's arterial blood gas (ABG) results are pH 7.48; PaCO2 30; HCO3- 23. How will the nurse interpret these results?

1. Compensated respiratory alkalosis 2. Uncompensated metabolic alkalosis 3. Uncompensated respiratory alkalosis 4. Compensated metabolic alkalosis Answer: 3 Rationale: The client's pH is high, indicating alkalosis. The PaCO2 is abnormal, indicating a respiratory basis. The HCO3- is normal, indicating that compensation has not started. Compensated respiratory alkalosis is incorrect because the HCO3- level would decrease with compensation. Uncompensated metabolic alkalosis is incorrect because the primary disturbance is respiratory, as indicated by the decrease in the CO2 parameter. Compensated metabolic alkalosis is incorrect because the primary disturbance is respiratory, as indicated by the decrease in the CO2 parameter. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: Note that the pH is high, so the condition is not compensated, eliminating compen- sated states. Choose respiratory because a low CO2 corre- lates with a high pH, whereas HCO3- at the lower end of the normal range does not correlate with a high pH.

The nurse is caring for a client who has a sodium level of 149 mEq/L. The nurse concludes that it is important to administer which of the following to this client?

1. Cough suppressant to treat symptomatic cough 2. 3 percent saline solution 3. Water 4. Lactulose (Chronulac) Answer: 3 Rationale: Clients with hypernatremia are thirsty, and need water replacement to balance their increased sodium levels. Cough medication and lactulose can further increase sodium levels, and should not be administered unless there is sufficient clinical information to warrant their use. Three-percent saline is a hypertonic solution that would also increase serum sodium levels, and should not be given to this client. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of measures that effectively treat hypernatremia. Use nursing knowledge and the process of elimination to make a selection.

A client will undergo scratch tests for allergies. In teaching the client about the planned tests, the nurse should include which statement?

1. "This test allows us to rule out one or two specific antigens." 2. "The scratch test is the most sensitive allergy test." 3. "Results can be obtained in 30 minutes." 4. "It involves drawing a small amount of blood for testing." Answer: 3 Rationale: A scratch test tests many allergens at once. It is of low sensitivity, but many allergens can be tested at once, and the results can be obtained in 30 minutes. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immunological Strategy: The core issue of the question is identification of appropriate concepts to teach a client about scratch tests for allergies. Use nursing knowledge and the process of elimination to make a selection.

A client with end stage renal disease is experiencing hypermagnesemia. The nurse explains that which treatment will decrease the magnesium level most effectively?

1. Dialysis 2. Diuretics 3. Fluid restriction 4. High-volume IV fluids Answer: 1 Rationale: Either hemodialysis or peritoneal dialysis is used to remove excess magnesium in the client with renal failure. Diuretics will not be effective if the kidneys are not functional. Fluid restriction will be part of the treatment for end stage renal disease but will be ineffective alone in decreasing magnesium level. High-volume IV fluid replacement is contraindicated in renal failure. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of effective therapies for increased magnesium levels. Note the critical words end stage renal disease, which lead you to look for a treatment that does not involve functional kidneys. Use nursing knowledge and the process of elimination to make a selection.

13 Shortly after a blood transfusion is initiated, a client experiences an adverse reaction. The nurse documents the event according to hospital policy. What should the nurse do with the remainder of the blood that has not been transfused?

1. Discard the blood in the appropriate biohazard bag. 2. Return the blood to the blood bank. 3. Send the blood to the chemistry laboratory for analysis. 4. Send the blood to the infection control department. Answer: 2 Rationale: When a transfusion reaction has occurred, the nurse must return any remaining blood to the blood bank. If a reaction had not occurred, the nurse would dispose of the blood in an appropriate biohazard bag. It would not be appropriate for the nurse to send the blood to the laboratory or to the infection control depart- ment. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is knowledge of critical actions to take when a transfusion reaction occurs. Use nursing knowledge and the process of elimination to make a selection.

A client is at risk for the developing a pressure ulcer and is placed on a repositioning regimen. The client does not like to lie on his side and complains about the need to turn. Which explanation by the nurse may enhance compliance? Select all that apply.

1. "Turning helps maintain skin integrity by alternating areas of pressure." 2. "Excess pressure interferes with skin absorption of vitamin D." 3. "Changing positions will promote circulation and prevent contractures." 4. "Changing position prevents tissue breakdown that could ultimately become infected." 5. "A repositioning schedule is a standard part of hospital policy. Answer: 1, 3, 4 Rationale: Turning a client is one of the principle methods of preventing skin breakdown. When a client's position is changed, circulation to the previous areas of pressure is restored and the joints can be moved and aligned to prevent development of contractures. A loss of skin integrity places the client at risk for bacterial invasion and subsequent infection. Unless the skin loss is extensive, the skin will continue to absorb vitamin D. Making a reference to policy does not promote client understanding or compliance. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Teaching and Learning Content Area: Fundamentals Strategy: The core issue of the question is promoting compliance through client teaching about the benefits of turning and repo- sitioning. Because there is more than one correct answer, look at each option as a true/false statement.

The nurse is caring for a client with hepatitis A. Which client statements indicate that teaching conducted by the nurse about disease transmission was effective? Select all that apply.

1. "We must avoid kissing." 2. "We can use the same bath towels." 3. "We must avoid eating with the same utensils." 4. "We must wear masks." 5. "No special precautions are needed. Answer: 1, 3 Rationale: Hepatitis A is an infectious disease transmitted by the fecal-oral route. Standard precautions are mandatory. Contact precautions are instituted if the client is incontinent of stool. Family members should avoid close contact with the client. They should not kiss the client or use the same eating utensils and bath towels. Masks are not necessary because the disease is not transmitted by the respiratory tract. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The critical words methicillin-resistant indicate a microorganism that is difficult to eradicate. Eliminate each of the incorrect options after visualizing each situation because they can be managed by use of standard precautions.

12 A nurse is caring for an immunocompromised client with cancer. At what white blood cell count level should the nurse consider implementing neutropenic precautions for this client?

1. 10,500/mm3 2. 7,650/mm3 3. 6,000/mm3 4. 2,000/mm3 Answer: 4 Rationale: The nurse should consider implementing neutropenic precautions when the white blood cell count is at or below 2,000/mm3. The normal white blood cell count is between 5,000 and 10,000/mm3; no neutropenic precautions are necessary as long as the WBC falls within the normal range. Cognitive Level: Applying Client Need: Reduction of Risk Potential Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is knowledge of white blood cell counts. Use nurs- ing knowledge to eliminate the WBC count that falls within the normal range.

The following order has been written: 1000 mL of D5RL to run over a 24 hour period. The solution is available with 15 gtt/mL drip factor. How much D5RL should the client receive in one hour?

1. 42 mL/hr 2. 4.2 mL/hr 3. 0.7 mL/hr 4. 7 mL/hr (1)

In prioritizing client care, you recognize that the client most at risk for fluid volume deficit is:

1. A 30-year-old man with a fractured tibia 2. An 82-year-old woman with a fractured hip 3. A 62-year-old man with a myocardial infarction 4. A 35-year-old woman who just delivered a baby (2) Rationale: Although all of these clients might experience fluid volume deficit, the most at risk are clients at the extreme of age, either young or old; in this case the 82-year-old client.

The client most at risk for metabolic alkalosis is:

1. A 30-year-old postsurgical client undergoing nasogastric suction 2. A 70-year-old client in a nursing home unable to access water freely 3. A 2-year-old infant receiving isotonic sodium chloride IV solution 4. A 54-year-old client who has just experienced a stroke (1) Rationale: Removal of gastric acids may result in met- abolic alkalosis. The client unable to access water is at risk for fluid volume deficit and hypernatremia. The infant is at risk for fluid volume excess. The client experiencing a stroke is not at risk for a specific fluid, electrolyte, or acid-base imbalance.

ABGs of a client admitted to the emergency de- partment shows pH 7.24, PCO2, 65 mm Hg, and HCO3− 24 mEq/L. The client is diagnosed with bacterial pneumonia and is started on antibiotics and oxygen. What is a priority nursing intervention?

1. Encourage coughing and deep breathing 2. Monitor vital signs frequently 3. Monitor cardiac rhythm 4. Encourage leg exercises (1) Rationale: The ABGs reveal respiratory acidosis. A primary intervention is to increase ventilation through "deep breathing and removal of secretions. Although vital sign and cardiac assessment are important, in- creasing ventilation will help resolve the problem. Leg exercises may be encouraged to prevent deep vein thrombosis, but are not related to the ABGs presented in this scenario.

5 Which postoperative client would be at risk for developing a sodium imbalance?

1. A client who has just had a tonsillectomy 2. A client who has a primary cesarean section for failure to progress in labor 3. A client who has a transurethral resection of the prostate (TURP) 4. A client who has a right knee arthroscopy Answer: 3 Rationale: A TURP procedure can place a client at risk for developing hyponatremia in the postoperative period due to increased fluid irrigation used during and after surgery. Clients with a TURP procedure have a CBI (continuous bladder irrigation) as a routine part of their postoperative care. The other options do not place a client at risk for development of sodium imbalances, because they do not require lengthy fluid and dietary restrictions, or excessive fluid irrigation. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge that procedures and surgeries requiring use of water for irriga- tion can lead to dilutional hyponatremia. Use nursing knowl- edge and the process of elimination to make a selection.

Chronic inflammation can be caused by all of these except:

1. A foreign body such as a bullet lodged in the tissue 2. A response to a normal body substance such as low-density lipoprotein lodged in excess in an arteriole wall 3. Use of an arthritic joint 4. A walled off tubercle (2) Rationale: Chronic inflammation is not caused by a response to a normal body substance such as low density lipoprotein lodged in excess in an arteriole wall.

7 The nurse has received an order to transfuse a client with one unit of PRBCs. In preparation for the infusion, the nurse selects the appropriate tubing for blood administra- tion. The nurse is aware that the tubing is manufactured with which feature?

1. A macrodrip chamber 2. An air vent 3. An in-line filter 4. Tinting that protects blood from exposure to light Answer: 3 Rationale: An in-line filter is required for the administration of blood, and blood administration tubing comes from the manufacturer with the filter in place. Tubing for blood administration is not manufactured with a macrodrip chamber, an air vent, or with tinting that pro- tects the blood from light, a feature that is not necessary for blood administration. Cognitive Level: Understanding Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The core issue of the question is knowledge that an in-line filter is required for blood transfusion. Use nursing knowledge and the process of elimination to make a selection.

A female client can move her right arm and leg but has hemiplegia on the left. What should the nurse instruct the nursing assistant to do on the client's left side during care?

1. Active range of motion 2. Passive range of motion 3. Isotonic exercises 4. Isometric exercises Answer: 2 Rationale: Passive range of motion is most appropri- ate because the client is unable to move that side of the body on her own. Active range of motion requires the client to move the body independently, isotonic exercises require the ability to tighten the muscles on the left side, and isometric exercises require the ability to perform resistance with the muscles on the left side all of which the client cannot do due to hemiplegia on the left side. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical words in the question are hemiplegia on the left side. This indicates that the client cannot move the left side of the body and is unable to actively participate in exercising the joints. The wording of the question tells you that there is only one correct answer.

The nurse would anticipate which finding in a client with an immunologic disorder associated with a human leukocyte antigen (HLA)?

1. Acute course 2. Frequent effects on reproductive capacity 3. Genetic determination 4. Chronic and possibly subacute course Answer: 4 Rationale: Diseases with HLA associations have poorly understood etiologies, are usually chronic or subacute in nature, and have limited effect on reproductive capacity. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge of diseases associated with the HLA antigen. Use nursing knowledge and the process of elimina- tion to make a selection.

22 A client admitted to the hospital with a 30-pound weight gain over the past month has a fat pad at the back of the neck and moon facies. Admission laboratory results indicate decreased serum potassium and magnesium, and elevated serum chloride and sodium levels. The nurse interprets that which disorder is most consistent with these electrolyte abnormalities?

1. Addison's disease 2. Cushing's syndrome 3. Burns 4. Syndrome of inappropriate ADH (SIADH) Answer: 2 Rationale: Cushing's syndrome causes low potassium and magnesium levels and an increase in sodium and chloride levels. The moon facies and fat pad at the back of the neck are also symptoms of excess corticosteroids. Addison's disease causes low sodium and increased magnesium and potassium levels. Burn states cause significant fluid and electrolyte disturbances (loss of sodium, chloride, and magnesium, with alterations in potassium depending on the stage of burn), but the presence of a moon facies and fat pad at the back of the neck is characteristic of Cushing's syndrome. SIADH is associated with hyponatremia. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is the ability to synthesize electrolyte results with a clinical picture in a client with Cushing's syndrome. Use nursing knowledge and the process of elimina- tion to make a selection.

The most important assessment in a client with hypocalcemia is:

1. Heart rhythm 2. Urine output 3. Trousseau's sign 4. Weight (3) Rationale: While hypocalcemia may affect cardiac rhythm, Trousseau's sign is most specific to calcium balance. Urine output and weight are important as- sessment parameters for fluid balance.

A client has received a granulocyte transfusion. What lab- oratory results should the nurse assess to determine if the client has benefited from the transfusion?

1. Hemoglobin and hematocrit 2. Erythrocytes 3. White blood cells 4. Platelets Answer: 3 Rationale: Granulocyte transfusions are adminis- tered to neutropenic clients with infections for white blood cell replacement. The other options would not be appropri- ate for evaluating this therapy. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: The core issue of the question is knowledge of appropriate outcomes of blood component therapy. Identification and understanding of the blood com- ponents are essential for answering the question correctly.

NCLEX Ch. 27: While completing a nursing assessment, the client states he is 70 years old, has a history of staphylococcus infections, increased intraocular pressure, and blurry vision. The nurse concludes that which item reported by the client is a risk factor for the development of cataracts?

1. History of staphylococcus infections 2. Increased intraocular pressure 3. Stated age of client 4. Long complaint of blurry vision Answer: 3 Rationale: Age above 65 is a risk factor for cataracts. Double vision, increased intraocular pressure, and blurry vision are signs of glaucoma. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Assessment Content Area: Fundamentals Strategy: The core issue of the question is knowledge of factors that increase client risk for conditions affecting sensory percep- tion. Use the process of elimination and nursing knowledge to make a selection.

If a client has been taking a steroid drug, wound healing will be delayed because the steroid drug:

1. Impedes macrophage migration 2. Reduces body temperature 3. Reduces appetite and thus results in poor nutrition 4. Prevents fluid from reaching the involved area (1) Rationale: The steroid drug impedes macrophage mi- gration, which delays wound healing if a person has been taking a steroid drug.

All of the following are risk factors for delayed wound healing except:

1. Inadequate nutrition 2. Repetitive injury 3. Tissue ischemia 4. Maintaining a moist environment (4) Rationale: This is not a risk factor for delayed wound healing.

Fever that is seen in a client with an infectious disease is most likely caused by:

1. Increased release of histamine 2. Increased release of interleukin 3. Increased number of bacteria in the body 4. Increased vasodilation in the area of injury (2) Rationale: This is the most likely cause of fever that is seen in a client with an infectious disease.

Which type of fluid can cause cells to swell and burst?

1. Isotonic 2. Hypotonic 3. Hypertonic 4. Tonic (2) "Rationale: Hypotonic solution causes fluid to move into the cells leading to swelling and in some cases bursting. An isotonic solution causes no fluid shift between compartments as it has the same tonicity as plasma. Hypertonic solutions cause fluid to move out of the cell resulting in shrinking of the cells. Tonic refers to the ability to cause fluid movement across membranes."

You are caring for a client with hyperkalemia. You prepare for administration of which medication?

1. Kayexalate 2. K-Lor 3. Kaopectate 4. Keflex (1) Rationale: Kayexalate is indicated for the removal of excess potassium. K-Lor is a potassium supplement in- dicated for clients with hypokalemia. Kaopectate is an antidiarrheal medicine, and Keflex is an antibiotic.

The first leukocytes attracted to an injured tissue are the:

1. Mast cells 2. Neutrophils 3. Lymphocytes 4. Eosinophils (2) Rationale: Neutrophils are the first leukocytes attracted to an injured tissue.

The nurse assessing a client for signs of hypocalcemia would conclude that this electrolyte imbalance exists after noting which finding?

1. Negative Chvostek's sign 2. Positive Trousseau's sign 3. Positive Kernig's sign 4. Hypoactive bowel sounds Answer: 2 Rationale: Clinical manifestations of hypocalcemia include a positive Trousseau's sign, which is presence of carpopedal spasm. A positive Chvostek's sign (twitching of muscles of cheek) is associated with hypocalcemia. Kernig's sign is an indication of meningeal irritation. Hypoactive bowel sounds are a sign of hypercalcemia. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of manifestations of hypocalce- mia. Use nursing knowledge and the process of elimination to make a selection.

The nurse teaches a client that which factor might increase risk of developing an exacerbation of systemic lupus erythematosus (SLE)?

1. Pregnancy 2. Hypotension 3. Fever 4. GI upset Answer: 1 Rationale: Pregnancy can be associated with an exac- erbation because of increased estrogen levels. Hypotension, fever, and GI upset do not exacerbate SLE. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Teaching and Learning Content Area: Adult Health: Immunological Strategy: The core issue of the question is risk factors and triggers for SLE. Use nursing knowledge and the process of elimination to make a selection.

A client presents with a serum sodium level of 115 mEq/L. A priority nursing intervention is:

1. Seizure precautions 2. Vital signs every two hours 3. Frequent oral care 4. Cardiac rhythm monitoring (1) Rationale: Clients with hyponatremia are at high risk for seizures. Vital sign assessment is important, but client safety takes priority. Frequent oral care would be important in a client with hypernatremia or fluid volume deficit. Cardiac monitoring is important in hyperkalemia or hypokalemia.

A nursing teaching strategy to reduce the develop- ment of an antibiotic-resistant organism is to:

1. Wash hands before and after all client contact 2. Keep people with a known infection in an isolation room 3. Stress the importance of taking all doses of an antibiotic when ordered 4. Have a client with a known infection wear a mask when in public areas (3) Rationale: This is a nursing teaching strategy to re- duce the development of an antibiotic resistant organism.

Which set of ABGs indicate compensated respiratory alkalosis?

1. pH 7.43, PCO2 32, HCO3− 18 mEq/L 2. pH 7.49, PCO2 32, HCO3− 20 mEq/L 3. pH 7.39, PCO2 48, HCO3− 28 mEq/L 4. pH 7.43, PCO2 38, HCO3 23 mEq/L (1) Rationale: The PCO2 is low, indicating alkalosis. To compensate, the body has excreted excess bicarbon- ate, and the HCO3 is low. This compensation has returned the pH within normal range.

Normal HCO3

22-26

Handout in class: The nurse asks her patient about past allergic reactions. The patient explains that she is allergic to amoxicillin as a child, when she developed a rash on arms and legs at 3 years old

2nd reaction will be worse. faster, stronger reaction. Do not administer cillin family antibiotics.

Normal PaCO2

35-45

A nurse is caring for a patient who is receiving IV Carmustine (BICNU) to treat multple myeloma. The nurse should recognize that the patient is at the greatest risk for infection for which of the following lengths of time after infusion?

4-6 weeks

Normal blood pH

7.35-7.45

Normal PO2 level

80-100

Normal O2 sats

97%-100%

A charge nurse is discussing the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will need to monitor the client's serum antimicrobial levels during the course of therapy." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile." A. INCORRECT: The nurse should obtain a specimen for culture and sensitivity prior to the initiation of antimicrobial therapy. B. INCORRECT: MRSA is resistant to all antibiotics, except vancomycin. C. CoRRECT: Monitoring antimicrobial levels ensures that therapeutic levels are maintained. D. INCORRECT: Discontinuing antimicrobial therapy prior to completing a full course of treatment increases the risk of producing resistant pathogens.

A nurse is reviewing the laboratory findings of a client who has a WBC count of 20,000/mm3. Based on these findings, the nurse should conclude that the client has which of the following?

A. Neutropenia B. Leukocytosis C. Hemolysis D. Leukopenia A. INCORRECT: Neutropenia is a neutrophil count of less than 2,000/mm3. B. CORRECT: Leukocytosis is a WBC count of greater than 10,000/mm3, which can indicate an inflammatory response to a pathogen or a disease process. C. INCORRECT: Hemolysis is the breakdown of red blood cells. D. INCORRECT: Leukopenia is a total WBC count of less than 4,300/mm3, which can indicate a compromised inflammatory response or a viral infection.

Antifungals

Action: Impairs cell membrane of fungus, causing increased permability Nystatin, Flucanozal (diflucan) Indication: Fungal infection SE: Thrombocytopenia (v platelets), liver, pruritus Nurse Actions: Avoid alcohol. Swish 2 mins and spit for liquid form (thrush)

Antivirals

Action: Inhibits DNA or RNA replication in virus Acyclovir (zovirax), Tamiflu Indications: HIV, encephalitis, herpes SE: HA, dizzy, seizures, D Nurse Actions: Monitor kidneys and liver, good hand washing with HIV (decreased immune system) Does not prevent transmission of disease, just slows progression of symptoms.

Chovostek's sign

Facial twitches

Bacteriostatic

Slows growth of bacteria

26 The nurse would report to the charge nurse that an assigned client has hyperkalemia after noting that the serum potassium level drawn that morning was greater than how many mEq/L? Provide a numerical answer.

____mEq/L Answer: 5.1 Rationale: Hyperkalemia exists when the serum potassium level rises above the upper limit of normal, which is 5.1 mEq/L. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge that hypocalcemia accompanies hypermagnese- mia. To answer correctly, you must also be able to recognize abnormal laboratory values. Use nursing knowledge and the process of elimination to make a selection.

BODY FLUID REGULATORS:renin-amgiotensin-aldosterone mechanism-RAAS (Renal System)

aldosterone hormone, determines amount of SALT and WATER reabsorbed in the kidneys

Immunoglobulins

also known as antibodies, are glycoprotein molecules produced by plasma cells (white blood cells). They act as a critical part of the immune response by specifically recognizing and binding to particular antigens, such as bacteria or viruses and aiding in their destruction.

Cytokines

are a broad and loose category of small proteins that are important in cell signaling. They are released by cells and affect the behavior of other cells. "the communicator"

A nurse should question the use of anastrozole (arimidex) for a patient who is

premenopausal. (Treats breast cancers in postmenopausal women ONLY. Estrogen is a contraindication)

BODY FLUID REGULATION: antidiuretic hormone(posterior pituitary gland and renal system) - vasopressin

regulates how much urine leaves the kidney, decreased urine production by reabsorbing water in renal tubules

A nurse is caring for a patient who is about to begin topotecan (Hycamtin) therapy to treat

resistant small-cell lung cancer.

