MED SURG 3, study set 1- inflammation, wound healing, and altered immune response
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Clean drug injection equipment before each use." b. "Ask those who share equipment to be tested for HIV." c. "Consider participating in a needle-exchange program." d. "Avoid sexual intercourse when using injectable drugs."
C
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing c. Rapid HIV antibody testing b. Enzyme immunoassay d. Immunofluorescence assay
A
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. A 56-yr-old with frequent explosive diarrhea b. A 33-yr-old with a fever of 100.8° F (38.2° C) c. A 66-yr-old who has white pharyngeal lesions d. A 23-yr-old who is complaining of severe fatigue
B
Which patient statement indicates that the nurse's teaching about tamoxifen has been effective? a. "I can expect to have leg cramps." b. "I will call if I have any eye problems." c. "I should contact you if I have hot flashes." d. "I will be taking the medication for 6 to 12 months."
B
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises c. Skin abrasions b. Tarry stools d. Bleeding gums
B
Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? a. Age c. Symptoms b. Lifestyle d. Sexual orientation
A
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count
C
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Minimizing sun exposure reduces risk for future BCC. d. Low dose systemic chemotherapy is used to treat BCC.
C
A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia c. Oral ulcers b. Vomiting d. Lip swelling
D
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive range of motion (ROM).
A
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily
A
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.
A
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a. Bone marrow biopsy b. Abdominal ultrasound c. Complete blood count (CBC) d. Activated partial thromboplastin time (aPTT)
A
After a 48-yr-old patient has had a modified radical mastectomy, the pathology report identifies the tumor as an estrogen-receptor positive adenocarcinoma. The nurse will plan to teach the patient about a. tamoxifen c. raloxifene (Evista). b. estradiol (Estrace). d. trastuzumab (Herceptin)
A
The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time? a. "Are you taking any medications?" b. "Do you have a productive cough?" c. "How often do you brush your teeth?" d. "Have you had an oral herpes infection?"
A
The nurse will anticipate teaching a patient who is diagnosed with lobular carcinoma in situ (LCIS) about a. tamoxifen c. lymphatic mapping. b. lumpectomy. d. MammaPrint testing.
A
The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Administer prescribed PRN hydrocodone 30 minutes before the change. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Soak the old dressings with sterile saline 30 minutes before the dressing change
A
Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.
A
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."
A
The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin
A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates around the room. b. The patient's visitors bring in fresh peaches. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.
B
A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a. Monitor the patient's edema. b. Administer a dose of epinephrine. c. Provide a prescription for oral antihistamines d. Ask the patient about the use of new skin products
B
A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. c. Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain.
B
A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.
B
Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b. Place a tourniquet above the site. c. Administer subcutaneous epinephrine. d. Reschedule the patient's other allergen tests.
B
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.
B
The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching? a. The patient has a history of dental caries. b. The patient swims several days each week. c. The patient snacks frequently during the day. d. The patient showers each day with mild soap.
B
The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders
B
The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders
B
Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.
B
Which action will the nurse include in the plan of care for a patient with right arm lymphedema? a. Avoid isometric exercise on the right arm. b. Assist with application of a compression sleeve. c. Keep the right arm at or below the level of the heart. d. Check blood pressure (BP) on both right and left arms.
B
Which information should the nurse include in teaching a patient who is scheduled for external beam radiation to the breast? a. The radiation therapy will take a week to complete. b. Careful skin care in the radiated area will be necessary. c. Visitors are restricted until the radiation therapy is completed. d. Wigs may be used until the hair regrows after radiation therapy.
B
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.
B
Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with thrombocytopenia who has oozing gums after a tooth extraction d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours
B
Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who is sneezing after subcutaneous immunotherapy c. Patient who has graft-versus-host disease and severe diarrhea d. Patient with multiple chemical sensitivities who has muscle stiffness
B
The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer? a. Fruit salad c. Creamed broccoli b. Baked chicken d. Toasted wheat bread
B Protein is needed for wound healing. To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products should also be avoided.
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Explain to the patient that this is an expected finding. c. Request that an antibiotic be prescribed for the patient. d. Advise the patient that this indicates influenza infection.
