Med Surg. Hematology, Oncology, & Endocrine Care

The nurse is caring for a client with poorly managed diabetes mellitus. The nurse is planning education for this client. Which statement by the client indicates a need for more education? -"As long as I administer insulin and maintain a normal glucose, I can eat whatever I want" -"As long as I inspect my feet for cuts or wounds daily, I shouldn't have to worry about getting a foot infection" -"I should check my glucose about six to seven times a day to get my HbA1C down" -"If I skip a couple meals, my glucose may go up"

-"As long as I administer insulin and maintain a normal glucose, I can eat whatever I want" This statement is not true, and indicates a need for more education. The client needs to eat a balanced diet along with insulin use to achieve stable glucose control. -"As long as I inspect my feet for cuts or wounds daily, I shouldn't have to worry about getting a foot infection" This statement is true. When the client practices frequent feet checks, they will catch any issues early enough to get treatment in a timely manner. -"I should check my glucose about six to seven times a day to get my HbA1C down" This statement is true. When a client's glucose level is poorly controlled, they must check their blood glucose often to understand how to better control the level. -"If I skip a couple meals, my glucose may go up" This statement is true. When the body goes into starvation mode, it starts to break down lipids which can spike the glucose levels.

The nurse is working with a client who has been diagnosed with Cushing's syndrome. The nurse has provided teaching about the disease process and management. Which of the following statements by the client demonstrates a need for additional teaching? -"I am secreting too much cortisol, which is what's causing my symptoms" -"I will need to take levothyroxine for the rest of my life" -"You are going to monitor my labs closely because electrolyte disturbances are common" -"If we don't treat this, it can become life-threatening"

-"I am secreting too much cortisol, which is what's causing my symptoms" This is a TRUE statement in regards to Cushing's syndrome. -"I will need to take levothyroxine for the rest of my life" Taking a thyroid medication is necessary for persons with hypothyroidism rather than hyperthyroidism. Taking this drug would cause the condition to worsen. -"You are going to monitor my labs closely because electrolyte disturbances are common" Electrolyte disturbances seen with Cushing's syndrome include hypokalemia, hypocalcemia. and hypernatremia. -"If we don't treat this, it can become life-threatening" If left untreated, Cushing's syndrome can progress to heart failure, as well as profound glucose abnormalities and electrolyte imbalances.

A nurse is educating a newly diagnosed diabetic client about what to do when they are sick. Which of the following statements by the client demonstrates that further education is necessary? -"I'll make sure to test my urine for ketones." -"My blood sugars may be elevated if I am sick." -"It's important to try to keep fluids down even if I am feeling ill." -"I can go ahead and double my insulin dosages while sick."

-"I'll make sure to test my urine for ketones." It is possible for a client who is ill to develop diabetic ketoacidosis or see higher levels of ketones in their urine. It is important for clients to test their urine for ketones at least daily, or more often if instructed. -"My blood sugars may be elevated if I am sick." Due to extra stress on the body, diabetic clients may experience elevated blood sugars when they are sick. It's important to continue to monitor their blood sugars closely during periods of illness. -"It's important to try to keep fluids down even if I am feeling ill." Clients should be instructed to ensure adequate or increased fluid intake to prevent dehydration. -"I can go ahead and double my insulin dosages while sick." When sick, a client with diabetes may experience higher blood sugars, but insulin dosages should continue to be based on the actual blood sugar level and food intake. Clients should not simply double their insulin levels, this would not be appropriate.

A nurse is caring for a postpartum client with disseminated intravascular coagulation. The client's family wants to understand what this means. What is the best response by the nurse? -"She is bleeding because there was too much trauma during delivery" -"She is bleeding heavily because her immune system is attacking her platelets" -"She is bleeding heavily because of an overreaction of her clotting system" -"She is bleeding heavily, but we can control it easily"

-"She is bleeding heavily, but we can control it easily" DIC is difficult and complicated to treat, plus this provides false hope to the client's family. -"She is bleeding because there was too much trauma during delivery" Although trauma is a risk factor for DIC, in this case, the trauma is not the reason she is bleeding so much in DIC. -"She is bleeding heavily because of an overreaction of her clotting system" This is the correct explanation of what is happening to the client in DIC. -"She is bleeding heavily because her immune system is attacking her platelets" This is not what happens in DIC - this is an explanation of Immune Thrombocytopenia Purpura.

A nurse is caring for a client with leukemia who is undergoing chemotherapy. The nurse is educating the client's family on what to expect throughout treatment. Which statement by the family would demonstrate understanding of education? -"The most likely complication he will experience from the leukemia is a stroke." -"Leukemia will cause him to bleed significantly, so we should get him an electric razor." -"The most important thing we can do to help is wash our hands and keep sick people away from the home." -"The most dangerous thing he will experience is the excessive vomiting and dehydration from chemo."

-"The most likely complication he will experience from the leukemia is a stroke." It is possible for a client with leukemia undergoing chemotherapy to experience a stroke, but it is not the most common or most likely complication of the leukemia itself. -"Leukemia will cause him to bleed significantly, so we should get him an electric razor." Although clients undergoing chemotherapy may experience thrombocytopenia, the leukemia itself does not cause this complication. Clients and their families should be educated on what things are signs and symptoms of the disease versus side effects of the treatment. -"The most important thing we can do to help is wash our hands and keep sick people away from the home." Clients with cancer undergoing chemotherapy most often die from infection due to immunosuppression, NOT from the cancer itself. This is especially the case in clients with leukemia as the leukemia itself has suppressed their immune system as well. Handwashing and avoiding sick contacts is one of the best ways to prevent infection in these clients. -"The most dangerous thing he will experience is the excessive vomiting and dehydration from chemo." Although this is common, the most dangerous complication for clients undergoing chemotherapy is infection due to the significant immunosuppression. Clients and their families should know how to address dehydration, but the MOST important thing is to prevent infection.

A newly diagnosed client with type 2 diabetes has been prescribed metformin as an oral hypoglycemic agent. Which best describes how the nurse would explain this medication? -"This is a type of oral insulin taken once a week" -"This medication is used for type 2 diabetes but not for type 1" -"You will need to take this when your blood glucose levels get low" -"You can also use this medicine if you develop complications such as diabetic ketoacidosis"

-"This is a type of oral insulin taken once a week" Metformin is taken daily. -"This medication is used for type 2 diabetes but not for type 1" Metformin is an oral hypoglycemic agent that is used in the management of type 2 diabetes. Metformin is used to control blood glucose levels by increasing the liver's sensitivity to glucose levels in the blood. The client takes it every day as an oral tablet. Metformin is used in type 2 diabetes, but never exclusively in type 1 diabetes. -"You will need to take this when your blood glucose levels get low" This medication is for keeping blood glucose levels from getting too high, not too low. -"You can also use this medicine if you develop complications such as diabetic ketoacidosis" Diabetic ketoacidosis is a situation that requires immediate medical attention. Metformin should never be used to treat diabetic complications.

A client is rushed to the emergency department after a peanut exposure and subsequent anaphylactic reaction. The nurse prepares to administer epinephrine. Which concentration and route should the nurse utilize? -1:10,000 given IV -1:10,000 given IM -1:1,000 given IM -1:1,000 given IV

-1:10,000 given IV This dose and route is for cardiac arrest. -1:10,000 given IM This is too high of a concentration to give intramuscularly. -1:1,000 given IM For an allergic reaction the concentration is 1:1,000 and is administered IM. IV epinephrine may be given for anaphylaxis, but only if the client has profound hypotension or is in cardiac arrest. -1:1,000 given IV This concentration is given IM, but not IV

A 9-year old child is brought to the emergency room in anaphylactic shock. Which of the following medication orders would be the most appropriate for this child? -50 mg Diphenhydramine PO -25 mg Diphenhydramine IM -0.5 mg of 1:10,000 Epinephrine IV -0.3 mg of 1:1,000 Epinephrine IM

-50 mg Diphenhydramine PO Not only is this dose too high for a 9 year old, but Diphenhydramine is not the appropriate treatment for anaphylaxis. -25 mg Diphenhydramine IM Diphenhydramine is not an appropriate treatment for anaphlyaxis. It could be given in a lower dose in PO form when initial allergy symptoms present, but once signs of anaphylaxis are present, Epinephrine is the correct treatment. -0.5 mg of 1:10,000 Epinephrine IV Epinephrine 1:10,000 concentration is used in cardiac arrest when given IV. In that case, it is given at a dose of 0.01 mg/kg. -0.3 mg of 1:1,000 Epinephrine IM Epinephrine 1:1,000 concentration should be given IM during an anaphylactic reaction. 0.3 mg is an appropriate dose for a 9 year old.

A nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which pH level would be consistent with this diagnosis? -7.52 -7.31 -7.35 -7.41

-7.52 This would be an alkalosis. -7.31 Normal pH range is 7.35 to 7.45. Acidosis exists with pH levels under 7.35. -7.35 This is a normal pH. -7.41 This is a normal pH.