A nurse is about to administer enfuvirtide (fuzeon) to a patient. The nurse should perform which of the following actions? Select all that apply....

-Admin the drug SQ -Discard unused portion -Roll the vial gently to reconstitute solution -Inject solution at room temp -Expect a cloudy solution Answer: 1,3,4

Handout in class: The nurse is caring for a patient preparing for a kidney transplant.

-Immunosuppressants forever. Be careful about contracting infections.

Handout in class: A nurse is caring for a patient who is being discharged home after splenectomy.

-Less exposure, good nutrition, good sleep, no razors or cutting skin, F/U labs, wear a mask in public, good handwashing.

Handout in class: A middle aged daughter of an elderly man in his 80's accompanies her father to a health exam and asks the nurse why her father has problems with skin irritations, urine retention, and difficulty with digesting his food.

-Skin irritation is his body's natural defense. Some are more sensitive than others. And if he developed a minor response as a child, the antibodies make th reaction more powerful with time. -Urine retention: decrease in muscle tone and sphincter control -Digestion: decrease in peristalsis and muscle tone

A nurse is caring for a patient who is about to begin taking mercaptopurine (purinethol) to treat leukemia. Which of the following instructions should the nurse include when talking with the patient about the drug? Select all that apply...

-Use contraception to avoid preggo -Perform oral hygiene frequently -Avoid activities that require mental alertness -Perform hand hygiene frequently*(SE: Decreased CBC) -Avoid activities that can cause injury (SE: decreased platelets) Answer: 1245

A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the nurse is most accurate?

1. "Everyone who enters your room must wear a mask to protect themselves from tuberculosis." 2. "Masks would not be necessary for visitors who have had tuberculosis before." 3. "It is less important for your family to wear masks, since they live in close contact with you." 4. "Only visitors who are at risk for tuberculosis need to wear a mask. Answer: 1 Rationale: Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne precautions would be initiated, requiring everyone to wear a special particulate respirator fit-tested mask. Individuals who have had tuberculosis in the past can be re-exposed and develop the active form of the disease again. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Look for similarities among the options in order to eliminate choices. In this case, the incor- rect options are similar in that they suggest certain individuals would not be required to wear masks.

17 A client is admitted to the hospital. Arterial blood gas (ABG) results are pH 7.50; PaCO2 40; HCO3- 29. Which question should the nurse ask the client to help determine an etiology for these results?

1. "Have you had diarrhea lately?" 2. "Do you have a history of COPD?" 3. "How long have you had nausea and vomiting?" 4. "Do you smoke?" Answer: 3 Rationale: ABG results reflect elevated pH, indicating alkalosis, and normal PaCO2 and an increased HCO3-, indicating metabolic alkalosis. Vomiting is a common cause of this condition. The presence of diarrhea is associated with metabolic acidosis. COPD is associated with respiratory acidosis. Smoking can be associated with respiratory acidosis if it leads to respiratory disease. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: An ability to interpret ABGs and specific knowledge of manifestations of metabolic alkalosis are needed to answer this question. Use nursing knowledge and the process of elimination to make your selection.

19 Which statement by the client indicates that discharge teaching for respiratory alkalosis is understood?

1. "I will not take so many antacids anymore." 2. "I will take a stress management class." 3. "I will not take my furosemide (Lasix) without taking my potassium supplement." 4. "I will tell the doctor the next time I have diarrhea for so long." 5. "I am more aware of how my breathing changes when I get nervous." Answer: 2, 5 Rationale: Respiratory alkalosis is caused by hyperventilation, which can be caused by stress and anxiety, as examples. It is important that clients who are prone to develop respiratory alkalosis be aware of how to manage causative factors. Antacids and diuretics are associated with metabolic alkalosis. Diarrhea is associated with metabolic acidosis. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Teaching and Learning Content Area: Adult Health: Endocrine and Metabolic Strategy: The critical word in the question is respiratory. Eliminate each of the incorrect options that would correlate better with a met- abolic condition than with a respiratory one. Alternatively, consider that a common cause of respiratory alkalosis is hyperventilation, which is often caused by anxiety, and managed with stress management.

A client is to start taking prednisone for treatment of rheumatoid arthritis (RA). Which client statement indicates that medication teaching was successful?

1. "I will take the medication on an empty stomach to maximize absorption." 2. "I will take the specific dose ordered at the same time every day." 3. "I will not have to limit my sodium intake." 4. "I will not have to adjust my insulin regimen." Answer: 2 Rationale: Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take this medication at the same time each day and to become aware of tapered-dose effect. Steroids are usually taken with foods to minimize GI upset. Steroids cause fluid retention, and therefore sodium intake may be restricted. Steroids increase blood glucose, so insulin therapy dosages may have to be adjusted. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Evaluation Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge of client teach- ing related to steroid therapy. Use nursing knowledge and the process of elimination to make a selection.

11 A client is scheduled for elective surgery in 4 weeks. When the nurse in the surgeon's office initiates preoperative education, the client expresses concern regarding the potential need for a blood transfusion. What is the nurse's best response to the client's concern?

1. "It is unlikely that you will lose that much blood during the surgery." 2. "Blood transfusions are safer now than in the past." 3. "Your family may be able to donate blood for you." 4. "You may want to consider an autologous blood transfusion." Answer: 4 Rationale: An autologous transfusion involves the collection of the client's blood prior to the anticipated need, thus compatibility is not problematic and the potential for contamination is eliminated. It would not be appropriate for the nurse to predict blood loss as a result of a surgical pro- cedure. Stressing the safety of blood transfusions may elicit a false sense of comfort for the client. While the family may be able to donate blood, this would not be as potentially benefi- cial to the client as an autologous blood transfusion. Not all relatives share the same blood type. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: The core issue of the question is knowl- edge of various types of transfusions. Use nursing knowledge, therapeutic communication skills, and the process of elimina- tion to make a selection.

A male client who has acquired immunodeficiency syndrome (AIDS) asks why oral progesterone (Megace) is being prescribed for treatment. What is the nurse's best response?

1. "Megace is used to treat the nausea associated with this infection." 2. "Megace is used as an appetite stimulant to boost nutritional support." 3. "Megace provides symptomatic relief of constipation." 4. "Megace is used as an antineoplastic agent for palliative treatment." Answer: 2 Rationale: While Megace is used as a palliative treatment for clients with advanced cancers, this is not the rationale for its use with AIDS. In clients with AIDS, it provides appetite enhancement. Side effects of Megace can include nausea and constipation. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Content Area: Adult Health: Immunological Strategy: The core issue of the question is the purpose of oral progesterone in a client with AIDS. Use nursing knowledge about anorexia as a symptom of AIDS and the process of elimination to make a selection.

A client asks, "How did I get scarlet fever?" What would be the nurse's best response?

1. "Scarlet fever is transmitted through sexual intercourse." 2. "You can get scarlet fever if you share contaminated needle or get a blood transfusion." 3. "Most people get it by eating contaminated food." 4. "You inhaled infected droplets in the air. Answer: 4 Rationale: Scarlet fever is transmitted by particle droplets larger than 5 microns. Scarlet fever is not transmitted through sexual intercourse or the blood, or by consuming contaminated food. Cognitive Level: Applying Client Need: Safe and Infection Control Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Begin by recalling that scarlet fever is transmitted by drop- lets. With this in mind, use the process of elimination to select the client situation that is compatible with the mode of transmission.

The following order has been written: Morphine sulfate 6 mg intravenous push as needed for pain. The following is available in the medication cart: Morphine sulfate 10 mg/1 mL. How much Morphine sulfate should the client receive as an intravenous push solution? Answer:___________mL

1. 6 mL 2. 0.6 mL 3. 0.06 mL 4. 60 mL (2)

The pediatric nurse would suspect severe combined immunodeficiency disorder (SCID) when which child is admitted to the hospital nursing unit?

1. A 2-month-old with thrush and low white blood cell counts 2. A 2-year-old with history of recent repeated infections 3. A newborn with positive TORCH titer 4. A newborn admitted with positive ELISA test Answer: 1 Rationale: The first infection often seen in these children is oral candidiasis (thrush). That symptom, along with the low WBC count, would be a warning symptom of SCID. A 2-year-old is unlikely to have survived this long undiagnosed. A TORCH titer is unrelated. ELISA tests evaluate HIV infection. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Child Health Strategy: The core issue of the question is the ability to identify signs and symptoms of SCID. Use nursing knowledge and the process of elimination to make a selection.

A male client suffered numerous types of wounds when he lost control of his motorcycle and was thrown onto the pavement. The client asks the nurse which wounds will scar more. The nurse's reply will be based on analysis that which wounds would generally be least likely to scar?

1. A wound that heals by primary intention 2. A wound that heals by secondary intention 3. A wound that becomes infected 4. A wound to an extremity Answer: 1 Rationale: Primary intention healing occurs when the wound edges are well approximated; wounds that heal by primary intention are least likely to scar. Wounds that heal by secondary intention have edges that cannot be approximated. The chance for scarring is greater for wounds that heal by secondary intention. Wounds that become infected are more likely to scar due to prolonged healing time, decreased probability of approximated wound edges, and increased chance of tissue loss. The fur- ther away from the heart, the longer the wound may take to heal. However, the location of a wound is not significant in regards to the likelihood of scarring. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of this question is knowledge of physiological wound healing. The question should be read carefully because the client asks which wounds will scar more and the stem asks which wound is least likely to scar.

A client with suspected severe acute respiratory syndrome (SARS) arrives at the emergency department. Which physician order should the nurse implement first?

1. Airborne and contact precautions 2. IV D5NS at 100 mL/hr 3. Nasopharyngeal culture for reverse-transcription polymerase chain reaction 4. Sputum for enzyme immunoassay testing Answer: 1 Rationale: SARS is a highly contagious viral respiratory illness that is spread by close person-to-person contact. SARS is transmitted by airborne respiratory route and by touching surfaces and objects contaminated with the virus. Instituting infection-control measures would be the first priority of the nurse. This action would protect both health care workers and other clients in the emergency department. Then all other interventions can be safely implemented. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical word first indicates all of the answers are correct and the nurse needs to set priorities. The first priority is to implement measures that protect the client and/or nurse—instituting airborne and contact precautions.

Which precaution would the nurse implement when admitting a client with herpes zoster to the nursing unit?

1. Airborne precautions 2. Contact precautions 3. Droplet precautions 4. Neutropenic precautions Answer: 2 Airborne until crusted over Then Contact once crusted Rationale: Herpes zoster is caused by the herpes virus varicella zoster. It can be transmitted by the airborne route until lesions have crusted over. It is not transmitted by droplets. Neutropenic precautions are not indicated, because the client is not at risk for contracting an infection from the nurse or other individuals. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Herpes zoster is a viral skin infection. Specific knowledge of the types of transmission-based precautions is needed to select the correct answer. Eliminate airborne and droplet precautions because herpes zoster is not transmitted on air currents. Next eliminate neutropenic precaution, which are are used with immunocompromised clients.

24 Which finding in a client's history would alert the nurse to assess for signs of hypophosphatemia?

1. Alcohol abuse 2. The oliguric phase of acute tubular necrosis 3. Short-term gastric suction 4. Occasional use of aluminum-containing antacids Answer: 1 Rationale: Poor nutritional intake, such as occurs in clients with alcoholism, can lead to hypophosphatemia. During oliguria, the kidneys are unable to excrete phosphorus, leading to hyperphosphatemia. Clients with prolonged (not short-term) gastric suction are more likely to experience hypophosphatemia. Prolonged or continuous use of aluminum-containing antacids (not occasional use) leads to hypophosphatemia. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of risk factors for hypophosphatemia. Use nursing knowledge and the process of elimination to make a selection.

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

1. Assess urinary output to determine renal perfusion 2. Apply cold, wet compresses to the site 3. Position the child's head to maintain an open airway 4. Establish intravenous access for medication delivery Answer: 3 Rationale: Maintaining an open airway is always the highest priority. With anaphylactic shock, the airway may constrict, mucous membranes swell, and air trapping occurs. The second priority would be airway access, followed by renal assessment, and finally site care. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Child Health Strategy: Use the ABCs—airway, breathing, and circulation to answer questions related to anaphylaxis. Airway is always the first priority in life-threatening situations.

The nurse includes in the plan of care to periodically monitor which item for a client who is at risk for developing hypocalcemia? Select all that apply.

1. Blood urea nitrogen (BUN) and creatinine levels 2. Constipation 3. Serum albumin level 4. Fluid overload related to intravenous saline therapy 5. Serum magnesium level Answer: 3, 5 Rationale: A client who is at risk for developing hypocalcemia requires monitoring of serum albumin (provides information relative to physiologically available calcium) level. Decreased magnesium levels are usually seen concurrently with low serum calcium levels. Assessing BUN and creatinine, constipation would be included for a client at risk for hypercalcemia, and assessing for fluid overload would be important for a client being treated with fluid therapy for hypercalcemia. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is the abil- ity to choose assessments to detect hypocalcemia. Use nurs- ing knowledge and the process of elimination to make a selection.

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

1. Calcium carbonate (Tums) 2. Ibuprofen (Motrin) 3. Acetylsalicylic acid (aspirin) 4. Acetaminophen (Tylenol) Answer: 1 Rationale: Excessive use of oral antacids can lead to metabolic alkalosis. Use of ibuprofen and Tylenol is not associated with the development of metabolic alkalosis. Overdoses of aspirin can be associated with the development of respiratory alkalosis, and eventually can lead to metabolic acidosis. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: Knowledge of medication side effects is needed to answer this question. First, eliminate ibuprofen and Tylenol because they are similar (non-opioid analgesics). Then, eliminate aspirin because acid would not lead to alkalosis. Alternatively, recall that calcium carbonate is an antacid, which in excess could lead to metabolic alkalosis.

The nurse is assessing a client with a mobility problem to determine an appropriate assistance device. The client's lower extremities have no paralysis, but are very weak. Upper-body strength is also reduced. The nurse should suggest which device for this client?

1. Cane 2. Four-wheeled walker 3. Canadian or elbow extension crutch 4. Lofstrand crutch" Answer: 2 Rationale: The client has bilateral weakness of the lower extremities, and the proper assistive device is one that will provide bilateral support. In this case, a walker provides the most support. Additionally, a four-wheeled walker does not require the client to lift the walker as steps are taken. A cane would provide only limited support for a client with very weak lower extremities. Canadian or elbow extension crutches and Loftstand crutches require upper body strength, an identified deficiency with this client. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: The core issue of the question is the assistive device that will provide the safest support to the client. The critical points of upper and lower extremity weakness in the stem of the question guide you to look for an option that provides bilateral support and minimal upper body strength.

All of the following clients appear in the emergency room during one shift. For which clients should the nurse expect the health care provider to order an antibiotic? Select all that apply.

1. Cat bite to the hand of an elderly client 2. Laceration from broken glass in a 6-year-old client 3. Stab wound in the arm of a 37-year-old client 4. Closed fracture to the ankle of a 40-year-old soccer player 5. A wrist sprain in a 17-year-old who was playing basketball Answer: 1, 2, 3 Rationale: A closed fracture or a sprain has no break in the skin. A cat bite, a laceration, and a stab wound all impair skin integrity, which could lead to infection, and thus may require prophylactic use of an antibiotic. Cognitive Level: Analyzing Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is appropriate use of antibiotic therapy. Restate this question in the following way: "Which client is not at risk for infection?" Use the process of elimination and nursing knowledge to make selections that pose little risk of infection.

10 The nurse concludes that a history of which condition places a client at risk for possible hypokalemia?

1. Chronic obstructive pulmonary disease (COPD) 2. Cirrhosis 3. Addison's disease 4. Chronic renal failure (CRF) Answer: 2 Rationale: In clients with cirrhosis, increased amounts of aldosterone are secreted, which leads to sodium retention and potassium excretion from the kidneys; these clients are likely to become hypokalemic. Clients with COPD are likely to develop hyperkalemia due to retention of acids, which lead to loss of hydrogen ions and retention of potassium as an alternate cation. Clients with Addison's disease (hypofunction of adrenal gland) are likely to develop hyperkalemia because of high sodium loss. Clients with CRF are likely to develop hyperkalemia because of inadequate potassium excretion. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is the abil- ity to discriminate predisposing factors for hypokalemia from factors for hyperkalemia. Use nursing knowledge and the process of elimination to make a selection.

18 A client's arterial blood gas (ABG) results are pH 7.36; PaCO2 50; HCO3- 28. What do these results indicate to the nurse?

1. Compensated respiratory acidosis 2. Compensated metabolic acidosis 3. Uncompensated metabolic acidosis 4. Uncompensated respiratory acidosis Answer: 1 Rationale: The pH is just within normal range, so the blood gas results are either normal or compensated. However, the PaCO2 is high, indicating a respiratory prob- lem, and thus the ABGs cannot be normal. The HCO3- is also high, which along with a normal pH indicates complete compensation. The metabolic acidosis options are incorrect because the primary disturbance is respiratory, as reflected by the correlation between an elevated PaCO2 and a pH toward the low end of normal. Uncompensated respiratory acidosis is incorrect because the HCO3- level would be normal if no compensation is taking place. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: Because the pH is within normal range, eliminate the uncompensated options. Choose respiratory over metabolic acidosis because the pH is near the acidic end of the range and the high CO2 corre- lates with acidosis, whereas a high HCO3- would correlate with an alkalotic state.

18 The nurse would review a client's electrolyte levels to detect a possible increase in magnesium if the client had which condition? Select all that apply.

1. Cushing's syndrome 2. Diabetes 3. Addison's disease 4. Splenomegaly 5. Dehydration Answer: 3, 5 Rationale: Addison's disease, known also as adrenal insufficiency, can cause increased magnesium levels resulting from volume depletion. Dehydration, or Deficient Fluid Volume, can lead to an elevated magnesium level because of hemoconcentration. Cushing's syndrome is hyperfunction of the adrenal gland and could lead to low magnesium levels from fluid overload. Diabetes mellitus could lead to low magnesium levels if osmotic diuresis is present from hyperglycemia. Splenomegaly is an unrelated finding. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of risk factors for hypermagnesemia. Use nursing knowledge and the pro- cess of elimination to make a selection.

14 A client with a low hemoglobin and hematocrit is to receive a unit of packed red blood cells (RBCs). Prior to initiating the transfusion, the nurse determines that the client's temperature is 100.8 degrees F orally. Based on this finding, what is the most appropriate action for the nurse to take?

1. Delay hanging the blood and notify the physician. 2. Begin the transfusion as prescribed. 3. Administer 650 mg of acetaminophen (Tylenol) and begin the transfusion. 4. Administer an antihistamine and begin the transfusion. Answer: 1 Rationale: Because the client is febrile, the nurse 16 must notify the health care provider. The health care pro- vider will determine if the client can tolerate the transfusion or if additional therapeutic intervention is warranted, which may include the administration of acetaminophen (Tylenol) or an antihistamine. The nurse cannot administer medications without an order from the health care provider. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the ques- tion is knowledge of critical actions to take when a client 17 requiring a blood transfusion has an elevated temperature. It is also essential that principles for drug administration are applied when making an answer selection.

17 A client has experienced an adverse reaction to a blood transfusion manifested by the development of pruritic rash and urticaria. What treatment should the nurse anticipate will be ordered for the client?

1. Diphenhydramine (Benadryl) 2. Acetaminophen (Tylenol) 3. Hydrocortisone cream 4. Acetylsalicylic acid (Aspirin) Answer: 1 Rationale: Diphenhydramine (Benadryl) is adminis- tered for the treatment of anaphylaxis. Benadryl competes with the H1 receptors on effector cells, thus blocking the effects of histamine. Tylenol would provide symptomatic relief from signs and symptoms of a transfusion reaction, but not be effective in stopping the reaction. Hydrocortisone would provide symptomatic relief from signs and symptoms of a transfusion reaction. Aspirin would not be indicated for treatment of a transfusion reaction. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The core issue of the question is knowledge of appropriate treatments for transfusion reac- tions. Use nursing knowledge and the process of elimination to make a selection.

The nurse would implement which of the following as a requirement of care specific to the client who has tuberculosis?

1. Disposal of needles and syringes in a rigid, puncture-proof container 2. Handwashing after removing contaminated gloves 3. Wearing a gown if splashing is possible 4. A private room with negative air flow Answer: 4 Rationale: The client with tuberculosis can spread the infection by breathing, and requires a private room and airborne precautions. Proper equipment disposal, hand washing, and wearing protective equipment as indicated are precautions that would be implemented with any client, regardless of medical diagnosis. Cognitive Level: Applying Client Need: Safe Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical word specific suggests that the correct option must apply to a client with tuberculosis and is not a general measure used for all clients. Next consider that this is transmitted by the airborne route to make the correct selection.

Which suggestion would the nurse give to a client with human immunodeficiency virus (HIV) infection to best alleviate nausea?

1. Drink liquids with meals. 2. Eat high-fat foods. 3. Eat small, frequent meals. 4. Lie down after eating. Answer: 3 Rationale: Small, frequent meals help lessen nausea because they require less work of digestion and do not overwhelm the client with food odors from a lengthy meal. Drinking liquids can give a sensation of fullness. High-fat foods are more difficult to digest and may distend the stomach. Lying down after eating can encourage reflux. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Teaching and Learning Content Area: Adult Health: Immunological Strategy: The core issue of the ques- tion is the ability to provide teaching to minimize nausea in a client with HIV. Use nursing knowledge and the process of elimination to make a selection.

Which suggestion by the nurse would be most helpful to a HIV + patient who has altered taste perception?

1. Drink plenty of salty broths and other fluids to stimulate taste buds. 2. Try zinc supplementation to improve taste perception. 3. Increase intake of meat to at least one serving per day. 4. Avoid using plastic eating utensils." "Answer: 2 Rationale: Zinc deficiency is associated with taste changes; therefore, supplementation may benefit a client experiencing altered taste perception. Drinking salty broth and fluids will not help with taste changes but may help restore electrolyte balance in clients experiencing diarrhea. Dairy products, fish, and poultry are better food choices than meat when taste is altered. Substituting plastic utensils for metal ones is suggested to decrease possibility of taste perception of metal. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge of measures to minimize taste alterations in a client with HIV infection. Use nursing knowledge and the process of elimination to make a selection.