B`
A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor crossmatching are positive d. Panel of reactive antibodies (PRA) percentage is low
C
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV
C
A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? a. Provide high-flow oxygen. b. Administer antihistamines. c. Assess the patient's airway. d. Remove the stinger from the site.
C
A patient newly diagnosed with stage I breast cancer is discussing treatment options with the nurse. Which statement by the patient indicates that additional teaching may be needed? a. "There are several options that I can consider for treating the cancer." b. "I will probably need radiation to the breast after having the surgery." c. "Mastectomy is the best choice to decrease the chance of cancer recurrence." d. "I can probably have reconstructive surgery at the same time as a mastectomy."
C
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."
C
A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Decreasing the tumor size will improve the effects of other therapy. d. Tumor growth will be controlled by the removal of malignant tissue.
C
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure
C
After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag
C
An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the medication at this time? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day.
C
The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant
C
The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Obtain the patient's blood pressure and heart rate. b. Question the patient about any clear nasal discharge. c. Observe for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.
C
The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a. Cool extremities c. Elevated temperature b. Pallor and weakness d. Low oxygen saturation
C
The nurse is caring for a patient with breast cancer who is receiving chemotherapy with doxorubicin and cyclophosphamide. Which assessment finding is most important to communicate to the health care provider? a. The patient complains of fatigue. b. The patient eats only 25% of meals. c. The patient's apical pulse is irregular. d. The patient's white blood cell (WBC) count is 5000/µL.
C
The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. A 35-yr-old patient who has wet desquamation associated with abdominal radiation b. A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. A 24-yr-old patient who received neck radiation and has blood oozing from the neck d. A 56-yr-old patient who developed a new pericardial friction rub after chest radiation
C
What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a. Plasmapheresis eliminates eosinophils and basophils from blood. b. Plasmapheresis decreases the damage to organs from T lymphocytes. c. Plasmapheresis removes antibody-antigen complexes from circulation. d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.
C
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include a. an RBC count of 4,500,000/mL. b. a hematocrit (Hct) value of 38%. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
D
A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/µL d. White blood cell (WBC) count of 2800/µL
D
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient will develop symptomatic HIV infection within 1 year." b. "The patient meets the criteria for a diagnosis of acute HIV infection." c. "The patient will be diagnosed with asymptomatic chronic HIV infection." d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."
D
A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Take this medication on an empty stomach. b. Take this medication with a full glass of water. c. You may have vivid and bizarre dreams as a side effect. d. Continue to use contraception while taking this medication
D
An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. c. avoid use of aspirin products. b. administer iron supplements. d. monitor fluid intake and output.
D
Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy
D
The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider? a. Frequent loose stools b. Nausea and vomiting c. Elevated white blood count (WBC) d. Increased carcinoembryonic antigen (CEA)
D
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cell (WBC) count 15,500/µL
D
Tamoxifen is used for estrogen-dependent breast tumors in premenopausal women. Raloxifene is used to prevent breast cancer, but it is not used postmastectomy to treat breast cancer. Estradiol will increase the growth of estrogen-dependent tumors. Trastuzumab is used to treat tumors that have the HER-2 receptor
study
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse cleans the ulcer with half-strength peroxide. b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer. c. The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe. d. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.
A
A patient diagnosed with breast cancer asks the nurse what "triple negative" means. An accurate response from the nurse about triple-negative breast cancer should include that a. the tumor is not likely to be responsive to hormone therapy. b. HER-2 receptor testing was repeated for a total of three samples. c. treatment with chemotherapy is not likely to be recommended. d. estrogen receptor testing identified the three hormones causing the cancer.
A
A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils
A
Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.
A
Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.
A
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.
A The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.
Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.
A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.
Mult. Choice The nurse in the outpatient clinic notes that the following patients have not received the human papillomavirus (HPV) vaccine. Which patients should the nurse plan to teach about benefits of the vaccine (select all that apply)? a. A 24-yr-old male patient who has a history of genital warts b. An 18-yr-old male patient who has had one male sexual partner c. A 38-yr-old female patient who has never been sexually active d. A 20-yr-old female patient who has a newly diagnosed Chlamydia infection e. A 30-yr-old female patient whose sexual partner has a history of genital warts
A, B, D
A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work.
