Med Surg 1 final

A client comes to the clinic and informs the nurse of swelling in right arm. There has been no injury or precipitating occurrence that caused the swelling. The nurse observes nonpitting edema from the upper arm to the fingertips. What action should the nurse initially perform?

inspect and measure the arm

A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?

naturally acquired active immunity

A client had the mumps as a child. What type of immunity does the client have?

naturally acquired active immunity

The nurse is caring for a client with a suspected diagnosis of HIV. The nurse is preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV?

obtain a written consent

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions?

Bacterial infection

When providing discharge teaching to a client with mitral valve prolapse, the nurse should include all of the following recommendations EXCEPT

Increase caffiene

A client's family member asks what hematopoiesis is. What should the nurse tell the family member?

The manufacture and development of blood cells

The nurse knows that women are at a greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause?

Vague symptoms

The nurse is obtaining data from an older adult client. What finding may indicate to the nurse the early symptom of left sided heart failure?

dyspnea on exertion

The nurse is caring for a client diagnosed with infectious mononucleosis who is having trouble eating. What would the nurse advise this client to improve his oral intake?

eat soft, bland foods and cold liquids

The nurse is caring for a group of clients. Which client does the nurse suspect is most likely to have mononucleosis?

A 19-year-old college student with cervical node enlargement and fever

The following clients are in need of exercise electrocardiography. Which client should the nurse identify as the most appropriate choice for a drug induced stress test?

A 55 year old electrician recovering from a fall and broken femur

A charge nurse is planning to admit several clients to the medical unit. Which of the following clients should the nurse assign to a private room?

A client who has neutropenia

A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take first?

perform hand hygiene before and after care

nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?

Assist with administering blood transfusion

The laboring mother asks the nurse if the baby will have some immunity to some diseases. What type of immunity will the baby have?

Passive immunity transferred by the mother

A client is admitted to the instensive care unit for cardiac tamponade. The nurse recognizes that cardiac tamponade is a life threatening condition that is primarily associated with which of the following disorders?

Pericarditis

A nurse is reviewing lab findings with a client. The clients asks why having elevated cholesterol is bad. The nurse should inform the client that high cholesterol can lead to which of the following cardiovascular disorders?

Atherosclerosis

A nurse is reinforcing teaching about controlling a bleeding episode with a parent of a child who has hemophilia. Which of the following statements by the parent indicates a need for further teaching?

"I will apply warm compresses over the site." REMEMBER ICE slows down blood to the site

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?

"It is a hyperimmune response to something in the environment that is usually harmless."

An adolescent client diagnosed with infectious mononucleosis asks the nurse if he will keep getting the disease. What is the best response by the nurse?

"One episode produces immunity, but the virus remains for a lifetime."

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?

"heparin prevents new clots from forming rather than dissolving established clots."

A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make?

"these organs are for immunity."

A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse?

"white blood cells are produced in the bone marrow"

A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm at the point of pressure that lasts more than a minute. Which of the following numbers should the nurse document to indicate the intesity of the client's edema?

3+

A client is admitted to the hospital with diagnosis of heart failure & the provider orders a BNP level. What result would indicate to the nurse he is in moderate heart failuer?

400 Less than 100 is normal 100-300 is mild 300-700 is moderate 700+ severe

A nurse has been asked by a physician to calculate a client's cardiac output. The clients most recent HR is 84 & their stroke volume is 70 mL. What is the client's cardiac output? Round to nearest whole number in L

6 L SV x HR = CO

A nurse is providing teaching about iron deficiency anemia to the parents of a 14 month old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?

Avoid a diet consisting of primarily milk

The nurse is caring for a client with CAD. What is an appropriate nursing action when evaluating a client with CAD?

Assess the charectaristics of the chest pain

The nurse is caring for a client with raynauds disease. When reviewing discharge education, what instructions should the nurse provide to the client to help prevent future attacks?

Avoid situations that trigger ischemic episodes

A client with heart failure is having a decrease in cardiac output. Which vital sign reading indicates to the nurse that this is occuring?

Blood pressure 88/46

The nurse is caring for a client in the hospital with chronic heart failure that has marked limitations in his physical activity. The client is comfortable when resting in bed or chair but when ambulating in the room or hall, he becomes short of breath & fatigues easily. What type of heart failure is this?

Class III moderate

A nurse is reviewing the laboratory data of a client who has acute leukemia and received aggressive chemotherapy treatment 10 days ago. Which of the following abnormalities should the nurse expect to see? (Select all that apply.)

Decreased WBC Decreased RBC Decreased Platelet

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.

Destruction of normally formed red blood cells Abnormal RBC production Blood loss

A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to the report to the provider?

