MED SURG ATI and Lacharity Exam 5

A nurse is providing information to a group of surgical nurses for a treatment of malignant hyperthermia. Which of the following should the nurse include in the information? (select all that apply) a. infuse iced IV fluids b. provide 100% oxygen c. place on a cooling blanket d. treat the condition while continuing surgery e. administer IV dantrolene

a, b, c, e

A nurse is assisting an anesthesiologist in the delivery of nitrous oxide per face mask to a client during the induction of anesthesia. Which of the following is a priority nursing action? a. assess oxygen saturation b. obtain blood pressure c. palpate heart rate d. check temperature

a. assess oxygen saturation

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 102.2 orally. Which of the following is an appropriate action by the nurse? a. inform the surgeon of the elevated temperature b. transfer the patient to the preoperative unit c. apply ice packs to the client's groin d. encourage the client to increase intake of clear liquids

a. inform the surgeon of the elevated temperature

A nurse is caring for a client who displays systemic toxic reaction following a regional block. Which of the following actions by the nurse is appropriate? a. monitor serum creatinine levels b. prepare to administer IV thiopental c. turn client to right side d. administration 0.9% sodium chloride 500 mL IV bolus

b. prepare to administer IV theopental

A nurse has administered midazolam (Versed) IV bolus to a client before a procedure. The client's blood pressure is 86/40 mm Hg and pulse is 134/min. Which of the following is an appropriate action by the nurse? a. administer naloxone (Narcan) IV b. administer morphine IV c. admnister 0.9% sodium chloride IV bolus d. administer atropine IV

c. administer 0.9% sodium chloride IV bolus

A nurse is caring for a client who has stage IV lung cancer and is 3 days postop following a wedge resection. the client states, i told myself that i would go through with the surgery if i quit smoking, if i could just live long enough to attend my daughters wedding. based on kubler-ross's model, which stage of grief is the client experiencing? a. anger b. denial c. bargaining d. acceptance

c. bargaining

a nurse is assisting a newly licensed nurse with postmortem care to a client. the family wishes to view the body. which of the following statements by the newly licensed nurse indicate an understanding of this procedure? select all that apply a. i will remove the dentures from the body b. i will make sure the body is lying completely flat c. i will apply fresh linens and place a clean gown on the body d. i will remove all equipment from the bedside e. i will dim the lights in the room

c. i will apply fresh linens and place a clean gown on the body d. i will remove all equipment from the bedside e. i will dim the lights in the room

A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following is an appropriate nursing action? a. decrease the client's fluid intake b. apply pressure to the puncture site c. place the clients HOB flat d. instruct the client to lie prone

c. place the client's HOB flat

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. which of the following rationales for self-care should the nurse communicate to the family? a. allowing the client to function independently will strengthen her muscles and promote healing b. the client needs to be given privacy at times for self- reflecting and organizing her life. c. the client's sense of loss can be lessened through retaining control of certain areas of her life d. performing ADLs is required prior to discharge from an acute care facility

c. the client's sense of loss can be lessened through retaining control of certain areas of her life

a nurse is caring for a client who has a terminal illness. death is expected within 24 hr. the client's family is at the bedside and asks the nurse about anticipated findings at this time. which of the following findings should the nurse include in the discussion? a. regular breathing patterns b. warm extremities c. increased urine output d. decreased muscle tone

d. decreased muscle tone- expected finding when client is approaching death

A preoperative nurse is caring for a client who is having a colon resection. Which of the following is an appropriate nursing action? a. encourage the client to void after medication administration b. administer antibiotics 30 min prior surgical incision c. remove hair using a manual razor d. remove nail polish on fingers and toes

d. remove nail polish on fingers and toes

1) When scheduling a patient for skin testing for allergies, which information is most important for the allergy clinic nurse to include in patient teaching? 1. Avoid taking antihistamines before the skin testing. 2. Skin testing may be done with an intradermal injection. 3. Swelling and itching may occur at the site of the skin testing. 4. Patient will need to wait in the clinic for 20 minutes after the testing.