A 12-year-old boy is diagnosed with early human immunodeficiency virus (HIV) infection secondary to factor transfusions for hemophilia. The family is very concerned about their ability to manage his care, risk of infection to family members, and whether the child should remain in the home. Which action by the nurse will best promote family coping at this time?

1. Explain to the family that the infection cannot be spread by casual contact. 2. Demonstrate positive acceptance of the child with each contact. 3. Explain that prophylactic drugs will prevent the virus from spreading. 4. Show the family how to wash their hands properly. Answer: 2 Rationale: The family has stated multiple concerns, and demonstrating acceptance of the child is the best way to foster acceptance of the child and development of further coping skills. Prevention of transmission, hand hygiene, and drug therapy are all important, but none of these individually targets the global concerns of the family. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Implementation Content Area: Child Health Strategy: The core issue of the question is the best nursing action to model acceptance of the child and enhance coping skills of the family. Select the option that is the most global in nature because the family has multiple concerns, and use the process of elimination to make a selection.

The nurse is leaving the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) microorganisms in a wound and the urine. Place the fol- lowing personal protective equipment in order of removal.

1. Eye protection 2. Gloves 3. Mask 4. Gown Fill in your answer below:____________ Answer: 2, 3, 4, 1 Removing: Gloves-->Mask-->Gown-->Eye prot. Rationale: Gloves are removed first because they would be most contaminated. The mask would be removed next, followed by the gown. Eye protection is removed last, followed by washing the hands. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Remember that removal of PPE should occur in order of most contaminated to least contaminated items.

The nurse is preparing to enter the room of a client with pneumonia caused by penicillin-resistant Streptococcus pneumoniae (PRSP). The client has a tracheostomy and requires suctioning. Put the following personal protective equipment in order of donning.

1. Eye protection 2. Gloves 3. Mask 4. Gown Fill in your answer below:______________ Answer: 4, 3, 1, 2 Donning: Gown-->Mask->Eye-->Gloves Rationale: The gown is applied first, as it takes the most time to don. The mask is donned next, followed by eye protection. These items can be more securely applied with ungloved hands. Gloves are donned last, so the gloves can be pulled up to cover the cuffs of the gown. Cognitive Level: Applying Client Need: Safty Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Rationalize the ordering based on nursing knowledge of standard precautions and surgical asepsis. Visualize the procedure to aid in choosing correctly.

5 A client who takes warfarin (Coumadin) arrives at the emergency department following a gunshot wound. The client's prothrombin time is twice the desired amount. The nurse expects the physician will order a transfusion of which blood product?

1. Fresh frozen plasma 2. Random donor platelets 3. Red blood cells 4. Crystalloids Answer: 1 Rationale: A transfusion of FFP is indicated for clients who are actively bleeding with a prothrombin time greater than 1.5 to 2.0 times the control in seconds. Platelets would be indicated for the client with thrombocytopenia. Red blood cells would be appropriate for the client with anemia. Crystalloids are given to help establish or maintain an adequate fluid and electrolyte balance. Cognitive Level: Analysis Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The core issue of the question is the ability to anticipate the need for fresh frozen plasma. Use nursing knowledge and the process of elimination to make a selection.

2 Which assessment of an adult client is a reliable indicator that therapy for Fluid Volume Excess is achieving the desired outcome? Select all that apply.

1. Full, bounding peripheral pulses 2. Flat neck veins with the head of the bed elevated 3. Hand vein emptying longer than 20 seconds 4. S3 heart sound clearly audible on auscultation 5. Lungs sounds are clear Answer: 2, 5 Rationale: Venous congestion results from fluid volume excess, and causes full, bounding pulses, delayed hand vein emptying, and S3 heart sounds. Flat neck veins with the head of the bed elevated are an indicator of the absence of venous congestion. With fluid overload, crackles can often be auscultated in lung fields. Absence of crackles is consistent with normal fluid balance. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Evaluation Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of signs of fluid overload and 5 normal findings. Use nursing knowledge and the process of elimination to make a selection.

Which treatment option does the nurse anticipate will be most appropriate for a client with a potassium level of 3.5 mEq/L?

1. Give sodium polystyrene sulfate (Kayexalate) per rectum. 2. Use salt substitutes in the diet. 3. Administer oral potassium chloride (KCl). 4. Continue to monitor and offer foods high in potassium. Answer: 4 Rationale: A serum potassium level of 3.5 mEq/L is at the low end of the normal range. With a low normal level, it is better to continue to monitor the client and offer foods that are good sources of potassium. In the absence of additional medical history, it is not advisable to use oral KCL or salt substitutes as sources of additional potassium. Kayexelate reduces the potassium level and is contraindicated in this client. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowl- edge of treatment measures depending on the severity of hypokalemia. First, recognize that this is a value at the low end of normal, and then select the mildest intervention of the choices provided. Note the critical word most, which indicates that some options may be plausible, but one is bet- ter than the others.

The nurse is preparing to irrigate a wound infected with vancomycin-resistant enterococci. What personal protective equipment (PPE) would the nurse wear?

1. Gloves, gown, and particulate respirator 2. Gloves and surgical mask 3. Gloves, eye protection, and shoe covers 4. Gloves, gown, eye protection, and surgical mask Answer: 4 Rationale: An infection with vancomycin-resistant enterococci requires transmission-based contact precautions. Since the nurse will be irrigating the wound and splatters of body fluids or exudates are possible, eye protection and surgical mask should be worn to protect the mucous membranes of the eyes, nose, and mouth. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves. Shoe covers are unnecessary. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Wound infections require contact precautions. Look for the option that identifies the correct PPE to be used with contact precautions. Eliminate options with particulate respirator and shoe covers, since these are unnec- essary. Choose the option containing eye protection because the risk for splatters exists.

In healing by primary intention the wound fills in from:

1. Granulation tissue from the bottom of the wound 2. Suturing layers of granulation tissue 3. Cell migration from the borders of the wound 4. All of these (3) Rationale: This fills the wound in healing by primary intention."

The nurse is restarting an IV line on a client known to have hepatitis B. Which precautions should the nurse use to protect against exposure? Select all that apply.

1. Handwashing 2. Gloves 3. Mask 4. Face shield 5. Gown Answer: 1, 2 Rationale: Handwashing and gloves are the only precautions needed for starting an IV. Masks, face shields, and gowns are appropriate for procedures that may result in body fluids splashing. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: Recall standard precautions and infectious disease precautions. Handwashing and use of gloves are appropriate for any procedure.

In establishing a plan of care to manage pain for a client with rheumatoid arthritis (RA), what intervention would the nurse use to increase the client's mobility?

1. Have the client work through pain by continuing exercise in order to establish endurance. 2. Have the client use pain medication only when pain is present. 3. Teach the client that both heat and cold applications may help to relieve pain. 4. Teach the client to flex muscle groups when pain is felt in an extremity. Answer: 3 Rationale: Heat and cold applications can provide analgesia and relieve muscle spasms. The individual client will have to determine whether heat, cold, or alternation of both is most effective. Exercising in the presence of pain may only further exacerbate pain. Pain medication should be taken on a regular schedule if the client has chronic pain so that the pain threshold can be raised and pain relief maintained at a constant level. Flexing of muscle groups is not related to effective pain control. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge of measures that relieve the symptoms of RA. Use nursing knowledge and the process of elimination to make a selection.

A postoperative client tells the nurse that he developed dehiscence after his last surgery and wants to make sure it doesn't happen this time. Which nursing intervention is most effective for attempting to prevent dehiscence in a postoperative client?

1. Helping the client lose weight 2. Preventing vomiting 3. Administering antibiotics 4. Keeping the wound dry Answer: 2 Rationale: Activities that are likely to lead to dehiscence include vomiting and coughing because they increase intraabdominal pressure. Clients who are obese and those with poor nutrition are candidates for dehiscence. Since the client is already postoperative, encouraging weight loss at this time would not affect risk for dehiscence, and there is no indication that the client is overweight. Administering antibiotics is effective in pre- venting or treating infection. Antibiotic therapy alone can- not prevent dehiscence. Keeping a wound dry will promote healing and prevent infection; however, this action alone will not prevent dehiscence. Cognitive Level: Analysis Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The core issue of the question is knowledge of risk factors for dehiscence. Recall that dehiscence is most likely to occur when there is some type of stress on the incision line. Consider that vomiting puts sudden tension on the suture line to select it as the option that is most likely to be harmful to the client.

The nurse is changing the abdominal dressing of a client who is 4 days postoperative. The nurse notes a moderate amount of serosanguineous drainage, wound edges not approximated, and puffy tissue protruding through the wound. What condition should the nurse suspect from the- ses manifestations?

1. Hemorrhage 2. Normal healing by primary intention 3. Normal healing by secondary intention 4. Evisceration Answer: 4 Rationale: Evisceration occurs when internal viscera protrude from an incision that is dehiscing. In this situation, the nurse notes changes in wound appearance such as increased serosanguineous drainage, edges lacking approximation, and the protruding viscera. The nurse notes a moderate amount of serosanguineous drainage, which should be nearly diminished by the 4th day postoperative. However, this description does not fit hemorrhage. Healing by primary intention includes well-approximated incision edges and no signs of infection or complication. Secondary healing is when the wound is extensive and the edges cannot or should not be approximated; healing time is prolonged. Cognitive Level: Analyzing Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of this question is the ability to draw accurate conclusions about the status of a surgical wound. Use the process of elimination and basic nursing knowledge to make a selection.

9 The nurse is caring for a client who has sustained partial and full thickness burns over 30% of his body 18 hours ago. The nurse assesses for which fluid and electrolyte imbalances at this time? Select all that apply.

1. Hyperkalemia 2. Hypokalemia 3. Hypervolemia 4. Hypercalcemia 5. Hypovolemia Answer: 1, 5 Rationale: During major burn injury, potassium shifts from the intracellular fluid to the extracellular fluid because of cell death, leading to high serum levels of potassium. Hypokalemia is not seen in burn clients during the time of fluid shifting secondary to trauma. The client with burns is more likely to be hypovolemic rather than hypervolemic and hypocalcemic rather than hypercalcemic at this time because of fluid and electrolyte loss caused by altered capillary integrity. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowl- edge that burn injury increases the risk of hyperkalemia. Use nursing knowledge and the process of elimination to make a selection.

13 The nurse is admitting a client who has metabolic alkalosis. The nurse plans to assess for manifestations of which electrolyte imbalance? Select all that apply.

1. Hypernatremia 2. Hypochloremia 3. Hypermagnesemia 4. Hypocalcemia 5. Hypokalemia Answer: 2, 4, 5 Rationale: Clinical manifestations of metabolic alkalosis are associated with the presence of tetany-like symptoms. Clients should be monitored for the presence of these symptoms because they usually correlate with low levels of calcium. Hypomagnesemia (not hypermagnesmia) can occur with hypocalcemia. Hyponatremia, hypochloremia, and hypokalemia can occur with metabolic alkalosis Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Teaching and Learning Content Area: Adult Health: Endocrine and Metabolic Strategy: Specific knowl- edge of the association between metabolic alkalosis and various electrolytes is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection.

A client receiving D5W at 100 mL/hr is most at risk for developing:

1. Hypernatremia 2. Hyponatremia 3. Fluid volume excess 4. Fluid volume deficit (2) Rationale: D5W is a hypotonic intravenous (IV) solu- tion. While administration of large volumes of any IV solution may result in fluid volume excess, a hypo- tonic IV solution also places the client specifically at risk for hyponatremia. Fluid volume deficit is not a risk of IV fluid administration.

In assessing a client who has been immobilized because of illness, the nurse would most likely document the client's muscles as which of the following?

1. Hypertrophied 2. Atrophied 3. Flexible 4. Hardened Answer: 2 Rationale: After immobilization, unexercised mus- cles will atrophy. Hypertrophy is the opposite of atrophy. Flexibility is a term most frequently applied to joint movement. Hardened is a term which describes muscles that have been developed by exercise or activity. Cognitive Level: Knowledge Client Need: Basic Care and Comfort Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: This question requires application of basic nursing knowledge and terminology to a client situa- tion. Select the term that is a common finding in clients who are immobilized.

The nurse would assess for which electrolyte imbalance as a common finding in a client with AIDS?

1. Hyponatremia 2. Hypernatremia 3. Hyperkalemia 4. Hypocalcemia Answer: 1 Rationale: Hyponatremia is a common finding in clients with AIDS. The incidence of opportunistic infections may contribute to this decrease in sodium. Hypernatremia, hyperkalemia, and hypocalcemia are not usually seen in clients who have AIDS. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Immunological Strategy: The core issue of the question is identification of an electrolyte disturbance that is more common to clients with AIDS. Use nursing knowledge and the process of elimination to make a selection.

19 The nurse concludes that a client does not have an increased magnesium level based on which finding?

1. Hypotension 2. Bradycardia 3. Supraventricular tachycardia (SVT) 4. Flushing and sweating Answer: 3 Rationale: SVT is seen with decreased magnesium levels, as are premature ventricular contractions and ventricular fibrillation. Hypotension, bradycardia, and flushing and sweating are associated with hypermagnesemia. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is the ability to discriminate signs of hyper- and hypomagnesemia. Use nursing knowledge and the process of elimination to make a selection.

Hypersensitivity disorders are due to:

1. Immune deficiency disorder, such as HIV 2. Autoimmune disorder, such as RA 3. Heightened immune response to an antigen 4. Desensitization of humoral immune components (3) "Rationale: Hypersensitivity disorders are because of a heightened immune response to an antigen."

3 The nurse returns to evaluate a client whose blood trans- fusion has been infusing for 30 minutes. Upon assessment, the nurse notes that the client is dyspneic and auscultates the presence of crackles in the lung bases with an apical heart rate of 110 beats per minute. What complication should the nurse suspect that the client is experiencing?

1. Immune response to transfusion 2. Hypovolemia 3. Fluid overload 4. Polycythemia vera Answer: 3 Rationale: Circulatory overload is a complication associated with rapid transfusion administration. Symptoms include bounding pulse, dyspnea, and crackles in the lungs. Crackles in the lungs would not be associated with the other options. Cognitive Level: Analyzing Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of the question is the ability to rec- ognize signs of circulatory overload. Use nursing knowl- edge and the process of elimination to make a selection.

The nurse writing a care plan determines that which nursing diagnosis is a priority early in the care of a client with scleroderma?

1. Impaired Skin Integrity 2. Disturbed Body Image 3. Activity Intolerance 4. Hopelessness Answer: 1 Rationale: Skin manifestations are a common finding in clients with scleroderma and therefore require preventative and supportive nursing care as the priority. As the disease progresses, dermatologic effects may lead to disturbances in body image. With disease progression, there may be an impact on respiratory and musculoskeletal function, leading to activity intolerance. Hopelessness can develop with worsening symptoms later in the disease process. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge that scleroderma is pri- marily a skin disorder in many cases and thus the primary nursing diagnosis needs to address loss of skin as a protec- tive barrier. Use nursing knowledge and the process of elimination to make a selection.

8 A postoperative client is to receive a transfusion of platelets because of a critically low platelet count. What knowledge should the nurse have related to the function of platelets?

1. Improves hemoglobin and hematocrit levels 2. Prevents formation of deep vein thrombosis 3. Decreases bleeding from a surgical site 4. Returns prothrombin time to expected range Answer: 3 Rationale: A transfusion of platelets is indicated for the client with active bleeding. A transfusion with PRBCs would result in increased hemoglobin and hematocrit levels. Platelet administration is not associated with the prevention of deep vein thrombosis. The administration of platelets is not associated with the return of the prothrombin time to normal. Cognitive Level: Understanding Client Need: Pharmacological and Parenteral Therapies Integrated Process: Teaching and Learning Content Area: Fundamentals Strategy: The core issue is knowledge related to platelet transfusion therapy. Recall that platelets are critical for proper blood clotting to select the correct answer.

Rest and immobilization are important to wound healing because they:

1. Increase circulation to involved area 2. Increase the metabolic rate 3. Prevent further injury to area 4. Prevent contractures in the involved area (3) Rationale: Rest and immobilization are important to wound healing because they prevent further injury to the area.

A client diagnosed with scleroderma reports painful fingers that change colors (pale to red) when washing dishes. Which suggestion by the nurse might help the client with this symptom?

1. Increase the water temperature. 2. Use gloves during dishwashing. 3. Start physical therapy to increase blood flow to the hands. 4. Take over-the-counter H2 receptor antagonist medications Answer: 2 Rationale: Clients who have scleroderma usually have Raynaud's phenomenon, which can be triggered by temperature changes, such as with prolonged contact with water. Use of gloves when washing dishes may prevent temperature changes yet still allow the client to participate in ADLs. Hotter water may increase the risk of scalding and so is not suggested. Physical therapy is indicated for treatment of esophageal problems associated with scleroderma. H2 receptor blockers help to treat esophageal problems associated with scleroderma. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immunological Strategy: The core issue of the question is recognition of Raynaud's syndrome as part of scleroderma and the ability to select an appropriate interven- tion for that problem. Use nursing knowledge and the pro- cess of elimination to make a selection.

The white blood cell (WBC) count of a client with systemic lupus erythematosus (SLE) shows a shift to the left. Which nursing diagnosis reflects the highest priority for this client?

1. Ineffective Health Maintenance 2. Impaired Skin Integrity 3. Ineffective Individual Coping 4. Ineffective Protection Answer: 4 Rationale: All identified nursing diagnoses are of concern for a client with SLE. However, the results of the laboratory test demonstrate an increased risk for infection that is due to the disease process and/or possible treatment measures such as steroids and immunosuppressive agents. A shift to the left in a WBC differential indicates an increased number of immature cells, suggesting infection. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Immunological Strategy: The core issue of the question is the ability to analyze WBC differential count data to determine risk of infection. Use nursing knowledge and the process of elimination to make a selection.

An adult client who, after being hospitalized 3 days ago, is having trouble sleeping. The nurse also notes some confusion during waking hours. What is the most appropriate nursing diagnosis for this client?

1. Ineffective Health Maintenance 2. Ineffective Individual Coping 3. Disturbed Sensory Perception 4. Disturbed Sleep Pattern Answer: 4 Rationale: The client is in a new environment. Changes in environment bring about uncertainty, and the client may be unable to sleep or may sleep less well than at home. Although the client is confused, there is no other data presented that could be the cause, making disturbed sleep pattern a more appropriate selection than disturbed sensory perception which relates to one of the five senses. Ineffective health maintenance and ineffective individual coping are more global nursing diagnoses, which do not address the client's specific manifestations of inability to sleep and daytime confusion. Cognitive Level: Analyzing Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: Exercise the ability to draw correct conclusions about client assessment data and translate it to a nursing diagnosis. In this case, the original problem is sleeping, and the correct answer is one that focuses on this problem.

11 Which health care provider order for potassium chloride (KCl) should the nurse question regarding a client with severe hypokalemia?

1. Infuse 1000 mL normal saline with 20 mEq KCl IV over 8 hours. 2. Give KCl 20 mEq PO daily after meals. 3. Infuse 1000 mL normal saline with 40 mEq KCl IV at 200 mL/hour. 4. Give 20 mEq KCl IV over 10 minutes. Answer: 4 Rationale: Potassium is never given as a bolus when it is administered intravenously. KCl should never be given rapidly or by IV push, because serious arrhythmias or cardiac arrest can occur. All of the other orders are within a safe and therapeutic range. Cognitive Level: Analyzing Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Planning Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the ques- tion is knowledge of safe and unsafe methods of administer- ing potassium as replacement therapy in hypokalemia. Use nursing knowledge and the process of elimination to make a selection.

Medication instruction for the client with rheumatoid arthritis (RA) should include which teaching points? Select all that apply.

1. Injection of gold salts requires monitoring for anaphylactic reactions every half-hour. 2. Treatment with sulfasalazine requires fluid restriction to avoid nausea and vomiting. 3. Acetaminophen may be used to decrease inflammation associated with RA. 4. Penicillamine may be safely used during pregnancy. 5. Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin may be used interchangeably to decrease inflammation. Answer: 1, 5 Rationale: Gold salts may cause anaphylaxis. NSAIDs and aspirin may be used interchangeably to decrease inflammation associated with RA. Sulfasalazine may cause nausea and vomiting, but fluids should be encouraged. Acetaminophen is an analgesic, but does not provide the anti-inflammatory effects of ASA and NSAIDs. Penicillamine cannot be used during pregnancy. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge of appropriate client teaching related to medications used to treat RA. Use nursing knowl- edge and the process of elimination to make a selection.

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

1. It directly opposes calcitonin. 2. It prevents renal disease in clients with hypocalcemia. 3. Calcium is absorbed in the intestines only under the influence of activated vitamin D. 4. The only way to obtain vitamin D is with oral supplementation. Answer: 3 Rationale: Calcium is absorbed in the intestines only under the influence of vitamin D, which is activated in the kidneys. Parathyroid hormone, not activated vitamin D, directly opposes calcitonin. Vitamin D does not prevent renal disease in hypocalcemia, but renal disease prevents activation of vitamin D, thereby reducing the body's ability to absorb calcium. There are other ways besides supplementation to obtain vitamin D in the body, such as exposure to sunlight. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowl- edge of the purpose and effects of vitamin D in a client with hypocalcemia. Use nursing knowledge and the process of elimination to make a selection.

The classic sign of swelling seen in the inflammatory process results from:

1. Leakage of plasma into the injured area 2. Increased blood circulation to the area 3. The presence of phagocytic activity in the area 4. Response to the cytokines released (1) Rationale: The classic sign of swelling seen in the inflammatory process results from leakage of plasma into the injured area.

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

1. Letting the client sleep to build up stamina 2. Maintaining strict precautions when entering and leaving the room so that the client feels he or she is getting the best care 3. Providing client care within a limited time frame to maintain isolation and keep client safe 4. Providing the client with diversional activities to enhance sensory input Answer: 4 Rationale: It is important to assess the psychosocial needs of a client on transmission-based precautions and to intervene to provide sensory stimulation for the client. Isolation procedures can cause clients to become depressed and withdrawn and to sleep excessively. Although it is important to maintain isolation precautions as ordered, attention must be given to include the client's psychosocial needs as part of the plan of care. Limiting contact time may be indicated for infection control, but it does not provide psychosocial support. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Immunological Strategy: The critical word in the question is psychosocial. With this word in mind, focus on the intervention that best meets nonphysical needs of the client. Use nursing knowledge and the process of elimination to make a selection.