A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics.
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Have the patient lie on the left side for 1 hour. c. Apply a sterile 2-inch gauze dressing to the site. d. Use a half-inch sterile gauze to pack the wound.
B
The nurse provides discharge teaching for a 61-yr-old patient who has had a left modified radical mastectomy and lymph node dissection. Which statement by the patient indicates that teaching has been successful? a. "I will need to use my right arm and to rest the left one." b. "I will avoid reaching over the stove with my left hand." c. "I will keep my left arm in a sling until the incision is healed." d. "I will stop the left arm exercises if moving the arm is painful."
B
A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient how to reduce risky behaviors. b. Inform the patient about the available treatments. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to identify individuals who had intimate contact with the patient.
C
A patient's 4 ´ 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing b. Nonadherent dressing c. Hydrocolloid dressing d. Transparent film dressing
C
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Check the patient's temperature again in 4 hours. d. Give acetaminophen (Tylenol) prescribed PRN for pain.
C
A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? a. Change the patient's bedding frequently. b. Apply a hydrocolloid dressing over the ulcer. c. Change the patient's position every 1 to 2 hours. d. Record the size and appearance of the ulcer weekly.
C
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions
C
The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week. b. Administer the scheduled dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.
C
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count trajectory b. HIV genotype and phenotype c. Patient's tolerance for potential medication side effects d. Patient's ability to follow a complex medication regimen
D
The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a. Eschar b. Slough c. Maceration d. Undermining
D
Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color c. Liver function b. Hematocrit d. Serum iron level
D
The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas
D
The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? a. Shortness of breath c. Transfusion reaction b. High blood pressure d. Extremity numbness
D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient complains of severe fatigue. b. Patient voids every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has crackles up to the midline posterior chest.
D Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer or are receiving chemotherapy.
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit 30% b. Platelets 95,000/µL c. Hemoglobin 10 g/L d. White blood cells (WBC) 2700/µL
D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.
Which example should the nurse use to explain an infant's "passive immunity" to a new mother? a. Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases
B
hich information will the nurse include in patient teaching for a 36-yr-old patient who is scheduled for stereotactic core biopsy of the breast? a. A local anesthetic will be given before the biopsy specimen is obtained. b. You will need to lie flat on your back and lie very still during the biopsy. c. A thin needle will be inserted into the lump and aspirated to remove tissue. d. You should not have anything to eat or drink for 6 hours before the procedure.
A
A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. Platelet count is 42,000/mL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.
A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/mL unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.
The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. Shortness of breath b. Shivering and chills c. Muscle aches and pains d. Temperature of 100.2° F (37.9° C)
A Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complications.
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list
B
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 10 for adequate protection. b. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. c. Water resistant sunscreens will provide good protection when swimming. d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
B
Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose rapid HIV-antibody test is positive b. Patient whose latest CD4+ count has dropped to 250/µL c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs
C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.
The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider? a. Hematocrit of 32% b. Pain with deep inspiration c. Serum sodium of 126 mEq/L d. Decreased breath sounds on left side
C The syndrome of inappropriate antidiuretic hormone (and the resulting hyponatremia) is an oncologic metabolic emergency and requires rapid treatment to prevent complications such as seizures and coma. The other findings also require intervention but are common in patients with lung cancer and not immediately life threatening.
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.
C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the drugs should be taken.
D
A 51-yr-old patient with a small immobile breast lump is considering having a fineneedle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that a. FNA is done in the outpatient clinic, and results are available in 1 to 2 days. b. only a small incision is needed, resulting in minimal breast pain and scarring. c. if the biopsy results are negative, no further diagnostic testing will be needed. d. FNA is guided by a mammogram, ensuring that cells are taken from the lesion
A
An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.
A
Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick injury with a suture needle during a surgery b. Splash into the eyes while emptying a bedpan containing stool c. Needle stick with a needle and syringe used for a venipuncture d. Contamination of open skin lesions with patient vaginal secretions
C
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list
B
A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma
B
A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find a different way to earn extra money." b. "I will take oral antihistamines before going to work." c. "I will get a prescription for epinephrine and learn to self-inject it." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."