The nurse working in the emergency department is receiving report. Out of the following group of clients, which would the nurse be concerned about developing hypovolemic shock? -A 16-year-old in diabetic ketoacidosis -A 19-year-old with tricholillomania -A 15-year-old with a urinary tract infection -A 20-year-old with fibromyalgia

-A 16-year-old in diabetic ketoacidosis Diabetic ketoacidosis (DKA) causes polyuria which can lead to severe dehydration and hypovolemic shock. The main concern of the nurse will be to treat the underlying cause, and keep the client hydrated. Causes of hypovolemic shock include body fluid depletion, hemorrhage due to trauma, surgery, GI ulcer, and increased clotting, dehydration due to nausea, vomiting and diarrhea, hyperglycemia, and diuretic therapy. -A 19-year-old with tricholillomania This client is not at risk for hypovolemic shock. -A 15-year-old with a urinary tract infection This client is not at risk for hypovolemic shock. -A 20-year-old with fibromyalgia This client is not at risk for hypovolemic shock.

A 78-year-old client is being admitted to the hospital for surgery. The client has a history of lymphoma that has returned twice after undergoing chemotherapy treatments, and has a DNR order in place in case of cardiac arrest. What is a true statement regarding a DNR order? Select all that apply. -A DNR order is a type of advance directive known as a provider order -The client's wishes for DNR must be communicated to the staff and a written copy of the order must be placed in the client's chart -Unless the DNR order is in the client's record, the nurse must initiate CPR if cardiac arrest occurs. -The DNR order can be signed by the power of attorney if the client goes into cardiac arrest -A DNR order is the same as a do not intubate order

-A DNR order is a type of advance directive known as a provider order A DNR order is part of an advance directive that is known as a provider order, in which the client has given specific directions not to have CPR. -The client's wishes for DNR must be communicated to the staff and a written copy of the order must be placed in the client's chart An advance directive specifies the client's decisions ahead of time before the client becomes unable to do so, and may include a DNR order. -Unless the DNR order is in the client's record, the nurse must initiate CPR if cardiac arrest occurs. A DNR order can be confusing to caregivers and family members who are present if a client is dying. -The DNR order can be signed by the power of attorney if the client goes into cardiac arrest A DNR order must be in place prior to the cardiac arrest event, or staff is required to begin CPR and other life-saving measures. A DNR order is not initiated after cardiac arrest occurs. -A DNR order is the same as a do not intubate order A person can have a "Do not intubate" order, but still require CPR if cardiac arrest occurs. If a person has a DNR order, CPR is NOT initiated in the event of cardiac arrest.

A 48-year-old client has been diagnosed with pancreatic cancer. The client asks the nurse, "How could this have happened to me?!" Which of the following has been shown to be a risk factor for development of pancreatic cancer? Select all that apply. -A history of eating disorders -Exposure to certain pesticides -Tobacco use -Female gender -Asian ethnicity

-A history of eating disorders This is not a risk factor for the development of pancreatic cancer. -Exposure to certain pesticides This is a risk factor for pancreatic cancer. -Tobacco use Cancer of the pancreas is a life-threatening condition with a poor prognosis, because clients who are diagnosed with pancreatic cancer usually have a large tumor by the time symptoms appear. Risk factors for this type of cancer include such factors as tobacco use, a high-fat diet, alcohol use, diabetes mellitus, and exposure to certain toxic chemicals, such as pesticides. Increased age is also a risk factor. -Female gender This is not a risk factor for the development of pancreatic cancer. -Asian ethnicity This is not a risk factor for the development of pancreatic cancer.

A client is scheduled to receive a fine needle aspiration of the thyroid gland for a biopsy. Which best describes how the nurse would teach the client about this procedure? -A very thin needle is used to take out a small portion of your thyroid gland -The surgeon makes an incision and removes a small area of your thyroid for testing -A needle is inserted then an ultrasound is done to assess the structure of your thyroid gland -The provider will inject medication and then take an x-ray

-A very thin needle is used to take out a small portion of your thyroid gland A fine-needle aspiration is one method of taking a biopsy of the thyroid gland when cancer is suspected. The provider applies a local anesthetic and then inserts a very thin needle into the tissue to aspirate a small number of cells. The process is mostly painless for the client and requires a small bandage over the site after it is complete. -The surgeon makes an incision and removes a small area of your thyroid for testing This describes an open surgical biopsy rather than a fine needle aspiration biopsy. -A needle is inserted then an ultrasound is done to assess the structure of your thyroid gland No ultrasound is done during a fine needle aspiration biopsy. Cells are taken for testing only. -The provider will inject medication and then take an x-ray This describes an open surgical biopsy rather than a fine needle aspiration biopsy.

The nurse is caring for a client with Addison disease. Which of the following manifestations of this condition should the nurse expect? Select all that apply. -Abdominal bloating -Hypertension -Chronic fatigue -Weight gain -Muscle weakness

-Abdominal bloating Bloating is correct. Addison disease is characterized by muscle weakness; anorexia; GI symptoms; fatigue; emaciation; dark pigmentation of the mucous membranes and the skin, especially of the knuckles/knees/elbows; hypotension; and low blood glucose, low serum sodium, and high potassium levels. Abdominal bloating is both a GI symptom and possible clinical sign of emaciation. -Hypertension Hypertension is incorrect. A deficiency in aldosterone causes a reduction in sodium and water retention, which decreases blood volume and lowers blood pressure. Aldosterone helps maintain the balance of the minerals sodium and potassium in your blood. Sodium and potassium work together to control the salt and water balance in your body and help keep blood pressure stable. -Chronic fatigue This is correct, chronic fatigue is present in Addison Disease due to the presence of adrenal insufficiency. -Weight gain Weight gain is incorrect. Addison Disease causes weight loss due to the lack of sodium and water retention. Also, because Addison Disease causes adrenal insufficiency where the cortex doesn't produce enough cortisol, blood glucose levels are not well controlled. -Muscle weakness Muscle weakness is correct. Lab values typically indicate hypoglycemia, hyponatremia, and hyperkalemia.

A nurse is caring for a client is undergoing a parathyroidectomy. Which potential risks must the nurse consider when caring for this client following surgery? -Acoustic neuroma -Negative nitrogen balance -Bronchial stridor -Hypocalcemia

-Acoustic neuroma This is a tumor associated with the inner ear and is unrelated to the parathyroid gland. -Negative nitrogen balance A negative nitrogen balance is associated with hyperthyroidism, as well as burns and other tissue injuries and periods of fasting, but not with a parathyroidectomy. -Bronchial stridor Bronchial stridor is not a risk, as a parathyroidectomy does not affect the bronchioles. -Hypocalcemia The post-operative parathyroidectomy client is at risk for hypocalcemia, because the parathyroid secretes parathyroid hormone (PTH), which increases the calcium level in the bloodstream by causing calcium release from bone tissue. The nurse can expect that the client who undergoes a parathyroidectomy will have serial calcium lab values drawn so the level can be closely monitored. Signs of hypocalcemia include tingling and twitching in the face and extremities.

A provider has prescribed hormone replacement therapy for a client who has Addison's disease. The nurse who is caring for this client understands the difference between Addison's disease and Cushing's syndrome as which of the following? -Addison's causes signs of masculinity in women while Cushing's causes atrophy of skin, tissues, and hair -Addison's occurs as the result of decreased secretions of hormones while Cushing's occurs as a result of increased secretion -Addison's requires treatment with lifetime hormone replacement therapy while Cushing's does not -Addison's is caused by hyperplasia of the adrenal gland while Cushing's is caused by pituitary enlargement

-Addison's causes signs of masculinity in women while Cushing's causes atrophy of skin, tissues, and hair Signs and symptoms of Addison's include weight loss, GI problems, lethargy and hyperpigmentation of the skin. Signs and symptoms of Cushing's include generalized weakness, truncal obesity, and masculine characteristics in women. -Addison's occurs as the result of decreased secretions of hormones while Cushing's occurs as a result of increased secretion Addison's disease and Cushing's syndrome are two conditions that develop as a result of abnormal secretion of hormones. In the case of Addison's disease, the client does not secrete enough adrenocortical hormones, and the treatment is to ADD glucocorticoid or mineralocorticoi medications as prescribed. In Cushing's syndrome, the client secretes too much cortisol due to a variety of potential factors, including ACTH secreting tumors or a metabolic disorder. -Addison's requires treatment with lifetime hormone replacement therapy while Cushing's does not Addison's requires lifelong glucocorticoid replacement, and clients with Cushing's who get an adrenalectomy will also require lifetime hormone replacement. -Addison's is caused by hyperplasia of the adrenal gland while Cushing's is caused by pituitary enlargement Cushing's is caused by the administration of glucocorticoids, or excess production of cortisol. Addison's is caused by the hyposecretion of adrenal cortex hormones.