6 An adult female client has a hemoglobin level of 9.2 grams/dL. The nurse interprets that this is most likely related to what condition?

1. Leukemia 2. Amenorrhea 3. Vitamin B12 deficiency anemia 4. Iron deficiency anemia Answer: 4 Rationale: Iron deficiency anemia can result from blood loss and is common in menstruating women; this is the most likely source of anemia in an adult female client. Leukemia is reflected in the white blood cell count. Amenorrhea, the absence of menstruation, is unlikely to cause of iron deficiency anemia. Vitamin B12 deficiency anemia is often associated with dietary deficiency, such as experienced by vegetarians or those who avoid dairy prod- ucts. Cognitive Level: Analyzing Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of the question is the ability to anticipate the needs of a cli- ent with iron deficiency anemia. Use nursing knowledge related to growth and development to help answer this question.

The correct order of these events in an inflammatory response is:

1. Mast cell degranulation, diapedesis of leukocytes, increased vascular permeability, and capillary dilatation 2. Mast cell degranulation, capillary dilatation, increased vascular permeability, and diapedesis of leukocytes 3. Diapedesis of leukocytes, increased capillary dilatation, increased vascular permeability, and mast cell degranulation 4. Increased capillary dilatation, mast cell degranu- lation, diapedesis of leukocytes, and increased capillary permeability (2) Rationale: This is the correct order for these events in an inflammatory response.

During the early stages of a chronic disease, clients tend to focus on:

1. Medication schedule 2. Interpretation of symptoms 3. Impact of lifestyle changes 4. Understanding the disease process (3) "Rationale: Clients tend to focus on lifestyle changes in the early stages of a chronic disease."

Which of the following physiological changes in the older client should a nurse consider when assessing an intravenous site?

1. Mental status 2. Limited income 3. Skin condition 4. Mobility intravenous calculations (3) "Rationale: The skin of an older adult is thinner, has less subcutaneous fat, and is more fragile. Consider the mental status of an older adult when obtaining consent or providing client education. The location of an intravenous site may limit a client's mobility, but this will not affect the nurse's assessment of the site."

A priority assessment for clients with fluid volume excess is:

1. Mental status 2. Weight 3. Postural vital signs 4. Urine output (2) Rationale: Mental status is rarely affected in a fluid excess without a change in osmolality. Postural vital signs are most important in clients with fluid volume deficit. Urine output may be increased or decreased, depending on the cause of the fluid excess. Weight is an important indicator of fluid balance.

1 A client has been admitted for dehydration after fasting for five days. For which acid-base imbalance would the nurse assess this client?

1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Answer: 1 Rationale: A prolonged fasting state can lead to dehydration. During fasting, the body reverts to cellular breakdown to maintain energy, and lactic and pyruvic acids build up in the body. This accumulation of acids leads to the development of metabolic acidosis. Metabolic and respiratory alkalosis are incorrect because alkalosis would not occur. Respiratory acidosis is incorrect because the primary disturbance is not respiratory. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: Note the critical word fasting that indicates this is a metabolic rather than respiratory problem, which eliminates respiratory acidosis and alkalosis. Choose metabolic acidosis because metabolic by-products are acidic in nature, not alkaline.

A client who has experienced cardiac arrest is most at risk for:

1. Metabolic acidosis 2. Respiratory alkalosis 3. Hyponatremia 4. Fluid volume excess (1) Rationale: Cardiac arrest is associated with tissue hypoxia and development of lactic acidosis. This causes a metabolic acidosis.

The goal of HAART is to:

1. Minimize side effects of the drugs 2. Encourage client compliance to the medication schedule 3. Lower the CD4 cell levels 4. Avoid viral resistance for each drug (4) "Rationale: The goal of HAART is to avoid viral resistance for each drug."

The nurse must apply an elastic bandage to support a client's sprained ankle. Which action should the nurse take during this procedure?

1. Moderately stretch the bandage and wrap it from distal extremity to proximal. 2. Wrap the extremity loosely enough to insert two fingers beneath the bandage. 3. Maintain a tight stretch with each wrap of the bandage. 4. Start proximal to the injury site and work distally. Answer: 1 Rationale: To prevent vascular impairment, proper application of elastic bandages is required. Wrapping distal to proximal is compatible with the flow of venous return. Wrapping the bandage evenly while stretching it moderately ensures that there will be even tension applied to the extremity while not occluding circulation. Wrapping the bandage loosely enough to be able to insert two fingers will not secure the bandage in place or provide adequate support for the injury. Excessive tension when applying an elastic bandage would cause circulation to be compromised. Wrapping in a proximal to distal direction would inhibit venous return. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is knowledge of basic wound care procedures. Use nursing knowledge of these procedures and concepts related to blood flow to make your selection.

The nurse is assisting a client who has methicillin-resistant Staphylococcus aureus in collecting a clean-catch urine specimen. Which protective equipment is unnecessary?

1. N95 particulate respirator 2. Gown 3. Eye protection 4. Sterile gloves Answer: 3 Rationale: Methicillin-resistant Staphylococcus aureus requires transmission-based contact precautions. Eye protection would be worn to protect the mucous membranes of the eyes when splatters of body fluids or excretions are possible. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves. N95 respirators are needed when caring for the client with tuberculosis, so it is inappropriate for this scenario. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The critical word unnecessary suggests that all but one of the answers are correct. Using the process of elimination, look for the choice that identifies personal protective equipment that is not needed for contact precautions.

Which assessment finding by the nurse warrants further investigation to determine if the client has rheumatoid arthritis (RA)?

1. Negative family history 2. Reports of prolonged morning stiffness lasting for 1 hour 3. Occasional use of NSAIDs for aches and pains 4. Reports of pain with movement Answer: 2 Rationale: Prolonged morning stiffness is associated with RA. A negative family history does not increase the risk of RA. Occasional use of NSAIDs is not by itself a direct link to the development of RA. Reports of pain with movement are more likely to be associated with degenerative joint disease (osteoarthritis). Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immunological Strategy: The core issue of the question is the ability to identify symptoms that are possibly associated with RA. Use nursing knowledge and the process of elimination to make a selection.

Place the following steps of venipuncture in order

1. Open all packages 2. Put on gloves 3. Verify physician order 4. Prep site 5. Perform venipuncture a.1,4,2,3,5 b.2,3,1,4,5 c. 1, 4, 3, 2, 5 d. 3, 1, 2, 4, 5" (d)

___________is the ability to cause fluid movement across membranes.

1. Osmosis 2. Hypertonic 3. Tonicity 4. Osomality (3) "Rationale: Tonicity is the ability to cause fluid move- ment across membranes. Osmosis is the movement of fluid through a semipermeable membrane. Hyperto- nicity refers to solutions that cause fluid to move out of the cell resulting in shrinking of the cells."

9 A client is admitted to the hospital with sudden onset of severe abdominal pain. Which arterial blood gas (ABG) value would the nurse expect to see with this client?

1. PaCO2 48 2. HCO3- 18 3. pH 7.32 4. SaO2 90 Answer: 2 Rationale: Acute pain usually leads to hyperventilation, which causes CO2 to be blown off, leading to an increased pH and decreased CO2 level. If the client has not compensated, the bicarbonate level will be normal. If the client is compensating, then the bicarbonate level will decrease in an attempt to restore the pH. A PaCO2 of 48 is incorrect because it reflects a slight elevation; if the client were in severe pain, the level would likely be lower as the client would have increased respirations. A pH of 7.32 is incorrect because the pH is slightly acidotic. An SaO2 of 90 is incorrect because the oxygen saturation should be within normal limits. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: Visualize a picture of the client in pain. This person is most likely to have an increased respiratory rate, which blows off CO2 and decreases the bicarbonate level as a compensatory mechanism. This will help you to easily choose the correct option.

Identify which of the following are components of blood (select all that apply):

1. Packed red blood cells 2. Normal saline 3. Fresh frozen plasma 4. Platelets (1, 3, 4) "Rationale: The other response is IV solution and not blood components."

15 A client presents to the emergency department following a motorcycle accident. The client is in hypovolemic shock. The health care provider has ordered plasma expansion. What blood product should the nurse anticipate that the client will receive?

1. Packed red blood cells 2. Cryoprecipitate 3. Platelets 4. Albumin Answer: 4 Rationale: Albumin is used as a plasma expander and is used in the treatment of hypovolemic shock. Packed RBCs are indicated in the treatment of anemia. Cryoprecipitate is administered to treat von Willebrand's dis- ease and fibrinogen levels below 100 mg/dL. Platelets are indi- cated in the treatment of thrombocytopenia. Cognitive Level: Analyzing Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The core issue of the question is knowledge of the uses of various blood products. Use nursing knowledge and the process of elimination to make a selection.

16 The following arterial blood gas (ABG) results are on the client's chart: pH 7.50; PaCO2 36; HCO3- 30. How will the nurse interpret this report?

1. Partially compensated metabolic alkalosis 2. Compensated respiratory alkalosis 3. Uncompensated metabolic alkalosis 4. Uncompensated respiratory alkalosis Answer: 3 Rationale: The pH indicates alkalosis; HCO3- is high, indicating a metabolic origin, and the PaCO2 is normal, which indicates that compensation has not taken place. Partially compensated metabolic acidosis is incorrect because with compensation, the PaCO2 level would be increased. Compensated and uncompensated respiratory alkalosis options are incorrect because the primary disturbance is metabolic, as reflected by the increased bicarbonate level. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: First, note that the pH is high, and so the imbalance cannot be compensated. Then note that HCO3- is the abnormally high value (not CO2), so the imbalance must be metabolic rather than respiratory. Choose uncompen- sated over compensated metabolic alkalosis because the CO2 (normally 35-45) has made no attempt to rise to com- pensate for the high HCO3-.

The nurse assigned to the respiratory care unit is working with four clients who have pneumonia. The nurse should assign the only remaining private room on the nursing unit to the client infected with which organism?

1. Penicillin-resistant Streptococcus pneumoniae pneumonia 2. Pseudomonas aeruginosa pneumonia 3. Pneumocystis carinii pneumonia 4. Legionella pneumophila pneumonia Answer: 1 Rationale: While each option contains "pneumonia," the causative agent is different for each. An organism that is "resistant" is a pathogenic microorganism that is difficult to treat and requires droplet precautions. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Note the critical word resistant in the correct option. This provides a clue that the infection is difficult to treat and requires specific additional infection control practices, in this instance droplet precautions. The pneumonias in the other options do not require transmission based precautions.

The family of a client with hypercalcemia states that the client is "not acting like himself." The nurse focuses assessment on which manifestation?

1. Personality change 2. Anxiety 3. Seizure activity 4. Carpal spasms Answer: 1 Rationale: Clinical manifestations of hypercalcemia include personality changes. Anxiety, seizures, and carpal spasms are manifestations of hypocalcemia. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of manifestations of hypercalce- mia. Use nursing knowledge and the process of elimination to make a selection.

15 Which medication reported by a client during a nursing history could be associated with the development of hypocalcemia?

1. Phenytoin (Dilantin) 2. Calcium carbonate (TUMS) 3. Calcitriol 4. Hydrochlorothiazide (HydroDIURIL) Answer: 1 Rationale: Antiepileptics such as phenytoin (Dilantin) alter vitamin D metabolism and lead to hypocalcemia. Calcium carbonate and calcitriol represent calcium sources, and the inclusion of these in a treatment plan would lead to increased serum calcium levels. Hydrochlorothiazide is incorrect because thiazide diuretics can lead to calcium retention. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of medications that increase the risk of hypocal- cemia. Use nursing knowledge and the process of elimina- tion to make a selection.

The nurse would take which action to protect the client from infection at the portal of entry?

1. Place sputum specimen in a biohazard bag for transport to the lab. 2. Empty Jackson-Pratt drain using sterile technique. 3. Dispose of soiled gloves in waste container. 4. Wash hands after providing client care. Answer: 2 Rationale: Using sterile technique to empty wound drains is aimed at interrupting the portal-of-entry link in the chain of infection. By using sterile technique, the nurse reduces the risk of introducing pathogens into the client's wound via the drain. Proper handling of specimens interrupts the chain of infection at the reservoir link. Disposing of gloves properly and washing hands after providing care break the chain of infection at the mode of transmission link. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Knowledge of the chain of infection is required. The portal of entry has to be a route whereby micro- organisms can enter the client, so select the option that is directly in contact with the client.

The nurse would expect to institute transmission-based precautions for a client with which infection?

1. Pneumonia caused by Pseudomonas aeruginosa 2. Pneumocystis carinii pneumonia 3. A sacral wound contaminated by Escherichia coli 4. A draining leg wound with methicillin-resistant Staphylococcus aureus Answer: 4 Rationale: Transmission-based precautions are required for all antibiotic-resistant microorganisms regardless of their mode of transmission. The other options indicate the need for medical and surgical asepsis in the care of the client but not the use of transmission-based precautions. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The critical words methicillin- resistant indicate a microorganism that is difficult to eradicate. Eliminate each of the incorrect options after visualizing each situation because they can be managed by use of stan- dard precautions.

The nurse needs to conduct an admission interview with a 74-year-old client who is hearing impaired. What should the nurse do to enhance the client's ability to hear? Select all that apply.

1. Position self to be within the client's line of vision 2. Dim the lights in the room 3. Over articulate words 4. Turn down the television in the room 5. Use a moderate rate and the same tone for all words Answer: 1, 4, 5 Rationale: The nurse should select a position within the client's line of vision to enable the client to read lips during the conversation. It is good to decrease back- ground noises that interfere with the client's ability to hear the nurse. It is also helpful to speak at a moderate rate and use the same voice tone throughout each sentence, not dropping the tone at the end of a sentence. The lighting should not be dimmed because doing so would interfere "with the client's ability to see the nurse clearly in order to read lips. Words should not be over articulated; exaggerated, unnatural movement of the lips can distort words for the client who relies on lip reading to compensate for hearing loss. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: The core issue of the question is effective communication strategies with a client whose hearing is impaired. Remember to focus on enhancing the client's vision during communication and use a moderate overall approach (i.e., not excessive or insufficient). When there are multiple correct answers to a question, consider each option as a true/false statement.

25 Which concurrent electrolyte imbalance should the nurse anticipate while caring for a client with hyperphosphatemia?

1. Potassium 2.8 mEq/L 2. Sodium 131 mEq/L 3. Calcium 6.8 mEq/L 4. Magnesium 3.4 mEq/L Answer: 3 Rationale: Calcium and phosphorus have an inverse relationship in the body. For this reason, when phosphorus levels are high, calcium levels are low. Sodium, potassium, and magnesium do not have an inverse relationship with phosphorus. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge that hypocalce- mia accompanies hypermagnesemia. To answer the question correctly, you must also be able to recognize abnormal labo- ratory values. Use nursing knowledge and the process of elimination to make a selection.

An 80-year-old client has been admitted to the nursing unit with Parkinson's disease. Which of the following activities would be most appropriate in preventing disuse syndrome?

1. Providing for the nutritional needs of the client 2. Promoting weight-bearing exercises 3. Encouraging 8 glasses of fluid in 24 hours 4. Turning and positioning every 2 hours Answer: 2 Rationale: Weight-bearing exercise is the best approach to preventing disuse syndrome. Disuse syndrome occurs because the stresses of weight bearing are absent and the bone releases calcium. While nutritional needs of a client with Parkinson's is an appropriate nursing intervention, it does not address the prevention of disuse syndrome. Encouraging fluids is important for the elderly client because they become easily dehydrated due to a decreased sense of thirst; however, it does not address the prevention of disuse syndrome. Turning and repositioning every 2 hours is an important nursing intervention to prevent skin breakdown; this action does not specifically address the prevention of disuse syndrome. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Apply knowledge related to the cause of disuse syndrome and the nursing interventions that will minimize it. Use concepts of basic nursing care to answer the question

What information will the nurse include when explaining therapeutic measures to a client taking methotrexate (Rheumatrex) for rheumatoid arthritis (RA)?

1. Relief of symptoms will be assessed for within 1 week of starting medication. 2. Fluids should be restricted to prevent possible edema formation. 3. Drug doses will be adjusted for optimum effect at lowest dose once relief has been established. 4. Six months of therapy will be adequate to stop the disease process from progressing. Answer: 3 Rationale: Methotrexate treatment takes several weeks to effect relief. Once relief is obtained, the dose is adjusted to achieve maximum response at the lowest dose. If the drug is discontinued, then symptoms of the disease do return. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immunological Strategy: The core issue of the question is knowledge of management principles for RA. Use nursing knowledge and the process of elimination to make a selection.

A 72-year-old client has been in the ICU for the past 2 days. Which intervention would be the most appropriate in decreasing the risk for sensory deprivation? Select all that apply.

1. Remove equipment from the room. 2. Explain procedures and routines to the client upon admission. 3. Provide a clock and calendar in the client's room. 4. Maintain a balance of activity and rest periods. 5. Maintain constant conversation when in the client's room. Answer: 3, 4 Rationale: Providing the client with a clock and calendar helps the client to be oriented to time and date. These would be meaningful stimuli for the client and decrease the chance for sensory deprivation. Activities and rest periods should be spaced and planned to balance high and low levels of sensory stimuli. It may not be realistic in an ICU to remove equipment from the room. Explaining all procedures and routines would increase the risk of overload. Continuous conversation is not therapeutic and could place the client at risk for sensory overload as a different problem. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is nursing actions that can prevent the client from experiencing sensory deprivation. Use knowledge of basic nursing mea- sures to help a client stay oriented to time, place, and person make appropriate selections.

The nurse is preparing to leave the room of a client on transmission-based precautions. Place in the correct order the steps the nurse would follow to remove personal pro- tective equipment and perform hand hygiene.

1. Remove gown. 2. Remove gloves. 3. Remove mask. 4. Remove eye protection. 5. Wash hands. Fill in your answer below:_________ Answer: 2, 3, 1, 4, 5 Removing: Gloves-->Mask-->Gown-->Eyes--> Wash hands Rationale: Gloves are removed first, as they would be the most contaminated. The mask would be removed next, followed by the gown. Eye protection is removed last, followed by hand washing. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Washing the hands is last. Removal of gloves is first, as the gloves would be the most contaminated.

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

1. Remove the stinger from the client's arm 2. Keep the client warm with soft blankets 3. Check the tongue for swelling and listen for stridor 4. Place client in the Trendelenburg position Answer: 3 Rationale: The priority intervention is to maintain a patent airway in a potential anaphylactic reaction. Therefore, the nurse should assess for swelling of the tongue and stridor, which could indicate impending respiratory obstruction. The other interventions are supportive measures that can be used during an allergic response. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Immunological Strategy: Remember in emergency or near-emergency situations to use the ABCs (airway, breathing, and circulation) to plan priorities of care. Use the process of elimination to make a selection.

The nurse determines that a client with a nasogastric tube on low suction for five days is at risk for developing which acid-base imbalance?

1. Respiratory acidosis 2. Metabolic alkalosis 3. Metabolic acidosis 4. Respiratory alkalosis Answer: 2 Rationale: A client who has prolonged nasogastric suction is apt to have higher levels of bicarbonate because of hydrogen ion loss. Bicarbonate excess leads to a metabolic disturbance and the development of metabolic alkalosis. Respiratory and metabolic acidosis are incorrect because the client will not experience acidosis. Respiratory alkalosis is incorrect because the primary disturbance is caused by retained levels of bicarbonate (not elimination of carbon dioxide) in the body. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: Eliminate respiratory imbalances first because nasogastric suction is a metabolic problem. Choose alkalosis recalling that pancreatic juices are rich in bicarbon- ate and are not neutralized because the nasogastric suction eliminates hydrochloric acid that would neutralize the alka- line pancreatic secretions.

A client is admitted to the hospital with atelectasis and reports of chest pain. For which acid-base imbalance would the nurse assess this client?

1. Respiratory alkalosis 2. Metabolic acidosis 3. Metabolic alkalosis 4. Respiratory acidosis Answer: 4 Rationale: A client with atelectasis has collapsed alveoli that retain CO2, which can lead to respiratory acidosis. The client most likely would have hypoventilation as a respiratory pattern, which would further contribute to the development of respiratory acidosis. Respiratory and metabolic alkalosis are incorrect because the client would not be in an alkalotic state. Metabolic acidosis is incorrect because the primary disturbance is respiratory. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The critical word in the stem of the question is atelectasis. Recall that this term is associated with respiratory problems to eliminate options referring to metabolic disorders. Choose respiratory acidosis over alkalosis recalling that CO2 retention characterizes many respiratory conditions, leading to acidosis (since CO2 acts as an acid in the body).

Early clinical manifestations of GVHD include:

1. Respiratory problems, for example interstitial pneumonitis 2. Skin rash and pruritus 3. Taut, firm, leather like skin 4. Dry lacrimal ducts and oral mucosa (2) "Rationale: The early clinical manifestations of GVHD are skin rash and pruritus."

Which of the following is not one of the five rights of medication administration?

1. Right medication 2. Right client 3. Right room 4. Right dose (3) "Rationale: The five rights are: right medication, right client, right dose, right time, and right route"

2 The nurse is preparing to administer a unit of packed red blood cells (PRBCs). When obtaining the necessary sup- plies, the nurse should obtain which IV solution to hang with the unit of blood?

1. Ringer's lactate 2. 5% dextrose in 0.9% sodium chloride 3. 5% dextrose in 0.45% sodium chloride 4. 0.9% sodium chloride Answer: 4 Rationale: Normal saline is the solution of choice when used as an adjunct to a transfusion. The other options are contraindicated due to the potential for clotting and hemolysis.

6 A client is admitted to the hospital with respiratory acidosis. The nurse considers that which condition could be an etiology for this state? Select all that apply.

1. Severe diarrhea for several days 2. Diabetic ketoacidosis 3. Obesity 4. Diuretics 5. Sedative overdose Answer: 3, 5 Rationale: Obesity can lead to chest wall abnormalities and hypoventilation, which can lead to respiratory acidosis. Sedative overdose depresses the central nervous system, which leads to hypoventilation and respiratory acidosis. Prolonged diarrhea can lead to the development of metabolic acidosis. DKA leads to the development of metabolic acidosis. Diuretic administration leads to the development of metabolic alkalosis. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: Note the term respiratory acidosis in the stem of the question. First evaluate each option to determine whether it would lead to acidosis and alkalosis. Then differentiate between respira- tory and metabolic acidosis to choose correctly. Note the wording of the question suggests that more than one option is correct.