B
According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection
B, C
The sister of a patient diagnosed with BRCA gene-related breast cancer asks the nurse, "Do you think I should be tested for the gene?" Which response by the nurse is most appropriate? a. "In most cases, breast cancer is not caused by having the BRCA gene." b. "It depends on how you will feel if the test is positive for the BRCA gene." c. "There are many things to consider before deciding to have genetic testing." d. "You should decide first whether you are willing to have a bilateral mastectomy."
C Although presymptomatic testing for genetic disorders allows patients to take action (e.g., mastectomy) to prevent the development of some genetically caused disorders, patients also need to consider that test results in their medical record may affect insurance, employability, and so on. Telling a patient that a decision about mastectomy should be made before testing implies that the nurse has made a judgment about what the patient should do if the test result is positive. Although the patient may need to think about her reaction if the test is positive, other issues (e.g., insurance) also should be considered. Although most breast cancers are not related to BRCA gene mutations, the patient with a BRCA gene mutation has a markedly increased risk for breast cancer.
The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea c. Hematuria b. Alopecia d. Xerostomia
C The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy.
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count c. Total lymphocyte count b. Reticulocyte count d. Absolute neutrophil count
D
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem? a. Encourage the patient to purchase a wig or hat to wear when hair loss begins. b. Suggest that the patient limit social contacts until regrowth of the hair occurs. c. Teach the patient to wash hair gently with mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once chemotherapy is complete.
A
An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals
A
An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals
A
An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching? a. Many drugs interact with antiretroviral medications. b. HIV infections progress more rapidly in older adults. c. Less frequent CD4+ level monitoring is needed in older adults. d. Hospice care is available for patients with terminal HIV infection.
A
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time? a. Encourage adequate nutrition, exercise, and sleep. b. Teach about the side effects of antiretroviral agents. c. Explain opportunistic infections and antibiotic prophylaxis. d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).
A
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. c. Check temperature every 4 hours. b. Encourage increased oral fluids. d. Increase intake of iron-rich foods.
A
The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient? a. "You will need to be retested in 2 weeks." b. "You do not need to fear infecting others." c. "Since you don't have symptoms and you have had a negative test, you do not have HIV)." d. "We won't know for years if you will develop acquired immunodeficiency syndrome (AIDS)."
A
When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating. b. The UAP adds baking soda to the patient's saline oral rinses. c. The UAP puts fluoride toothpaste on the patient's toothbrush. d. The UAP has the patient rinse after meals with a saline solution
A
Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast c. Strawberry and banana fruit plate b. Cantaloupe and cottage cheese d. Cornmeal muffin and orange juice
A
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains
A
Which patient will the nurse plan on teaching about the Gardasil vaccine? a. A 24-yr-old female patient who has not been sexually active b. A 34-yr-old female patient who has multiple sexual partners c. A 24-yr-old female patient who is pregnant for the first time d. A 34-yr-old female patient who is in a monogamous relationship
A
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Have the patient lie on the left side for 1 hour. c. Apply a sterile 2-inch gauze dressing to the site. d. Use a half-inch sterile gauze to pack the wound.
B
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).
B
After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple leg wounds with eschar to be debrided b. The patient receiving chemotherapy who has a temperature of 102° F c. The patient who requires analgesics before a scheduled dressing change d. The newly admitted patient with a stage IV pressure ulcer on the coccyx
B
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.
B
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available
B
The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patient's bedpan. b. The UAP stands by the patient's bed for 30 minutes talking with the patient. c. The UAP places the patient's bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.
B
The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b. Document the patient's history and teach about clinical manifestations of a type I latex allergy. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.
B
The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of malignant tumors." b. "After a couple of years I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."
B
The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of malignant tumors." b. "After a couple of years I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."
B
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient how to dispose of tissues with respiratory secretions. b. Stock the patient's room with the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.
B
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient has had the heel ulcers for 6 months. b. The patient takes oral hypoglycemic agents daily. c. The patient states that the ulcers are very painful. d. The patient has several incisions that formed keloids.
B
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? a. The platelet count is 52,000/µL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.
B
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 10 for adequate protection. b. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. c. Water resistant sunscreens will provide good protection when swimming. d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
B
Which statement by a patient would alert the nurse to a risk for decreased immune function? a. "I had a chest x-ray 6 months ago." b. "I had my spleen removed after a car accident." c. "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."
