med surg exam 2

The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client's priority problem? A. Joint pain B. ADL dependence C. Risk for falls D. Muscle stiffness

A

How do plasma cells provide immune protection? A. They actively secrete immunoglobulins against specific antigens. B. They interact with virgin B lymphocytes at first exposure to an antigen, enhancing B-lymphocyte sensitization. C. They regulate the function of natural killer cells, preventing unnecessary damage or death to normal healthy body cells. D. They are responsible for balancing helper cell activity with regulator T-cell activity, ensuring that an immunologic response can be mounted whenever the body is invaded by pathologic microorganisms but limiting the response when the body receives antigens as drugs or food.

A

The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds? A. "Please roll onto your left side." B. "Lay all the way down on your back." C. "Please hold your breath while I use my stethoscope." D. "I will just take your pulse instead."

A

When answering the call light for a client on bedrest, the nurse finds the client's visitor unconscious on the floor with no discernable pulse and not breathing. The nurse estimates that at least 2 minutes have passed since the client's light first came on. What is the nurse's priority action? A. Initiate CPR with chest compressions. B. Perform an abdominal thrust maneuver. C. Assess the visitor for the presence of a head injury. D. Ask the client what event led up to the visitor's fall.

A

A nursing assistant in a nursing home reports to the nurse that an 87-year-old nursing home client has a 6-inch reddened wound with pus draining from it on his shin where he scratched it open yesterday. After directly assessing the client's wound, what are the most relevant priority actions for the nurse to take? Select all that apply. A. Take a photo of the wound to show the primary health care provider when rounds are made 2 days from now. B. Assess the client for signs and symptoms of systemic infection, including temperature elevation. C. Notify the primary health care provider now and request a prescription for antibiotic therapy. D. Ask the primary health care provider to prescribe a tetanus booster vaccination. E. Immediately obtain a specimen for culture and sensitivity testing. F. Cleanse the wound and apply a dry dressing to it.

A, B, C, F

A client had a left noncemented posterolateral total hip arthroplasty 2 days ago. Which statements will the nurse include in health teaching for the client? Select all that apply. A. "Practice leg exercises each day as instructed." B. "Take deep breaths and use incentive spirometry every 2 hours." C. "Be sure to cross your legs to be more comfortable in a chair." D. "Report sudden increased hip pain or rotation immediately to the nurse." E. "Stand on your right leg and pivot into the chair when getting out of bed."

A, B, D, E

When preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? Select all that apply. A. Nits can be removed with a fine-tooth comb. B. Parasites eventually die off without treatment. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest any place on the body with hair, including eyelashes and axillae.

A, C, D, E

Which teaching will the nurse provide to the client who just underwent a skin biopsy and had sutures placed to close the wound? Select all that apply. A. Use antibiotic ointment as prescribed. B. Return for suture removal in 2 to 3 days. C. Report redness to the health care provider. D. Keep dressing moist so skin does not dry out. E. Use tap water or saline to remove any crusting.

A, C, E

The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."

A, C, E, F

Which assessment findings will the nurse expect for the client with early-stage rheumatoid arthritis? Select all that apply. A. Joint inflammation B. Subcutaneous nodules C. Severe weight loss D. Fatigue E. Thrombocytosis F. Anorexia

A, D, F

Which statement(s) regarding type III hypersensitivity reactions is/are true? Select all that apply. A. Type III responses are usually directed against self cells and tissues. B. Susceptibility for developing a type III hypersensitivity response follows an autosomal dominant pattern of inheritance. C. The hypersensitivity starts as a type II reaction that progresses to a type III reaction. D. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. E. Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity. F. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

A, E

The nurse is conducting an admission assessment on a male client. Which assessment data does the nurse identify as a risk factor for cardiovascular disease? Select all that apply. A. BMI of 26 B. BP of 120/66 mm Hg C. Triglycerides 140 mg/dL D. Moderate exercise for 20 to 30 minutes weekly E. Exposure to secondhand cigarette smoke F. History of repeated streptococcal tonsillitis G. Family history of cardiovascular disease

A, E, F, G

A client who underwent radical neck surgery for head and neck cancer 5 days ago tells the nurse that he is worried because his right shoulder is lower than the left and does not go back into place when he tries to raise it. What is the nurse's best response? A. "I will notify the surgeon right away because some leftover tumor must be pressing on the nerve." B. "The nerve to the shoulder was removed during surgery. Physical therapy will help you to use other muscles to regain some motion." C. "This problem is not related to your surgery. If it persists after you go home you will need to see your primary health care provider about it." D. "Your time under anesthesia was long and you are not yet fully recovered. It is likely you will regain full motion in that shoulder by the end of the week."