A client is enroute to the Emergency Department with a hyperosmolar, hyperglycemic state (HHS). The nurse will anticipate doing which of the following? -Address dehydration -Administer insulin -Maintain IV access -Lower blood pressure -Routine antibiotics

-Address dehydration Dehydration is one of the effects of hyperosmolarity, so the nurse will anticipate and prepare for IV fluid resuscitation of the client. -Administer insulin The nurse will need to treat the cause of the hyperosmolarity, which involves lowering the blood glucose level. Clients with HHS have blood glucose levels >600 mg/dL, and giving insulin as ordered will help correct this. -Maintain IV access A client with HHS may have mild to severe alterations in mental status. The nurse will anticipate this and plan to maintain client safety as necessary. -Lower blood pressure Hypertension is not an expected symptom of hyperosmolar hyperglycemia. Instead, the client may demonstrate a decreased blood pressure. -Routine antibiotics HHS is not treated using antibiotics unless infection is suspected.

A nurse in the intensive care unit (ICU) is caring for a client with diabetic ketoacidosis (DKA). Which of the following is NOT a priority nursing intervention for this client? -Administer IV regular insulin -Administer hypertonic saline for fluid resuscitation -Monitor blood glucose at least hourly -Monitor serum potassium levels and replace as needed

-Administer IV regular insulin Clients with DKA will require IV insulin therapy to bring their blood sugars down and correct the ketoacidosis. This is a priority intervention. -Administer hypertonic saline for fluid resuscitation While fluid resuscitation is a cornerstone of DKA treatment, they are treated with isotonic fluid replacement rather than hypertonic. The primary fluid choice would be normal saline or D5 1/2NS once the sugar comes down a bit. -Monitor blood glucose at least hourly POC glucose levels will be monitored at least hourly, if not more often, especially when insulin therapy is in use. This is a priority intervention. -Monitor serum potassium levels and replace as needed Clients with DKA will be admitted with a high potassium, but then insulin therapy can drop the potassium levels rapidly. Monitoring potassium levels closely is very important in DKA.

A nurse is working with a client who is brought in the emergency department with abdominal pain and dehydration. His glucose level is 388 mg/dL and he has positive serum ketones. Based on theses symptoms and lab values, which action would the nurse expect to perform first? -Administer IV regular insulin at 0.1 unit/kg bolus -Administer 0.25% NaCl at a rate of 200 mL/hr -Provide breathing support with bag-mask ventilation -Establish central line access

-Administer IV regular insulin at 0.1 unit/kg bolus This client is experiencing diabetic ketoacidosis (DKA), which is a life-threatening complication of diabetes that can cause severe hyperglycemia. The client may have blood glucose levels above 300 mg/dL and a rapid breakdown of fat for energy. In this situation, the nurse should administer isotonic fluids to maintain hydration and give a bolus of insulin to bring down the blood glucose levels. -Administer 0.25% NaCl at a rate of 200 mL/hr This is a hypotonic solution. Administering hypotonic solutions at a rapid rate in DKA can lead to cerebral edema. -Provide breathing support with bag-mask ventilation The client in this example is not experiencing respiratory distress. The first action the nurse would perform out of the choices is to give IV insulin as ordered. -Establish central line access The initial interventions for the client in DKA can be done with a 20 gauge peripheral IV.

A client who is receiving a blood transfusion has developed symptoms of circulatory overload. Which of the following nursing interventions are most appropriate in this situation? Select all that apply. -Administer ampicillin -Provide patient oxygen -Elevate the head of the bed -Increase fluid rate -Administer furosemide (Lasix)

-Administer ampicillin Giving the client an antibiotic would not help with symptoms of circulatory overload. -Provide patient oxygen This is an appropriate nursing intervention with fluid overload. -Elevate the head of the bed This intervention will help a client with fluid overload. Circulatory overload can occur after a blood transfusion if there is too much fluid in the client's circulation, and symptoms of this include distended neck veins, difficulty breathing, and wet lung sounds. Nursing interventions include providing oxygen as needed, elevating the head of the bed, and administering furosemide, which is a diuretic. -Increase fluid rate The client needs LESS fluid circulating, not more. -Administer furosemide (Lasix) This is an appropriate nursing intervention with fluid overload.

After starting a transfusion of packed red blood cells on a client, the nurse notes that the client has developed chills, flank pain, and new hematuria. The nurse suspects an acute hemolytic reaction to the blood. What should the nurse do first? -Administer diphenhydramine -Administer normal saline solution intravenously -Obtain a urine sample for the lab -Stop the transfusion

-Administer diphenhydramine This is incorrect. Although all the interventions may be appropriate, the highest priority is to stop the transfusion immediately so the reaction does not progress. -Administer normal saline solution intravenously This is incorrect. Although all the interventions may be appropriate, the highest priority is to stop the transfusion immediately so the reaction does not progress. -Obtain a urine sample for the lab This is incorrect. Although all the interventions may be appropriate, the highest priority is to stop the transfusion immediately so the reaction does not progress. -Stop the transfusion This is correct. Although all the interventions may be appropriate, the highest priority is to stop the transfusion immediately so the reaction does not progress.

The nurse is caring for a client with immune thrombocytopenic purpura. Which of the following interventions would the nurse expect to employ? -Administer fresh frozen plasma -Monitor for fever -Monitor for thromboses -Administer immunoglobulin and steroids

-Administer fresh frozen plasma Emergency management of this condition may include platelet transfusions, but not FFP. -Monitor for fever Fever is not a side effect of immune thrombocytopenic purpura. -Monitor for thromboses Rather than blood clotting, the client is at risk for bleeding. -Administer immunoglobulin and steroids Clients with immune thrombocytopenic purpura have bleeding problems and are treated with immunoglobulin and steroids. Treatment with corticosteroids slows the rate of platelet destruction, and helps reduce bleeding and bruising. Immunoglobulins suppress anti-platelet antibodies.

A 25-year-old client has been diagnosed with HIV. Which of the following manifestations of endocrine dysfunction have been associated with this type of infection? -Adrenal insufficiency -Testicular hypertrophy -Excess parathyroid hormone secretion -Diabetes insipidus

-Adrenal insufficiency HIV infection can cause a number of endocrine-related dysfunctions in the affected client. A nurse caring for a client with HIV may most likely see adrenal insufficiency, decreased testosterone and androgen function and altered thyroid function. None of these alterations are related to CD4 counts and can appear in the early or late stages of HIV infection. -Testicular hypertrophy This is not routinely associated with HIV infection. -Excess parathyroid hormone secretion This is not routinely associated with HIV infection. -Diabetes insipidus This is not routinely associated with HIV infection.

A nurse is caring for a 43-year-old client who has been diagnosed with Hashimoto's thyroiditis. The nurse expects which of the following findings with Hashimoto's thyroiditis? Select all that apply. -An elevated T3 -Anti-TPO -A low T3 -An elevated T4 -An elevated TSH

-An elevated T3 An elevated T3 level (>135 ng/dL) is expected in hyperthyroidism. -Anti-TPO Anti-TPO antibodies are found in 90% of patients with Hashimoto's thyroiditis. -A low T3 Hashimoto's thyroiditis causes a low T3 level (< 77 ng/dL). -An elevated T4 Hashimoto's thyroiditis causes a normal to low T4 level (< 5.4 ug/dL). -An elevated TSH Hashimoto's thyroiditis is an autoimmune disorder in which the immune system attacks the thyroid gland. As a result, the TSH level increases (> 4.25 IU/mL)>

A client has been infected with HIV for 5 years. Which of the following would require a change in the client's diagnosis from being HIV-positive to having AIDS? -An estimation of six months left to live -A hemoglobin level of 13.2 g/dL -The presence of HIV for at least ten years -A CD4 count of less than 200 cells/mm3

-An estimation of six months left to live Criteria to diagnose AIDS is 1) CD4 T-cell count <200 cells/L and/or the following: presence of a fungal, viral, protozoal or bacterial infection; presence of an opportunistic cancer; wasting syndrome; AIDS dementia complex. -A hemoglobin level of 13.2 g/dL HIV affects white blood cells, not red blood cells. -The presence of HIV for at least ten years The client must meet specific criteria to have progressed to AIDS. -A CD4 count of less than 200 cells/mm3 A person who is infected with HIV has the potential to develop AIDS, which is a very advanced stage of the infection. The person can become very ill from opportunistic infections, which take advantage of the lack of immune response against pathogens. A person with HIV can be classified as having AIDS when his CD4 count drops to below 200 cells/mm3 and/or he has serious symptoms from an opportunistic infection.

A client is newly diagnosed with Addison's disease. The nurse understands that this condition includes a decrease of which of the following hormones? Select all that apply. -Androgen -Testosterone -Mineralcorticoids -Insulin -Glucocorticoids

-Androgen This is a hormone also secreted by the adrenal cortex. -Testosterone Testosterone is secreted mainly by the gonads. A small amount of testosterone is secreted by the adrenal cortex, but deficiency in adrenal cortex hormones does not produce a deficiency in testosterone. -Mineralcorticoids These hormones are secreted by the adrenal cortex, and are deficient in Addison's disease. -Insulin Insulin is secreted by the pancreas. -Glucocorticoids Glucocorticoids are secreted by the adrenal cortex.

