Infection, inflammation, informatics, tissue integrity, pressure ulcers nclex ?

A client with a deep tissue injury and white exudate develops a fever. Which test should the nurse anticipate being prescribed by the healthcare​ provider? 1) ESR 2) Culture and sensitivity of the wound bed 3) Urine culture and sensitivity 4) Serum

​2) Culture and sensitivity of the wound bed Rationale: The wound bed can be cultured to determine the organism causing the infection. ESR can determine the presence of osteomyelitis. Serum protein helps establish nutritional status. Urine culture and sensitivity will determine presence of a urinary tract infection​ (UTI).

The charge nurse receives report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure​ injuries? (Select all that​ apply.) 1) Client with type 1 diabetes mellitus 2) Client admitted to an acute care unit 3) Client who is​ 92-years-old 4) Client with a history of anorexia nervosa 5) Client on bedrest

1) Client with type 1 diabetes mellitus 3) Client who is​ 92-years-old 4) Client with a history of anorexia nervosa 5) Client on bedrest ​Rationale: A client on bedrest is​ immobile, which increases the risk for developing pressure injuries. An older adult client is at risk because of the loss of lean body​ mass, epidermal​ thinning, decreased skin​ elasticity, and increased skin dryness. A client with type 1 diabetes mellitus is at risk because of compromised oxygen delivery to the tissues. A client with a history of anorexia nervosa is at risk because of inadequate​ nutrition, which leads to weight​ loss, muscle​ atrophy, and loss of subcutaneous tissue. A client admitted to an acute care unit is not usually at risk for developing a pressure injury.

The nurse prepares to administer dexamethasone to a client with diabetes experiencing inflammation. For which side effect should the nurse monitor in the​ client? 1) Increased temperature 2) Hypotension 3) Hyper glycemic 4) Hyperkalemia

3) Hyperglycemic ​Rationale: Glucocorticoids can elevate the blood sugar. When giving the medication to clients with​ diabetes, the nurse should monitor for hyperglycemia. Other potential side effects of glucocorticoids include​ hypokalemia, hypertension, and signs of heart failure. Glucocorticoids do not result in increased temperature.

A client asks the nurse how to obtain the​ client's lab results and history of visits. Which informatics application should the nurse​ recommend? 1) Insurance billing summary 2) Telehealth 3) Clinical decision support 4) Patient portal

4) Patient portal ​Rationale: A patient portal allows clients to access parts of the electronic health​ record, schedule​ appointments, and communicate with providers. Telehealth describes the assessment and care being provided remotely through the use of technology. Clinical decision support is the use of data to trigger alerts and recommendations for treatment options. An insurance billing summary is not a useful tool in this situation.

A client who is coughing has blood in the sputum. In which phase of the nursing process should the nurse document these​ findings? 1) Implementation 2) Diagnosis 3) Evaulation 4) assessment

4) assessment ​Rationale: Gathering data about the​ client's symptoms is part of the assessment. Data are analyzed during the diagnostic phase. Response to treatment is the evaluation phase. Actions to address the symptoms are performed during the implementation phase.

The nurse notes circular lesions on a​ client's upper back. Which condition should the nurse consider prior to​ examination? (Select all that​ apply.) 1) Ringworm 2) Tinea versicolor 3) Poison ivy 4) Herpes zoster 5) Contact dermatitis

1) Ringworm 2) Tinea versicolor ​Rationale: The circular lesions may be attributed to either ringworm or tinea versicolor. Circular lesions are not characteristic of poison​ ivy, herpes​ zoster, or contact dermatitis.

The nurse is caring for a client with an open pressure injury with minimal necrotic tissue. Which dressing should the nurse identify as most appropriate for the​ client? 1) ​Wet-to-dry gauze dressing with sterile normal saline 2) Skin prep Granulex 3) Transparent dressing 4) Hydrocolloid dressing

1) ​Wet-to-dry gauze dressing with sterile normal saline ​ Rationale: Wet-to-dry gauze dressing with sterile normal saline will soften the necrotic tissue so it will adhere to the gauze and be debrided with the dressing change. Granulex is appropriate for intact skin. Transparent and hydrocolloid dressings help to prevent skin breakdown.

The nurse is caring for a client with acne. Which condition describes the​ nurse's understanding of the classification of​ acne? 1)Inflammatory 2) Infectious 3) Neoplastic 4) Dermatitis

​1)Inflammatory Rationale: The nurse caring for the client with acne understands that the classification of acne is inflammatory. Acne is not classified as infectious or neoplastic. Dermatitis is another inflammatory disorder of the skin.

The nurse is planning care for a client with limited knee function due to arthritis. Which intervention should the nurse include in this​ client's plan of​ care? (Select all that​ apply.) 1) Providing antipyretics as prescribed 2) Encouraging rest of the affected joint 3) Encouraging participation in physical therapy as prescribed 4) Assessing pain level and providing medication as prescribed 5) Providing antiarthritis medications as prescribed

​2) Encouraging rest of the affected joint 3) Encouraging participation in physical therapy as prescribed 4) Assessing pain level and providing medication as prescribed 5) Providing antiarthritis medications as prescribed Rationale: Interventions appropriate when function is impaired because of inflammation include encouraging rest of the affected​ joint, assessing and providing​ analgesics, treating the underlying health​ problem, and participating in physical therapy. Antipyretics would be appropriate if the inflammation were systemic and not localized.

The nurse is caring for an adolescent female client who has begun menstruating. Which preexisting disorder should the nurse expect to be exacerbated by the hormonal changes that​ occur? 1) Warts 2) Contact dermatitis 3) Eczema 4) Fungal tinea

​3) Eczema Rationale: Eczema is exacerbated by the hormonal changes that accompany menstruation. The incidence of warts and fungal tinea infections increase due to the involvement with sports and use of public showers. Contact dermatitis is not associated with hormonal changes that occur during menstruation.

The nurse is caring for a client with incontinence of urine and sudden onset of watery diarrhea. Which action should be included in the plan of care to maintain skin​ integrity? (Select all that​ apply.) 1) Apply a moisturizing barrier cream to the skin at greatest risk of breakdown. 2) Assess skin systematically at least once a day. 3) Massage bony prominences at least twice daily to promote circulation. 4) Increase humidity in the room and limit exposure to cold. 5) Clean skin immediately at the time of soiling and routinely.

1) Apply a moisturizing barrier cream to the skin at greatest risk of breakdown. 2) Assess skin systematically at least once a day. 4) Increase humidity in the room and limit exposure to cold. 5) Clean skin immediately at the time of soiling and routinely ​Rationale: To maintain skin integrity of a client with incontinence of urine and​ stool, the nurse should assess skin systematically at least once a​ day, clean skin immediately upon soiling and​ routinely, increase the humidity in the room and limit exposure to​ cold, and apply a barrier cream to the skin at the greatest risk of breakdown. Bony prominences should not be massaged.

The nurse conducts screening for inflammatory diseases with clients of a community health clinic. Which test should the nurse​ perform? 1) Skin Test 2) Urine Test 3) MRI 4) X-ray

1) Skin Test ​Rationale: Skin testing identifies allergens that trigger an inflammatory response. Urine​ tests, MRIs, and​ x-rays are not used for routine screening for inflammatory diseases.

While applying lotion to the skin of an older adult​ client, the client asks why it is more important to take better care of the skin now than at a younger age. Which aspect of integumentary changes in older adult clients should the nurse include in the​ response? (Select all that​ apply.) 1) Decreased turnover of the outer skin layer 2) Increased efficiency of blood circulation to skin 3) Faster wound healing 4) Impaired skin barrier 5) Greater sensitization to allergens

1) Decreased turnover of the outer skin layer​ 4) Impaired skin barrier 5) Greater sensitization to allergens Rationale: The integumentary changes that occur in older adult clients include impaired skin​ barrier, greater sensitization to​ allergens, and a decreased turnover of the outer skin layer. Wound healing is slowed and circulation to the skin decreases.