An infant is admitted to the pediatric unit with a diagnosis of sepsis. The nurse is completing a nursing assessment. What would be the priority nursing assessment for this infant?

1. Skin Integrity 2. Temperature 3. Jaundice 4. Respiratory Function Answer: 4 Rationale: Altered temperature, jaundice, and respi- ratory distress are all symptoms of sepsis in infants. Respiratory function is the highest priority because without an adequate airway and breathing, the client cannot main- tain life. Skin integrity is a routine assessment. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Child Health Strategy: Use the ABCs and the process of elimination to make a selection. Airway and breathing typically take prior- ity in situations of high acuity, such as sepsis.

3 A client is admitted to the hospital with a diagnosis of respiratory acidosis secondary to overdose of barbiturates. Which assessment would the nurse anticipate? Select all that apply.

1. Slow, shallow respirations 2. Tetany symptoms 3. Increased deep tendon reflexes 4. Palpitations 5. Headache Answer: 1, 5 Rationale: Clients with respiratory acidosis from ingestion of barbiturates would have slow and shallow respirations, leading to hypoventilation. Tetany symptoms, increased deep tendon reflexes, and palpitations are associ- ated with respiratory alkalosis. Headache is associated with respiratory acidosis because the increased CO2 level causes cerebral vasodilation, which leads to headache. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: Recall that barbi- turates are central nervous system (CNS) depressants, while palpitations, tetany and increased deep tendon reflexes indi- cate CNS excitation. Choose slow shallow respirations as consistent with CNS depression, and choose headache because of the dilating effect of retained CO2 on cerebral blood vessels.

23 A home health nurse is making a visit to an older adult client with a history of heart failure (HF). The client was prescribed diuretics twice a day and a low-sodium diet. The nurse should be most concerned about which current laboratory result?

1. Sodium 145 mEq/L 2. Chloride 90 mEq/L 3. K+ 4.2 mEq/L 4. HCO3ﰆ 27 mEq/L Answer: 2 Rationale: The decreased chloride level is of greatest concern because it can be associated with dilutional hypochloremia from fluid overload. The client's history of HF places the client in a higher risk category for fluid retention. The sodium, potassium, and bicarbonate levels are within normal range and are reassuring. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is the ability to determine abnormal electrolyte levels. Use nursing knowledge and the process of elimination to make a selection.

21 The nurse reviews the laboratory test results for a client with preeclampsia, expecting to find which value?

1. Sodium 148 mEq/L 2. Sodium 125 mEq/L 3. Magnesium 3.1 mEq/L 4. Magnesium 1.2 mEq/L Answer: 4 Rationale: A decreased magnesium level can occur in toxemia of pregnancy, preeclampsia, and eclampsia, causing seizures. A magnesium level of 3.1 mEq/L is an increased level, the opposite of the concern for this client. Sodium is not the electrolyte of concern in a client with preeclampsia. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowledge of conditions that are consistent with decreased magnesium levels, and the ability to determine a reduced level. Use nursing knowledge and the process of elimination to make a selection.

Cell mediated immunity is initiated by

1. Specific antigen recognition by T.cells 2. Nonspecific antigen recognition by B cells 3. Release of complement cells into the blood stream 4. Release of cytokines from white blood cells (1) "Rationale: Cell-mediated immunity is initiated by specific antigen recognition by T cells."

6 The nurse is caring for a client who has a sodium level of 128 mEq/L. As part of the care, the nurse will restrict which item for this client?

1. Sports drinks, such as Gatorade 2. Eggs and cheese products 3. Salt on the diet tray 4. Water Answer: 4 Rationale: Hyponatremia can also be referred to as dilutional hyponatremia or water intoxication. Water restriction would be an important part of the treatment plan when caring for a client who has hyponatremia. Restrictions of Gatorade (electrolyte-rich solution), eggs, cheese products, and salt on the diet tray are not indicated, because the client is experiencing a sodium deficit. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the ques- tion is effective treatment measures for hyponatremia. Use nursing knowledge and the process of elimination to make a selection.

A client with vancomycin-intermediate-resistant Staphylococcus aureus (VISA) is admitted to the nursing unit. What type of precautions should the nurse institute?

1. Standard precautions 2. Neutropenic precautions 3. Droplet precautions 4. Contact precautions Answer: 4 Rationale: Clients with antibiotic-resistant microorganisms must be isolated with transmission-based precautions. The organism is transmitted via close person- to-person direct contact and by touching contaminated sur- faces and objects. Standard precautions are used with all clients, regardless of medical diagnosis. Reverse isolation is instituted for immunocompromised clients. This organism is not transmitted via droplet nuclei. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical words vancomycin-intermediate-resistant suggest the microorganism is difficult to eradicate, indicating it is highly contagious. Eliminate standard and neutropenic, as they are not disease-specific precautions. Select contact over droplet, recalling that Staphylococcus aureus is a micro- organism that is commonly found on skin.

A client with a known infection must be managed by using which identified method of precaution?

1. Strict asepsis 2. Standard precautions 3. Droplet precautions 4. Transmission-based precautions (2) Rationale: A client with a known infection must be managed by using standard precautions.

The nurse assesses the client with rheumatoid arthritis for which characteristic joint changes? Select all that apply.

1. Swan-neck deformity 2. Heberden's and Bouchard's nodes 3. Tophi 4. Charcot's joints 5. Ulnar deviation Answer: 1, 5 Rationale: Swan-neck deformity occurs at the proximal interphalangeal (PIP) joints in rheumatoid arthritis. Ulnar deviation occurs as the joint deteriorates and is a visible finding in clients with RA. Heberden's and Bouchard's nodes are commonly found in clients with osteoarthritis. Tophi (firm, moveable nodules) are associated with gout. Charcot's joint is considered a neuropathic disorder that falls under the broader category of rheumatism. It is not specific to RA and is more likely to be seen as a complication in clients with diabetes. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Immunological Strategy: The core issue of the question is identification of signs and symptoms of RA. Use nursing knowledge and the process of elimination to make selections.

Parents report their 6-month-old daughter has had diarrhea and vomiting for 24 hours. Which assessment finding do you expect to find that suggests fluid volume deficit?

1. Swelling of extremities 2. Increased number of diaper changes 3. Depressed fontanelles 4. Weight gain (3) Rationale: Swelling and weight gain are signs of fluid volume excess. Although the child may need in- creased diaper changes because of diarrhea, those are not a sign of fluid volume deficit. Depressed fon- tanelles occur in young children with fluid volume deficit.

10 A nurse has received a report on a client being admitted with anemia who requires a blood transfusion. The nurse will anticipate which assessment findings? Select all that apply.

1. Tachycardia 2. Hypertension 3. Headache 4. Diaphoresis 5. Bounding peripheral pulses Answer: 1, 3 Rationale: Key features of anemia include coolness to touch, intolerance to cold, tachycardia, ortho- static hypotension, and headaches. The other options are not associated with anemia. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Assessment Content Area: Fundamentals Strategy: The core issue of the question is the ability to antici- pate the needs of a client with moderately severe anemia. When there is more than one correct answer to a question, consider each option as a true/false statement.

4 What instruction should the nurse include in an education program to prevent dehydration for a high school hiking club that is planning a 12-mile hike in early summer?

1. Take water and commercial sports drinks to sip often along the way. 2. Drink large amounts of water, at least 16 ounces every hour, while hiking. 3. Take salt tablets every 3-4 hours, and drink plenty of water while in the heat. 4. Stop every 4 hours along the way, and drink a few ounces of water while resting. Answer: 1 Rationale: Drinking a combination of water and sports drinks is helpful. Sports drinks provide carbohydrates, water, and electrolytes. Drinking large amounts of only water fails to replace electrolytes, which can lead to water intoxication. Salt tablets are no longer recommended, because too much salt has a hypertonic effect, causes diuresis, and can actually worsen fluid loss. Those who exercise in hot climates need to continuously replace both fluid and electrolyte losses. A few ounces of fluid every 4 hours is insufficient. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowl- edge of measures to prevent fluid and electrolyte imbalance during exercise. Use nursing knowledge and the process of elimination to make a selection.

A client on complete bed rest is at risk for disuse syndrome. The nurse should consider which client goal as appropriate?

1. The client has shorter periods of immobility. 2. The client remains free of contractures in lower extremities. 3. The nurse turns the client every 2 hours. 4. The nurse performs passive range of motion to lower extremities every 4 hours. Answer: 2 Rationale: Disuse syndrome is a result of prolonged immobility. Stating "the client remains free of contractures" describes in active terms the desired outcome for the client. Using "shorter periods of immobility" does not provide a specific expectation or outcome for the client. Stating that the nurse will turn the client every 2 hours is an interven- tion and not a goal. A goal needs to state a specific expecta- tion or outcome for the client. Stating that the nurse will perform passive range of motion every 4 hours is an inter- vention and not a goal. A goal needs to state a specific expectation or outcome for the client. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: Apply knowledge related to the nursing process, the pathophysiology of disuse syndrome, and appropriate client goals. Recall that goal statements are indicators of what the nurse wants to happen as a result of care. With these general principles in mind, eliminate each of the incorrect responses.

8 The community health nurse is assigned to a client who recently was discharged from the hospital with resolving hypernatremia. During the initial assessment interview, what information would be of critical importance in determining a plan of care for this client?

1. The client lives on the second floor of an apartment building that has an elevator. 2. The client needs to walk 100 feet each day to reach the mailbox for the apartment building. 3. The client performs self-monitoring of blood glucose once a day. 4. The client uses Alka-Seltzer on a frequent basis for gastrointestinal complaints. Answer: 4 Rationale: The frequent use of Alka-Seltzer can cause an increase in serum sodium levels. It is important during an initial assessment to obtain information about all medications (prescription and OTC) that a client is taking. Elevator use and 100-foot walking distance are incorrect because they would not cause or aggravate a sodium imbalance, although it is helpful data for mobility status. Self monitoring of blood glucose suggests that the client might have diabetes, but this does not relate to increases in serum sodium levels. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issue of the question is knowl- edge of factors that can lead to elevated serum sodium lev- els. Use nursing knowledge and the process of elimination to make a selection.

The nurse determines that a client receiving a unit of packed red blood cells (PRBCs) is experiencing a trans- fusion reaction. After stopping the blood transfusion, what actions should the nurse promptly take next? Select all that apply.

1. The physician should be notified. 2. Obtain a white blood cell count. 3. Run normal saline at keep vein open (KVO) rate. 4. Infuse a normal saline bolus. 5. Obtain vital signs every 5 minutes. Answer: 1, 3, 5 Rationale: The physician should be notified, but the nurse is to stop the transfusion immediately and keep the IV line open with normal saline. The client should be closely monitored and not left alone. The nurse is to stop the transfusion immediately and keep the IV line open with nor- mal saline. The client will need to be monitored closely. Vital signs should be obtained as frequently as every 5 minutes, and the client should not be left alone. A white blood cell count would be ordered by the physician; however, this action would not be independently initiated by the nurse without contacting the physician first. A saline bolus would be ordered by the physician; however, this action would not be independently initiated by the nurse without contacting the physician first. Cognitive Level: Analyzing Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is the ability to take proper action when a transfusion reaction is suspected. When there is more than one correct answer to a question, each option should be considered as a true/false statement.

Passive immunity involves

1. Transfer of antibodies through the heart of the mother to fetus 2. Inoculation with vaccine containing live or killed infectious organisms 3. Development of sensitized lymphocytes within the host body 4. Response of memory cells to entry of an infectious organism (2) "Rationale: Passive immunity involves inoculation with vaccine containing live or killed infectious organisms."

The nurse who is providing care to a group of clients concludes that the client with which health problem exhibits a type III immune-complex-mediated hypersensitivity reaction? (Type I involves IgE, Anaphylaxis and seasonal allergies. Type II involves igG and IgM, cytotoxic, Ex: Drug induced anemia. Type III are immune complex systems involving IgG and IgM with activation of complement. Type IV are mediated by T cells instead of antibodies Ex: skin allergy or poison ivy)

1. Transfusion reaction 2. Goodpasture's syndrome 3. Transplant rejection 4. Systemic lupus erythematosus Answer: 4 Rationale: Transfusion and Goodpasture's are examples of type II cytotoxic hypersensitivity reactions and are involved with the activation of complement. Lupus is an example of a type III hypersensitivity reaction, which involves IgG and IgM with the activation of complement. Transplant rejection is a Type IV hypersensitivity reaction. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Immunological Strategy: The core issue of the question is the ability to associate various types of hypersen- sitivity reactions with their etiologies. Use nursing knowledge and the process of elimination to make a selection.

A client has a pressure ulcer on the left hip. The nursing staff has written a nursing diagnosis of Impaired Skin Integrity with a client goal of "skin heals by 6/12." Prior to June 12, the nurse evaluates progress on reaching this goal. Which statement is the best notation of progress toward the goal?

1. Turned every 2 hours; avoided positioning on left side 2. Wet to moist dressing changed every 4 hours 3. No additional areas of skin breakdown noted 4. Wound less reddened; granulation tissue noted Answer: 4 Rationale: The description refers to the wound itself and is the best indication of the wound's current status. A decrease in redness and the presence of granulation are indicators that the goal of ulcer healing is evident. The other options do not address progress toward the goal of ulcer healing. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Apply knowledge regarding the nursing process and the concepts of documentation. Distinguish which option most accurately answers the question.

20 A client is admitted with severe diarrhea. Arterial blood gas (ABG) results are pH 7.33; PaCO2 42; HCO3- 20. The nurse concludes this client has which acid-base imbalance?

1. Uncompensated metabolic acidosis 2. Compensated respiratory acidosis 3. Compensated metabolic acidosis 4. Uncompensated respiratory acidosis Answer: 1 Rationale: The pH and HCO3- are decreased, indicating metabolic acidosis. The PaCO2 is normal, indicating that compensatory mechanisms have not started working. Compensated or uncompensated respiratory acidosis is incorrect because the primary disturbance is metabolic, as indicated by the low bicarbonate level. Compensated metabolic acidosis is incorrect because with compensation, a decrease in PaCO2 to restore balance would be expected. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: First, correlate diarrhea with a metabolic problem to eliminate compensated respiratory acidosis and uncompensated respiratory acidosis. Then, note that the pH is not within normal limits to choose uncompensated meta- bolic acidosis over compensated metabolic acidosis.

11 A client is admitted to the hospital with numerous episodes of muscle weakness and twitching. Arterial blood gas (ABG) results are pH 7.44; PaCO2 49; HCO3- 30. How would the nurse interpret these findings?

1. Uncompensated metabolic acidosis 2. Compensated respiratory alkalosis 3. Uncompensated respiratory alkalosis 4. Compensated metabolic alkalosis Answer: 4 Rationale: The pH is just below the high limit, and the HCO3- is elevated, indicating a metabolic problem. The PaCO2 is elevated, indicating compensation, so the correct interpretation is compensated respiratory alkalosis. Uncompensated metabolic acidosis is incorrect because the client is not acidotic. Compensated respiratory alkalosis is incorrect because the CO2 would be decreased rather than elevated. Uncompensated respiratory alkalosis is incorrect because the primary disturbance is metabolic, and the CO2 is elevated rather than decreased. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: Note that the pH is within normal range, which indicates that the condtion is compensated, thus eliminating acidosis options. Note the high HCO3- is a metabolic indicator (not respir tory), and is consistent with a pH near the high end of normal, to help you choose the compensated respiratory alkalosis option.

10 A client is admitted to the hospital with an acid-base imbalance. Arterial blood gas (ABG) results are pH 7.33; PaCO2 49; HCO3- 28. How would the nurse interpret these results?

1. Uncompensated respiratory acidosis 2. Metabolic alkalosis, uncompensated 3. Partially compensated respiratory acidosis 4. Partially compensated metabolic acidosis Answer: 3 Rationale: The pH is low, indicating acidosis; the PaCO2 is elevated, indicating a respiratory basis; and the HCO3- is elevated, indicating that compensatory mechanisms are partially working. Uncompensated respiratory acidosis is incorrect because compensation is taking place due to increased HCO3- level. Uncompensated metabolic alkalosis is incorrect because the client is not alkalotic. Partially compensated metabolic acidosis is incorrect because the primary disturbance is respiratory. The change in the PaCO2 level is greater than the change in the HCO3- level, which indicates a respiratory disturbance. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: First, eliminate the option with alkalosis because the pH of 7.33 indicates acidosis. Next, note that both the CO2 and HCO3- levels are abnor- mal, indicating that the body is attempting to compensate (eliminating uncompensated). Choose correctly from the remaining options noting the elevated CO2 "matches" a respiratory acidosis, and the HCO3- (an alkaline substance) is rising to try to compensate.

A client, admitted to the hospital for gallbladder surgery, is diagnosed as having a vitamin C deficiency. The nurse places high priority on assessing this client for which development postoperatively?

1. Unusual muscle weakness 2. Mental confusion 3. Delayed wound healing 4. Ataxia upon ambulating Answer: 3 Rationale: Protein and vitamin C are necessary for building and maintaining tissues. A deficiency of vitamin C would prolong wound healing. The other options are not manifestations of a vitamin C deficiency. Cognitive Level: Understanding Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of this question is the role of vitamin C in wound healing. Use nursing knowledge and the process of elimination to make a selection.

A 92-year-old client is in the hospital. The client is very hard of hearing, and the nurse needs to do the admission interview. Which action is appropriate for the nurse when assessing the client?

1. Use a cotton swab to clean cerumen in the client's ear before the interview. 2. Speak louder into the client's ear determined to have better hearing. 3. Lower the pitch of the voice and face the client during the interview. 4. Put new batteries in the hearing aid to ensure proper functioning. Answer: 3 Rationale: Hearing loss, especially of upper-range tones, is common in the elderly. Speaking to the client slowly and in a lower-pitched voice while facing the client is the best means of communication. Cleaning cerumen from the client's ears will not overcome age-related hearing loss. Depending on the level of hearing loss, speaking louder into the ear with the better hearing may still not be an effective action. The question states that the client is hard of hearing without reference to a hearing aid; if a hearing aid is used, changing the batteries may not be an effective action. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Apply knowledge related to communicating with a client who is hearing impaired. Remember that if the age of the client is included in the stem, it important in determining the cor- rect option. Consider the question as it is written and do not make assumptions.

A client has weakness of the lower extremities and uses crutches for mobility. What client behavior should indicate to the nurse that the client needs further teaching about using crutches?

1. Uses the swing-to gait 2. Uses axillary crutches 3. Bears weight on the armpits 4. Replaces rubber tips on the crutches "nswer: 3 Rationale: The weight of the body should be borne on the arms, not the axillae. When clients allow the axillae to bear the weight of the body, they are at risk of developing crutch palsy, a nerve damage. This behavior would require additional client teaching. The ability to perform the swing-to gait represents correct use of crutches, and therefore no further teaching is needed on those points. Axillary crutches are crutches that are appropriately positioned beneath the axilla of the body. If a cli- ent is able to use axillary crutches without bearing weight on the armpits, no further teaching is needed. Placing new rubber tips on the crutches indicates an awareness of equipment safety that requires no further teaching. Worn crutch tips can cause a client to slip or fall. Cognitive Level: Analyzing Client Need: Reduction of Risk Potential Integrated Process: Nursing Process: Evaluation Content Area:Fundamentals Strategy: The core issue of the question is proper use of crutches. Keep in mind that this question has a negative stem and the correct answer is the option that reflects incorrect information.

An elderly postoperative client's abdominal wound is still healing weeks after the surgery. The client asks the clinic nurse why the wound is healing so slowly. Which factors should the nurse identify that negatively affect healing in the elderly? Select all that apply.

1. Vascular changes 2. Nutritional status 3. Decreased activity 4. Keloid formation 5. Nutrient absorption Answer: 1, 2, 5 Rationale: Vascular changes in the elderly client, such as atherosclerosis and atrophy of capillaries, impair blood flow to the wound and negatively affect healing. Wound healing requires increased dietary intake of protein and vitamin C. The diet of an elderly may be inadequate for a variety of reasons such as: difficulty with chewing or swallowing; lack of access to food sources; or food choices restricted by finan- cial status. In the elderly client, deficient absorption of nutrients can occur because of chewing difficulties, decreased peristalsis, and/or reduced secretion of digestive enzymes; all of which can contribute to a delay in healing. A decreased activity level with aging does not diminish local blood supply to a healing wound. Keloid formation is an abnormal type of healing of a wound which is not specific to the elderly client. Cognitive Level: Analysis Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: The core issue of the question is age- related changes that have a negative impact on wound heal- ing. This question has more than one correct answer and each option should be approached as a true/false statement before selecting the answer.

NCLEX (32) A client is to receive a unit of packed red blood cells (PRBCs). The nurse and another nurse have confirmed that the correct blood for the client has been obtained from the blood bank. Immediately prior to starting the blood transfu- sion, what client assessment should the nurse make?

1. Vital signs 2. Skin color 3. Hemoglobin level 4. Creatinine clearance Answer: 1 Rationale: Vital signs are taken immediately prior to beginning the transfusion. Because most blood transfusion reactions occur within 15 minutes of starting infusion, it is of great importance to establish the pre- infusion baseline immediately prior to beginning the transfusion. Skin color, hemoglobin levels, and creatinine clearance would be important considerations; however, they would not be so essential that they should take place immediately prior to the start of the transfusion. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Assessment Content Area: Fundamentals Strategy: The question focuses on the action that should be taken immediately prior to beginning a blood transfusion. Knowledge of the appropriate process is essential.

8 Which client medication should the nurse review first for its potential interaction in a client admitted to the hospital in a state of alkalosis?

1. Warfarin (Coumadin) 2. Metformin (Glucophage) 3. Digoxin (Lanoxin) 4. Ibuprofen (Motrin) Answer: 3 Rationale: Alkalosis, especially respiratory alkalosis, makes the client more sensitive to the effects of digoxin; toxicity can develop even at therapeutic levels. A serum digoxin level should be obtained, and the client evaluated for potential digoxin toxicity. Warfarin affects clotting factors. Metformin can cause the development of lactic acidosis. Ibuprofen can cause gastric irritation. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: endocrine and Metabolic Strategy: Specific knowledge of medications that are affected by alkalosis is needed to answer this question. Use nursing knowledge and the pro- cess of elimination to make your selection.

The nurse's forearm becomes splattered with blood while inserting an intravenous catheter. What action should the nurse take?