A 31-year-old client comes to the healthcare center for help with emotional disturbance. The provider diagnoses the client with hypothyroidism. Which of the following psychological conditions is most likely associated with hypothyroidism? -Anger and aggression -Anxiety -Dementia -Depression

-Anger and aggression Irritability is associated with hyperthyroidism, but lethargy is a symptom associated with too little thyroid hormone, rather than anger and aggression -Anxiety Irritability is associated with hyperthyroidism, but lethargy is a symptom associated with too little thyroid hormone, rather than anger and aggression -Dementia These are not associated with hypothyroidism. -Depression Hypothyroidism can lead to a number of alterations in body systems for the affected client. Because the thyroid gland is associated with body metabolism, the client may suffer from multiple negative effects. Depression is a common psychological condition associated with hypothyroidism, so the nurse who cares for a client with depression should be prepared to consider the potential effects between the thyroid gland and cognitive function.

A nurse receives a client that came by ambulance. The nurse suspects that this client is in diabetic ketoacidosis (DKA). Which of the following signs would suggest DKA? -Anuria -Fruity breath -Halitosis -Strawberry red tongue

-Anuria Anuria is the inability to urinate. A client in DKA will have polyuria, not anuria. -Fruity breath Clients in DKA often have fruity odor on their breath, which is caused by excess ketones in the body. -Halitosis Halitosis, or odorous breath can indicate tonsilloliths, not DKA. -Strawberry red tongue A strawberry red tongue can indicate Kawasaki's syndrome, but not DKA.

A 40-year-old client has thyroid dysfunction and is working with a nurse to determine what lifestyle changes will help this condition. The nurse mentions that vitamins A and D may help to regulate thyroid production. Which of the following foods could the nurse suggest for the client? -Apples -Salmon -Peanut butter -Pinto beans

-Apples While apples are a healthful food choice, they do not contain significant amounts of vitamins A and D. -Salmon The nurse can make nutritional recommendations for the client that will improve physical function and have an effect on some symptoms associated with endocrine dysfunction. Increasing intake of vitamins A and D may help to regulate thyroid production. In this situation, the nurse could recommend intake of fish, such as salmon or cod, or fortified breads and cereals. -Peanut butter Peanut butter does not contain significant amounts of vitamins A and D. -Pinto beans Beans do not contain significant amounts of vitamins A and D.

A 68-year-old client is being treated for leukemia, but his prognosis is very grim. The client asks the nurse about how he is doing. Which statement from the nurse is most appropriate? -Are you worried about how sick you will get? -Tell me your thoughts about reaching the end of your life and dying -Some people get to this point and they want to give up. Is that how you are feeling right now? -Based on what we have talked about, how do you think you are doing?

-Are you worried about how sick you will get? Since the client's question is vague, this is a signal to the nurse that the client wants to talk, so the nurse can ask additional questions to figure out where to take the conversation. The client may be worried and will break down and cry, in which case the nurse would offer presence. The client may want to know something specific about the course of the disease, in which case the nurse would give information. When a client wants to talk about his condition, the nurse must be honest and should not avoid discussion of a painful or sensitive situation. -Tell me your thoughts about reaching the end of your life and dying This is an indirect and insensitive comment. -Some people get to this point and they want to give up. Is that how you are feeling right now? It is important for the nurse to draw out how the client is feeling, but not prescribe feelings or suggest that they may be feeling a certain way. -Based on what we have talked about, how do you think you are doing? This statement belittles the client, as if they should have remembered something and they forgot.

A nurse is caring for a client in the hospital with advanced HIV infection. The client is suffering from malnutrition and has been losing weight. Which of the following interventions are appropriate to manage this client's nutrition? Select all that apply. -Assess the client's ability to feed himself, chew and swallow -Administer intravenous fluids as ordered -Encourage the client to use incentive spirometry -Consult with a dietitian for nutrition guidance -Offer oral supplements

-Assess the client's ability to feed himself, chew and swallow Good nutrition increases infection resistance and raises the client's energy level. The nurse should assess the client's ability to take in food in order to determine how to manage nutritional status. -Administer intravenous fluids as ordered A client with advanced HIV infection must stay hydrated in addition to nutritional support. -Encourage the client to use incentive spirometry Incentive spirometry, while useful for promoting lung expansion, does not directly contribute to weight management in the client infected with HIV. -Consult with a dietitian for nutrition guidance The client with advanced HIV infection is at risk of weight loss and malnutrition, and once the client's BMI is below 18, there is an accelerated progression of the disease and increased mortality. Nutrition promotion is very important. The nurse can promote weight gain and nutrition by requesting a dietary consult, assessing the client's ability to eat independently, chew and swallow, and administer IVF as ordered. These interventions, along with antiretroviral therapy and exercise will increase the quality of life, and ultimately extend the life of the HIV-infected client. -Offer oral supplements Oral supplements are an easy way for a client to receive extra protein and calories.

A client with Cushing's syndrome has become more withdrawn from friends and relatives because of changes in appearance. Upon admission to the healthcare center, the nurse gives the client a nursing diagnosis of Social Isolation related to discomfort with others and feelings of rejection by other people. Which of the following nursing interventions is most appropriate in this situation? -Assist the client with finding a church that she can join -Help the client to monitor her diet to include more sources of carbohydrates from whole grains and vegetables -Help the client to consider what small changes she could make to integrate herself into the community and make new friends -Teach the client to verbalize I feel that you are rejecting me when in social circles

-Assist the client with finding a church that she can join Although a church is a potential place for the client to find social community, the nurse should tailor options based on the client's preferences, which may not necessarily include a church. -Help the client to monitor her diet to include more sources of carbohydrates from whole grains and vegetables This is not related to the client's problem of social isolation. -Help the client to consider what small changes she could make to integrate herself into the community and make new friends Social isolation can be seen among some clients who struggle with their appearance because of changes due to a disease process, including endocrine dysfunction. Social isolation leads to loneliness and studies show that clients usually feel increasing depression because of lack of social interaction. The nurse may help the client in this situation to make small changes in her lifestyle that could slowly integrate her back into the community where she could meet new people and expand her network of friends. -Teach the client to verbalize I feel that you are rejecting me when in social circles Using "I feel" statements is useful between two people, but is not intended for use in a group setting.

The nurse walks into a client's room and notices that their skin is a dark bronze color. The nurse knows this could indicate which of the following diseases? -Bell's palsy -Alcoholism -Huntington's disease -Addison's disease

-Bell's palsy This condition is characterized by muscle weakness to one side of the face, but does not involve a change in skin color. -Alcoholism A client with alcoholism can develop jaundice, which is characterized by yellowing of the skin and eyes. The color is yellow, however, and not bronze. -Huntington's disease Huntington's disease is characterized by involuntary movements, but not a change in skin color. -Addison's disease Clients with Addison's disease can develop bronze colored skin.

A client is being tested for Graves' disease. The nurse knows that which one of the following lab panels would be used to rule out this condition? -Cardiac panel -Renal panel -Liver panel -Thyroid panel

-Cardiac panel This panel is used to evaluate whether a myocardial infarction has occurred. It gives no information regarding Graves' disease. -Renal panel This panel is used to evaluate kidney function rather than thyroid. -Liver panel This panel will help test liver function, not thyroid function. -Thyroid panel Graves' disease is an autoimmune disease associated with hyperthyroidism. The client would need a thyroid panel in order to rule out the condition.

While eating dinner in a restaurant, a customer develops an anaphylactic reaction. A nurse nearby notices the problem and stops to help. The first action of the nurse should be which of the following? -Check the client's pulse -Ask the client if they are ok -Lowering the client to the ground -Assess the client's skin for flushing

-Check the client's pulse The nurse can check the pulse but first must assess the airway. -Ask the client if they are ok The priority when assisting a person in anaphylactic shock is to first assess airway. This can be done by asking a question. If the person can talk, they are breathing and the airway is open. In anaphylaxis, the airway can quickly close, so having the client continue to talk helps the nurse to be aware of the airway patency while doing other tasks like checking a pulse. The nurse should also ask if the client has an Epipen because administering epinephrine as soon as possible will buy valuable airway time for the client while they wait for help to arrive. The subsequent interventions are to have someone call for help, and assist the client with Breathing, Circulation, Disability (level of consciousness), and Exposure to the allergen. -Lowering the client to the ground The client may be lowered to the ground, or may already be on the ground. Priority one is the airway. -Assess the client's skin for flushing This is usually obvious, and the nurse is assessing many things at once during an anaphylactic emergency, but airway management is the first

The nurse is caring for a client with diabetic ketoacidosis (DKA). The client suddenly becomes confused. Which of the following actions should the nurse perform first? -Check the client's pupillary reaction -Call the provider -Check the client's glucose level -Check the client's vital signs

-Check the client's pupillary reaction First check glucose, then vital signs, then based on the glucose level the nurse may need to administer an amp of D50. The provider will also be notified. -Call the provider The nurse must figure out if the cause of the confusion is related to the client's blood sugar level and get the clinical information for SBAR report before calling the provider. -Check the client's glucose level If a client with DKA becomes confused, they may be hypoglycemic OR hyperglycemic. The nurse should check the glucose level, then obtain a set of vitals, then call the provider. -Check the client's vital signs This is the second action to perform after obtaining a glucose level.