The nurse is reviewing the chart of a client who is pregnant and reports​ "red patches of skin that​ itch." Which assessment finding should the nurse​ anticipate? 1) Eczematous skin changes around the neck 2) Seborrheic dermatitis 3) Lacy exanthema on the cheeks 4) Scaly rash on the chest

1) Eczematous skin changes around the neck ​Rationale: Atopic eruption of pregnancy is a common​ pregnancy-specific skin disorder that is characterized by eczematous skin​ changes, most often around the neck and flexor surfaces of the body. A scaly rash on the​ chest, lacy​ exanthema, and seborrheic dermatitis are not associated with pregnancy.

The nurse is preparing a client scheduled for a skin biopsy. The client asks how this will be done. Which procedure should the nurse​ include? (Select all that​ apply.) 1) Excision 2) Punch 3) Shaving 4) Incision 5) Culture

1) Excision 2) Punch 3) Shaving 4) Incision ​Rationale: A skin biopsy can be obtained by a​ punch, incision,​ excision, or shaving. Cultures are used to identify infections obtained from tissue​ samples, wounds,​ drainage, lesions, or serum.

A client is in the​ high- Fowler position to facilitate breathing. Which body pressure area should the nurse be most concerned​ about? 1) Heels 2) Zygomatic bone 3) Knee 4) Ilium

1) Heels ​Rationale: A client in Fowler position has pressure on the​ heels, pelvis,​ sacrum, and vertebrae. A client in the lateral position has pressure on the knee and ilium. A client in the prone position has pressure on the zygomatic bone.

The nurse is teaching a class about the Office of the National Coordinator for Health Information Technology and meaningful use objectives. Which item should be​ included? (Select all that​ apply.) 1) Improving care coordination to improve client outcomes 2) Controlling and monitoring​ clients' healthcare choices 3) Ensuring the security and privacy of protected medical information 4) Reducing health disparities by improving safety and quality of care 5) Engaging clients and their families in the​ client's care

1) Improving care coordination to improve client outcomes 3) Ensuring the security and privacy of protected medical information 4) Reducing health disparities by improving safety and quality of care 5) Engaging clients and their families in the​ client's care ​Rationale: The Office of the National Coordinator for Health Information Technology​ (ONC) monitors the achievement of meaningful use​ objectives, which are reported back to the Centers for Medicare and Medicaid Services​ (CMS) in order to authorize financial reimbursement. Meaningful use objectives include improving care​ coordination, reducing health disparities among U.S. citizens by improving the safety and quality of​ care, ensuring the security and privacy of protected medical​ information, and engaging clients and their families in the​ client's care. Meaningful use objectives do not include controlling and monitoring​ clients' healthcare choices.

The nurse is describing applications of telehealth. Which activity should the nurse​ include? (Select all that​ apply.) 1) Managing acute and chronic conditions of the client 2) Having the client meet with a virtual health coach 3) Allowing clients to consult with healthcare providers regardless of location 4) Watching clients perform a return demonstration of skills 5) Using dual webcams to visually assess the​ client's condition

1) Managing acute and chronic conditions of the client 2) Having the client meet with a virtual health coach 4) Watching clients perform a return demonstration of skills 5) Using dual webcams to visually assess the​ client's condition

A client with inflammation asks about foods or supplements that can reduce inflammation. Which nutrient should the nurse list as being beneficial to the​ client? (Select all that​ apply.) 1) Probiotics 2) Saturated fats 3) Foods rich in cholesterol 4) Antioxidants vitamins 5) Omega-3 fatty acids

1) Probiotics 4) Antioxidants vitamins 5) Omega-3 fatty acids ​Rationale: An​ anti-inflammatory diet consists of foods high in​ omega-3 fatty​ acids, antioxidant​ vitamins, and probiotics.​ Pro-inflammatory foods contain saturated​ fats, cholesterol, and a high glycemic index.

The nurse is teaching a client who is newly diagnosed with inflammation. Which systemic manifestation of inflammation should the nurse include in the​ teaching? (Select all that​ apply.) 1) Respiratory rate of 22 breaths per minute 2) White blood cell count of ​4000/mm3 3) Oral temperature of 101F 4) Blood pressure of​ 148/88 mmHg 5) Heart rate of 104 beats per minute

1) Respiratory rate of 22 breaths per minute 3) Oral temperature of 101F 5) Heart rate of 104 beats per minute

The nurse is caring for a client admitted with a pressure injury. Which data should the nurse document when assessing the pressure​ injury? (Select all that​ apply.) 1) Signs of infection 2) Integrity of the surrounding tissue 3) Color of the wound bed 4) Stage of the ulcer 5) Home management of the pressure injury

1) Signs of infection 2) Integrity of the surrounding tissue 3) Color of the wound bed 4) Stage of the ulcer ​Rationale: Documenting the stage of the pressure​ injury, color of the wound​ bed, integrity of the surrounding​ tissue, and signs of infection are of utmost importance. Assessment of home management does not need to be documented.

The nurse is caring for a client with impaired mobility. Which concern regarding tissue integrity should the nurse​ address? (Select all that​ apply.) 1) Skin Breakdown 2) Allergic response 3) Increased susceptibility to microorganisms 4) Pressure ulcer formation 5) Production of exudate

1) Skin Breakdown 4) Pressure ulcer formation ​Rationale: The effects that impaired mobility have on tissue integrity include skin breakdown and pressure ulcer formation. The immune system mediates an allergic response. Exudate is a response to infection. Increased susceptibility to microorganisms may result from a compromised immune system.

A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. Which stage should the nurse document this ulcer to​ be? 1) Stage 4 2) stage 3 3) Stage 2 4) Stage 1

1) Stage 4 ​Rationale: A stage 4 pressure injury may be covered with eschar. Eschar is not present in stage 1 or stage 2. Stage 3 pressure injuries may have eschar​ present, but tissue damage is limited to the subcutaneous tissue.

A client with deep tissue damage develops eschar. Which procedure should the nurse anticipate being​ prescribed? 1) Surgical debridement 2) Application of a moisture-retaining protective dressing 3) Application of a petroleum ointment 4) Application of a barrier cream

1) Surgical debridement ​Rationale: When eschar has​ formed, surgical debridement and removal of necrotic material is necessary. Application of a barrier cream is appropriate for intact skin. Use of petroleum ointment is not appropriate. Application of a​ moisture-retaining protective dressing is appropriate for a pressure injury without eschar or after the eschar has been surgically removed.

A client has a​ follow-up appointment for treatment of a pressure injury. Which client outcome should indicate to the nurse that treatment goals have been​ met? (Select all that​ apply.) 1) The wound has decreased in size. 2) The client has enrolled in a smoking cessation program. 3) There is greenish exudate on the dressing. 4) The client and family demonstrate an understanding of preventive care measures. 5)The​ client's BMI is​ 16, and the weight is down by 4 pounds.

1) The wound has decreased in size. 2) The client has enrolled in a smoking cessation program. 4) The client and family demonstrate an understanding of preventive care measures. ​Rationale: The client and family demonstrate an understanding of wound​ care, the wound has decreased in​ size, and the client has enrolled in a smoking cessation program indicate that nursing interventions and education have been effective. Greenish exudate indicates a possible infection. The​ client's decrease in weight indicates that nutrition may not be adequate for optimal wound healing and maintenance of proper weight.