1. Wash blood away with isopropyl alcohol. 2. Wipe blood away with a tissue. 3. Flush forearm with hot water, letting water flow from elbow toward fingers. 4. Wash forearm with soap and water. Answer: 4 Rationale: Washing the skin with the combination of soap and water will remove the blood through mechanical friction. While alcohol can kill bacteria, it cannot kill viruses and fungi. Tissues would not adequately remove the blood. Hot water can burn the nurse, and water alone is inadequate in removing the blood. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is the most effective means of reducing the risk of bloodborne disease transmission after contact with the skin. Recall principles of medical asepsis and use the process of elimination to make a selection.

The nurse would take which actions to comply with principles of medical asepsis? Select all that apply.

1. Wash hands before and after assisting client with personal hygiene. 2. Wear gown and gloves when working with client on contact precautions. 3. Re-cap needle after administering insulin. 4. Insert needle into rubber port of a previously used multidose vial without swabbing it with alcohol. 5. Use surgical facemask while working with client who has tuberculosis. Answer: 1, 2 Rationale: Washing hands before and after assisting a client with personal hygiene, and wearing a gown and gloves when working with a client on contact precautions are core principles of medical asepsis. Recapping the needle after administering insulin violates principles of medical asepsis. Inserting a needle into the rubber port of a previously used multidose vial without swabbing it with alcohol violates principles of surgical asepsis. Using a surgical facemask while working with a client who has tuberculosis violates principles of transmission-based precautions for a client with tuberculosis. The nurse should wear an N95 (fit-tested) mask instead of a simple surgical mask. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Knowledge of medical versus surgical asepsis is essential to answer this question. Note that hand hygiene, gown and gloves use medical aseptic technique, while capping and not wiping do not. Also discard surgical face mask because it addresses transmission-based precautions and is an incorrect statement.

Which actions by the nurse comply with core principles of surgical asepsis? Select all that apply.

1. Wash hands before and after client care. 2. Keep sterile field in view at all times. 3. Wear personal protective equipment. 4. Add contents to sterile field holding package 6 inches above field. Answer: 2, 4 Rationale: Keeping the sterile field in view and holding items 6 inches above the sterile field are core princi- ples of surgical asepsis. Washing hands after providing care and wearing personal protective equipment are core princi- ples of medical asepsis. The outer 1 inch of a sterile field is considered contaminated, not 1.5 inches. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is the ability to discriminate between medical and surgical asepsis and to choose correct interventions that support surgical asepsis. Use these principles and the process of elimination to make a selection.

NCLEX: The nurse would perform which action when washing hands as part of medical asepsis before caring for a client in an outpatient clinic? Select all that apply.

1. Wash hands with the hands held higher than the elbows. 2. Adjust temperature of water to the hottest possible. 3. Scrub hands and nails with a scrub brush for 5 minutes. 4. Use a clean paper towel to turn water off. 5. Rub vigorously using firm circular motions. Answer: 4, 5 Rationale: A paper towel is used to shut off the faucet because the faucet is considered contaminated. Rubbing vigorously using firm circular motions creates fric- tion on the skin to assist in cleansing. The hands are consid- ered to be more contaminated than the elbows, and the hands should be held down so water flows from least con- taminated to most contaminated. Hot water can result in burns to the nurse. Warm water protects from burns and removes less protective skin oil than hot water. A surgical scrub is performed over 5 minutes while in medical asepsis hands are washed for at least 10-15 seconds. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is utilization of medical asepsis. Recall basic principles of care and use the process of elimination to make a selection.

A client is exhibiting sudden onset of crackles in the lungs, moist respirations, and rapid respiratory rate. Which intervention should be performed first?

1. Weigh the client 2. Assess capillary refill 3. Measure edema 4. Reduce IV rate (4) Rationale: Weighing the client and measuring edema are important interventions in clients with fluid vol- ume excess. However, the priority intervention is to reduce the cause of the excess, in this case, the IV fluid. Capillary refill is an important assessment but is not specific for assessing fluid balance.

The nurse would assess for which signs and symptoms in a client who has metabolic acidosis? Select all that apply.

1. Weight gain 2. Rapid, deep respirations 3. Drowsiness 4. Decreased respiratory rate and depth 5. Melena Answer: 2, 3 Rationale: Clients who have metabolic acidosis develop Kussmaul's breathing (rapid and deep respirations). Drowsiness occurs because of the CNS depressant effect of acidosis. Weight gain is not an associated finding with metabolic acidosis. Shallow breathing is associated with the development of metabolic alkalosis. Melena (blood in stool) is not associated with metabolic acidosis. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Adult Health: Endocrine and Metabolic Strategy: The critical words in the stem of the question are metabolic acidosis. Recall that in metabolic abnormalities, the respiratory system helps to compensate; this will help to eliminate weight gain and melena. Choose rapid breathing over slower shallower breathing because this option assists the body to "blow off" acid in the form of CO2. Finally, choose drowsiness recalling that acidosis causes CNS depression, while alkalosis causes CNS excitation.

3 The nurse concludes that which sign reliably indicates that ascites fluid is being effectively mobilized in response to therapy? Select all that apply.

1. Weight gain of 1 pound in 24 hours 2. Increase in urine output 3. Drop in blood pressure 4. Hand veins fill slowly 5. Abdominal girth has decreased by 1 inch in 24 hours Answer: 2, 5 Rationale: Ascites is a form of third space fluid in the abdomen. Therapy is aimed at moving third space fluid back into the circulation, where it can be eliminated by the kidneys. When this fluid is drawn back into the vascular space (leading to a rise in BP and venous pressure), the kidneys increase the urine output to eliminate the excess fluid. Loss of fluid results in loss of weight and abdominal girth decreases. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Evaluation Content Area: Adult Health: Endocrine and Metabolic Strategy: The core issues of the question are recognition of ascites as a third space fluid and knowledge of effective mobilization of that fluid. Recall that mobilized fluid must be eliminated via the kidneys to assist in making a selection.

The nurse is caring for a pediatric client with acquired immunodeficiency syndrome (AIDS). Which activity by the nurse should be reported to the employee health department as an exposure for the nurse?

1. While flushing out the used bedpan, fluid splashes in the nurse's eyes. 2. The nurse does not wear a mask while in the client's room. 3. During the bath, the nurse removes gloves when giving a backrub on intact skin. 4. The nurse is stabbed with a sterile syringe to be used to draw up the client's medications. Answer: 1 Rationale: Body fluid-contaminated liquids may contain the human immunodeficiency virus (HIV) and can be absorbed through the eye mucosa. The other activities do not expose the nurse to blood and/or body fluids of the client and therefore pose no risk of contracting HIV. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Evaluation Content Area: Child Health Strategy: The core issue of the question is the ability to identify a breach in standard precautions. Use nursing knowledge about transmission of HIV via body fluids and the process of elimination to make a selection.

Identify the two major types of phlebitis:_____and ______.

1. chemical and mechanical 2. infected and soft 3. extravasation and vesicant 4. infiltration and occluded (1) "Rationale: Chemical phlebitis occurs when the medi- cation itself causes irritation of the vein wall. Mechan- ical phlebitis occurs when the cannula causes the vein to become inflamed. Phlebitis can be present without infection and typically presents as a hard cord. Extravasation refers to the leakage of a vesicant into the surrounding tissue. A vesicant is a medication that can cause tissue damage if infused outside of the vein into the surrounding tissue. Infiltration refers to the infusion of a fluid or medication into the surrounding tissue. An occluded or blocked cannula will not cause phlebitis."

2 A client is admitted to the hospital after vomiting for three days. Which arterial blood gas (ABG) result would the nurse expect?

1. pH 7.30; PaCO2 50; HCO3- 27 2. pH 7.47; PaCO2 43; HCO3- 28 3. pH 7.34; PaCO2 50; HCO3- 28 4. pH 7.48; PaCO2 30; HCO3- 23 Answer: 2 Rationale: Vomiting leads to the loss of hydrochloric acid from gastric acids. Hydrogen ions must leave the blood to replace this acidity in the stomach. Metabolic alkalosis occurs and is reflected by elevated pH and HCO3-, and normal PaCO2. The ABG with the pH of 7.30 is incorrect because it reflects respiratory acidosis with partial compensation (decreased pH, and elevated PaCO2 and HCO3-). The ABG with the pH of 7.34 is incorrect because it reflects a mixed acid-base imbalance (metabolic alkalosis with respiratory acidosis) with a normal pH, and elevated PaCO2 and HCO3-. The ABG with the pH of 7.48 is incorrect because it reflects respiratory alkalosis (increased pH, decreased PaCO2, and normal HCO3-). Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: Note the critical word vomiting, and recall that stomach contents are rich in acid. Loss of acid would raise the pH (eliminating options with pH of 7.30 and 7.34) and lead to increased free circulat- ing HCO3-, eliminating the ABG with the pH of 7.48.

4 A client is admitted with a diagnosis of renal failure. Which arterial blood gas (ABG) result would the nurse expect to see with this client?

1. pH 7.49; PaCO2 36; HCO3- 30 2. pH 7.30; PaCO2 35; HCO3- 18 3. pH 7.31; PaCO2 50; HCO3- 23 4. pH 7.43; PaCO2 48; HCO3- 30 Answer: 2 Rationale: Clients with renal failure have difficulty synthesizing HCO3- in the renal tubules secondary to the renal failure. These clients also retain K+, and subsequently develop metabolic acidosis. The ABG with the pH of 7.30 reflects uncompensated metabolic acidosis. The ABG with the pH of 7.49 is incorrect because it reflects metabolic alkalosis (increased pH and HCO3-) and normal PaCO2. The ABG with the pH of 7.31 is incorrect because it reflects respiratory acidosis (decreased pH, increased PaCO2) and normal HCO3-. The ABG with the pH of 7.43 is incorrect because it reflects a mixed acid-base imbalance metabolic alkalosis with a respiratory acidosis (normal pH, and increased PaCO2 and HCO3-). Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Endocrine and Metabolic Strategy: First, recognize renal failure as a met- abolic condition in which there is an impaired ability to eliminate metabolic acids and wastes, leading to acidosis. With this in mind, eliminate options that have elevated or normal pH. Then choose the option with the HCO3- of 18 rather than 23 because 18 is low while 23 is normal.

The tip of the central venous catheter lies in the _____________.

1. right atrium 2. axillary vein 3. distal one-third of the superior vena cava 4. external jugular vein (3) "Rationale: CDC as well as the Infusion Nurses Soci- ety recognize the distal one-third of the superior vena cava as the preferred location for a central venous catheter. All other locations are considered peripheral locations."

The cephalic vein runs along the:_____________

1. thumb side of the arm 2. little finger side of the arm 3. inner surface of the forearm 4. back of the hand (1) "Rationale: The cephalic vein can be a found along the thumb side of the wrist. The basilic vein can be found running along the little finger side of the arm. The vein that runs along the inner aspect of the forearm is the median vein. The dorsal metacarpal veins can be found on the back of the hand."

Sero-conversion is the presence of antibodies of HIV in the blood and are detected by diagnostic studies within:

1.One to two weeks after exposure to HIV 2. One to three months or more after exposure to HIV 3. One month following the start of antiretroviral drug therapy 4. Six months, when immune antibody complexes are formed (2) "Rationale: Sero-conversion antibodies to HIV are detected by diagnostic studies within one to three months or more after exposure to HIV."

Cephalosporins (Bacteriocidal)

1st Gen: Cephalexin (Keflex) 2nd Gen: Cefaclor (Ceclor) 3rd Gen: Ceftriaxone (rocephin) 4th Gen: cefepime (Maxipine) Indications: pharyngitis, tonsillitis, ear infection, URI, meningitis, UTIs SE: Abd pain, N/V/D, ^ bleeding, rash, superinfections

Cytotoxic (killer) T cells

A T lymphocyte (a type of white blood cell) that kills cancer cells, cells that are infected (particularly with viruses), or cells that are damaged in other ways.

Interferons (IFNs)

A group of signaling proteins made and released by host cells in response to the presence of several pathogens, such as viruses, bacteria, parasites, and also tumor cells. Cytokines

Interleukins (IL)

A subset of a larger group of cellular messenger molecules called cytokines, which are modulators of cellular behaviour. Like other cytokines, interleukins are not stored within cells but are instead secreted rapidly, and briefly, in response to a stimulus, such as an infectious agent.

A nurse is preparing to administer a varicella immunization to a client. Which of the following questions by the nurse is appropriate?

A. "Are you allergic to eggs?" B. "Are you allergic to baker's yeast?" C. "Are you pregnant?" D. "Do you have a history of Guillain-Barré syndrome?" A. INCORRECT: This question by the nurse is not appropriate because an allergy to eggs should be reviewed if the client is to receive an influenza immunization. The nurse should ask about allergy to gelatin and neomycin, which may be used in the ingredients of the varicella vaccine. B. INCORRECT: This question by the nurse is not appropriate because an allergy to yeast should be reviewed if the client is to receive HPV. The nurse should ask about allergy to gelatin and neomycin, which may be used in the ingredients of the varicella vaccine. C. CORRECT: The nurse should ask whether the client is pregnant because the varicella immunization is contraindicated during pregnancy. D. INCORRECT: This question by the nurse is not appropriate because Guillain-Barré syndrome is not a contraindication for varicella immunization, but it is a contraindication for other immunizations.

3. A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.)

A. "I feel lightheaded." B. "I feel as though my heart is racing." C. "I feel a little short of breath." D. "The nurse's aide told me that my blood pressure was 150/90." E. "I think my ankles are less swollen. A. INCORRECT: A clinical manifestation of fluid overload is hypertension. Lightheadness is a clinical manifestation of hypotension. B. CoRRECT: A clinical manifestation of fluid overload is tachycardia due to the increased blood volume, which causes the heart rate to increase. C. CoRRECT: A clinical manifestation of fluid overload is shortness of breath or dyspnea due to the increased amount of fluid entering the air spaces in the lungs, which reduces the amount of circulating oxygen. D. CoRRECT: A clinical manifestation of fluid overload is hypertension due to the increased blood volume, which causes the blood pressure to increase. E. INCORRECT: A clinical manifestation of fluid overload is edema. If the client's ankles are less swollen, this is an indication that the edema is decreasing.

5. A charge nurse is leading a staff education session about caring for a client who has hypocalcemia. Which of the following statements by a staff nurse indicates the need for further teaching?

A. "I should monitor for hand spasms during blood pressure cuff inflation." B. "Clients who have a vitamin D deficiency are at risk for hypocalcemia." C. "Clients who have hypocalcemia are at risk for pathologic fractures." D. "I should implement seizure precautions for a client who has hypocalcemia." A. INCORRECT: This statement does not require further teaching. Hand/finger spasms during sustained blood pressure cuff inflation (positive Trousseau's sign) are an indication of hypocalcemia. B. INCORRECT: This statement does not require further teaching. Vitamin D deficiency, such as with alcohol use disorder, increases the risk for hypocalcemia. C. CoRRECT: This statement requires further teaching. Clients who have hypercalcemia are at risk for pathologic fractures. D. INCORRECT: This statement does not require further teaching. Clients who have hypocalcemia are at risk for seizures due to overstimulation of the central nervous system.

4. A nurse educator is teaching a module about preventing IV infections during new employee orientation. Which of the following statements by a newly hired nurse indicates understanding of the teaching?

A. "I will leave the IV catheter in my client after the IV antibiotics are completed." B. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C. "If my client needs to use the rest room, it would be safer to disconnect his IV infusion as long as I clean the injection port thoroughly with an antiseptic swab." D. "I will change continuous infusion tubing no more frequently than every 96 hours and change intermittent infusion tubing every 24 hours." A. INCORRECT: It is recommended to remove catheters as soon as they are no longer clinically indicated to eliminate a portal of entry for pathogens or bacteria. B. INCORRECT: It is recommended to use a sterile needle/catheter for each insertion attempt for client safety and prevention of infection. C. INCORRECT: It is not recommended to disconnect tubing for convenience because this increases the risk of bacteria entering the system. D. CoRRECT: It is recommended to change the primary intermittent tubing set every 24 hr and change continuous infusion tubing no more frequently than every 96 hr to prevent the entry of pathogens or bacteria into the client's bloodstream

2. A nurse is teaching a newly licensed nurse on the proper procedure for inserting an IV catheter for a preoperative client. Which of the following statements by the nurse indicates understanding of the procedure?

A. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B. "I will insert the needle into the client's skin with the bevel up at an angle of 10° to 30°." C. "I will apply pressure approximately 1.25 inches below the insertion site prior to removing the needle." D. "I will choose the antecubital fossa vein for IV insertion due to its size and easily accessible location." A. INCORRECT: After seeing a flashback of blood, the nurse lowers the hub close to the skin to prepare for threading the needle into the vein, then loosens the needle from the catheter and pulls back slightly on the needle so that it no longer extends past the tip of the catheter. Use the thumb and index finger to advance the catheter into the vein until the hub rests against the insertion site. Inserting the needle all the way into the vein could puncture the vein. B. CoRRECT: The nurse inserts the catheter into the skin with the bevel up at an angle of 10° to 30° using a steady, smooth motion. This is the optimal angle to prevent puncture of the posterior vein wall. C. INCORRECT: The nurse applies pressure approximately 1.25 inch above the insertion site to reduce the backflow of blood into the vein prior to removing the needle. D. INCORRECT: The nurse should not use the antecubital fossa vein for IV insertion, except for emergency access, because mobility of the client's arm is limited.

4. A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the following statements by the new nurse indicates the teaching has been effective?

A. "Metabolic acidosis can occur due to diabetic ketoacidosis." B. "Metabolic acidosis can occur in a client who has myasthenia gravis." C. "Metabolic acidosis can occur in a client who has asthma." D. "Metabolic acidosis can occur due to cancer." A. CORRECT: Metabolic acidosis results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis. B. INCORRECT: Respiratory acidosis can occur in a client who has myasthenia gravis. C. INCORRECT: Respiratory acidosis can occur in a client who has asthma. D. INCORRECT: Respiratory acidosis can occur due to cancer.

ATI Fundamentals (ch. 49) 1. A nurse on the IV team is conducting an education program for a newly hired nurse. After discussing complications of IV therapy, which of the following statements by the nurse indicates an understanding of clinical manifestations of infiltration? (Select all that apply.)

A. "The temperature around the IV site is cooler." B. "The rate of the infusion increases." C. "The skin at the IV site is red." D. "The IV dressing is damp." E. "The tissue around the venipuncture site is swollen." A. CoRRECT: A decrease in skin temperature around the site is a clinical manifestation of infiltration due to the IV solution entering the subcutaneous tissue around the venipuncture site. B. INCORRECT: When infiltration occurs, the rate of infusion may slow or stop, not increase as the solution is no longer infusing directly into the vein. This occurs due to dislodgment of the catheter or rupture of the vein. C. INCORRECT: When infiltration occurs, the skin around the IV site is pale, not red, because the solution is no longer infusing directly into the vein and enters the subcutaneous tissue around the venipuncture site. D. CoRRECT: A damp IV dressing is a common finding of infiltration due to the IV solution entering the subcutaneous tissue and leaking out through the venipuncture site. E. CoRRECT: Swollen tissue around the venipuncture site is a clinical manifestation of infiltration due to the IV solution entering the subcutaneous tissue and causing swelling, as the fluid is no longer infusing into the vein.

A nurse in a clinic is caring for a client who is to receive an immunization. The client asks about contraindications to immunizations. Which of the following is an appropriate response by the nurse? (Select all that apply.)

A. "The use of corticosteroid medications is a contraindication." B. "An anaphylactic reaction is a contraindication for administration of any type of immunization." C. "The common cold is a contraindication for receiving an immunization." D. "Your provider will weigh the risks if you have experienced any contraindications." E. "HIV is a contraindication for receiving any immunization." A. CORRECT: The client should not receive immunizations if taking corticosteroids, which are immunosuppressant medications. B. INCORRECT: The client who has experienced an anaphylactic reaction can receive other immunizations that contain different substances. C. INCORRECT: The client who has a common cold may receive an immunization because the client is not immunosuppressed. D. CORRECT: The client who has experienced contraindications should inform the provider so the provider can weigh the risks of an immunization. E. CORRECT: HIV is considered a contraindication for receiving an immunization because of immunosuppression.

A nurse is preparing to administer an IM injection of immune globulin to a client who has been exposed to hepatitis A. Which of the following statements by the nurse is appropriate?

A. "This medication offers permanent immunity to hepatitis A." B. "This medication involves receiving three injections over several months." C. "This medication provides you with an immune response more quickly than your body can produce it." D. "This medication contains an attenuated virus to help your body create antibodies." A. INCORRECT: The statement by the nurse is not appropriate because this medication produces passive-artificial immunity that lasts only several weeks or months. B. INCORRECT: This statement by the nurse is not appropriate because this medication produces passive-artificial immunity and is given one time after exposure to hepatitis A. C. CORRECT: This statement by the nurse is appropriate because this medication produces passive-artificial immunity and contains antibodies to help protect against hepatitis A for several weeks or months. D. INCORRECT: This statement by the nurse is not appropriate because this medication contains antibodies, not an attenuated virus

A nurse is discussing the infection process at a staff education session. Which of the following examples are appropriate for the nurse to include when discussing the direct contact mode of transmission? (Select all that apply.)

A. A client vomits on a nurse's uniform. B. A nurse has a needle stick injury. C. A mosquito bites a hiker in the woods. D. A nurse finds a hole in his glove while handling a soiled dressing. E. A person fails to wash her hands after using the bathroom. A. CoRRECT: Transmission from a client's emesis is identified as person-to-person or direct contact. B. INCORRECT: Transmission from a needle or other inanimate object is identified as indirect contact. C. INCORRECT: Transmission from an insect is identified as vector-borne. D. INCORRECT: Transmission from a soiled dressing or other inanimate object is identified as indirect contact. E. CoRRECT: Transmission from a client's contaminated hands is identified as person-to-person or direct contact.

3. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients is at risk for hypervolemia?

A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites A. INCORRECT: A client who has adrenal insufficiency is at risk for isotonic fluid volume deficit (hypovolemia). B. CoRRECT: A client who has heart failure is at risk for hypervolemia. C. INCORRECT: A client who has diabetic ketoacidosis is at risk for dehydration. D. INCORRECT: A client who has ascites is at risk for hypovolemia.

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect?