B

The nurse is caring for a client immediately following a cardiac catheterization. Which assessment data require immediate nursing intervention? A. Blood pressure 146/70 mm Hg B. Hematoma developing at insertion site C. Client reports headache pain D. Client reports extreme thirst

B

The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which assessment finding requires immediate nursing intervention? A. Increased itching B. Temperature of 100°F C. Presence of new plaques on leg D. Expression of impaired self-image

B

Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy? A. Avoid injecting it in a site near a cutaneous lesion. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because it causes extreme drowsiness.

B

Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."

B

Which intervention will the nurse delegate to assistive personnel (AP) for a client who has poor personal hygiene? Select all that apply. A. Obtain a social history. B. Assist the client with bathing. C. Help the client with brushing of teeth. D. Tell the client that he or she smells bad. E. Consult social services to assess the client's living conditions. F. Teach client and family members how to help with personal hygiene. G. Notify the health care provider of suspected drug or alcohol addiction. H. Assess for cognitive function or physical limitations that can interfere with grooming.

B, C

The primary health care provider prescribes daily celecoxib for a client experiencing persistent joint pain in both knees. Which health teaching will the nurse provide for the client regarding this drug for long-term pain control? Select all that apply. A. "Take the prescribed drug before breakfast each day." B. "Report any sign of bleeding, including bloody or dark, tarry stool." C. "Do not take other NSAIDs while on celecoxib." D. "Report any major changes in the amount of urine you excrete each day." E. "Follow up with lab tests to assess liver function."

B, C, D

Which assessment data regarding a lesion found on a 39-year-old client who uses a tanning bed requires nursing intervention? Select all that apply. A. Symmetrical and light pink B. Brownish-purple with irregular borders C. Changed in shape since last appointment D. 8 mm wide and described as itching often E. Regular border with fixed size and elevation

B, C, D

The nurse is assessing a client who has late-stage rheumatoid arthritis. Which assessment findings would the nurse expect for this client? Select all that apply. A. Joint inflammation B. Severe weight loss C. Bony nodules D. Joint deformities E. SjÖgren syndrome

B, C, D, E

Which statement(s) regarding type I hypersensitivity reactions is/are true? Select all that apply. A. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine. B. The response is characterized by the five cardinal symptoms of inflammation. C. Type I responses are usually directed against non-self but the response is excessive. D. Susceptibility for developing a type I hypersensitivity response follows an X-linked recessive pattern of inheritance. E. This type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus. F. Responses always occur within minutes of exposure to the allergen. G. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

B, C, G

Which information is most relevant for the nurse to teach a client about CPAP therapy for OSA? Select all that apply. A. Avoid alcoholic beverages or drugs that make you sleepy within 3 hours of bed time. B. Clean the mask device daily. C. Ensure your mask device fits tightly enough to prevent air leaks. D. Keep open flames such as candles out of the room when CPAP is in use. E. Seal the mask edges to your face with petroleum jelly. F. Use only sterile water in the humidifier tank. G. Use the CPAP during all sleep periods, especially in bed. H. Do not share your mask or tubing system with others.

B, C, G, H

In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side effects does the nurse teach the client to expect? Select all that apply. A. Scalp and eyebrow alopecia B. Taste sensation loss or changes C. Bloody and purulent sinus drainage D. Increased risk for skin breakdown E. Moderate weight gain F. Increased risk for cavities G. Gastroesophageal reflux H. A persistent blue tinge to the skin and mucous membranes around the mouth

B, D, F

A client shows the nurse two pictures of the same lesion, taken 1 month apart. Which assessment finding requires nursing intervention? A. The light pink color of the lesion is the same in both photographs. B. The lesion has almost disappeared by the time of the second photograph. C. The lesion borders have expanded and are shaped differently in the second picture. D. The lesion's well-approximated margins and size look no different in either photograph.

C

A client with a large, irregularly shaped mole on the upper chest expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a dermatologic health care provider. B. Ask if there are any other lesions that are bothersome. C. Perform a head-to-toe skin assessment and document the findings. D. Teach about the importance of avoiding excessive sun exposure and tanning beds.

C

A client with severe angioedema and tongue swelling from a drug allergy has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare? A. Nasal CPAP B. Tracheotomy C. Cricothyroidotomy D. Endotracheal intubation

C

Assistive personnel (AP) are assigned to care for a client who had a cemented total knee arthroplasty yesterday. Which observation by the AP indicates a need for follow-up by the nurse? A. "The client's surgical knee is very swollen and discolored." B. "The client states that the surgical knee is very painful when moving it." C. "The client's lower leg on the surgical side is painful and red." D. "The client needs assistance with walking to the bathroom."