1

A hospitalized patient with acquired immunodeficiency syndrome (AIDS) has wasting syndrome. Which nursing action is appropriate to assign to an LPN/LVN who is providing care to this patient? 1. Administering oxandrolone 5 mg/day 2. Assessing the patient for other nutritional risk factors 3. Developing a plan of care to improve the patient's appetite 4. Providing instructions about a high-calorie, high- protein diet

1

A patient with newly diagnosed acquired immunodeficiency syndrome (AIDS) has a 6-mm induration at 48 hours after a skin test for tuberculosis (TB). Which action will the nurse anticipate taking next? 1. Arrange for a chest x-ray to check for active TB. 2. Tell the patient that the TB test results are negative. 3. Teach the patient about multidrug treatment for TB. 4. Schedule TB skin testing again in 12 months.

1

A patient with systemic lupus erythematosus (SLE) is admitted to the hospital with acute joint inflammation. Which information obtained in the laboratory testing will be of highest concern to the nurse? 1. Elevated blood urea nitrogen level 2. Increased C-reactive protein level 3. Positive antinuclear antibody test result 4. Positive lupus erythematosus cell preparation

1

A received diphenhydramine 50 mg PO. Which patient information is most indicative of a need for action by the nurse? 1. The patient is preparing to drive home. 2. The patient reports itching at the site of the rash. 3. The patient has a history of constipation. 4. The patient states, "My mouth feels so very dry!"

1

The nurse is evaluating a patient with human immunodeficiency virus (HIV) who is receiving trimethoprimsulfamethoxazole (TMP-SMX) as a treatment for Pneumocystis jiroveci pneumonia. Which information is most important to communicate to the health care provider? 1. The patient reports a blistering rash. 2. The patient's fluid intake is 2 L/day. 3. The patient's potassium is 3.4 mg/dL (3.4 mmol/L). 4. The patient enjoys spending time outside in the sun.

1

The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will be delegated to unlicensed assistive personnel (UAP) working for the agency? 1. Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. Assessing the community to determine which population groups to target for education

1

The nurse obtains this information when assessing a patient with human immunodeficiency virus (HIV) who is taking antiretroviral therapy. Which finding is most important to report to the health care provider? 1. The blood glucose level is 144 mg/dL (8 mmol/L). 2. The hemoglobin level is 10.9 g/dL (109 g/L). 3. The patient reports frequent nausea. 4. The patient's viral load has increased.

1

The nurse is working with a patient who has a new diagnosis of human immunodeficiency virus (HIV) and who reports current use of injectable heroin and methamphetamine. Which actions by the nurse are appropriate? Select all that apply. 1. Refer the patient to a substance abuse treatment program. 2. Plan for the patient to participate in a needle exchange program. 3. Coordinate the patient's schedule for directly observed antiretroviral drug treatment. 4. Instruct the patient that ongoing injectable drug use is a contraindication for antiretroviral therapy. 5. Provide patient education about the risk of transmitting HIV to others when sharing needles.

1, 2, 3, 5

A patient who has human immunodeficiency virus (HIV) and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider? 1. The patient exclaims, "I'm afraid I'm going to die right here!" 2. The prescribed patient medications include midazolam 2 mg IV immediately. 3. The patient is diaphoretic and tremulous and reports dizziness. 4. The symptoms occurred suddenly while the patient was driving to work.

2

An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone 20 mg/day for 4 days. Which action prescribed by the health care provider is most important for the nurse to question? 1. Discontinue prednisone after today's dose. 2. Give a "catch-up" dose of varicella vaccine. 3. Check the patient's C-reactive protein level. 4. Administer ibuprofen 800 mg PO TID.

2

Initiation of subcutaneous etanercept for a patient with rheumatoid arthritis is being considered. Which patient information is most important for the nurse to communicate with the health care provider? 1. The patient is currently taking methotrexate. 2. The patient has a positive tuberculin skin test result. 3. The patient has had type 2 diabetes for 5 years. 4. The patient is anxious about having to self-inject.

2

The hospital employee health nurse is completing a health history for a newly hired staff member. Which information given by the new employee most indicates the need for further nursing action before the new employee begins orientation to patient care? 1. The employee takes enalapril for hypertension. 2. The employee has allergies to bananas, avocados, and papayas. 3. The employee received a tetanus vaccination 3 years ago. 4. The employee's tuberculin skin test has a 5-mm induration at 48 hours.