Dyspnea REMEMBER ABC APROACH

A nurse is assisting with the discharge of a child who has sickle cell anemia and is recovering from an acute sickle cell crisis. Which of the following instructions should the nurse reinforce with the child's parents?

Encourage the child to increase his fluid intake.

A nurse is caring for a client who was recently diagnosed with aortic regurgitation. Which information from the client's history may indicate the cause of their aortic regurgitation?

Endocarditis

A nurse is planning care for a client with an aortic aneurysm. WHich of the following interventions should the nurse include in the plan? (Select all that apply)

Enforce strict bed rest Administer hypertensives Minimize environmental stimuli

Which type of cardiomyopathy is associated with syncope?

Hypertrophic

The nurse notes that a client is experiencing a change in mental status. Why should the nurse report this finding to the provider if the client also has a cardiovascular disorder?

It may indicate a problem with oxygenation

A nurse is assisting with the plan of care for a client who has a new DVT in his leg. Which of the following interventions should the nurse include in the plan?

Keep the clients affected leg elevated

A nurse is reinforcing teaching for the parent of a toddler who has iron deficiency anemia and a new prescription for liquid iron solution. Which of the following instructions by the nurse is the priority?

Keep the iron stored away in a locked cabinet SAFETY is always a priority

A client is scheduled for a Schilling's test in the morning. What diagnostic results would be indicated if the test is positive? Select all those that apply

Pernicous, malabsorption, & sickle cell

A nurse is collecting data from a client who has leukemia. Which of the following findings has the highest priority?

Platelet count of 125,000 THIS is LOW

A nurse is reviewing laboratory values of a client who has immune thrombocytopenic purpura (ITP). Which of the following laboratory results should the nurse expect to be decreased?

Platelets

The nurse is reviewing the lab work of a client diagnosed with infective endocarditis. Which diagnostic study confirms the diagnosis?

Positive blood culture

A nurse is caring for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse implement?

Report a temperature of 38.3° C (101° F) or greater

A nurse is reinforcing discharge teaching with a client who is immunocompromised. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Restrict visitors with active infections Instruct the client to eat cooked foods only

The nurse is talking with a 9-year-old child diagnosed with acute leukemia who will soon begin chemotherapy. The child expresses worry that when her hair falls out, her friends won't like her or want to play with her anymore. Which response by the nurse would be most appropriate?

Talk with the child and her family about wearing a wig, cap ,or scarf.

A client is scheduled for percutaneous coronary angioplasty immediatly following confirmed diagnosis of acute myocardial infarcation. The client is overtly anxious and crying. Which response by the nurse is most appropriate?

Tell me what concerns you most

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain to the client that, after the laboratory has the enzyme immunoassay (EIA) results, it will use which of the following tests to confirm the diagnosis?

Western Blot assay

Which nursing action would be of greatest importance in the management of a client preparing for angioplasty?

Withhold anticoagulant therapy

A client with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse expect is happening?

acute chest syndrome

A nurse is reviewing a client's admission laboratory values. The client has thrombocytopenia with a platelet count of 34,000/mm3. Which of the following actions should the nurse take?

apply pressure for 3-5 minutes following venipuncture

A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions?

candidiasis

A nurse is caring for a client immediately following a cardiac cathertization via the femoral artery. Which of the following actions by the nurse is most appropriate?

check pedal pulses every 15 mins

The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O 2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?

give oxygen per nasal canula

The nursing instructor is teaching her clinical group about laboratory test results. What is the major function of erythrocytes?

transport of O2 to the tissues and removal of co2 from the tissues

A client is awaiting the availability of a heart transplant. What option may be available to the client as a bridge to transplant?

ventricular assist device (VAD)

The nurse is caring for a client with aortic stenosis. The nurse should anticipate administering which of the following medications? (Select all that apply)

Anti hypertensive Cardiac glycosides Diuretics Nitrates

The nurse is caring for a post cardiac catheterization client in the recovery room. Which of the following is a priority nursing consideration?

Assess the client's dressing

In addition to the patient history, symptoms, and blood studies, what is considered the definitive diagnostic technique for leukemia?

Bone marrow aspiration

Which of the following is not an expected assessment finding for a client with myocarditis?

Bradycardia

A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy?

Bring the viral load to a virtually undetectable level

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

Change litter box w/ gloves & take temperature daily

The nurse is caring for a client with thrombophlebitis. When assessing this client, which signs/symptoms should prompt the nurse to immediately notify the provider?

Chest pain & dyspnea

A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?

Drink at least eight glasses of fluid daily.

A nurse is collecting data from a client who has mitral stenosis. Which Of the following findings is a manifestation of this condition?

Dyspnea on exertion

A nurse is monitoring a client who is receiving chemotherapy and has a platelet count of 22,000 mm3. Based on this lab result, which of the following findings should the nurse identify as the priority?