C

How do macrophages contribute to the neutrophils that occurs in response to an acute bacterial infection? A. when invasion occurs, macrophages mature into neutrophils, increasing their circulating numbers B. macrophages have only an indirect role in neutrophilia by secreting substances that reduce bone marrow production of erythrocytes and platelets C. at the onset of invasion, macrophages secrete a colony-stimulating factor to induce the bone marrow to increase production and release of neutrophils D. inflammatory damage to macrophages allows release of proteolytic enzymes that enhance liver production of all white blood cell types, including mature segmented neutrophils

C

The nurse is assessing a client with heart failure. Which assessment data are the best indicator of fluid balance? A. Blood pressure 144/79 mm Hg B. Urine output 200 mL in the last 4 hours C. Weight increase of 9 lb in the past week D. Generalized edema in the lower extremities

C

The white blood cell count with differential of a client undergoing preadmission testing before surgery indicates a total count of 5000 cells per cubic millimeter (mm3) of blood. Which of the follow differential counts or percentages does the nurse report to the surgeon to prevent harm? A. Eosinophils 300/mm3 B. Monocytes 600/mm3 C. Segmented neutrophils 2000/mm3 D. Lymphocytes 2100/mm3

C

Which action will the nurse perform first for a client in anaphylaxis to prevent harm? A. Applying oxygen by nonrebreather mask B. Administering IV diphenhydramine C. Injecting epinephrine D. Initiating IV access

C

Which client statement regarding treatment of a skin infection requires intervention by the nurse? A. "I am not going to share my clothes with anyone else." B. "Because I am over 60, I am going to get the shingles vaccine." C. "It is important to keep my skin very moist, so I will use lotion." D. "If I get a fever or chills, I will contact my primary health care provider."

C

Which new-onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm? A. Increased bruising B. Increased daily output of slightly foamy urine C. Failure to see letters in the middle of a word D. Sensation of nausea within an hour of taking the drug

C

Which cells, products, or actions are involved in long-lasting immunity resulting from exposure to a specific antigen? select all that apply. A. antibody attenuation B. interleukin 10 (IL-10) C. memory B cells D. monocyte maturation E. neutrophilia F. phagocytosis

C, D

A client has just come to the floor after undergoing inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse's priority action? A. Administer the prescribed antiemetic by the intravenous or rectal route. B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team. C. Cut the wires holding his jaws together, and carefully remove them from the mouth. D. Reposition the client to the side and suction the mouth with a large-bore catheter.

D

How will the nurse describe a shave biopsy to a client? A. "A scalpel will be used to remove a deep sample of skin." B. "A small plug of tissue will be removed with a circular cutting instrument." C. "A deep specimen of skin will be taken, and the area will be sutured closed." D. "A razor blade will be gently moved across the skin's surface to obtain a sample."

D

The nurse is caring for a client who had an anterior total hip arthroplasty yesterday. For which commonly occurring postoperative complication will the nurse monitor for this client? A. Pneumonia B. Paralytic ileus C. Wound dehiscence D. Venous thromboembolism

D

What teaching will the nurse provide when educating about carbon monoxide prevention? A. "Carbon monoxide is only dangerous if accompanied by fire." B. "Black smoke can be seen when carbon monoxide is in the air." C. "Your skin will turn a blue color if you have carbon monoxide poisoning." D. "Put carbon monoxide detectors in your home, because this is an odorless gas."

D

When making rounds, the nurse observes that a cognitively impaired client has a partial airway obstruction from inspissation. What is the nurse's priority action? A. Place the bed in reverse Trendelenburg position and apply humidified oxygen by nasal cannula. B. Check the flow sheet to assess for trends in the client's oxygen saturation patterns. C. Determine which assistive personnel (AP) provided this client's morning care today. D. Immediately provide complete oral care to this client.

D

When teaching a community group about burn prevention, which education will the nurse include? A. "Have a smoke detector in one central spot in the home." B. "If you use home oxygen, turn it down when you are smoking." C. "Set your water heater temperature below 160°F (71°C.)." D. "Plan several ways of escape from the home in case the primary exit is blocked."

D

Which change would the nurse expect to see in the white blood cell differential of a client who has a prolonged, severe intestinal helminth infestation? a. band neutrophils outnumber segmented neutrophils b. macrophage count is low c. monocyte count is high d. eosinophil count is high

D

Which nursing action has the highest priority when caring for a client with any type of facial or laryngeal trauma? A. Managing pain B. Providing nutrition C. Assessing self-image D. Maintaining a patent airway

D