The nurse is caring for a client at risk for a pressure injury. Which action should the nurse use to maintain the skin​ integrity? (Select all that​ apply.) 1) Treating dry skin with moisturizing lotions directly applied to moist skin after bathing 2) Cleaning the skin immediately if exposed to urine or feces 3) Avoiding exposure to high humidity 4) Assessing the skin upon admission and then daily using the same screening tool 5) Scrubbing the skin to clean it thoroughly when bathing

1) Treating dry skin with moisturizing lotions directly applied to moist skin after bathing 2) Cleaning the skin immediately if exposed to urine or feces 4) Assessing the skin upon admission and then daily using the same screening tool ​Rationale: To maintain skin integrity for clients at risk for pressure​ injuries, assess the skin upon admission and then​ daily, using the same screening​ tool; treat dry skin with moisturizing lotions directly applied to moist skin after​ bathing; and immediately clean the skin if exposed to urine or feces. Do not scrub the​ client's skin when​ bathing; instead, minimize the force and friction applied to the skin to prevent injury. Avoid exposing the client to cold and low humidity.

The nurse is preparing to perform an assessment on a client. Which factor should the nurse include in the integumentary​ assessment? (Select all that​ apply.) 1) Turgor 2) Texture 3) Sensation 4) Nails 5) Temperature

1) Turgor 2) Texture 4) Nails 5) Temperature ​Rationale: An integumentary assessment includes the​ nails, skin​ turgor, texture, and temperature. Sensation is included in a neurological examination.

A client asks what effect nutrition has on skin integrity. Which response should the nurse make that explains the relationship of nutrition to pressure injury​ development? 1) ​"Poor dietary intake of​ kilocalories, protein, and iron can increase the risk of pressure​ injuries." 2) ​"Increased dietary intake of carbohydrates and minerals can cause pressure​ injuries." 3) ​"Increased dietary intake of protein can cause pressure​ injuries." 4) ​"Poor dietary intake of carbohydrates and minerals can increase the risk of pressure​ injuries."

1) ​"Poor dietary intake of​ kilocalories, protein, and iron can increase the risk of pressure​ injuries." ​Rationale: Poor dietary intake of​ kilocalories, protein, and iron has been associated with the development of pressure injuries. An association between minerals and risk of pressure injury development is unknown. Increased intake of protein will not cause pressure injuries to develop.

The nurse is teaching a group of new mothers about the best way to prevent infections in children. Which statement by the new mothers should indicate to the nurse that the teaching was​ effective? 1)​"Proper hand hygiene should be used​ consistently." 2) ​"I should make sure my child takes a full spectrum of​ vitamins." 3) ​"My child has a natural immunity to most​ microorganisms." 4) ​"I should not take my child out in public more than once a​ week."

1)​"Proper hand hygiene should be used​ consistently." ​Rationale: Hand​ hygiene, comprehensive​ immunizations, proper​ nutrition, adequate​ hydration, and appropriate rest are essential to preventing or treating infections in children. Children do not have natural immunity. Vitamin supplements are used if prescribed by the healthcare professional. There is no reason to restrict the​ child's exposure to others.

A​ preschool-age client is experiencing​ "burning" with urination and a fever of​ 102°F (38.9°C). Which intervention should the nurse make a priority​? ​(Select all that​ apply.) 1) Teaching about vaccinations 2) Administering prescribed antipyretics 3) Administering prescribed fluids 4) Monitoring intake and output closely 5) Providing warming blankets

2) Administering prescribed antipyretics 3) Administering prescribed fluids 4) Monitoring intake and output closely ​Rationale: Treatment for an infection includes fluid​ therapy, monitoring of intake and​ output, and providing antipyretics as prescribed. The client has a fever and may be uncomfortable with a warming blanket. Vaccination teaching is not a priority for this client.

A​ school-age client with a fever is being tested for possible kidney failure. Which collaborative intervention should the nurse make a priority for this​ client? 1) Practicing medical asepsis 2) Administering prescribed intravenous antibiotics 3) Using sterile technique 4) Performing hand hygiene

2) Administering prescribed intravenous antibiotics ​Rationale: Providing prescribed medications is a collaborative intervention. Using sterile​ technique, hand​ hygiene, and medical asepsis are independent nursing interventions.

The nurse is caring for a child who is suspected of having an inflammatory disorder involving internal organs. Which diagnostic test should the nurse expect will be ordered for the​ child? 1) Bronchoscopy 2) Exhaled breath condensates 3) Bronchoalveolar lavage 4) Blood tests

2) Exhaled breath condensates rationale: The best procedure to assess for inflammation in internal organs of children is to analyze exhaled breath condensates. This test is noninvasive and appropriate for children. Bronchoscopy and bronchoalveolar lavage are both invasive procedures better suited for use on adults. Negative blood tests should be interpreted with caution in children with potential inflammatory disorders. Normal blood test results are common for children with inflammatory disorders such as IBD and acute glomerulonephritis. False positives may also occur for some laboratory​ tests, such as an increase in alkaline phosphatase in healthy children and adolescents who are still growing.

A preadolescent client is experiencing​ fatigue, headache, sore​ throat, and a​ low-grade fever over the last 2 days. Which disease process should the nurse assess for if this client has an allergy to​ corticosteroids? 1) Chickenpox 2) Mononucleosis 3) Rubella 4) Measles

2) Mononucleosis ​Rationale: Mononucleosis may be treated with corticosteroids to reduce inflammation. Corticosteroids are not used to treat​ rubella, measles, or chickenpox.

Which factor should the nurse exclude as a benefit of electronic medical​ records? 1) Tracking client data over time 2) Notifying clients of upcoming appointments 3) Identifying the need for mammograms 4) Recognizing the need for vaccines

2) Notifying clients of upcoming appointments ​Rationale: Tracking client data over​ time, identifying the need for​ vaccines, and identifying the need for mammograms are all benefits of electronic medical records. Notifying clients of upcoming appointments is not a benefit of electronic medical records.

A client with an upper respiratory infection is receiving radiation treatments. What is the reason the nurse explains the risk of infection to the​ client? 1) Radiation is only destructive to tissue. 2) Radiation kills both cancerous and healthy cells. 3) Radiation is lethal to only cancerous cells. 4) Radiation only kills the targeted cells.

2) Radiation kills both cancerous and healthy cells. ​Rationale: Some medical therapies may predispose an individual to infection. Radiation treatments for cancer destroy not only cancerous cells but also some normal​ cells, thereby rendering the client more vulnerable to infection.

The nurse performing a home visit for an older adult client determines the client would benefit from teaching about the promotion of skin integrity. Which assessment finding indicates the need for further​ teaching? 1) The client applies a moisturizer after bathing. 2) The client uses a body spray perfume. 3) The client showers four times a week. 4) The client washes the hands with soap and running water before eating.

2) The client uses a body spray perfume. ​Rationale: The client using a body spray perfume is at risk of impaired skin integrity. Perfumes contain​ alcohol, which dries the skin. Showering four times a​ week, applying a moisturizer after​ bathing, or washing hands with soap and running water prior to eating do not place the client at risk for impaired skin integrity.

The nurse notes that a client appears to have an integumentary infection. Which diagnostic test should the nurse anticipate will be​ prescribed? 1) Punch biopsy 2) Wood lamp 3) Patch test 4) Skin shaving

2) Wood lamp ​Rationale: The nurse anticipates a Wood lamp test to be prescribed to identify an integumentary infection. A patch test is used to identify an allergy. Punch biopsy and skin shaving are procedures used to obtain a skin biopsy.