2

The nurse assesses a 24-year-old patient with rheumatoid arthritis who is considering using methotrexate for treatment. Which patient information is most important to communicate to the health care provider? 1. The patient has many concerns about the safety of the drug. 2. The patient has been trying to get pregnant. 3. The patient takes a daily multivitamin tablet. 4. The patient says that she has taken methotrexate in the past.

2

The nurse is supervising a student nurse who is caring for a patient with human immunodeficiency virus (HIV). The patient has severe esophagitis caused by Candida albicans. Which action by the student requires the most rapid intervention by the nurse? 1. Putting on a mask and gown before entering the patient's room 2. Giving the patient a glass of water after administering the prescribed oral nystatin suspension 3. Suggesting that the patient should order chile con carne or chicken soup for the next meal 4. Placing a "No Visitors" sign on the door of the patient's room

2

The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs/LVNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN/LVN? 1. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition 2. Collecting data about the patients' responses to medications used for pain and anorexia 3. Developing UAP training programs about how to lower the risk for spreading infections 4. Assisting patients with personal hygiene and other activities of daily living as needed

2

When the occupational health nurse is teaching unlicensed assistive personnel (UAP) about bloodborne pathogen exposure and human immunodeficiency virus (HIV) risk, which information is most important to emphasize? 1. Occupational transmission of HIV from patients to health care workers is relatively rare. 2. Occupational exposure to HIV-containing fluids should be reported immediately to the supervisor. 3. Treatment for occupational exposure to HIV may include use of antiretroviral medications. 4. Postexposure treatment will include HIV testing at baseline and at several intervals after the exposure.

2

Which of these patients cared for by the nurse in the clinic presents the highest risk for infection with human immunodeficiency virus (HIV) during sexual intercourse? 1. Uninfected man who reports performing oral inter- course with an HIV-infected woman 2. Uninfected man who is the receiver during anal intercourse with an HIV-infected man 3. Uninfected woman who has had vaginal intercourse with an HIV-infected man 4. Uninfected woman who has performed oral inter- course with an HIV-infected woman

2

A few minutes after the nurse has given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should the nurse take first? 1. Start oxygen at 6 L/min using a face mask. 2. Obtain IV access with a large-bore IV catheter. 3. Give epinephrine 0.5 mg intramuscularly. 4. Administer albuterol per nebulizer mask.

3

A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine and methylprednisolone. Which staff member is best to assign to care for this patient? 1. RN who floated to the medical unit from the coronary care unit for the day 2. RN with 3 years of experience in the operating room who is orienting to the medical unit 3. RN who has worked on the medical unit for 5 years and is working a double shift today 4. Newly graduated RN who needs experience with IV medication administration

3

A patient with a history of liver transplantation is receiving cyclosporine, prednisone, and mycophenolate. Which finding is of most concern? 1. Gums that appear very pink and swollen 2. Blood glucose level of 162 mg/dL (9 mmol/L) 3. Nontender lump above the clavicle 4. Grade 1+ pitting edema in the feet and ankles

3

A patient with wheezing and coughing caused by an allergic reaction is admitted to the emergency department. Which medication will the nurse anticipate administering first? 1. Methylprednisolone 100 mg IV 2. Cromolyn 20 mg via nebulizer 3. Albuterol 3 mL via nebulizer 4. Aminophylline 500 mg IV

3

A patient seen in the sexually transmitted disease clinic has just tested positive for human immunodeficiency virus (HIV) with a rapid HIV test. Which action will the nurse take next? 1. Ask about patient risk factors for HIV infection. 2. Send a blood specimen for Western blot testing. 3. Provide information about antiretroviral therapy. 4. Discuss the positive test results with the patient.