The nurse is preparing to give a client their morning medications. Which medication needs to be given first? -Ciprofloxacin -Calcium carbonate -Lisinopril -Levothyroxine

-Ciprofloxacin The nurse does not need to space out the administration of ciprofloxacin with other medications. It can be given concurrently. -Calcium carbonate This medication is appropriate to give concurrently with other medications. -Lisinopril This medication can be given along with other medications. -Levothyroxine Levothyroxine is a medication that should be given on an empty stomach, 30 minutes before meals or other medications, because there are many substances that will bind to levothyroxine and cause the drug to be absorbed erratically.

After shift change, a nurse takes over care for a postpartum client who had been bleeding moderately and is staying on the labor unit for closer watching. What assessment finding should the nurse be the most concerned about? -Client has not voided since straight cath two hours ago -Client has some bleeding around her IV site -Client is passing large clots -Bleeding has not stopped yet

-Client has some bleeding around her IV site This could be a possible sign of Disseminated Intravascular Coagulation. Further assessment, testing, and monitoring should be performed. -Client is passing large clots It is expected that the client will pass clots - this is a good sign that the blood is starting to clot in the uterus. -Bleeding has not stopped yet The nurse should not be extremely concerned unless bleeding is getting worse. -Client has not voided since straight cath two hours ago This is not concerning because it is not a big window of time. If her fundus was boggy or it had been a longer time then we would be concerned about emptying her bladder.

A nurse is caring for a client who has been diagnosed with Cushing's syndrome. The client is at risk of impaired skin integrity related to skin dryness and edema. Which of the following goals would be most appropriate for this client? -Client will demonstrate a knowledge of the layers of skin and underlying tissues -Client's pain will be managed using pharmacologic medications for the next 12 hours -Client will have improved body image before discharge from the hospital as evidenced by verbalizing acceptance of skin appearance -Client will support skin integrity by applying healing ointments and protective measures

-Client will demonstrate a knowledge of the layers of skin and underlying tissues This detailed knowledge is not necessary in order for the client to be able to properly care for skin. -Client's pain will be managed using pharmacologic medications for the next 12 hours Obesity, skin changes, and fatigue are some common symptoms of Cushing syndrome, but pain is not. -Client will have improved body image before discharge from the hospital as evidenced by verbalizing acceptance of skin appearance Body image issues related to Cushing syndrome are usually due to body shape rather than skin appearance. More importantly, the nurse should teach the client proper skin care to prevent breakdown due to changes from the syndrome. -Client will support skin integrity by applying healing ointments and protective measures A client with endocrine dysfunction such as Cushing syndrome may be at greater risk of skin changes, including skin breakdown. The nurse should teach the client how to care for the skin, which may involve applying protective ointments and taking measures to keep the skin intact.

A client who has recovered from cancer surgery requires lymphedema therapy. Which best describes an activity that would occur with this type of therapy? -Compression garment wear -Upper arm strengthening -Pain medication administration -Cognitive-behavioral therapy

-Compression garment wear Lymphedema is the swelling that sometimes occurs following certain types of surgery. It most often develops in the groin, arms, legs, or neck. Compression garments are used to control edema and fluid, and to promote venous return of blood to the heart. Compression garments are typically fitted by a professional who can educate the client about their use. -Upper arm strengthening When a client has lymphedema, strengthening is not a treatment goal. Upper arm exercises can be done to increase lymphatic drainage, but the idea behind the exercise is lymph drainage, not strengthening. This is done in a controlled manner with compression sleeves in place with therapy assistance. -Pain medication administration Pain medication is given for comfort, but is not a therapy activity. -Cognitive-behavioral therapy Cognitive-behavioral therapy is not a treatment given to clients with lymphedema.

A client who has hypothyroidism takes a prescription of levothyroxine. Which of the following side effects is most closely associated with this medication? -Confusion and aggression -Ascites -Weight loss -Bradycardia

-Confusion and aggression This is not a commonly reported side effect of levothyroxine. -Ascites This is not a commonly reported side effect of levothyroxine. -Weight loss Levothyroxine (Synthroid) is a supplement taken for the replacement of thyroid hormone among people who have hypothyroidism. Some common side effects associated with this drug are weight loss, increased appetite, sweating, and hyperactivity. -Bradycardia This is not a commonly reported side effect of levothyroxine.

A nurse has been ordered to administer one unit of packed red blood cells to a client who is in the pre-op holding room. The nurse notes that the client has not signed consent for blood products yet. Which of the following elements must the nurse consider when obtaining informed consent for blood product administration? Select all that apply. -Contact the physician to explain the blood transfusion for informed consent -Ensure that the patient understands the risks of transfusion -Contact the hospital notary to assist with signing the consent -Obtain one consent that will be applicable for all blood products throughout the patient's hospitalization -Administer the transfusion and sign the consent afterward

-Contact the physician to explain the blood transfusion for informed consent The nurse can get informed consent for a blood transfusion. -Ensure that the patient understands the risks of transfusion As with other types of medical procedures, a client should sign informed consent before receiving a blood transfusion. -Contact the hospital notary to assist with signing the consent A notary is not needed to validate signatures with blood consent. The nurse or doctor and the client signing the form is appropriate. -Obtain one consent that will be applicable for all blood products throughout the patient's hospitalization In many cases, once the client has signed the consent for the current hospitalization, it applies to future transfusions that will be given during the current treatment period. -Administer the transfusion and sign the consent afterward Although in a life threatening situation this is appropriate, it is not appropriate in a non-emergent situation. Informed consent should be obtained first.

The nurse is caring for a client with Cushing's syndrome. The nurse knows that this disease is caused by hypersecretion of which of the following hormones? Select all that apply. -Cortisol -Aldosterone -Testosterone -Adrenocorticotropic hormone -Follicle-stimulating hormone

-Cortisol Cortisol secreted in excess leads to Cushing's syndrome. -Aldosterone Aldosterone, which is the hormone responsible for the secretion of sodium and water from the body, is one of the hormones that is hypersecreted in Cushing's syndrome. -Testosterone Testosterone, an androgen, is excessively secreted in a client with Cushing's syndrome, along with cortisol and aldosterone. -Adrenocorticotropic hormone This hormone, also known as ACTH, is often hypersecreted in the client with Cushing's syndrome. -Follicle-stimulating hormone This hormone is secreted by the pituitary gland, and while Cushing's can be caused by a pituitary tumor, excess FSH is not related to Cushing's syndrome.

A nurse is caring for a 6-year-old child who has severe vitamin C deficiency. The nurse notes that the child's skin has areas of purpura. This condition of most likely described as which of the following? -Clusters of blood vessels around body orifices -Dilated blood vessels under the skin -Yellow or brown, flat, irregularly-shaped lesions -Dark red, flat, scattered macules

-Dark red, flat, scattered macules Purpura is a condition that develops when the capillaries leak blood under the skin. It causes dark red or purple flat macules on the skin and it may be associated with low platelet levels in the bloodstream. Purpura can develop from a number of conditions including vitamin C deficiency (scurvy), cytomegalovirus, rubella, and some blood clotting disorders. -Clusters of blood vessels around body orifices Purpura refers to flat red or purple macules, not clusters of blood vessels around body orifices. -Yellow or brown, flat, irregularly-shaped lesions This describes a highly suspicious skin lesion that a dermatologist would need to examine. It is not purpura. -Dilated blood vessels under the skin This describes spider veins, not purpura.

A nurse is counseling a client who has hypertension and type 2 diabetes. During the initial assessment, the nurse notes that the client has a blood pressure of 148/92 mmHg, a BMI of 28, and a blood glucose level of 161 mg/dL. Which of the following information about health and wellness would be most beneficial for the nurse to teach this client? -Describe how the client can limit fat intake in the diet to less than 45% of total daily calories -Tell the client to first control the hypertension, and then glucose levels are more likely to normalize -Help the client understand how to lose weight to get their BMI to less than 25 -Explain to the client that weight loss would be beneficial and that a low-carb diet is best

-Describe how the client can limit fat intake in the diet to less than 45% of total daily calories Fat intake should be between 20-35% for adults. -Tell the client to first control the hypertension, and then glucose levels are more likely to normalize The underlying cause of elevated glucose and hypertension is most likely the client's high BMI. If the BMI is lowered by weight loss, then the other values will likely normalize. -Help the client understand how to lose weight to get their BMI to less than 25 A BMI of 28 is considered overweight. This client also has an elevated blood glucose and a high blood pressure reading. Both glucose issues and hypertension can usually be improved if an overweight client makes lifestyle changes to get to a healthy weight and normal body mass index. If the nurse helps the client to understand the importance of weight management, the client can choose to improve their weight and improve their blood pressure and blood glucose as well. -Explain to the client that weight loss would be beneficial and that a low-carb diet is best A low-carb diet is not the best weight loss choice for everyone. A dietician consult can help the client to choose the best weight loss plan, tailored to their preference and circumstance.