The nurse is reviewing documentation on a client at risk for developing a pressure injury. Which note in the documentation should indicate to the nurse that the plan of care has been followed​ correctly? 1) ​"Client turned every 4​ hours." 2) ​"Client refusing meals. Nutritional consult​ prescribed." 3) ​"Client comfort and pain level assessed​ daily." 4) ​"Client ate all of lunch. Given a nutritional​ supplement."

2) ​"Client refusing meals. Nutritional consult​ prescribed." ​Rationale: Nutritional consults should be prescribed for clients with inadequate nutritional intake. Clients should be turned every 2 hours. Client comfort and pain should be assessed more often than daily. Nutritional supplements should be given to clients who eat​ 50% or less of their meals.

The nurse is reviewing the chart of a client who has developed keloids as a result of multiple surgeries. Which assessment finding should the nurse​ anticipate? 1) Wearing away of the superficial epidermis 2) ​Elevated, irregular, darkened area 3) ​Flat, irregular area of connective tissue 4) ​Rough, thickened, hardened area of epidermis

2) ​Elevated, irregular, darkened area ​Rationale: The nurse can expect to find an​ irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. A scar is a​ flat, irregular area of connective tissue left after a lesion or wound has healed. A wearing away of the superficial epidermis causes a​ moist, shallow depression known as erosion. Lichenification is characterized by a​ rough, thickened, hardened area of epidermis.

The nurse is reviewing the chart of a client diagnosed with neurofibromatosis. Which change in skin pigmentation should the nurse anticipate finding based on the​ client's diagnosis? 1) Acanthosis nigricans 2) Actinic keratosis 3) Cafe au lait spots 4) Hemangioma

3) Cafe au lait spots ​Rationale: The nurse can expect to find​ café au lait spots on the skin of the client who is diagnosed with neurofibromatosis.​ Café au lait spots are hyperpigmented​ freckle-like macules that can vary in color from light brown to dark​ brown, with borders that may be smooth or irregular. A hemangioma is the most common tumor of infancy. Lesions may be superficial or deeper and vary in color. Actinic keratosis is precancerous changes in skin cells that occur from many years of sun exposure. Hyperglycemia is a common cause of acanthosis​ nigricans, which is characterized by​ dark, thickened, velvety discoloration in body folds and​ creases, usually around the​ neck, axilla, and groin.

The nurse is caring for a client with severe systemic inflammation. Which medication should the nurse expect to find listed on the​ client's medication administration record​ (MAR)? 1) esomeprazole 2) sumatriptan 3) Dexamethasone 4) Regular Insulin

3) Dexamethasone ​ Rationale: Dexamethasone is a​ glucocorticoid, a steroid used in the treatment of severe inflammation. Insulin is used in the treatment of diabetes​ mellitus, esomeprazole is a proton pump inhibitor used to treat​ acid-reflux disease, and sumatriptan is used to treat migraine headaches.

The nurse is planning a webinar about the benefits of using uniform language in the electronic health record. Which information should the nurse​ include? (Select all that​ apply.) 1) It decreases nurse​ educators' ability to teach vital concepts related to the nursing process. 2) It reduces the emphasis on the need for critical thinking when providing client care. 3) It helps healthcare organizations validate the benefits and costs of nursing care. 4) It enhances the individual​ nurse's decision making at the point of care. 5) For healthcare​ organizations, it facilitates the measurement of nursing​ care's impact on the client.

3) It helps healthcare organizations validate the benefits and costs of nursing care. 4) It enhances the individual​ nurse's decision making at the point of care. 5) For healthcare​ organizations, it facilitates the measurement of nursing​ care's impact on the client

The nurse is planning teaching for a client with infected contact dermatitis. Which information should the nurse include in the​ teaching? 1) Use cold water and a mild soap to cleanse skin. 2) Stop antibiotics when redness disappears. 3) Keep nails trimmed short. 4) Cover the infected site with a sterile dressing.

3) Keep nails trimmed short. ​Rationale: The nurse will instruct the client to keep nails trimmed short to avoid scratching the infected dermatitis. It is not necessary to cover the infected site with a sterile dressing or cleanse the skin with cold water. The skin can be cleansed with tepid water. Antibiotics should be taken until all of the medication is completed as ordered.

While assessing the skin of a client who has undergone​ surgery, the nurse observes erythema to the left scapulae. Which action should the nurse take before reassessing the skin to determine if the erythema is a pressure​ injury? 1) Cover the area with a dressing. 2) Massage the scapulae with lotion 3) Reposition the client 4) Apply a warm blanket

3) Reposition the client ​Rationale: The nurse should reposition the client to remove pressure from the scapulae and then reassess for redness in​ one-half or​ three-fourths the time it took to create the reddened area. If the reddened area does not​ clear, the client has a stage 1 pressure injury. Massaging the scapulae with​ lotion, applying a warm​ blanket, or covering the area with a dressing are not the most appropriate actions to take before reassessing the client.

A client who has been sedated and on mechanical ventilation for several days is on a​ low-air-loss bed;​ however, the client has a localized purple area of discoloration over the coccyx that does not blanch. Which pressure injury should the nurse suspect for this​ client? 1) Stage 3 pressure injury 2) Bruising 3) Suspected deep tissue injury 4) Stage 1 pressure injury

3) Suspected deep tissue injury ​Rationale: Deep tissue injury is suspected when intact skin has a localized purple discoloration and does not blanch when pressed. A thin blister or eschar can develop very quickly. The assessment does not describe bruising. A stage 1 pressure injury has intact skin with localized redness that does not blanch when pressed. A stage 2 pressure injury has a shallow open wound or blister without sloughing.

The nurse is discussing a method of measuring nursing care and its impact on the​ client, as well as validating the benefits and actual costs of nursing care. Which is the nurse​ discussing? 1) Clinical decision support systems 2) Nursing research 3) Uniform language 4) ​Evidence-based practice

3) Uniform language ​Rationale: Benefits of using uniform language include a better capability to measure nursing care and its impact on the client and to validate the benefits and actual costs of nursing care to administrators. Uniform language also allows easier retrieval of​ evidence-based information. Clinical decision support systems are tools designed to supplement​ decision-making processes during and after client care. Point of care refers to the​ nurse's ability to perform client interventions or testing using portable devices near the client.​ Evidence-based practice is reflective of research.

The infection control nurse in the nursing home is interviewing a new resident. Which question should the nurse ask to assess the​ client's risk of​ infection? 1) ​"Are you a​ high-school graduate?" 2) ​"Do you exercise​ regularly?" 3) ​"How have your previous infections been​ treated?" 4) ​"How long did you live in your previous​ home?"

3) ​"How have your previous infections been​ treated?" ​Rationale: Asking about previous infections and their treatment will give helpful information to assess the​ client's risk of infection. The facts about​ exercise, education, and residence are not relevant.

The nurse is discussing interventions to prevent infection with a group of new colleagues. Which statement indicates that this discussion has been​ effective? ​1) "Wearing gloves is the best way to reduce the spread of​ infection." 2) ​"Limiting exposure to the client to every 2 hours decreases the spread of​ infections." 3) ​"Proper hand hygiene is the key to reducing the spread of​ infection." 4) ​"The use of personal protective equipment is the main way to reduce the spread of​ infection."

3) ​"Proper hand hygiene is the key to reducing the spread of​ infection." ​Rationale: Hand hygiene is identified as the best way to prevent the spread of infection. Wearing gloves as a part of standard precautions is​ effective; however, doing so does not replace hand hygiene. It is unrealistic to limit client care to every 2 hours. Personal protective equipment is an approach to reduce the spread of​ infection; however, it does not replace hand hygiene.