4

A patient with human immunodeficiency virus (HIV) who has been started on antiretroviral therapy is seen in the clinic for follow-up. Which test will be best to monitor when determining the response to therapy? 1. CD4 level 2. Complete blood count 3. Total lymphocyte percent 4. Viral load

4

After change-of-shift report, which newly admitted patient should the nurse assess first? 1. A patient with human immunodeficiency virus (HIV) whose CD4 count is 45 mm3 (45 cells/mcL) 2. A patient with acute kidney transplant rejection who has a scheduled dose of prednisone due 3. A patient with graft-versus-host disease who has frequent liquid stools 4. A patient with hypertension who has angioedema after receiving lisinopril

4

The nurse is caring for a patient with rheumatoid arthritis who is taking naproxen twice a day to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider? 1. Joint pain worse in the morning 2. Dry eyes bilaterally 3. Round and moveable nodules under the skin 4. Dark-colored stools

4

Which finding will be most important for the nurse to report to the health care provider about a patient who is taking prednisone chronically after an organ transplant? 1. Multiple arm bruises 2. Sodium level of 146 mEq/dL (146 mmol/L) 3. Blood glucose of 110 mg/dL (6.1 mmol/L) 4. Black-colored stools

4

A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? a. assess bowel sounds b. administer antiemetic medication c. restart prescribed IV fluids d. insert a prescribed nasogastric tube

A assess bowel sounds

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39 C (102.2 F) orally. Which of the following actions should the nurse take? a. inform the surgeon of the elevated temperature b. transfer the client to the preoperative unit c. apply ice packs to the groin d. encourage the client to increase intake of clear liquids

A inform the surgeon of the elevated temperature

A nurse is reviewing the medical records of several clients in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (select all that apply) a. a client who has a WBC of 22,500/uL b. a client who uses an insulin pump c. a client who takes warfarin daily d. a client who has heart failure e. a client who has BMI of 26

A, B, C, D a client who has a WBC of 22,500/uL a client who uses an insulin pump a client who takes warfarin daily a client who has heart failure

A nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (select all that apply) a. urine output less that 25 mL/hr b. hematocrit 53% c. BUN 24 mg/dL d. tenting of the skin over the sternum e. apical pulse rate 62/min

A, B, C, D urine output less that 25 mL/hr hematocrit 53% BUN 24 mg/dL tenting of the skin over the sternum

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a. encourage use of the incentive spirometer every 2 hr b. instruct the client to splint the incision when coughing and deep breathing c. reposition the client every 2 hr d. administer antibiotic therapy e. assist with early ambulation

A, B, C, E encourage use of the incentive spirometer every 2 hr instruct the client to splint the incision when coughing and deep breathing reposition the client every 2 hr assist with early ambulation

A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (select all that apply) a. "Take your heart medication with a sip of water before surgery" b. "Splint the abdominal incision with a pillow when coughing and deep breathing" c. "Bed rest is recommended for the first 48 hours" d. "Anti-embolism stockings are applied before surgery" e. "You can eat solid foods up to 4 hours before surgery"

A, B, D "Take your heart medication with a sip of water before surgery" "Splint the abdominal incision with a pillow when coughing and deep breathing" "Anti-embolism stockings are applied before surgery"

A nurse is preoperative teaching a client scheduled for abdominal surgery. Which of the following statements by the nurse are appropriate? (select all that apply) a. take your blood pressure medication with a sip of water before surgery b. splint the abdominal incision with a pillow when coughing and deep breathing c. bedrest is recommended for the first 48 hrs d. antiembolism stockings are applied before surgery e. you may eat solid foods up to 4 hours before surgery

A,B,D

A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come speak with you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling."

A. "Would you like me to contact the chaplain to come speak with you?" D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling."

A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C."I will wear a mask when around family members who are ill." D."I will cook vegetables before eating them."

A. A client who has AIDS should avoid changing the litter box to prevent acquiring toxoplasmosis. B. A client who has AIDS should avoid consuming raw fruits due to the presence of bacteria that can cause opportunistic infections. C. Due to compromised immune response, a client who has AIDS should avoid contact with family members who are ill. D. CORRECT: A client who has AIDS should cook vegetables before eating to kill bacteria that cause opportunistic infections.