Ecchymosis

What medication would you give a renal patient to boost their red blood cells

Epoetin alfa; epogen

the client is taking a medication that has the side effect of depressing the hematopoietic system. What signs of Leukopenia should the nurse monitor for the while the client is taking this medication

Fever, sore throat, chills

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?

Fresh fruit basket

A nurse is preparing an in-service about HIV for a group of newly hired assistive personnel. Which of the following statements should the nurse include about HIV transmission?

HIV is transmitted through contact with infected body fluids

A nurse is caring for a child who has nosebleed. Which of the following actions should the nurse take?

Have the child sit with her head tilted forward and hold pressure on her nose for 10 min

A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Limit the number of healthcare workers that enter the room

The nurse is providing discharge instruction to client with heart failure. What type of diet should the nurse request the dietician discuss with the client?

Low sodium

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer in order to relive the client's pain?

Morphine

A nurse working on a cardiac unit is reviewing lab data for four clients. Each client has had their creatine kinase & troponin levels drawn. Which of the following clients should the nurse recognize has sustained cardiac damage?

Mr. G with a creat level of 180. Normal creatine levels are 30-170 Normal troponin T level is less than 0.1 Normal troponin I level is less than 0.03

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Natural killer cells

The nurse will be assisting the physician with a bone marrow aspiration, Where should the nurse cleanse, clip hair, and drape the skin before the procedure?

Over the posterior iliac crest

A nurse is reviewing test results for a child with suspected hemophilia. Which of the following laboratory results should the nurse expect to be outside normal range?

PTT

The nurse is sending a client to be fitted for a compression garment for the treatment of lymphedema after having a mastectomy and node dissection. What does the nurse inform the client that will do to decrease the edema? Select all that apply.

Prevents tissue refilling with an excess volume of lymph Helps muscles to propel lymphatic drainage Increases local tissue pressure Decreases the stretching of the skin

A nurse is contributing to the plan of care for a child who has sickle cell crisis. Which of the following actions should the nurse recommend to include?

Promote hydration with IV and oral fluids

A nurse is caring for a client who has AIDS and anorexia. Which of the following actions should the nurse take to increase the client's body weight?

Provide supplemental vitamins

A client with mitral stenosis develops a productive cough with pink frothy sputum. The best interpretation made by the nurse would be to further evaluate for which complication?

Pulmonary edem

The nurse is instructing a client on the use of compression garments for the use of lympedema.. What should be included in the instructions. Select all that apply.

Purchase 2 garments Change the garments in the morning & Evening Limit time not worn to 30-60 minutes

The nurse is caring for a client with a nursing diagnosis of ineffective tissue perfusion. Which area of the heart would the nurse anticipate being compromise?

RT ventricle

What type of cells are seen in Hodgkin's Lymphoma?

Reed-Sternberg cells

A 55 year old client presents to the ER complaining of exertional dyspnea. Upon exam the nurses assess the dependent edema 3+ in the clients lower extremities, ascities in the abdomen & hepatomegaly. The nurse recognizes that these signs & symptoms coordinate with which type of cardiomyopathy?

Restrictive

A nurse is contributing to the plan of care for an older adult client who has a WBC of 2000/mm3 after three rounds of chemotherapy. Which of the following interventions should the nurse include in the plan?

Serve cooked fruit with meals

A nurse is caring for a male client with Buerger's disease. The client asks "What did I do to cause this to happen to me?" The nurse should explain to the client that the development of buerger's disease is most closely associated with which modifiable risk factor?

Smoking

A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, 'My heart is racing.' The nurse notes that the client's face has become flushed. Which of the following actions should the nurse take first?

Stop the transfusion

The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?

There is excess fluid volume in the interstial space of the lower extremities

the nurse is inspecting the tonsils for a client with a fever and a sore throat. The nurse observes purulent exudate on the surface of the tonsils. What does this finding indicate to the nurse?

Tonsilitis

After a 6 hour onset of acute chest pain, the client is brought to the emergency room for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time?

Troponin- they become elevated 6-12 hours after

A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client?

aplastic anemia

A client will be receiving a Hepatitis B vaccination prior to employment in a dialysis center. What type of immunity will this provide?

artificially acquired active immunity

A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers. What severe complication should the nurse be alert for with cytomegalovirus?

blindness

The nurse is caring for three clients who have the following blood count values: Client A has 24,500/mm 3 white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C has a 250,000/mm 3 platelet count. Which statement correctly describes the condition of each client?

Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count.

A nurse is caring for a client who was diagnosed with HIV 6 months ago. The client came to the clinic for testing to determine disease progression. Which of the following laboratory tests should the nurse expect the provider to prescribe?

Quantitative RNA assayy