The government affects the process of transitioning to the use of electronic medical records​ (EMRs). Which statement by the nurse describes this​ process? 1) ​"The Office of the National Coordinator for Health Information Technology authorizes financial​ reimbursement." 2) ​"The Centers for Medicare and Medicaid Services monitors achievement of meaningful use​ objectives." 3) ​"The Centers for Medicare and Medicaid Services monitors the transition of EMRs at the federal​ level." 4) ​"The Office of the National Coordinator for Health Information Technology is the sole agency overseeing transitioning to​ EMRs."

3) ​"The Centers for Medicare and Medicaid Services monitors the transition of EMRs at the federal​ level." ​Rationale: On a federal​ level, the Centers for Medicare and Medicaid Services​ (CMS) and the Office of the National Coordinator for Health Information Technology​ (ONC) oversee the process of transitioning to the use of EMRs. The ONC monitors the achievement of meaningful use​ objectives, which are reported to the CMS to authorize financial reimbursement.

The nurse reviewing a​ newborn's chart notes Mongolian spots found on a prior assessment. Which describes the​ nurse's understanding of the​ etiology? 1) Immune-mediated 2) Dilated blood vessels 3) Minor trauma 4) Congenital

4) Congenital ​Rationale: Mongolian spots are​ congenital, non-blanching, hyperpigmented patches most commonly seen over the lumbosacral area. Mongolian spots do not result from minor​ trauma, are not​ immune-mediated, and do not occur due to dilated blood vessels.

The nurse is reviewing the chart of a client diagnosed with paronychia. Which assessment finding should the nurse​ anticipate? 1) Fungal oral mucosal infection 2) Infection of the hair follicles 3) Superficial skin infection in children 4) Infection around the fingernail

4) Infection around the fingernail ​Rationale: Paronychia is a soft tissue infection around the fingernail. Folliculitis is an infection of the hair follicles. A fungal oral mucosal infection is known as candidiasis. Impetigo is a superficial skin infection in children.

The nurse is caring for an older adult client who is significantly underweight. Which intervention should the nurse include in the plan of care for the client to maintain skin​ integrity? 1) Explain the need to receive adequate exposure to sunlight. 2) Instruct the client to avoid the use of topical skin lotions. 3) Recommend daily exercise followed by thorough bathing. 4) Review safety strategies to prevent injuries and falls.

4) Review safety strategies to prevent injuries and falls. ​Rationale: The intervention the nurse will include in the plan of care to help maintain the skin integrity of the older adult client who is significantly underweight is reviewing the safety strategies to prevent injuries and falls. Avoiding topical skin lotions is applicable if they contain alcohol due to the drying effect alcohol has on the skin. Daily bathing may contribute to dry skin. Adequate exposure to sunlight does not contribute to the maintenance of skin integrity.

The nurse is assessing a child who reports feeling nauseated and just​ "sick." Which type of organism should the nurse suspect is causing the​ child's illness? 1) Bacteria 2) Parasites 3) Influenza 4) Virus

4) Virus ​Rationale: Infections are a normal part of​ childhood, and most children experience some kind of infection from time to time. The majority of these infections are caused by​ viruses, and for the most part they are transient and relatively benign and can be overcome by the​ body's natural defenses and supportive care.​ Bacteria, influenza, and parasites are not the reason for common infections seen in childhood.

The nurse is assessing diffuse bullae and vesicles on a​ client's hands and arms. Which question should the nurse ask the​ client? 1) ​"Do you have a history of​ psoriasis?" 2) ​"Have you been scratching your​ skin?" 3) ​"Do you have a history of chronic​ dermatitis?" 4) ​"Have you been in contact with poison​ ivy?"

4) ​"Have you been in contact with poison​ ivy?" ​Rationale: Bullae and vesicles are found on a client who has been in contact with poison ivy. Scales is a finding associated with psoriasis. Excoriation is a result of scratching the surface of the skin. Findings associated with chronic dermatitis include lichenification.

The nurse is evaluating teaching provided to a client with chronic inflammation. Which client statement indicates to the nurse that teaching has been​ successful? 1) ​"I ignore the pain until I​ can't stand it​ anymore." 2) ​"I think it would be best if I just died right​ now." 3) ​"I lie in bed most​ days." 4) ​"I limit doing things that aggravate the​ pain."

4) ​"I limit doing things that aggravate the​ pain." ​Rationale: For chronic​ inflammation, the client should be instructed to use coping techniques to minimize effects of physical limitations and emotional distress and​ disease-appropriate methods to reduce the impact of the disease on the​ client's lifestyle. Evidence that teaching has been effective is the client limiting activities that aggravate the pain. Lying in​ bed, wishing to​ die, and ignoring the pain all indicate that teaching has not been effective.

The infection control nurse is discussing the pharmacologic challenges of treating infection with a group of nurses. Which statement should the infection control nurse​ include? 1) ​"We offer the agent that we have samples of in our​ office." 2) ​"We try at least two agents to see which is more​ effective." 3) ​"We look at the newest agent on the​ market." 4) ​"We look for an effective agent with little​ toxicity."

4) ​"We look for an effective agent with little​ toxicity." ​Rationale: Once the causative agent and affected body system have been​ identified, specific therapy to cure the infectious disease can begin. The perfect​ anti-infective agent destroys pathogens while preserving host​ cells, is effective against many organisms while not promoting the development of​ resistance, distributes to necessary​ tissues, and remains in the body for relatively long periods. Because no available antimicrobial meets all these​ criteria, healthcare providers look for an agent that is​ effective, has little​ toxicity, can be administered with relative​ convenience, and is cost effective. In the process of​ selection, characteristics of both the client and the infecting organism are considered. Treatment of an infection is not focused on the newest​ agent, the use of multiple​ agents, or using samples of agents in the office.

The public health nurse is teaching community members about the reasons to get an annual flu shot. Which reason should the nurse​ include? (Select all that​ apply.) 1) The new vaccine has specific antigens predicted for that year. 2) People without health insurance are at higher risk of getting the flu. 3) People living in apartment buildings have a higher probability of getting the flu. 4) The predominant flu virus strain changes from year to year. 5) ​Infants, young​ children, and people aged 50 or older are more likely to get the flu.

​ 1) The new vaccine has specific antigens predicted for that year. 4) The predominant flu virus strain changes from year to year. 5) ​Infants, young​ children, and people aged 50 or older are more likely to get the flu. Rationale: The predominant flu virus strain changes from year to year. The new vaccine has specific antigens predicted for that year.​ Infants, young​ children, and people aged 50 or​ older, are more likely to get the flu. People living in apartment buildings or who lack health insurance are not at increased risk of getting the flu.

A client is suspected of having a deep tissue injury. Which intervention should the nurse include in the plan of​ care? (Select all that​ apply.) 1) Application of a nonadhesive protective dressing 2) Application of a moisturizing barrier cream 3) ​Wet-to-damp dressing changes twice daily 4) Debridement of wound bed and edges 5) Consideration of appropriate support surfaces and other measures to remove all pressure

​1) Application of a nonadhesive protective dressing 2) Application of a moisturizing barrier cream 5) Consideration of appropriate support surfaces and other measures to remove all pressure Rationale: To treat a client with a suspected deep tissue​ injury, the nurse should apply a moisturizing barrier​ cream, a nonadhesive protective​ dressing, and consider support surfaces that will remove all pressure from the area. Debridement of wound bed and edges and​ wet-to-damp dressing changes are not appropriate for deep tissue injuries.

A client with a fever of​ 102.5°F (39.2°C),​ chills, and dyspnea is experiencing respiratory distress. Which collaborative intervention should the nurse identify as the priority​? 1) Apply oxygen via face mask and notify the healthcare provider. 2) Obtain a sputum culture. 3) Administer acetaminophen. 4) Administer intravenous fluids of normal saline at 100​ mL/hr.