A nurse is assessing a client for HIV. Which of the following are risk factors associated with this virus? (Select all that apply.) A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult woman E. Occupational exposure

A. CORRECT: Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take cautionary measures to prevent HIV exposure. B. INCORRECT: Women who are pregnant should be tested for HIV, but pregnancy is not a risk factor associated with this virus. C. INCORRECT: Having a monogamous sex partner is not a risk factor associated with the HIV virus. D. CORRECT: Being an older adult woman is a risk factor associated with the HIV virus due vaginal dryness and the thinning of the vaginal wall. E. CORRECT: Occupational exposure, such as being a health care worker, is a risk factor associated with the HIV virus.

A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors associated with this virus? (Select all that apply.) A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult woman E. Occupational exposure

A. CORRECT: Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take precautionary measures to prevent HIV exposure. B. Women who are pregnant should be tested for HIV, but pregnancy is not a risk factor associated with this virus. C. Having a monogamous sex partner is not a risk factor associated with the HIV virus. D. CORRECT: Being an older adult woman is a risk factor associated with the HIV virus due vaginal dryness and the thinning of the vaginal wall. E. CORRECT: Occupational exposure, such as being a health care worker, is a risk factor associated with the HIV virus.

A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to con rm HIV infection? (Select all that apply.) A. Western blot B. Indirect immunofluorescence assay C. CD4 T‐lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid (CSF) analysis

A. CORRECT: Positive results of a Western blot test con rm the presence of HIV infection. B. CORRECT: Positive results of an indirect immunofluorescence assay con rm the presence of HIV infection. C. CD4+ T‐lymphocyte count assists with classifying the stage of HIV infection. D. HIV RNA quantification tests are used to determine vial level and to monitor treatment. E. CSF analysis can be used to con rm meningitis.

A nurse is caring for a client who is suspected of having HIV. Which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply.) A. Western blot B. Indirect immunofluorescence assay C. CD4+ T-lymphocyte count D. CD4+ T-lymphocyte percentage of total lymphocytes E. Cerebrospinal fluid (CSF) analysis

A. CORRECT: Positive results of a Western blot test confirm the presence of HIV infection. B. CORRECT: Positive results of an indirect immunofluorescence assay confirm the presence of HIV infection. C. INCORRECT: CD4+ T-lymphocyte count assists with classifying the stage of HIV infection. D. INCORRECT: CD4+ T-lymphocyte percentage of total lymphocytes assists with classifying the stage of HIV infection. E. INCORRECT: CSF analysis can be used to confirm meningitis.

A nurse working in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1° C (100.6° F) orally. The client is afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply.) A. Perform a physical assessment. B. Determine when current symptoms began. C. Teach the client about HIV transmission. D. Draw blood for HIV testing. E. Obtain a sexual history.

A. CORRECT: The nurse should perform a physical assessment to gather data about the client's condition. This is an appropriate action by the nurse. B. CORRECT: The nurse should gather more data to determine whether the clinical manifestations are acute or chronic. This is an appropriate action by the nurse. C. INCORRECT: Teaching the client about HIV transmission is not an appropriate action by the nurse at this time. This is not a priority action for the nurse to include at this time. D. INCORRECT: Drawing blood for HIV testing is not an appropriate action by nurse at this time. This is not a priority action for the nurse to include at this time. E. CORRECT: The nurse should obtain a sexual history to determine how the virus was transmitted. This is an appropriate action by the nurse.

A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1° C (100.6° F) orally. The client is afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply.) A. Perform a physical assessment. B. Determine when manifestations began. C. Teach the client about HIV transmission. D. Draw blood for HIV testing. E. Obtain a sexual history.

A. CORRECT: The nurse should perform a physical assessment to gather data about the client's condition. B. CORRECT: The nurse should gather more data to determine whether the manifestations are acute or chronic. C. Teaching the client about HIV transmission is not an appropriate action by the nurse at this time. D. Drawing blood for HIV testing is not an appropriate action by nurse at this time. E. CORRECT: The nurse should obtain a sexual history to determine how the virus was transmitted.

A nurse is completing discharge instructions with a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C. "I will wear a mask when around family members who are ill." D. "I will cook vegetables before eating them."