A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster A. INCORRECT: A pink body rash can indicate an allergic reaction. B. INCORRECT: Red circles with white centers occur with ringworm. C. INCORRECT: A red edematous rash bilaterally on the cheeks can indicate systemic lupus erythematosus. D. CoRRECT: Vesicles that follow along a unilateral dermatome can indicate herpes zoster

4. A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the nurse use to perform this test?

A. Apply a blood pressure cuff to the client's arm. B. Place the stethoscope bell over the client's carotid artery. C. Tap lightly on the client's cheek. D. Ask the client to lower his chin to his chest. A. INCORRECT: This is performed to assess for Trousseau's sign. B. INCORRECT: This is performed to auscultate a carotid bruit. C. CORRECT: The nurse taps the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of his face. (this indicates hypocalcemia) D. INCORRECT: This is performed to assess for range of motion of the neck.

A nurse is preparing to administer a scratch test to a client who has suspected food and environmental allergies. Which of the following actions should the nurse perform prior to the procedure? (Select all that apply.)

A. Cleanse the client's skin with povidone-iodine (Betadine). B. Ask the client about previous reactions to allergens. C. Ask the client about medications taken over the past several days. D. Inform the client to expect itching at one site. E. Obtain emergency resuscitation equipment. A. INCORRECT: The nurse should use soap and water to cleanse the skin. Povidone-iodine could interfere with an allergen and elicit a response. B. CORRECT: The nurse should ask the client about any previous reactions to allergens, which could indicate an increased risk of an anaphylactic reaction. C. CORRECT: The nurse should ask the client about medications taken over the past several days. Antihistamines and corticosteroids should not be taken within the past 5 days due to their ability to suppress reactions. D. CORRECT: Histamine will be applied as a control site so the client will experience itching at this site. E. CORRECT: Emergency equipment should be available, even if the client denies experiencing an anaphylactic reaction.

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? (Select all that apply.)

A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with his hips and knees bent. E. Offer the client a warm beverage, such as herbal tea. A. CoRRECT: The nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. B. INCORRECT: An abdominal binder can help prevent, not treat, a wound evisceration. C. INCORRECT: The nurse should not handle or apply pressure to any exposed organs or tissues because these actions increase the risks of trauma and perforation. D. CoRRECT: This position minimizes pressure on the abdominal area. E. INCORRECT: The nurse must keep the client NPO in anticipation of the surgical team taking him back to the surgical suite for repair of the evisceration.

ATI MS (43) 1. A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that apply.)

A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea A. CORRECT: Decreased skin turgor is a clinical manifestation present with fluid volume deficit. Skin turgor is decreased to due to the lack of fluid within the body and results in dryness of the skin. B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit. The urine is concentrated due to urinary output being decreased. C. INCORRECT: Bradycardia is not a clinical manifestation present with fluid volume deficit. D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit. Low-grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body. E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.

5. A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance?

A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy A. CORRECT: Hyperkalemia, an increase in serum potassium, is a laboratory finding associated with diabetic ketoacidosis. B. INCORRECT: Hyponatremia, a decrease in serum sodium, is a laboratory finding associated with heart failure. C. INCORRECT: Hypernatremia, an increase in serum sodium, is a laboratory finding associated with Cushing's syndrome. D. INCORRECT: Hypocalcemia, a decrease in serum calcium, is a laboratory finding is found in clients following a thyroidectomy.

2. A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative of fluid volume excess? (Select all that apply.)

A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness A. CORRECT: Dyspnea is a clinical manifestation present with fluid volume excess. Dyspnea is due to an excess of fluids within the body and lungs, and the client is struggling to breath to obtain oxygen. B. CORRECT: Edema is a clinical manifestation present with fluid volume excess. Edema is due to the excess of fluid within the body. Weight gain can be a result of edema. C. INCORRECT: Bradycardia is not a clinical manifestation related to fluid volume excess. D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess. Blood pressure rises as the heart must work harder due to the excess fluid. E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess. Weakness is due to the excess fluid that is retained, which depletes energy and increases the workload for the body.

2. A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse should assess for which of the following clinical manifestations?

A. ECG changes B. Constipation C. Polyuria D. Hypotension A. CORRECT: The nurse should assess the client for ECG changes. Potassium levels can affect the heart and result in arrhythmias. B. INCORRECT: Constipation is a clinical manifestation of hypokalemia. C. INCORRECT: Polyuria is a clinical manifestation of hypokalemia. D. INCORRECT: Hypotension is a clinical manifestation of hypokalemia.

An adolescent who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply.)

A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care A. INCORRECT: The client is not at either extreme of the age spectrum. B. CoRRECT: Diabetes mellitus places this client at risk for impaired circulation. C. CoRRECT: Diabetes mellitus places this client at risk for impaired immune system function. D. INCORRECT: There is no indication that the client is malnourished. E. INCORRECT: There is no indication that there have been any breaches in aseptic technique during wound care.

A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.)

A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate A. CoRRECT: A fever indicates that the infection is affecting the whole body, and therefore systemic. B. CoRRECT: Malaise indicates that the infection is affecting the whole body, and therefore systemic. C. INCORRECT: Edema is a localized symptom indicating a localized, not systemic, infection. D. INCORRECT: Pain and tenderness is a localized symptom indicating a localized, not systemic, infection. E. CoRRECT: An increase in pulse and respiratory rate indicates that the infection is affecting the whole body, and therefore systemic.

2. A nurse is reviewing the laboratory test results for a client who is receiving treatment for septicemia with a prolonged fever. Which of the following indicates the client is developing dehydration? (Select all that apply.)

A. Hct 55% B. Serum osmolarity 260 mOsm/kg C. Serum sodium 150 mEq/L D. Urine specific gravity 1.035 E. Serum creatinine 0.6 mg/dL A. CoRRECT: An increased Hct is an indication of dehydration. B. INCORRECT: A serum osmolarity greater than 300 mOsm/kg is an indication of dehydration. C. CoRRECT: An elevated serum sodium level is an indication of dehydration. D. CoRRECT: An increased urine specific gravity is an indication of dehydration. E. INCORRECT: An elevated serum creatinine level is an indication of dehydration.

ATI Fundamentals (57) 1. A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. Which of the following is an expected finding? (Select all that apply.)

A. Hot, dry skin B. Hypertension C. Tachycardia D. Syncope E. Decreased skin turgor A. INCORRECT: Cool clammy skin is an expected finding of hypovolemia. B. INCORRECT: Hypotension is an expected finding of hypovolemia. C. CoRRECT: Tachycardia is an expected finding of hypovolemia. D. CoRRECT: Syncope is an expected finding of hypovolemia. E. CoRRECT: Decreased skin turgor is an expected finding of hypovolemia.

3. A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?

A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hypomagnesemia A. INCORRECT: An increase in calcium is not indicated with nasogastric losses due to suctioning. B. CORRECT: The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium. C. INCORRECT: An increase in phosphatemia is not indicated with nasogastric losses due to suctioning. D. INCORRECT: A decrease in magnesium is not indicated with nasogastric losses due to suctioning

A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first?

A. Implement airborne precautions. B. Obtain a sputum culture. C. Administer prescribed antituberculosis medications. D. Recommend a screening test for family members. A. CoRRECT: The safety risk to the nurse and others is transmission of the infection. The first action is to place the client on airborne precautions. B. INCORRECT: Obtaining a sputum culture is an appropriate action, but it does not address the safety risk and therefore is not the first action the nurse should take. C. INCORRECT: Administering prescribed medications is an appropriate action, but it does not address the safety risk and therefore is not the first action the nurse should take. D. INCORRECT: Recommending screening tests for those in close contact with the client is an appropriate action, but it does not address the safety risk and therefore is not the first action the nurse should take.

A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment findings should the nurse expect? (Select all that apply.)

A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst A. CoRRECT: Pain and tenderness at the wound site are expected findings with an incisional infection. B. CoRRECT: Fever and chills are expected findings with an incisional infection. C. CoRRECT: Reddened or inflamed wound edges are expected findings with an incisional infection. D. INCORRECT: Serosanguineous drainage is more common immediately after surgery. Purulent drainage is an expected finding with an incisional infection. E. INCORRECT: Changes in thirst have many causes. That finding alone does not indicate an incisional infection.

4. A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care?

A. Infuse hypotonic IV fluids. B. Implement a fluid restriction. C. Increase sodium intake. D. Administer sodium polystyrene sulfonate (Kayexalate). A. CoRRECT: Hypotonic IV fluids, such as 0.225% sodium chloride, are indicated for the treatment of hypernatremia related to fluid loss. B. INCORRECT: Increased fluid intake is indicated for the treatment of hypernatremia. C. INCORRECT: Decreased sodium intake is indicated for the treatment of hypernatremia. D. INCORRECT: Administration of Kayexalate is indicated for the treatment of hyperkalemia.

4. A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3° C (100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?

A. Initiate fluid restrictions to limit intake. B. Observe for signs of hypertension. C. Encourage the client to ambulate to promote oxygenation. D. Monitor respirations for shortness of breath A. INCORRECT: The nurse should not initiate fluid restrictions to limit intake. This would be an appropriate action for a client who has fluid volume excess. The client is dehydrated, and fluids should be encouraged. B. INCORRECT: The nurse should not be monitoring for signs of hypertension. This would be an appropriate action for a client who has fluid volume excess. The client is hypotensive due to fluid volume depletion. The nurse should monitor the client for hypotension. C. INCORRECT: The nurse should not encourage the client to ambulate to promote oxygenation. This would be an appropriate action for a client who has fluid volume excess. The client is experiencing dizziness due to dehydration and is at risk for falling. The nurse should keep the client in bed and assist him to the bathroom as needed. D. CORRECT: It is an appropriate action for the nurse to monitor the client's respiratory status and for shortness of breath. The client has a nonproductive cough with diminished breath sounds in the right lower lobe. This client is dehydrated and has fluid volume deficit.

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.

A. Keep the head of the bed elevated 30 degrees. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed. A. CoRRECT: Slight elevation reduces shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. B. INCORRECT: Massaging the skin over bony prominences can traumatize deep tissues. C. INCORRECT: Cornstarch can create gritty particles that can abrade sensitive skin. D. CoRRECT: The client should sit on a gel, air, or foam cushion to redistribute weight away from ischial areas. E. INCORRECT: Frequent position changes are important for preventing skin breakdown, but every 3 hr is not frequent enough. The nurse should reposition the client at least every 2 hr.

A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests the client is experiencing postherpetic neuralgia?

A. Linear clusters of vesicles present on the client's right shoulder B. Purulent drainage from both of the client's eyes C. Decreased white blood cell count D. Report of continued pain following resolution of rash A. INCORRECT: Localized linear clusters of vesicles are an expected finding of herpes zoster rather than postherpetic neuralgia. B. INCORRECT: Eye infection is a potential complication of herpes zoster but does not suggest postherpetic neuralgia. C. INCORRECT: Immunosuppression increases the client's risk for herpes zoster but does not suggest postherpetic neuralgia. D. CoRRECT: Pain that persists following resolution of the vesicular rash is an indication of postherpetic neuralgia.

A nurse is reviewing strategies to promote comfort with a client who received an immunization. Which of the following information should the nurse include? (Select all that apply.)

A. Massage the injection site. B. Apply a cool compress to the injection site. C. Take acetaminophen or ibuprofen. D. Use the affected extremity. E. Apply an antimicrobial ointment to the injection site. A. INCORRECT: Massaging the injection site for any extended period of time can increase localized discomfort. B. CORRECT: Applying a cool compress to the injection site can relieve discomfort from the localized reaction. C. CORRECT: Taking an antipyretic can relieve a low-grade fever and localized discomfort at the injection site. D. CORRECT: Mobilizing the affected extremity will help relieve discomfort due to a localized reaction. E. INCORRECT: Applying an antimicrobial ointment at the injection site is not indicated

3. A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit?

A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia A. INCORRECT: Moist skin is a clinical manifestation indicative of fluid volume excess. B. INCORRECT: Distended neck veins is a clinical manifestation indicative of fluid volume excess. C. INCORRECT: Increased urinary output is a clinical manifestation indicative of fluid volume excess. D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a clinical manifestation indicative of fluid volume deficit.

A nurse is reviewing the laboratory findings of a client who has the measles. The nurse should expect to find an increase in which of the following types of WBCs?

A. Neutrophils B. Basophils C. Monocytes D. Eosinophils A. INCORRECT: Neutrophils are increased when an acute bacterial or fungal infection is present. B. INCORRECT: Basophils are increased when leukemia is present. C. CORRECT: Monocytes are increased when a viral infection such as measles occurs and chronic inflammation is present. D. INCORRECT: Eosinophils are increased when an allergic reaction occurs or chronic inflammation is present.

5. A nurse is assessing a client who is receiving IV therapy and reports pain in his arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to do first?

A. Obtain a specimen for culture. B. Apply a warm compress. C. Administer analgesics. D. Discontinue the infusion. A. INCORRECT: Although it is recommended to obtain a specimen for culture as a component in the treatment of cellulitis, it is not the first action the nurse should take. B. INCORRECT: Although it is recommended to apply a warm compress as a component in the treatment of cellulitis, it is not the first action the nurse should take. C. INCORRECT: Although it is recommended to administer analgesics as prescribed as a component in the treatment of cellulitis, it is not the first action the nurse should take. D. CoRRECT: The greatest risk to the client is infection. The first action the nurse should perform in the treatment of cellulitis is to stop the infusion and remove the catheter because the catheter may be the source of infection.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.)

A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that may result in contamination from secretions A. INCORRECT: A nurse should place a client in a private room and initiate droplet precautions if he has pertussis. The client's room does not need to have negative air pressure. B. CoRRECT: The nurse should wear a mask when within 3 ft of the client. C. CoRRECT: The nurse should place a surgical mask on the client during transport to another area of the facility. D. INCORRECT: The nurse should wear a gown when performing care that may result in contamination from body fluids. E. CoRRECT: A gown should be worn if the nurse's clothing or skin may be contaminated with body secretions or excretions.

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.)

A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A. CoRRECT: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies. B. CoRRECT: Reporting of communicable and infectious diseases assists with determining public health priorities. C. CoRRECT: Reporting of communicable and infectious diseases assists with ensuring proper medical treatment is available. D. INCORRECT: Endemic disease is already prevalent within a population, so reporting is not necessary. E. CoRRECT: Reporting of communicable and infectious diseases assists with monitoring for common-source outbreaks.

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

A. Prodromal B. Incubation C. Convalescence D. Illness A. INCORRECT: The prodromal stage consists of nonspecific clinical manifestations of the infection. B. INCORRECT: The incubation period consists of the time when the pathogen first enters the body prior to the appearance of any symptoms of infection. C. INCORRECT: Convalescence is when acute symptoms of the infection fade. D. CoRRECT: The illness stage is when the client experiences signs and symptoms specific to the infection

3. A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained. Based on the laboratory findings, which of the following conditions should the nurse expect?

A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis A. INCORRECT: Respiratory acidosis would not be indicated for this client. B. INCORRECT: Respiratory alkalosis would not be indicated for this client. C. INCORRECT: Metabolic acidosis would not be indicated for this client. D. CORRECT: Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.

A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? (Select all that apply.)

A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area A. CoRRECT: Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. B. INCORRECT: Sutured surgical incisions heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. C. INCORRECT: Unless the bone edges have pierced the skin, a casted bone fracture is an injury to underlying structures and does not require healing of the skin. D. INCORRECT: Lacerations sealed with tissue adhesive heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. E. CoRRECT: Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges

5. A nurse is assessing a client who has pancreatitis. His arterial blood gases reveal metabolic acidosis. Which of the following is an expected finding? (Select all that apply.)

A. Tachycardia B. Hypertension C. Bounding pulses D. Hyperreflexia E. Dysrhythmia F. Tachypnea A. INCORRECT: Tachycardia is not an expected finding in a client who has pancreatitis and metabolic acidosis. B. CORRECT: Hypotension is an expected finding of metabolic acidosis. C. CORRECT: Weak peripheral pulses is an expected finding of metabolic acidosis. D. CORRECT: Hyporeflexia is an expected finding of metabolic acidosis. E. CORRECT: Dysrhythmia is an expected finding in a client who has pancreatitis and metabolic acidosis. F. CORRECT: Tachypnea is an expected finding in a client who has pancreatitis and metabolic acidosis.

ATI MS (44) 1. A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L. Which of the following treatments can result in these laboratory findings?

A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50 mL/hr C. 5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr D. Administration of glucocorticoids A. CORRECT: Receiving three tap water enemas can result in a decrease in serum sodium and potassium in the client. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution. B. INCORRECT: Receiving 0.9% sodium chloride solution IV at 50 mL/hr would not produce these results. C. INCORRECT: Receiving 5% dextrose in water solution with 20 mEq of K+ at 80 mL/hr would not produce these results. D. INCORRECT: Receiving glucocorticoids would not produce these results.

A nurse is preparing to document the administration of a meningococcal vaccine to a client. Which of the following should the nurse include in the documentation? (Select all that apply.)

A. Time of administration B. Name of vaccine manufacturer C. Vaccine expiration date D. Date of administration E. Serial number of the vaccine A. INCORRECT: Documentation of the time the vaccine was administered is not included. B. CORRECT: The nurse should document the name of the vaccine manufacturer. C. CORRECT: The nurse should document the expiration date of the vaccine. D. CORRECT: The nurse should document the date the vaccine was administered. E. INCORRECT: The nurse should document the lot number, not the serial number, of the vaccine.

A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse recognize as atypical indications of an infection? (Select all that apply.)

A. Urinary incontinence B. Malaise C. Acute confusion D. Fever E. Agitation A. CoRRECT: Urinary incontinence is an atypical indication of infection in an older adult client. B. INCORRECT: Malaise is a typical indication of infection. C. CoRRECT: Acute confusion is an atypical indication of infection in an older adult client. D. INCORRECT: Fever is a typical indication of infection. E. CoRRECT: Agitation is an atypical indication of infection in an older adult client.

2. A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are obtained. Which of the following findings should the nurse expect?

A. pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3- 24 mEq/L B. pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3- 23 mEq/L C. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L D. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L A. CORRECT: A pneumothorax can cause alveolar hyperventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis. B. INCORRECT: Arterial blood gases reflecting respiratory acidosis is not indicated for this client. C. INCORRECT: Arterial blood gases reflecting metabolic acidosis is not indicated for this client. D. INCORRECT: Arterial blood gases reflecting metabolic alkalosis is not indicated for this client.

ATI MS (45) 1. A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of 104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and deep. Which of the following arterial blood gases findings should the nurse expect?

A. pH 7.68, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 24 mEq/L B. pH 7.48, PaO2 100 mm Hg, PaCO2 28 mm Hg, HCO3- 23 mEq/L C. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L D. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L A. INCORRECT: These arterial blood gases indicate metabolic alkalosis. B. INCORRECT: These arterial blood gases indicate metabolic alkalosis. C. CORRECT: An aspirin overdose would result in arterial blood gas findings of metabolic acidosis. D. INCORRECT: These arterial blood gases indicate respiratory alkalosis.

Metabolic alkalosis

Acid loss(vomiting), accumulation of HCO3, decrease of H+

Metabolic acidosis

Acid production with out adequate secretion, decreased HCO3(loss from diarrhea), increased H+

Innate Immunity

Acquired from mom

Methotrexate (MTX) Antineoplastic drug (antimetabolite)

Action: Interferes with cell division Indications: Acute leukemia, Psoriasis, Cancer of colon, breast, stomach and pancreas, Sickle cell anemia SE: N/V, v CBC, Alopecia, Renal dysfunction Nurse Actions: Good mouth care, Small frequent feedings, Counsel about body image changes, Infection control precautions

Cyclophosphamide (Cytoxan) Antineoplastic drug (alkylating agent)

Action: Interferes with rapidly reproducing cell DNA Indications: Leukemia, Multiple Myeloma SE: N/V, v CBC, Alopecia Nurse Actions: Monitor for infection, Avoid IM injections when platelet count is low to minimize bleeding

Antiretrovirals

Action: Slows the growth of HIV to prevent AIDS Not a cure, slows virus from replicating. 70% decline in death rate in US. Decreases transmission from mom to fetus by 70%. Expensive: $20,000/year HIV/AIDs Med Names- 'RTI' Nucleoside reverse transcriptase inhibitor (NRTI) Nonnucleoside reverse transcriptase inhibitor (NNRTI) Protease inhibitor (PI) Nucleotide reverse transcriptase inhibitor (NtRTI) Fusion (entry) inhibitor HIV integrase inhibitor SE: N/V/D, HA, blood disorders, lactic acidosis, lipodystrophy Nurse Actions: Good hand hygiene

Toxoid

Active portion removed but still can be recognized by body's immune system. Ex: Tdap immunization

Sandra's Immune Response Breakdown

Adaptive Immune System: -Humoral Mediated Immunity: B cells swallow antigen -Cell-Mediated: Mediated by T cells. T cells mature by lymphokines. Killer vs. helper cells. T cells help B cells multiply and mature into plasma cells. Create mature plasma cells to produce antibodies. -Lymphocyte: B cells move from bone marrow to the thymus gland to mature into plasma cells.

A nurse should understand that enfuvirtide (Fuzeon) is an appropriate choice for patients who have which of the following?

Advanced HIV disease

Nursing Assessment for risk factors of infection

Age, breaks in skin, illness or injury, substance abuse, environmental factors, chronic disease, medications, medical procedures, lifestyle factors(immunizations, stress, foods) Perform Physical Assessment: General appearance, integumentary system, lymph nodes, site of medical procedures (IV, catheter, etc).

Humoral-mediated immunity

Also called the antibody-mediated beta cellularis immune system, is the aspect of immunity that is mediated by macromolecules (as opposed to cell-mediated immunity) found in extracellular fluids such as secreted antibodies, complement proteins and certain antimicrobial peptides. Humoral immunity is so named because it involves substances found in the humours, or body fluids. Many of the bacteria that cause infectious disease in humans multiply in the extracellular spaces of the body, and most intracellular pathogens spread by moving from cell to cell through the extracellular fluids. The extracellular spaces are protected by the humoral immune response, in which antibodies produced by B cells cause the destruction of extracellular microorganisms and prevent the spread of intracellular infections

Penicillins (PCN)- "cillin" Bacteriocidal

Amoxicillin, Ampicillin, Methicillin, Penicillin, Nafcillin Caution: Pregnancy, breastfeeding, OCP Indications: Moderate to severe infections, URI SE: Rash, v CBC, strep throat, D, superinfections Nurse Actions: Good oral care, Give on empty stomach. Yogurt or buttermilk if D. Back up birth control.