​1) Apply oxygen via face mask and notify the healthcare provider. Rationale: Because the client is demonstrating signs of respiratory​ distress, applying oxygen is the priority. A sputum culture is a diagnostic tool for determining the reason for the distress.​ However, this is not the priority. Antipyretics assist with fever​ reduction; but this is not the priority. Hydration is a key element of managing clients with fever and​ pneumonia, but it is not the priority.

A vial of blood has fallen on the floor of a​ client's room. Which agent should the nurse expect to be used to clean this​ spill? 1) Chlorine 2) Hydrogen peroxide 3) Phenol 4) Triclosan

​1) Chlorine Rationale: Chlorine or bleach is effective in cleaning up blood spills. Phenol is also used to disinfect surfaces but is not effective with spores. Triclosan is used to clean hands and intact skin to battle bacteria. Hydrogen peroxide is used as an agent to clean up contaminated surfaces.

The nurse is preparing a presentation on infections. Which factor regarding chronic infections should be​ included? 1) Chronic infections can persist for long periods. 2) Chronic infections only affect susceptible hosts. 3)Chronic infections do not affect young children. 4) Chronic infections generally appear suddenly.

​1) Chronic infections can persist for long periods. Rationale: Chronic infections develop slowly over a period of time and can persist for long periods. Acute and chronic infections can affect susceptible​ hosts, especially young children who do not have strong immune systems.

The nurse is using the electronic health record​ (EHR) to document client information. Which information is communicated to the healthcare provider through the​ EHR? (Select all that​ apply.) 1) Client responses to nursing interventions 2) Acute changes in the​ client's condition 3) Client vital signs 4) Medications administered to the client 5) Assessment notes on the​ client's condition

​1) Client responses to nursing interventions 3) Client vital signs 4) Medications administered to the client 5) Assessment notes on the​ client's condition Rationale: Most EHRs allow nurses to input a wide range of data without leaving the​ client, including vital​ signs, medication administration​ records, assessment​ notes, and responses to nursing interventions. The EHR is not a substitute for​ in-person and other means of verbal communication with​ peers, fellow health​ professionals, and especially the client. Acute changes in the​ client's condition still require a phone call to the healthcare professional.

Which term should the nurse use to describe the computerized medical​ record? (Select all that​ apply.) 1) Computerized patient record 2) Clinical information system 3) Electronic health records system 4) Administrative information system 5) Clinical decision support system

​1) Computerized patient record 3) Electronic health records system Rationale: Other terms commonly used to describe the computerized medical record​ (CMR) include electronic health records system​ (EHRS), electronic medical record​ (EMR), electronic health record​ (EHR), computerized patient record​ (CPR), patient medical records software​ (PMRS), and personal health record​ (PHR). Clinical decision support systems are a type of artificial intelligence that analyze data and provide information about​ evidenced-based practices. A clinical information system allows multiple disciplines to simultaneously access the​ client's chart and record data that can be viewed and analyzed by multiple healthcare providers in real time. An administrative information system provides support and management for the business aspects of health care.

The nurse cares for a client newly diagnosed with inflammation. Which laboratory test should the nurse expect to be​ prescribed? 1) Erythrocyte sedimentation rate​ (ESR) 2) Serum chemistries 3) Prothrombin time​ (PT) 4) Hemoglobin and hematocrit​ (H/H)

​1) Erythrocyte sedimentation rate​ (ESR) Rationale: The ESR is the primary laboratory test to detect the presence of inflammation. It measures how far the erythrocyte settles in a tube over a period of time. Higher readings indicate inflammation. The​ H/H, serum​ chemistries, and PT are not used to diagnose inflammation.

A client with poor nutritional intake is at high risk for developing pressure injuries. Which device should the nurse identify as appropriate for this​ client? (Select all that​ apply.) 1) Gel flotation pads 2) Memory foam chair pad while client is in chair 3) Foam wedges and pillows 4) static low-air-loss bed 5) Rolled blankets to protect heels

​1) Gel flotation pads 2) Memory foam chair pad while client is in chair 3) Foam wedges and pillows 4) static low-air-loss bed Rationale: Gel flotation pads can be used to protect bony prominences and are filled with a substance similar to fat. A static​ low-air-loss bed is made up of many​ air-filled cushions that can be reduced under bony prominences and inflated to provide support in other areas. Foam wedges and blocks can be used to prevent​ bone-on-bone contact and support positioning. Memory foam chair pads distribute weight more evenly over the surface of the seat and can mold to the body. Foam​ blocks, not rolled​ blankets, are used to protect heels from shearing and limit pressure.

The nurse is caring for a client with localized inflammation. Which finding should the nurse expect to assess in this​ client? (Select all that​ apply.) 1) Palpable warmth of the extremity 2) Oral temperature of 101 3) Localized edema 4) Tenderness with palpation or movement 5) White blood cell count of​ 15,000

​1) Palpable warmth of the extremity 3) Localized edema 4) Tenderness with palpation or movement Rationale: Localized​ edema, tenderness with palpation or​ movement, and palpable warmth of the extremity are all signs of localized edema. Additional signs are redness and reduced function of the extremity. Increased oral temperature and elevated white blood cell counts are indicative of systemic inflammation.

A pregnant client is diagnosed with an inflammatory disorder. Which disorder should the nurse monitor for in the​ client? 1) Preeclampsia 2) Preterm birth 3) Low-birth-weight infant birth 4) Placenta previa

​1) Preeclampsia Rationale: Preeclampsia is an​ inflammatory-mediated hypertensive disorder of pregnancy. There is no evidence that inflammation is associated with​ low-birth-weight infant​ birth, preterm​ birth, or placenta previa.

During a home​ visit, the nurse is concerned that a client is experiencing acute inflammation. Which finding caused the nurse to make this​ determination? (Select all that​ apply.) 1) Skin area hot to touch 2) Pain level of 7 on a scale from 1 to 10 3) Skin area swollen 4) Skin area reddened 5) Pink and red wound tissue

​1) Skin area hot to touch 2) Pain level of 7 on a scale from 1 to 10 3) Skin area swollen 4) Skin area reddened Rationale: With acute​ inflammation, the typical signs of inflammation-​redness, ​swelling, pain,​ heat, and impaired function-occur. The presence of pink and red wound tissue indicates that​ granulation, or healing of an acute inflammatory​ process, is occurring.

The nurse reviews alginate dressings with a new nurse. For which type of pressure injury should the nurse identify this dressing is​ used? (Select all that​ apply.) 1) Stage 4 without eschar 2) Stage 2 3) Stage 4 with eschar 4) Stage 3 5) Stage 1

​1) Stage 4 without eschar 2) Stage 2 4) Stage 3 Rationale: Alginate dressing should be used for stage​ 2, 3, and 4 without eschar pressure​ injuries, but not for stage 4 with eschar pressure injuries. An alginate dressing is not used for stage 1 pressure injuries.

The nurse is teaching a client experiencing inflammation. Which sign of inflammation should the nurse include in the​ teaching? (Select all that​ apply.) 1) Swelling 2) Pain 3) Paralysis 4) Paresthesia 5) Redness

​1) Swelling 2) Pain 5) Redness Rationale: The typical signs of inflammation are​ redness, swelling,​ pain, heat, and impaired function. Paralysis and paresthesia are not signs of inflammation.

The nurse identifies that a client is at risk for impaired skin integrity. Which intervention should the nurse add to this​ client's plan of​ care? (Select all that​ apply.) 1) Use positioning devices. 2) Inspect the skin every day. 3) Place the client in the​ side-lying position only. 4) Avoid massaging bony prominences. 5) Keep the head of the bed elevated more than 30 degrees.