A. INCORRECT: A client who has AIDS should avoid changing the pet litter box to prevent acquiring toxoplasmosis. B. INCORRECT: A client who has AIDS should avoid consuming raw fruits due to the presence of bacteria that can cause opportunistic infections. C. INCORRECT: Due to compromised immune response, a client who has AIDS should avoid contact with family members who are ill. D. CORRECT: A client who has AIDS should cook vegetables before eating to kill bacteria that cause opportunistic infections.

A nurse is caring for a client who has HIV and has been newly diagnosed with Burkitt's lymphoma. Which of the following HIV infection stages is the client in? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

A. INCORRECT: In stage 1, there are no defining conditions. B. INCORRECT: In stage 2, there are no defining conditions. C. CORRECT: In stage 3, there are one or more defining conditions present. These can include candidiasis of the esophagus, bronchi, trachea, or lungs; chronic ulcers of herpes simplex; HIV‑related encephalopathy; disseminated or extrapulmonary histoplasmosis; Kaposi's sarcoma; and Burkitt's lymphoma. D. INCORRECT: In stage 4, there is no information available.

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

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

A nurse is reviewing the laboratory findings of a client who has the measles. The nurse should expect to find an increase in which of the following types of WBCs? A. Neutrophils B. Basophils C. Monocytes D. Eosinophils

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

A nurse is preparing to administer a scratch test to a client who has suspected food and environmental allergies. Which of the following actions should the nurse perform prior to the procedure? (Select all that apply.) A. Cleanse the client's skin with povidone-iodine (Betadine). B. Ask the client about previous reactions to allergens. C. Ask the client about medications taken over the past several days. D. Inform the client to expect itching at one site. E. Obtain emergency resuscitation equipment.

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

A nurse is providing teaching for a client who has stage 2 HIV disease and is having dif culty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching. A. "I will choose a diet high in fat to help gain weight." B. "I will be sure to eat three large meals daily." C."I will drink up to 1 liter of liquid each day." D."I will add high‐protein foods to my diet."

A. The client should be taught to avoid high‐fat foods to gain weight because fat intolerance—causing flatus, bloating, and diarrhea—is common in clients who have HIV/AIDS. B. The client should be taught that small frequent meals (such as six meals daily) are better tolerated than three large meals. C. The client should be taught to drink 2 to 3 L of liquids daily to maintain nutrition status. D. CORRECT: The client should be taught to add high‐protein, high‐calorie foods to the diet daily as the best way to gain weight and maintain health.

A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider (select all that apply) a. potassium 3.9 mEq/L b. sodium 145 mEq/L c. creatinine 2.8 mg/dL d. blood glucose 235 mg/dL e. WBC 17,850/mm3

C, D, E creatinine 2.8 mg/dL blood glucose 235 mg/dL WBC 17,850/mm3

A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (select all that apply) a. explain to the client the purpose of having the procedure b. inform the client of risks to having the procedure c. ensure the client signing the informed consent form d. witness the client signing the informed consent form e. determine if the client is capable of understanding the reason for the procedure

C, D, E ensure the client signing the informed consent form witness the client signing the informed consent form determine if the client is capable of understanding the reason for the procedure

A nurse in the preoperative unit is assessing a client's laboratory values before surgery. Which of the following should the nurse report to the provider? (select all that apply) a. potassium 3.9 mEq/L b. Sodium Chloride 145 mEq/L c. Creatinine 2.8 mg/dL d. Blood glucose 235 mg/dL e. WBC 17,850

C,D,E

A nurse is obtaining informed consent for a client who is having a paracentesis. Which of the following are appropriate nursing actions? (select all that apply) a. explain to the client the purpose of having the procedure b. inform the client of risks to having the procedure c. ensure the client understood the information about the procedure d. witness the client signing the informed consent form e. determine if the client is mentally capable of understanding the reason for the procedure

C,D,E

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? a. compare and contrast the peripheral pulses b. apply a warm blanket c. assess dressings d. place the client in a lateral position

D place the client in the lateral position

A preoperative nurse is caring for a client who is having colon resection. Which of the following actions should the nurse take? a. encourage the client to void after b. administer antibiotics 2 hr prior to surgical incision c. remove hair using a manual razor d. remove nail polish on fingers and toes

D remove nail polish on fingers and toes