HIV/ANEMIA/GI/HEP/SCI/BONES/DM Quiz
A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching?
"Monitor your blood glucose levels at least every 4 hours while sick."
A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond?
"Viral hepatitis is not spread through casual contact."
The patient diagnosed with hepatitis A asks how the infection may have been contracted. Which response by the nurse is correct?
"You may have been exposed when you ate shrimp at the outdoor seafood festival last weekend."
The nurse is preparing to administer two units of packed red blood cells to a client, which IV solution should the nurse use during the infusion?
0.9% Sodium Chloride
While assessing a client admitted 2 days ago with a fractured hip, the nurse notes that the client is confused, tachypneic, restless, and petechiae appears over the neck area. Which is the most important intervention for the nurse to implement?
Administer prescribed oxygen via nasal cannula
Which action by the nurse is most effective to prevent exposure to the human immunodeficiency virus (HIV)?
Always use standard precautions with all clients in the workplace.
When planning discharge teaching for the client who was admitted with a sickle cell crisis, which instruction will the nurse include?
Avoid exposure to crowds as much as possible.
A client with a T2-to-T3 spinal cord injury suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first?
Check the Foley catheter for a kink.
A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from the therapy if the client exhibits which?
Decreased bleeding from the wound.
To assist an older patient with diabetes to engage in moderate daily exercise, which action is most important for the nurse to take?
Determine what types of activities the patient enjoys.
A client is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What is the priority nursing action?
Document stoma assessment findings.
A patient has a history of diabetes mellitus. Which clinical finding by the nurse would indicate the patient is hyperglycemic?
Increased urination
A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which is the most appropriate nursing intervention?
Instruct the client to rotate sites for insulin injection.
Which clinical manifestations would the nurse expect to see in a client with severe anemia? Select all that applies)
Lethargy, Pallor, Dyspnea
A client is being treated for acute low back pain. The nurse should immediately report which of these clinical manifestations to the health care provider (HCP)?
New onset of foot drop
Which assessment finding would the nurse expect to see in a client with pernicious anemia?
Red, beefy tongue
The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis?
Severe, steady right lower quadrant pain at McBurney's Point.
A client is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider?
Slow capillary refill of the left foot.
A client who has a fracture is being treated with traction as pictured below. Which assessment finding will require immediate intervention?
The traction weights are resting on the floor.
The nurse determines that administration of hepatitis B vaccine to a client has been effective when a specimen of the client's blood reveals which?
anti-HBs