​1) Use positioning devices. 2) Inspect the skin every day. 4) Avoid massaging bony prominences. Rationale: Using positioning devices such as pillows or foam wedges to protect bony​ prominences, not massaging bony​ prominences, and inspecting the skin daily help prevent skin breakdown. A​ side-lying position or keeping the head of bed elevated more than 30 degrees can put pressure on specific body areas.

The nurse is describing the function of a Global Location Number​ (GLN) as it relates to standardization. Which statement is​ accurate? 1) ​"A GLN makes it easier for the healthcare institution to be​ located." 2) ​"A GLN helps identify the room assignments of clients admitted to the healthcare​ facility." 3) ​"A GLN increases the ease of locating supplies in the healthcare​ institution's storage​ facility." 4) ​"A GLN replaces the custom item numbers of the healthcare​ institution's products."

​1) ​"A GLN makes it easier for the healthcare institution to be​ located." Rationale: The materials management and supply chain community sought standardization through measures including issuing each facility a GLN instead of an account​ number, which improves the ease of locating healthcare institutions. Standardization strategies also included assigning each product used in a healthcare facility a Global Trade Item Number​ (GTIN) as opposed to a custom item number.

The nurse manager observes a new nurse talk with a client with a stroke and decreased mobility about ways to prevent pressure injures. For which statement should the nurse manager​ intervene? 1) ​"Due to decreased mental​ status, you will need to be turned every 2​ hours." 2) ​"We will ensure your diet contains adequate​ calories, protein,​ vitamins, and​ iron." 3) ​"You can help by using your right side to make small adjustments to your left side every 30 minutes or​ so." 4) ​"We will keep your skin​ clean, dry, and moisturized to prevent tissue​ damage."

​1) ​"Due to decreased mental​ status, you will need to be turned every 2​ hours." Rationale: There is no indication the client has decreased mental status. The client should be turned and repositioned every 2 hours. Keeping the skin​ clean, dry, and moisturized will help prevent tissue damage. A diet with adequate​ calories, protein,​ vitamins, and iron will help to prevent skin breakdown. The client can be encouraged to participate by helping to move the left side every​ 15-30 minutes. Even small adjustments of​ 10-20 degrees can prevent tissue injury.

A nurse is discussing the effects of using uniform language in the electronic health record​ (EHR). Which statement should the nurse​ include? 1) ​"Retrieval of​ evidence-based information about client care is easier when using a uniform​ language." 2) ​"Most computerized systems use uniform language to integrate nursing terminologies into the​ EHR." 3) ​"The use of uniform language will increase the number of steps in the nursing research​ process." 4) ​"Documentation is more challenging when computerized systems incorporate uniform​ language."

​1) ​"Retrieval of​ evidence-based information about client care is easier when using a uniform​ language." Rationale: Most computerized systems do not provide a way to integrate nursing terminologies directly into the​ EHR, which is reflective of a barrier to the use of uniform language in research environments. The use of uniform language combined with the ability to query EHRs should make nursing research easier.​ However, the steps of the nursing research process should remain the same. For the nurse​ researcher, using uniform language increases the ease of documentation and retrieval of​ evidence-based information about client care.

A client asks how to prevent developing inflammation when aging. Which response should the nurse make to this​ client? 1) ​"The best way is to avoid known​ triggers, if you have​ them." 2) ​"The best way is to eat a diet high in refined sugars and low in​ fiber." 3) ​"Avoid over-the-counter medications and​ supplements." 4) ​"Smoking has been shown to decrease​ inflammation."

​1) ​"The best way is to avoid known​ triggers, if you have​ them." Rationale: A trigger is a substance that causes an inflammatory response. Triggers can be food or beverages or substances like​ pollen, dust, animal​ dander, or cigarette smoke. Avoiding triggers will prevent an excessive inflammatory response. A diet low in refined sugars and high in fiber will decrease the risk for inflammation. Some​ over-the-counter medications​ (aspirin and​ ibuprofen) and supplements​ (omega-3 fish​ oil) are helpful in treating inflammation.

A client with inflammation caused by a severe ankle injury is being prepared for discharge. Which intervention to reduce inflammation should the nurse include when teaching the client and​ family? (Select all that​ apply.) 1) Limiting build intake 2) Application of ice packs 3) Coping Skills 4) Positioning 5) Aerobic Exercise

​2) Application of ice packs 3) Coping Skills 4) Positioning Rationale: The nurse should teach the client coping skills to deal with the healing and recovery​ time, positioning to reduce discomfort and prevent further​ injury, and application of ice packs to reduce swelling and pain. Aerobic exercise on an injured ankle is not recommended. Clients should maintain an adequate intake of liquids to prevent dehydration.

The nurse is assisting nursing assistive personnel​ (NAP) reposition a client who is immobile and has been lying on the left side. For which action by the NAP should the nurse​ intervene? 1) Looks at the skin over bony prominences on the left side 2) Asks for help pulling the client back up to the head of the bed 3) Places pillows under the​ client's legs to keep heels off the bed 4) Places a foam wedge under the​ client's left hip

​2) Asks for help pulling the client back up to the head of the bed Rationale: Clients should not be pulled up in​ bed, as shearing forces and friction can break down skin tissue. Clients should be lifted instead of being pulled. It is appropriate for the foam wedge to be placed under the​ client's left side. The skin over bony prominences on the left side should be inspected when the client is turned. It is appropriate to use pillows to keep the​ client's heels off the bed.

An older adult client with diabetes has an inflamed area on a toe that is suspected of being cellulitis. Which manifestation of infection should the nurse expect in this​ client? (Select all that​ apply.) 1) Elevated WBC count 2) Inflammation 3) Elevated RBC count 4) Pain 5) fever

​2) Inflammation 4) Pain Rationale: In older adult​ clients, common signs of infection such as fever and elevated WBC count may be absent with cellulitis. Inflammation and pain are universal manifestations of cellulitis. RBC counts do not increase in the presence of an infection.

The nurse is assessing a client who reports shortness of​ breath, fever, and a productive cough. Which diagnostic test should the nurse anticipate being​ prescribed? 1) CT scan 2) Sputum culture and sensitivity 3) Bronchoscopy 4)HIV serology

​2) Sputum culture and sensitivity Rationale: The​ client's symptoms are suggestive of pneumonia. A sputum specimen may be ordered to determine which infectious microorganism may be present and which antibiotics to use to treat the infection. A bronchoscopy may be done when infection or tumors are suspected or to remove secretions from the bronchial​ tree; however, it will not be performed first. A CT scan might be indicated if the client does not respond to other treatment. A test for HIV may be indicated if treatment is unsuccessful.

The nurse is assessing a client. What is the reason the nurse asks the client to rate the level of stress experienced over the last 6​ months? 1) To determine if the client remembers events in the last 6 months 2) To measure the​ client's severity of emotional stressors 3) To document the​ client's ability to answer difficult questions 4) To determine if the client can use a health scale rating

​2) To measure the​ client's severity of emotional stressors Rationale: Excessive stress predisposes people to infections. The​ nature, number, and duration of physical and emotional stressors can influence susceptibility to infection. Stressors elevate blood​ cortisone, and the prolonged elevation of blood cortisone decreases​ anti-inflammatory responses, depletes energy​ stores, leads to a state of​ exhaustion, and decreases resistance to infection. The interview is not about answering difficult​ questions, using a health scale​ rating, or having a memory test.