Cell-mediated immunity

An immune response that does not involve antibodies, but rather involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.

Primary Infection

Any type of infection

Diseases caused by inflammatory effect:

Arthritis, myocardial, obesity

Immune Response

B cell encounters matching antigen B cell engulfs antigen B cell combines with T cell Mature cells release antibodies

A nurse is caring for a patient who is about to begin taking zovirax to treat herpes simplex. The nurse shoudl monitor for which labs?

BUN. (this is hard on kidneys)

Handout in class: The parents of a newborn question the nurse about the need for vaccines.

Babies don't have an immune system. More prone to infection. Breast feeding helps immunity. Vaccine helps prevent infection or decrease severity.

A nurse is caring for a patient who is taking coumadin and about to start bactrim to treat UTI. the nurse should question the drug regimen because the two drugs together could increase the patient's risk for?

Bleeding

Diagnostic Tests for Infection

CBC with Diff, blood culture, urine culture, throat/wound cultures, disease titres (rubella), Immunoglobulins (IGG and IGM), Sed rate (ESR), Iron level

Handout in class: A mother asks the nurse how her daughter got the measles and when will she not be contagious?

CDC states 4 days before symptoms and 4 days after symptoms. Anytime there is fever, drainage, and cough present.

A patient who is taking amoixicillin to treat URI contacts the nurse to report rash and wheezing. Which of the instructions should the nurse provide?

Call emergency services right away.

Suppressed Immune Response

Can cause cancer, infection. Symptoms: Report of frequent infections, poor wound healing, fatigue, malaise, weight loss Prevention: Immunizations, avoid high risk behaviors, nutrition, exercise, infection control measures

Immunogen

Capable of producing immune system reaction

When administering erythromycin to a patient who has pneumococcal pneumonia, the nurse should monitor for which of the following adverse effects of the drug?

Cardiac dysrythmias

Trouseaus's sign

Carpopedal spasms

A nurse is caring for a patient who is about to begin taking tamoxifen (soltamox) to treat breast cancer. The nurse should recognize the need for cautious use of the drug if the patient also has which of the following?

Cataracts. (SE: Cataracts)

TB

Caused by mycobacterium tuberculosis. Highly contagious, airborne transmission. Very resistant to drugs. Therapy lasts 6-12 months. Isoniazid (INH) SE: Hepatitis, Peripheral neuritis Rifampin (Rifadin) SE: Hepatitis, Fever Streptomycin SE: Nephrotoxicity, Ototoxicity Nurse Actions: Used in combo with 2+ meds. Cover mouth and nose when coughing. Place used tissues in plastic bags, wear face mask in crowds until 3 sputum cultures are negative. Inpatient: airborne precautions with N95 mask

Secondary Infection

Caused from something else. Ex: A patient was vented and now he has vented pneumonia. Or Bedsores on someone who recently had surgery.

A primary is considering the various pharmacologic options for a patient who has a gynecologic infection and history of alcohol use disorder. Which medication can cause a reaction similar to Antabuse if the patient drinks while taking the medication? Select all that apply.

Cefotetan, Flagyl

Handout in class: A young adult asks the nurse why the doctor ordered a CBC with diff?

Certain types of WBC can help diagnose certain infections or problems. Neutrophil: bacteria

Antineoplastics

Chemotherapy Medications Kill or control cancer cells Target specific area affected by cancer Different types of chemotherapy medications available Alkylating Agents: Chlorambucil (Leukeran) Cyclophosphamide (Cytoxan) Antimetabolites: Flurouracil Methotrexate Hydroxyurea Hormonal Agents: Tamoxifen (Nolvadex) SE: v CBC, N/V, Impaired oral mucous membrane, Fatigue Nurse Actions: Monitor bleeding, bleeding gums, bruising, urine and emesis, Avoid IM injections and rectal temperatures, Monitor I&O, Prevent infection by hand washing, Oral hygiene measures, Encourage rest and discuss measures to conserve energy

Fluroquinolones- "floxacin" Bacteriocidal

Ciprofloxacin (cipro), levofloxacin (levaquin), norfloxacin (noroxin) Indications: E.Coli SE: HA, N/D, achilles tendon rupture Nurse Actions: Take 1 hour before or 2 hours after meals. Report tendon pain. Push fluids, give antacids 2 hours AFTER this medication if warranted; not with this med.

Endogenous Infection

Coming from the inside. Ex: Chickenpox can turn into shingles

Exogenous Infection

Coming from the outside source

Altered Immunity

Conditions in which immune responses are suppressed or exaggerated. Immunocompromised or exagerated responses, like in anaphylaxis.

Infection Control Precautions

Contact precautions Airborne precautions: N95 mask. TB and measles Droplet precautions: Flu, Strep, etc

A nurse is caring for a patient who is about to begin taking macrodantin to treat URI. The nurse should tell the patient to report which of the following adverse effects?

Cough

A nurs is caring for a patient who is about to begin taking keflex to treat bacterial meningitis. The nurse shoudl explain to the patient the need to monitor which of the following lab tests?

Creatinine

Neutropenia

Decreased neutrophils An abnormally low count of neutrophils, a type of white blood cell that helps fight off infections, particularly those caused by BACTERIA and fungi.

A nurse should question the use of cyclophosphamide for a patient who has which of the following?

Dehydration

A nurse is caring for a patint who is about to begin zovirax IV to treat a viral infection. The nurse should recognize the cautious use of the drug is essential if the patient also has which of the following?

Dehydration. (this med is hard on kidneys)

A nurse is caring for a patient who is about to begin intrathecal cytarabine (depoCyt) therapy to treat meningeal leukemia. The nurse should explain that the patient should also receive which of the following drugs to reduce the risk of neurotoxicity?

Dexamethasone. (It also helps prevent nausea.)

A nurse is preparing to admin Amphotericin B IV to a patient who has systemic fungal infection. Which of the following should the nurse admin prior to infusion to minimize adverse reactions? Select all that apply.

Diphenhydramine, ibuprofen

Tetracyclines- "cycline" Bacteriostatic

Doxycycline, minocycline, tetracycline Indications: Chlamydia, acne, gonorrhea, malaria prophylaxis, lymes SE: Discoloration of teeth, glossitis (inflammation of tongue), dysphagia (difficulty swallowing), rash, D Nurse Actions: Back up birth control. Ineffective if dairy is taken with medication. Discolors teeth in children.

Leukocytosis

Elevated WBC. Can be caused from stress, allergies, inflammation in body. Not always related to infection.

Allergy to PCN

Erythromycin and Cephalosporin are both 1st choice drug if patient is allergic to PCN

Macrolides: "...thro...mycin" Bacteriostatic

Erythromycin, azithromycin/zithromax, Z-pak Indications: Whooping cough, H.Pylori, Legionnaires, URI, prophylaxis dental tx, acne SE: GI, D, liver, superinfections Nurse Actions: Take 1 hour before or 2 hours after meals. Monitor LFT

ATI: Pharm-Infection: Which of the following drugs should a provider prescribe for a patient who has streptocococcal pharyngitis and is allergic to PCN?

Erythrymycin

Handout in class: A 42 year old woman is going to have her first chemotherapy treatment for breast cancer and asks the nurse if she needs to stay away from children because she is a 1st grade teacher.

Exposure will increase the risk of getting infections. Talk to your oncologist.

Vaccine S.E.

Fever, minor body aches, drowsy, anorexia, irritability, vomiting, pain/redness/swelling at the site

While assessing a patient who is receiving interferon alfa-2a (roferon-A) to treat Kaposi's sarcoma, the nurse should check for which of the following possible indications of an adverse reaction?

Fever. (Antineoplastics decrease immune system)

Aminoglycosides- "mycin" (Bacteriocidal)

Gentamycin, Neomycin, Streptomycin, Tobramycin Indications: CNS infections, respiratory infections, GI, UTI, TB SE: Ototoxicity, kidneys, anorexia, N/V/D Nurse Actions: Check hearing, kidney function, encourage fluids, small frequent meals

Red Man Syndrome

Goes from trunk and then up the body. Large amount of histamine, causing hypotension, flushing, red rash. Give antihistamine for this.

A nurse is caring for a patient who is about to begin taking ketoconazole to treat fungal infection. The nurse should tell the patient to report which adverse reaction?

Gynecomastia

When caring for a patient who is taking flutamide to treat prostate cancer, the nurse should monitor the patient for which of the following adverse effects of the drug?

Gynecomastia

CBC with Differential Neutrophils

HIGH Neutrophils: Known as neutrophilia -Acute bacterial infections and also some infections caused by viruses and fungi -Inflammation (e.g., inflammatory bowel disease, rheumatoid arthritis) -Tissue death (necrosis) caused by trauma, major surgery, heart attack, burns -Physiological (stress, rigorous exercise) -Smoking -Pregnancy—last trimester or during labor -Chronic leukemia (e.g., myelogenous leukemia) LOW neutrophils: Known as neutropenia -Myelodysplastic syndrome -Severe, overwhelming infection (e.g., sepsis--neutrophils are used up) -Reaction to drugs (e.g., penicillin, ibuprofen, phenytoin, etc.) -Autoimmune disorder -Chemotherapy -Cancer that spreads to the bone marrow -Aplastic anemia

CBC with Differential Basophils

HIGH basophils: Known as basophilia -Rare allergic reactions (e.g., hives, food allergy) -Inflammation (rheumatoid arthritis, ulcerative colitis) -Some leukemias (e.g., chronic myeloid leukemia) LOW basophils: Known as basopenia As with eosinophils, numbers are normally low in the blood; usually not medically significant.

CBC with Differential Eosinophils

HIGH eosinophils: Known as eosinophilia -Asthma, allergies such as hay fever -Drug reactions -Inflammation of the skin (e.g., eczema, dermatitis) -Parasitic infections -Inflammatory disorders (e.g., celiac disease, inflammatory bowel disease) -Certain malignancies/cancers -Hypereosinophilic myeloid neoplasms LOW eosinophils: Known as eosinopenia This is often difficult to determine because numbers are normally low in the blood. One or an occasional low number is usually not medically significant.

CBC with Differential Lymphocytes

HIGH lymphocytes: Known as lymphocytosis -Acute viral infections (e.g., hepatitis, chicken pox, -cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes, rubella) -Certain bacterial infections (e.g., pertussis (whooping cough), tuberculosis (TB)) -Lymphocytic leukemia -Lymphoma LOW lymphocytes: known as lymphopenia or lymphocytopenia -Autoimmune disorders (e.g., lupus, rheumatoid arthritis) -Infections (e.g., HIV, TB, hepatitis, influenza) -Bone marrow damage (e.g., chemotherapy, radiation therapy) -Immune deficiency

CBC with Differential Monocytes

HIGH monocytes: Known as monocytosis -Chronic infections (e.g., tuberculosis, fungal infection) -Infection within the heart (bacterial endocarditis) -Collagen vascular diseases (e.g., lupus, scleroderma, rheumatoid arthritis, vasculitis) -Inflammatory bowel disease -Monocytic leukemia -Chronic myelomonocytic leukemia -Juvenile myelomonocytic leukemia LOW monocytes: Known as monocytopenia Usually, one low count is not medically significant. Repeated low counts can indicate: -Bone marrow damage or failure -Hairy-cell leukemia

Human Leukocyte antigens

HLA system is the locus of genes that encode for proteins on the surface of cells that are responsible for regulation of the immune system in humans. These help with diagnosis of autoimmune disorders.

HyperCalcemia

High calcium ion levels

HyperMagnesemia

High magnesium ion levels

HyperPhosphatemia

High phosphorus ion levels

HyperKalemia

High potassium ion levels

HyperNAtremia

High sodium ion levels

Hypertonic

High solute concentration, cells shrink/give up fluid, examples 5% dextrose in NS

Lecture: How does infection occur?

Host, Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry

Exaggerated Immune Response

Hypersensitivity. Ex: Latex, medication allergies, food, mold. Localized effects: Skin rash, N/V, swelling Systemic: Multiple systems involved. Anaphylaxis. Airway occlusion, shock. Consequences: Destruction of body tissue (arthritis, lupus), abnormal cell growth (cancer), Change in organ function (Atherosclerosis, renal disease)

Respiratory alkaloids

Hyperventilation, decrease in CO2, CNS irritant, alters available calcium(trouseaus and chovostek)

Respiratory acidosis

Hypoventilation, increased CO2, CNS suppression

The nurse should caution the patient about taking which of the following types of OTC drugs while receiving therapy?

Ibuprofen (Interactions: NSAIDS)

Acquired Immunity

Immunity developed due to exposure to pathogens

When talking to a patient who is about to begin vincristine therapy to treat lymphoma, the nurse should include which of the following instructions?

Increase fiber intake. (SE: Severe constipation and bowel impaction)

Fluid overload assessment

Increased BP, supplemental O2, ABG's, O2 sats, patient in semi-fowlers, daily wt, document edema, monitor I&O, restrict fluid and sodium intake, reposition every two hours, support extremities

Stages of Infection

Incubation: 1day-months or a year depending on infection Prodromal: 1st vague symptom Illness Decline Convalescence: Repairing time. Wound repairs itself, immune system increases and gets better.

Tamoxiphen (Nolvadex) Antineoplastic drug (hormonal agent)

Indication: Breast Cancer SE: N/V, Hot flashes, Increased appetite, Sodium and Fluid retention Nurse Actions: Monitor the injection site (severe pain or burning that lasts minutes to hours)

Metronidazole (Flagyl) Bacteriocidal

Indication: yeast infection, abcess, gangrene, diabetic skin ulcers, deep wound infections SE: N, dry mouth, HA, fatigue, bitter taste Nurse Actions: Avoid alcohol with this med. Good oral care. No alcohol within 48 hours of taking this med.

Unless there are any specific contraindications, which of the following immunizations should the adults get once a year?

Influenza

Primary Immune Response

Initial recognition of antibody. Ex: 2 year old gets exposed to chickenpox

A nurse is caring for a patient who is about to begin taking INH to treat TB. The nurse should tell the patient to report which adverse effect of the drug? Select all that apply.

Jaundice, Numbness in hands, Dizziness

Bacteriocidal

Kills bacteria

Macrophage

Large cells that recognize, engulf, and destroy cells.

Monocyte

Largest WBC. Macrophage. A large phagocytic white blood cell with a simple oval nucleus and clear, grayish cytoplasm.

A nurse is caring for a patient who is about to receive gentamycin to treat systemic infection. The nurse should question the use of the drug for a patient who is also taking which drug?

Lasix (furosemide). *(gentamycin is hard on kidneys and if the person is dehydrated it will be worse. )

HypoCalcemia

Low calcium ion levels

HypoMagnesemia

Low magnesium ion levels

HypoPhosphatemia

Low phosphorus ion levels

HypoKalemia

Low potassium ion levels

HypoNAtremia

Low sodium ion levels

Hypotonic

Lower solute concentration/more fluids, fluid shifts from low to high concentration, examples: D5W and 0.45% NS

Diffusion

Moves particles from high solute concentration area to a low solute concentration area

Osmosis

Moving water from a low to high particle concentration area

A nurse should question the use of maraviroc (selzentry) for a patient who has which of the following?

Non-Chemokine receptor 5 (CCR5)-tropic HIV-1 (This drug IS a Chemokine receptor 5 (CCR5) tropic HIV drug.)

Vaccine Contraindications

Pregnancy, allergies, blood products within the last 3 months, acute infection

A nurse is caring for a patient who is about to begin taking ritonavir (norvir) to treat HIV. The nurse should explain that the patient will receive norvir along with at lease one other reverse transciptase inhibitor to....

Prevent drug resistance

Wound Healing

Primary Intention: Wound edges are approximated Secondary Intention: Tissue loss, not approximated Tertiary Intention: Wound vac

Body's Defense Mechanisms

Primary defense: Skin Secondary Defense: WBCs Tertiary Defence: Cell and humoral mediated

A patient is taking tetracycline orally to treat chlamydia, contacts the provider to report severe blood-tinged diarrhea. Recognizing the side effects, the nurse should suspect what?

Pseudomembranous enterocolitis

A nurse is caring for a patient who is about to begin delavirdine (rescriptor) therapy to treat HIV-1. The nurse should tell the patient to report which of the following adverse reactions of the drug?

Rash

BODY FLUID REGULATORS: Volume receptors

Release ANP(arterial diuretic peptide), stimulates kidneys to excrete sodium and water

A primary care provider should prescribe a lower dose of Azectam for a patient who has a URI and also has which of the following?

Renal impairment

Secondary Immune Response

Repeat encounter of same antigen. Ex: That same child is now 13 years old and exposed to chicken pox virus again.

A nurse should understand that raltegravir (Isentress) treats patients who have which of the following?

Resistant HIV disease

BODY FLUID REGULATORS: Excretion of co2

Respiratory system

BODY FLUID REGULATORS: Arterial photoreceptor reflex

SNS causes deconstruction, inhibition of SNS causes vasodilation

Fluid Deficit assessment

SOB, decreased BP, supplemental O2, monitor for LOC, monitor heart irregularities or tachycardia, IV isotonic fluid replacement, encourage fluids, place in shock position: reverse trendelenberg, monitor I&O

A nurse is caring for a patient who is about to begin Flagyl to treat anaerobic intra-abdominal infection. The nurse should recognize that cautious use of the drug is indicated if the patient also has which of the following?

Seizure disorder

Handout in class: The nurse is calming a mother down after she brought her 7 year old child into the UC with signs of anaphylactic shock from a bee sting.

Signs: SOB, hives, swelling, ^P, vBP Calm mom down so that doesn't make child worse.

Isotonic

Solutions are equally concentrated, isotonic fluid expands in extracellular fluid but doesn't change it, examples are 0.9% NS and 5% D5W

Staging of ulcers

Stage I: Reddened area Stage 2: blistering. Partial thickness loss of dermis. Stage 3: Full thickness skin loss with damage to subcutaneous tissue. Stage 4: bone and muscle involved. Necrosis might be involved. Unstagable: Due to eschar or bruising

While administering IV cefotetan to a patient to treat bacterial meningitis, the nurse finds the IV insertion site warm and reddened. Which of the following action should the nurse take?

Stop the infusion

A patient who is taking imipenam (primaxin) to treat bacterial infection contacts the provider to report an inability to eat because of mouth pain. Recognizing the adverse side effects of imipenem, the nurse should suspect what?

Suprainfection

A nurse is caring for a patient who is about to begin nystatin to treat organ candida that resulted from tetracycline. Which of the following instructions should the nurse include about the preparation?

Swish before swallowing.

A patient who is taking cipro to treat URI contacts the nurse to report dyspepsia. The nurse should recommend which instruction?

Take the antacid 2 hours after taking the drug

A nurse is caring for a patient who is taking Cipro to treat UTI and has rheumatoid arthritis, for which he takes Prednisolone. Recognizing the adverse effects of cipro, the nurse should tell the patient to report?

Tendon pain

Active Immunity

The body recognizes a foreign protein and begins producing own antibodies to react with it.

Osmolality

The number of absolutes per kilogram of fluid

Stress

The stress hormone Cortisol lowers the WBC. Cortisol can be released with unhealthy coping strategies such as drinking, overeating, smoking, over exercising. Types: -Physical: Surgery, trauma, over-exercising, lack of sleep -Psychological: Relationship, new situations -Perceived: Phobias, change, vacation. Gender: -Female have more autoimmune disorders than men. Estrogen has a negative effect on the immune system -Males: Androgens preserve some parts of the immune system.

Helper T cells

They help the activity of other immune cells by releasing T cell cytokines. These cells help suppress or regulate immune responses. They are essential in B cell antibody class switching, in the activation and growth of cytotoxic T cells, and in maximizing bactericidal activity of phagocytes such as macrophages.

Antigen

Toxin or pathogen that gets the immune response going

Passive Immunity

Transferred from one person to another. Maternal to fetus.

When considering drug therapy options for a patient who has metastatic breast cancer that is positive for the HER2, the nurse should choose which of the following drugs?

Trastuzumab (herceptin)

Sulfonamides- "sulfa" Bacteriostatic

Trimethoprim/Sulfamethoxazole (bactrim), sulfasalazine (Azulfidine) Indications: Ear infection, meningitis, UTI, chrons, colitis SE: Crystalluria, proteinuria, photosensitive, GI, periph neuropathy, stomatitis (inflammation of tongue) Nurse Actions: Fluids, protect from sun, good mouth care

A nurse is caring for a patient who is about about to begin gentamycin therapy to treat infection. The nurse should monitor for which of the following?

Urine output

When talking with a patient who is about to begin taking methotrexate (trexall) therapy to treat non-Hodgkin lymphoma, the nurse should include which of the following instructions?

Use a soft bristled toothbrush. (SE: oral ulcers and bleeding risk)

A nurse is caring for a patient who takes oral contraceptives and is about to begin rifampin therapy to treat TB. The nurse should include which of the following instructions?

Use back up methods

A primary provider is prescibing drug therapy for a patient whose sputum culture indicate methicillin-resistant Staph-Aureas (MRSA). Which of the folling drugs should be administered?

Vancomycin

Glycopeptides- "mycin" Bacteriocidal

Vancomycin (Vancocin) Indications: Staph SE: Thrombophlebitis, abscess, kidneys, ototoxicity, chills, fever, rash, Red Man Syndrome Nurse Actions: Monitor kidneys. Given IV. Give antihistamine if Red Man Syndrome. Monitor for superinfection. Monitor Vanco trough level 30 min before next dose to make sure they are not overmedicated.

When caring for a patient who is receiving vincristine to treat lung cancer, the nurse should monitor for which of the following that indicates an adverse effect?

Weak hand grasps. (SE: neuropathy and decreased strength)

A nurse is caring for a patient who is about to being taking Chloroquine (arelan) to treat malaria. When talking with the patient about taking the drug, the nurse should include which of the following? Select all that apply.

Wear sunglasses outside, Avoid driving, take with food.

9 The nurse has received an order to transfuse two units of PRBCs to a client. Each 350 mL unit is to infuse over a two hour period. The nurse would administer the infusion at an hourly rate of _____ mL/hour. Record your answer rounding to a whole number.

______ml/hr Answer: 175 Rationale: If a 350 mL unit of packed red blood cells is to infuse over 2 hours, the rate will be 175 mL per hour. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Use knowledge of pharmacological math to calculate the infusion rate.