The nurse is performing an admission assessment on a client and notes that the client has a moon-shaped face. The nurse understands that this could indicate which of the following? -Down's syndrome -Huntington's disease -Addison's disease -Cushing's syndrome

-Down's syndrome Down's syndrome is characterized by poor muscle tone and a flattened appearance to the face, but not a moon-shaped face. -Huntington's disease This disease is characterized by involuntary movements most noted in the face, but the client with Huntington's disease will not have a moon-shaped face. -Addison's disease A client with Addison's disease may have areas of the skin that are darkened, but a moon-shaped face is not characteristic of this disease. -Cushing's syndrome A client with Cushing's syndrome will likely have a moon-shaped face, due to redistribution of fat from the disease process.

A client has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is NOT a priority nursing intervention for this client? -Encourage increased dietary intake of sodium -Increase fluid intake to at least 2L/day -Flush NG tube with normal saline rather than sterile water -Initiate seizure precautions

-Encourage increased dietary intake of sodium SIADH causes significant hyponatremia, therefore clients should be encouraged to increase dietary intake and/or to take supplemental sodium replacements until the SIADH is resolved. -Increase fluid intake to at least 2L/day SIADH causes extreme over-retention of water, therefore these clients should have a fluid restriction, not an increase. Typically these clients will be restricted to 500-1,000 mL per day to prevent further hemodilution. -Flush NG tube with normal saline rather than sterile water Clients with SIADH should be on a free water restriction. They should not be drinking straight water, nor should their feeding tubes be flushed with water. Clients should consume juice, coffee, tea, soda, and tubes should be flushed with saline to prevent further water intoxication. -Initiate seizure precautions SIADH can cause severe hyponatremia which puts the client at massive risk for seizures. Seizure precautions should be implemented right away.

An HIV-infected client is in the hospital after developing an opportunistic infection. The client's spouse will provide care to the client at home. What information should the nurse provide to the caregiver about providing home care for the client? Select all that apply. -Encourage the caregiver to seek help with client care when necessary -Teach the caregiver to delay getting immunized for the client's sake -Teach the caregiver not to insist the client get out of bed for a day if the client is tired -Remind the caregiver not to share personal tools such as toothbrushes or razors -Educate the caregiver to wash fruits and vegetables when preparing food

-Encourage the caregiver to seek help with client care when necessary Being a caregiver for a loved one with HIV is multifaceted and exhausting, both physically and mentally. The caregiver needs to know how to prevent the client from getting infections, how to prevent the spread of HIV, and how to promote the client's wellness. Additionally, they must attend to their own physical and emotional needs to prevent caregiver burnout. -Teach the caregiver to delay getting immunized for the client's sake Due to the decreased immune response of the client, it is very important for the caregiver to stay up to date on immunizations. -Teach the caregiver not to insist the client get out of bed for a day if the client is tired It is important for the client to remain active, or at least get up each day to prevent irreversible deconditioning. The caregiver should encourage the client to remain active as long as they can. -Remind the caregiver not to share personal tools such as toothbrushes or razors These teaching points will help prevent the client from getting infections. -Educate the caregiver to wash fruits and vegetables when preparing food This removes pathogens from food, which is important for the immunocompromised client.

A nurse is administering human immunodeficiency virus testing at a community screening event. When providing education, which of the following will the nurse use to classify the disease? -Endemic -Pandemic -Epidemic -Academic

-Endemic It describes a permanent existence of a disease. -Pandemic This describes a worldwide spread of disease. -Epidemic This describes a local outbreak of a disease. -Academic This describes education.

Which of the following is considered to be a counterregulatory hormone that works against the effects of insulin in the bloodstream? Select all that apply. -Estrogen -Growth hormone -Melatonin -Cortisol -Glucagon

-Estrogen This is a female sex hormone, not a counterregulatory hormone. -Growth hormone Growth hormone is a counterregulatory hormone. -Melatonin This is a hormone that regulates sleep and wake cycles, but does not affect glucose movement into cells. -Cortisol Cortisol is a counterregulatory hormone. -Glucagon Insulin lowers blood glucose by facilitating glucose movement into cells, so when glucose levels rise in the bloodstream, the body normally responds by secreting insulin. Glucagon, cortisol, and growth hormone, along with adrenaline, are the main counterregulatory hormones. These work against the action of insulin, therefore protecting the body from hypoglycemia. Counterregulatory hormones keep glucose in the bloodstream (and out of the cells).

A client has an order to receive one unit of fresh-frozen plasma (FFP). Based on the nurse's understanding of this blood product, the nurse knows that which of the following are true regarding FFP? Select all that apply. -FFP is often used to treat acute coagulopathy states -FFP cannot be administered to someone who is immunocompromised -FFP is packed in a preservative solution -FFP often contains a certain amount of red blood cells to distribute hemoglobin -FFP usually contains water, proteins, and a small amount of carbohydrates

-FFP usually contains water, proteins, and a small amount of carbohydrates Fresh-frozen plasma is a type of blood product that contains the fluid portion of blood and not the blood cells. A unit of FFP contains a mixture of water, protein, and a small amount of carbohydrates. -FFP often contains a certain amount of red blood cells to distribute hemoglobin It does not contain blood cells. -FFP is packed in a preservative solution There are no additives in the plasma to preserve it. It is preserved by freezing at a specific time and temperature. -FFP is often used to treat acute coagulopathy states It is often administered as treatment when a client has trouble with blood clotting. -FFP cannot be administered to someone who is immunocompromised It has undergone viral inactivation and is safe for someone who is immunocompromised.

After receiving report from the night shift nurse, the nurse is looking over the current complaints. The nurse assistant lets the nurse know that all four clients are hyperglycemic. The nurse knows that which of the following client symptoms is the priority to see first? Fatigue Headache Febrile Altered mental status

-Fatigue A client with fatigue is stable and can wait to be seen. -Headache This client is stable and can wait to be seen. -Febrile The client with a fever may be hyperglycemic because of an infection. This client would not take priority over the client with altered mental status. -Altered mental status Hyperglycemia with altered mental status is concerning for diabeteic ketoacidosis. It is important that all hyperglycemic clients be seen within a reasonable amount of time because leaving the glucose high eventually creates more problems, but a DKA client is already in an emergent stage and needs to be seen first. Altered mental status is a concern of a worsening condition that needs to be assessed.

A client is suffering from excess cortisol excretion as a result of an adenoma on the pituitary gland. Which of the following changes is an expected finding in a client with this condition? Select all that apply. -Fatty tissue deposits in the face and upper back -Lesions on the peripheral extremities -Swelling in the neck and throat -Skin that bruises easily -Increase in the number of stretch marks

-Fatty tissue deposits in the face and upper back Cortisol is a stress hormone secreted from the adrenal glands near the kidneys. Excess cortisol production can cause a number of changes associated with different body systems., including obesity and fatty tissue deposits on the face and upper back. -Lesions on the peripheral extremities Excess cortisol secretion does not cause lesions. -Swelling in the neck and throat Fatty deposits can occur in the face from excess cortisol secretion, but this is different from swelling. Swelling in the neck and throat would indicate an emergency situation and require immediate medical attention. -Skin that bruises easily Excess cortisol leads to easily bruised skin. This is a common symptom of Cushing's syndrome. -Increase in the number of stretch marks Skin changes that may be seen with excess cortisol include purple stretch marks (striae), easy bruising, weight gain, fatty tissue deposits in the midsection, upper back and face, excess body hair in women, and decreased fertility in men.

A client with neuropathy is being discharged home. The nurse is providing discharge education on which of the following medications for neuropathy? -Gabapentin -Glipizide -Gentamicin -Guaifenesin

-Gabapentin Gabapentin is an analgesic adjunct that treats seizures, neuropathic pain, peripheral neuropathy. -Glipizide This is an anti-diabetic medication the stimulates the release of insulin from the pancreas. -Gentamicin This is an anti-infective that is the next step in treatment for gram negative bacteria when penicillins are ineffective. -Guaifenesin This is an expectorant for loosening mucus in the airways.

A nurse is preparing to give blood products to a client who is experiencing excess bleeding after surgery. Prior to administration, which action should the nurse perform first? -Gather appropriate equipment for blood product administration -Ensure that there is an order for the transfusion -Prime the IV tubing with normal saline -Document the client's vital signs

-Gather appropriate equipment for blood product administration This is one step in the transfusion process, but to be safe and efficient, the first thing the nurse should do is double check that there is an order to transfuse blood products. -Document the client's vital signs The nurse first needs to make sure there is an order to transfuse. Vitals have to be taken right before started the infusion so this would have to be repeated if other steps are not taken first. -Ensure that there is an order for the transfusion Blood transfusions are relatively common procedures in hospital nursing. The nurse who administers blood products should be familiar with the risks of transfusion reactions and the institution's transfusion protocol. Prior to starting a transfusion, however, the first action of the nurse is to verify that an order exists and check the details of the order against the blood product. -Prime the IV tubing with normal saline The nurse first needs to double-check that there is an order to administer blood. If not, any steps taken could be a waste of time and resources if there is not an order.