A client has an area of eschar over a wound. What is the reason the nurse expects this wound to be​ debrided? 1) to promote healing of deep tissues before superficial tissues 2) To remove dead tissue 3) To dry the tissues of the wound 4) To approximate the wound edges

​2) To remove dead tissue Rationale: Removal of dead tissue is needed to support healing. Wound debridement is done to remove dead​ tissue, slough, and debris from the wound bed. Debridement is not done to dry the tissues of the​ wound, approximate the wound​ edges, or promote healing of the deep tissues before superficial tissues.

The nurse is reviewing a​ client's chart who presents to the clinic with report of a​ "skin rash." Which descriptive characteristic indicates a specific skin disorder that the nurse may​ consider? (Select all that​ apply.) 1) Pruritus 2) Wheal 3) Vesicle 4) Macule 5) Exudate

​2) Wheal 3) Vesicle 4) Macule Rationale: Characteristics of skin disorders include​ macules, wheals, and vesicles. Exudate is fluid drainage from a wound. Pruritus is itching of the skin.

The mother of a​ 10-year-old client is pleased to hear that the​ child's blood work for inflammation was negative but asks why the child continues to have symptoms. Which response by the nurse is the most​ appropriate? 1) ​"The level of inflammation has​ subsided." 2) ​"Normal results are common in children with​ inflammation." 3) ​"Blood tests are not useful to diagnose the presence of​ inflammation." 4) ​"The child is experiencing a mild case of​ inflammation."

​2) ​"Normal results are common in children with​ inflammation." Rationale: Blood tests will be used when assessing a child with an inflammatory disorder. Caution must be taken when interpreting the results of blood tests for these clients since normal blood test results are common for children with inflammatory disorders. A normal blood test in a child with inflammation does not mean that the level of inflammation has​ subsided, or that the child is experiencing a mild case of the inflammation. Blood tests are useful to diagnose the presence of inflammation.

A client with inflammation is prescribed naproxen. Which information should the nurse include when teaching about this​ medication? (Select all that​ apply.) 1) ​"This medication increases the risk for​ infection." 2) ​"This medication might interact with​ diuretics." 3) ​"Take this medication with food or​ milk." 4) ​"Do not abruptly discontinue this​ medication." 5) ​"Watch for bleeding or bruising while on this​ medication."

​2) ​"This medication might interact with​ diuretics." 3) ​"Take this medication with food or​ milk." 5) ​"Watch for bleeding or bruising while on this​ medication." Rationale: Naproxen is an NSAID. NSAIDs can cause gastric​ upset, so they should always be taken with food or milk. They also increase the clotting​ time, so clients should watch out for bleeding or bruising. NSAIDs may interact with​ diuretics, causing a decrease in the effectiveness of the NSAID. Glucocorticoids increase the risk for infection and should not be stopped abruptly.

The nurse is discussing factors that are attributed to allergic contact dermatitis with a client. Which factor should the nurse include in the​ discussion? (Select all that​ apply.) 1) Dry Environment 2) Infrequent hand washing 3) Exposure to plants 4) Exposure to perfumes 5)Exposure to soap

​3) Exposure to plants 4) Exposure to perfumes 5)Exposure to soap Rationale: Factors that are attributed to allergic contact dermatitis include​ soap, plants, and perfumes. Dry environments and infrequent hand washing are not associated with allergic contact dermatitis.

The nurse assessing a client notes the client is at risk for candidiasis. Which client behavior observed by the nurse would support this​ conclusion? 1) The client applies a moisturizer immediately after washing the hands. 2) The client used a​ child's brush to fix the hair. 3) The client is on an antibiotic. 4) The client washes the hands four times in an hour.

​3) The client is on an antibiotic. Rationale: The client taking the antibiotic is at risk for candidiasis. The antibiotic alters the normal flora in the​ body, resulting in the potential for opportunistic​ infections, such as​ candidiasis, to occur. A client using a​ child's brush is at risk for parasite transmission. The client who washes the hands four times in an hour is at risk of impaired skin integrity. The client who applies moisturizer immediately after washing the hands is not at risk for​ candidiasis, and this demonstrates good skin care.

The nurse is caring for a client who is positive for HIV. Which classification of medication that targets the phases of HIV replication should the nurse expect to be​ prescribed? 1) Antifungal 2) Antipyretic 3) Antibiotic 4) Antiretroviral

​4) Antiretroviral Rationale: Antiretroviral medications target specific phases of the HIV replication​ cycle, requiring multiple drugs to be taken concurrently. Antibiotics may be used prophylactically to prevent infection or used to treat existing bacterial infection. A specific antibiotic is chosen based on the pathogen causing the infection. Antifungals are selective for fungal plasma membranes. They inhibit ergosterol synthesis. Antipyretics relieve pain and reduce fever.

A client is being treated for an inflammatory response. Which strategy should the nurse emphasize to prevent episodes of inflammation in the​ future? 1) Taking aspirin prophylactically 2) Eating a​ well-balanced diet 3) Engaging in frequent hand washing 4) Avoiding a trigger

​4) Avoiding a trigger Rationale: A major strategy to prevent the onset of an inflammatory response is to avoid a known trigger for the response. Prophylactic​ aspirin, eating a​ well-balanced diet, and engaging in frequent hand washing are not strategies to prevent the onset of an inflammatory response.

The nurse is caring for a client with cellulitis. What is the reason the nurse applies warm saline compresses to the​ area? 1) tissue integrity maintenance 2) Infection control 3) Enhanced blood flow 4) Pain reduction

​4) Pain reduction Rationale: Applying warm compresses to the affected area of a client with cellulitis is a comfort measure meant to reduce pain. Warm compresses will not control infection. The warm compresses are not used to enhance blood flow or maintain tissue integrity.

The nurse wants to ensure that a safe level of narcotic medications is being prescribed for a client who may have an issue with addiction. Which informatics application should the nurse​ use? 1) The​ client's health history and records 2) Telemedicine 3) Clinical decision support 4) Statewide prescription database

​4) Statewide prescription database Rationale: A statewide database that tracks prescription narcotics can help ensure that clients are not given unsafe amounts of pain medications. This process can also identify specific providers who may be issuing prescriptions for narcotics in an irresponsible manner. Telemedicine is the remote access of healthcare services through technology. Clinical decision support describes the use of data from an electronic health record​ (EHR) to identify best practices. A review of medical records is always​ advisable, but this is not an application of informatics.

The nurse is caring for an older client whose​ C-reactive protein test is elevated. Which interpretation should the nurse derive from this​ result? 1) The client is suffering from gallbladder disease. 2) The result is an indication that the client has asthma. 3) The client probably has suffered a stroke. 4) The increased result may be an indicator of overall poor health.

​4) The increased result may be an indicator of overall poor health. Rationale: In older​ adults, C-reactive protein​ (an inflammatory​ marker) may be an indicator of overall poor​ health, which makes them more susceptible to chronic illnesses and cognitive decline. More diagnostic information is needed to determine if the client is experiencing a specific inflammatory disease like gallbladder or asthma.​ C-reactive protein is not elevated with a stroke.

The nurse is preparing teaching materials for the parents of a​ 7-year-old child who is newly diagnosed with a severe allergy to dust. Which instruction should the nurse include in this​ teaching? 1) ​"Avoid exposure to all animals and​ pets." 2) ​"Ensure that all rooms in the home are​ carpeted." 3) ​"Place plants on high shelves in the​ home." 4) ​"Remove stuffed toys from the​ home."

​4) ​"Remove stuffed toys from the​ home." Rationale: A major strategy to prevent the onset of an inflammatory response is to avoid a known trigger for the response. Clients with a history of hypersensitivity to substances such as dust should avoid them. Stuffed toys accumulate dust and should be removed from the home. Animals and pets are not associated with a dust allergy. Plants are not associated with a dust allergy. Carpeting will accumulate dust and should be removed from the home.