B
Which statement by a patient would alert the nurse to a risk for decreased immune function? a. "I had a chest x-ray 6 months ago." b. "I had my spleen removed after a car accident." c. "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."
B
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema
B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.
A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan? a. Donor bone marrow is transplanted through a sternal or hip incision. b. Hospitalization is required for several weeks after the stem cell transplant. c. The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d. Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone.
B The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line so the transplant is not painful, nor is an operating room or incision required.
A patient tells the nurse, "I would like to use a home genetic test to see if I will develop breast cancer." Which is the nurse's best initial response? a. "Home genetic testing is very expensive." b. "Are you prepared to cope with a positive result?" c. "Are you concerned about developing breast cancer?" d. "Genetic testing only determines if you are at higher risk for breast cancer."
C
A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? a. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.
C
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? a. "Thinking about dying will not improve the course of AIDS." b. "Do you think that taking an antidepressant might be helpful?" c. "Can you tell me more about the thoughts that you are having?" d. "It is important to focus on the good things about your life now."
C
A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem? a. Add protein powder to foods such as casseroles. b. Tell the patient to eat foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add spices to enhance the flavor of foods that are served.
C
A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments.
C
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose of 136 mg/dL b. Oral temperature of 101° F (38.3° C) c. Separation of the proximal wound edges d. Patient complaint of increased incisional pain
C
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will help decide the treatment for my enlarged prostate." d. "The biopsy will indicate whether the cancer has spread to other organs."
C
The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "I will need follow-up examinations for many years after treatment before I can be considered cured." d. "Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation."
C
Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family
C
Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."
C
Which nursing action should be included in the plan of care for a patient returning to the surgical unit after a left modified radical mastectomy with dissection of axillary lymph nodes? a. Obtain a permanent breast prosthesis before the patient is discharged from the hospital. b. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes. c. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm. d. Insist that the patient examine the surgical incision when the initial dressings are removed.
C
The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient complains of feeling "constantly tired." b. The patient can't explain the effects of indinavir (Crixivan). c. The patient reports missing some doses of zidovudine (AZT). d. The patient reports having no side effects from the medications
C Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of AZT.
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? a. Nystatin tablet b. Oral acyclovir (Zovirax) c. Oral saquinavir (Invirase) d. Aerosolized pentamidine (NebuPent)
C It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drugresistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.
C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.
After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/µL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time
C Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/µL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain.
A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Provide teaching about the importance of nutritional intake. d. Apply prescribed anesthetic gel to oral lesions before meals.
D
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.
D
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution.
D
A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's symptoms did not improve in 2 months. d. There is a 2-cm wheal at the site of the allergen injection.
D
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.
D
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise.
D
The nurse explains to a patient being prepared for colposcopy with a cervical biopsy that the procedure a. involves dilation of the cervix and biopsy of the tissue lining the uterus. b. will take place in a same-day surgery center so that local anesthesia can be used. c. requires that the patient have nothing to eat or drink for 6 hours before the procedure. d. is similar to a speculum examination of the cervix and should result in little discomfort.
D
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/ µL c. HIV-positive patient with a CD4+ count of 160/µL who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
D
The nurse will plan to teach a 51-yr-old man who is scheduled for an annual physical examination about a(n) a. increased risk for testicular cancer. b. possible changes in erectile function. c. normal decreases in testosterone level. d. prostate specific antigen (PSA) testing.
D
When the nurse is working in the women's health care clinic, which action is appropriate to take? a. Teach a healthy 30-yr-old patient about the need for an annual mammogram. b. Discuss scheduling an annual clinical breast examination with a 22-year-old patient. c. Explain to a 60-yr-old patient that mammography frequency can be reduced to every 3 years. d. Teach a 28-yr-old patient with a BRCA-1 mutation about magnetic resonance imaging (MRI).
D
Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? a. Teach the patient to rest the brain by avoiding new activities. b. Teach that "chemo-brain" is a short-term effect of chemotherapy. c. Report patient symptoms immediately to the health care provider. d. Suggest use of a daily planner and encourage adequate rest and sleep.
D