A nurse is caring for a client with a gastric ulcer who begins to have active bleeding. Which of the following is the priority nursing intervention? -Instruct on proper eating habits -Give blood if low hemoglobin -Give fluid and electrolytes -Give NSAIDs for pain

-Give blood if low hemoglobin The nurse will monitor the client for signs of hypovolemic shock, dehydration, and sepsis, and be prepared to give blood as ordered. Fluid and electrolytes can be given and the nurse should instruct the client on proper eating habits, but these are not the priority in this situation. -Instruct on proper eating habits While this intervention the nurse will eventually perform for a client with a bleeding gastric ulcer, they are not the priority. -Give fluid and electrolytes While this intervention the nurse will eventually perform for a client with a bleeding gastric ulcer, they are not the priority. -Give NSAIDs for pain NSAIDs are contraindicated for the client with an acute hemorrhagic gastric ulcer.

A client who has suffered a traumatic brain injury (TBI) has developed diabetes insipidus. A home health nurse is seeing the client in his home to help him manage his care at home. Which of the following teaching points would the nurse offer to help prevent injury in this client? -Have the client ensure easy access to the bathroom or bedside commode -Tell the client to reduce fluid intake and avoid drinks that contain caffeine -Reinforce keeping a fan on in the room next to the bed while sleeping -Encourage the client to wear socks and extra blankets when sleeping at night Submit

-Have the client ensure easy access to the bathroom or bedside commode A client with diabetes insipidus and a history of TBI may be at higher risk of injury, particularly if he must get up to use the bathroom frequently. The nurse should ensure that the client knows to keep the home organized and free from clutter and to keep a clear walkway to the bathroom or the commode so that the client will not be injured when he gets up to use the bathroom. -Tell the client to reduce fluid intake and avoid drinks that contain caffeine Diabetes insipidus results in excessive excretion of water in the form of dilute urine. It is a regulation problem related to the pituitary gland, so reducing fluid intake or avoiding caffeine will not alleviate the problem. -Reinforce keeping a fan on in the room next to the bed while sleeping Adding a fan by the bed is an additional tripping hazard for the client. This decreases safety rather than making the area safer. -Encourage the client to wear socks and extra blankets when sleeping at night Socks increase the chance of a slip and fall. Extra blankets are difficult to manage at night when a person is in a hurry to get to a toilet. These actions would decrease safety rather than make the area safer.

The nurse is admitting a client with diabetic ketoacidosis (DKA). The client has a history of type 1 diabetes and informs the nurse that she been taking really good care of herself and her blood glucose has been "really really good." Which of the following assessment data leads the nurse to question this statement? -Hemoglobin A1C 13% -Fingerstick blood sugar of 492 mg/dL -Fruity breath -Total cholesterol 321 mg/dL

-Hemoglobin A1C 13% A hemoglobin A1C of 13% indicates that over the last 3 months the client has been averaging a blood sugar of 326 mg/dL, indicating very poorly controlled blood sugars. -Fingerstick blood sugar of 492 mg/dL A current blood sugar of 492 mg/dL is concerning, but it is indicative of the client's current state, not the client's overall glucose control. -Fruity breath Fruity breath is consistent with the client's current condition of diabetic ketoacidosis. -Total cholesterol 321 mg/dL The cholesterol level is high, but is unrelated to the client's claim of tight blood glucose control.

The following CBC lab results are delivered on a client. Which of the following values represents an indication for a transfusion of packed red blood cells (PBRCs)? -Hgb 6.2 g/dL -Platelets 40,000/microliter -HCT 41% -WBC 2.4

-Hgb 6.2 g/dL This represents a client who is anemic and likely requires a blood transfusion. -Platelets 40,000/microliter This client is thrombocytopenic, but a transfusion of PRBCs will not correct this. -HCT 41% This is within the normal range for both men and women. This client is not anemic. WBC 2.4 This client has leukocytopenia, but a blood transfusion will not correct this.

A client who is receiving heparin for a history of blood clots has developed heparin-induced thrombocytopenia. His platelet count is 90,000/mcL. Which of the following nursing interventions is most appropriate in this situation? -Hold the heparin dose and contact the physician -Give protamine sulfate to counteract the heparin -Continue to administer the heparin as scheduled and monitor for complications -Administer half of the dose of heparin instead of the full amount

-Hold the heparin dose and contact the physician A client who develops thrombocytopenia while taking heparin is at risk of hemorrhage. With heparin-induced thrombocytopenia (HIT), the body can eventually produce an inflammatory response and thromboses can occur. The nurse should notify the provider of the client's platelet count and wait for further orders before administering the next heparin dose, knowing that the provider will likely change to different anticoagulant therapy. -Give protamine sulfate to counteract the heparin The treatment for HIT is to discontinue all heparin products, including heparin flushes, begin an alternative anticoagulant therapy and eventually place the client on warfarin once platelet levels have recovered. -Continue to administer the heparin as scheduled and monitor for complications Once thrombocytopenia has occurred, the nurse should not administer another dose of heparin and should contact the provider. -Administer half of the dose of heparin instead of the full amount Once thrombocytopenia has occurred, the nurse should not administer another dose of heparin and should contact the provider.

A 36-year-old client must undergo a total thyroidectomy for treatment of thyroid cancer. Which of the following has been shown as a complication of this type of surgery? -Hypercalcemia -Voice changes -Jugular vein distention -Injury to the clavicle

-Hypercalcemia A thyroidectomy can cause hypocalcemia, but not hypercalcemia. The nurse will monitor calcium levels as ordered and administer calcium if necessary. -Voice changes Total thyroidectomy involves the removal of the thyroid gland from the neck. It may be done as a response to thyroid cancer or in cases of a goiter or thyroid nodules when the gland is no longer functional. Because of the location of the thyroid, the client is at risk of voice changes associated with the surgery if the vocal cords are damaged during the surgical procedure. The nurse monitors for dysphonia and a high-pitched voice postoperatively. -Jugular vein distention Removal of the thyroid gland does not result in heart failure or pulmonary hypertension, or any other condition that leads to jugular vein distention. -Injury to the clavicle The thyroid is on the neck, so injury to the clavicle is not likely.

A nurse is caring for a client who has diabetes and has developed hypoglycemia. Which vital signs would be most consistent with this condition? -Hyperthermia -Hypotension -Low oxygen saturation -Tachycardia

-Hyperthermia This is not a symptom of hypoglycemia. -Hypotension This is not a symptom of hypoglycemia. -Low oxygen saturation This is not a symptom of hypoglycemia. -Tachycardia A client who is experiencing hypoglycemia may demonstrate changes in vital signs. The nurse should look for adrenergic symptoms such as tachycardia, hypertension, hypothermia, and tachypnea.

A client is taking antithyroid medication. The nurse knows that this medication is taken for which of the following conditions? Select all that apply. -Hyperthyroidism -Myasthenia gravis -Thyroid storm -Grave's disease -Hypercalcemia

-Hyperthyroidism Hyperthyroidism occurs when the thyroid gland produces too much thyroxine. Antithyroid medication such as methimazole is given which reduces the amount of thyroxine in the body. -Myasthenia gravis This is a neurological disorder that is unrelated to the thyroid. -Thyroid storm This is a disorder in which too much thyroid hormones are being released causing a life-threatening situation with extremely high blood pressure, pulse, and temperature. Antithyroid medicine is appropriate for this situation. -Grave's disease This is caused by hyperthyroidism, so antithyroid medication is given to manage this disorder. -Hypercalcemia Hypercalcemia can occur when the parathyroid gland is disturbed. This can occur from surgery or a tumor, but is unrelated to overproduction of thyroid hormones.

Which of the following electrolyte imbalances is an expected finding for a client with Cushing's Syndrome? Select all that apply. -Hypokalemia -Hypocalcemia -Hypochloremia -Hyponatremia -Hypomagnesemia

-Hypokalemia Cushing's syndrome includes excess aldosterone levels, which causes hypernatremia. When sodium is high in the body, the kidneys excrete more potassium, so hypokalemia is an expected finding. -Hypocalcemia Low calcium levels are expected in the client with Cushing's syndrome. -Hypochloremia Chloride is more likely to be high than low. Hypochloremia is not an expected finding in the client with Cushing's syndrome. -Hyponatremia A client with Cushing's syndrome is not excreting sodium (Na) normally, causing a build-up of Na in the blood. Therefore hypernatremia is an expected finding, not hyponatremia. -Hypomagnesemia Hypomagnesemia is not an expected finding in the client with Cushing's syndrome.

A nurse is caring for a client who has been diagnosed with syndrome of inappropriate anti-diuretic hormone (SIADH). What type of electrolyte imbalance would the nurse most likely see in this situation? -Hyponatremia -Hypocalcemia -Hypermagnesemia -Hyperkalemia

-Hyponatremia Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition in which the body produces too much anti-diuretic hormone. The condition causes the affected person to retain fluid. This causes low levels of sodium, which leads to many of the symptoms of SIADH, such as changes in level of consciousness and mental status. -Hypocalcemia Low calcium levels are not the defining electrolyte imbalance seen in SIADH. -Hypermagnesemia SIADH causes dilution of the blood, therefore increased serum magnesium would not be seen. -Hyperkalemia SIADH causes dilution of the blood, therefore increased serum potassium would not be seen.

A 28-year-old female client has been diagnosed with type 2 diabetes. The nurse is talking with the client about diet, such as what foods to include and what foods to avoid. Which statement made by the client indicates that more teaching is needed? -I should increase my fiber intake to at least 45 grams each day -I shouldn't drink more than one alcoholic beverage each day -I should try to eat carbohydrates that come from whole grains and fruits -I can't go on a high-protein diet to lose weight. I need some carbs in my diet

-I should increase my fiber intake to at least 45 grams each day Dietary instruction is very important when working with diabetic clients. Often, a diabetic client has a lot of information to learn, and the nurse can have the client teach back information to assess learning. The nurse should teach the client to increase fiber intake to 25 to 35 grams per day to regulate the gastrointestinal system. 45 grams per day is too much fiber intake. This can cause gastrointestinal difficulties such as bloating and gas, so the client who is not used to consuming large amounts of fiber should increase their intake slowly. -I shouldn't drink more than one alcoholic beverage each day This statement is appropriate and demonstrate understanding on the part of the client. -I should try to eat carbohydrates that come from whole grains and fruits This statement is appropriate and demonstrate understanding on the part of the client. -I can't go on a high-protein diet to lose weight. I need some carbs in my diet This statement is appropriate and demonstrate understanding on the part of the client.

A client is preparing to undergo a radical prostatectomy. During the pre-operative visit, the client asks the nurse, "When do I get to eat again?" Which response from the nurse is accurate? -I will begin to give you food after you leave the recovery room -You will be able to eat breakfast the next morning after your surgery -The surgeon will decide when you will be able to eat, I can't estimate when that will be -You will most likely have something to drink starting soon after your surgery

-I will begin to give you food after you leave the recovery room The nurse would not begin to give the client food unless he or she has first tolerated clear liquids, then the client can advance to crackers or something easily digestible. -You will be able to eat breakfast the next morning after your surgery There are many factors that affect when a client will be able to eat, including type of surgery, time of day the surgery is performed, length of surgery, and client's response to anesthesia. It may not necessarily be breakfast the next morning. -The surgeon will decide when you will be able to eat, I can't estimate when that will be In general, the nurse is able to estimate that the client may begin to drink and eat after the procedure. The surgeon will be the one to advance the diet, but the nurse notes clinical signs that indicate the client is ready to advance to eating food, and will report this information so the surgeon can write an order to advance to the next step. -You will most likely have something to drink starting soon after your surgery A client who undergoes surgery is not allowed to eat or drink before the procedure. Afterward, the client may not be ready to eat a meal right away because of factors such as the effects of medications administered, or the complexity of the surgery. In most cases, the client may start with liquids soon after surgery and if these are tolerated, the client can advance to eating solid foods.

A client with a central line requires urgent replacement of potassium. Which of the following is the best way to give potassium to this client? -IV replacement of no greater than 20 mEq/hr -A bolus of 20 mEq K over 10 minutes -Oral K replacement with meals -IV replacement at no greater than 10mEq/hr

-IV replacement of no greater than 20 mEq/hr IV replacement of potassium can be given at no greater than 10 mEq/hr in peripheral lines and no greater than 20 mEq/hr in a central line. As this client has a central line placed, the nurse can give K at a rate of up to 20 mEq/hr. -A bolus of 20 mEq K over 10 minutes Potassium cannot be given as a bolus. -Oral K replacement with meals Oral K replacement is not used in urgent situations. -IV replacement at no greater than 10mEq/hr Central line replacement allows a rate of up to 20 mEq/hr.

A nurse has an order to administer IVIG to a client with leukemia. Which of the following is a true statement regarding this type of blood product? Select all that apply. -IVIG is administered at a rate determined by the provider -IVIG is used to treat immune system disorders -IVIG may be created from donors or synthetically manufactured -IVIG is run through a transfusion similar to administration of blood products -IVIG may cause anaphylaxis with administration

-IVIG is administered at a rate determined by the provider The type and rate of administration is determined by the provider or pharmacist. -IVIG is used to treat immune system disorders Intravenous immune globulin (IVIG) is a product found in blood plasma that may be administered to some clients as treatment for certain types of immune system disorders. -IVIG may be created from donors or synthetically manufactured IVIG cannot be synthetically manufactured. -IVIG is run through a transfusion similar to administration of blood products It is given in a manner similar to administration of blood products. -IVIG may cause anaphylaxis with administration This is true of IVIG.

A client with difficulty breathing gets a CT scan that shows multiple clots in the lungs as well as in the heart and kidneys. Which blood clotting condition does this client most likely have? -Hemophilia -Idiopathic thrombocytopenic purpura -Disseminated intravascular coagulation -Wiskott-Aldrich syndrome

-Idiopathic thrombocytopenic purpura This is an autoimmune disorder in which platelets are destroyed and the client is unable to clot. The client will bruise easily. -Hemophilia This is a disorder in which the blood is missing certain clotting factors and clotting is abnormal. -Wiskott-Aldrich syndrome This is a rare disorder in which microthrombocytopenia is present. This means that the platelets are very small and limited in number causing prolonged bleeding. -Disseminated intravascular coagulation This occurs because the activation of the clotting cascade causes mini clots to form all throughout the vasculature of the body.

A client has been admitted to the hospital for surgery. The client has a history of leukemia and has developed septicemia. Which of the following situations is this client most likely at risk for? -Impaired spontaneous ventilation -Risk for thermal injury -Altered tissue perfusion -Risk for aspiration

-Impaired spontaneous ventilation This client is immunocompromised and septic. This results in infection but does not affect the lungs initially. -Risk for thermal injury Neither leukemia or septicemia result in a risk for burns. -Altered tissue perfusion Septicemia can be a life-threatening condition for a client, particularly in someone who is immunocompromised, such as with a diagnosis of leukemia. Septicemia is dangerous because the infection is widespread and affects circulation and cardiac output. The client may develop alterations in vascular volume and capillary permeability, eventually affecting perfusion of the distal tissues. Without adequate treatment, it can lead to organ failure because of altered tissue perfusion. -Risk for aspiration The condition of the client does not result in impaired swallowing ability.

The nurse is caring for a client who is 32 weeks pregnant and diagnosed with disseminated intravascular coagulation. Which of the following lab values does not support the client's diagnosis? -High platelet count -Prolonged prothrombin time (PTT) -Decreased hematocrit -Increased D-Dimer

-Increased D-Dimer In DIC, D-Dimer is increased -Decreased hematocrit A client with DIC is at risk for hemorrhage, which lowers the hematocrit. This is an expected finding. -Prolonged prothrombin time (PTT) This is an expected finding in DIC due to the depletion of coagulation factors. -High platelet count A decreased platelet count is a finding consistent with DIC. A high platelet count would be unexpected.

A nurse is working on a busy unit and answers a phone call. The lab is calling with results of a blood glucose level. What should the nurse do? -Indicate to the caller that the nurse cannot receive the result over the phone -Write down the results, read back the results to the caller and receive confirmation -Request that the lab email the result to transfer to the client's electronic medical record -Repeat the results to the caller, write the result on a scrap paper and transfer the result to the chart

-Indicate to the caller that the nurse cannot receive the result over the phone Calling in lab values to the nurse is a safety measure, and is only done with critical lab results. The nurse can receive lab results over the phone and must pass along the information to the assigned nurse and provider. -Write down the results, read back the results to the caller and receive confirmation While the lab can send the results electronically, they will call to report critical lab values. The nurse who receives the telephone result writes down the results, reads back the results to the caller, and gets confirmation of the correct result. The lab value is then passed along to the nurse caring for the client, and the client's provider. -Request that the lab email the result to transfer to the client's electronic medical record The result is already in the client's EMR. The phone call is an additional safety measure. -Repeat the results to the caller, write the result on a scrap paper and transfer the result to the chart The chart will already have the lab result electronically, so the nurse does not need to transfer any results.

A nurse is caring for a client that has just been diagnosed with Type II Diabetes. Which of the following would NOT be an appropriate education topic regarding foot care for this newly diagnosed client? -Inspect feet on a daily basis -Wear open-toed shoes -Separate overlapping toes -Dry feet entirely after bathing

-Inspect feet on a daily basis All diabetic clients should visually inspect their feet daily because neuropathy can cause them to not feel a wound developing. This is an appropriate topic to include. -Wear open-toed shoes Open-toed shoes should actually be discouraged, as they increase the likelihood of injury. Due to the diabetes, they will have an increased healing time and greater difficulty with wound healing, therefore it's essential to prevent injury as much as possible. -Separate overlapping toes If clients have toes that overlap anatomically, they should separate the toes when cleaning the feet AND when drying them to make sure no ulcers develop between toes. This would be an appropriate teaching topic. -Dry feet entirely after bathing Moisture can increase the chances of wounds developing, therefore drying feet entirely is very important for diabetic clients at risk for poor wound healing. This is a proper topic to include.

Which of the following are complications of diabetes mellitus? Select all that apply. -Insulin reaction -Coronary artery disease -Cerebrovascular disease -Fibromyalgia -Diabetic retinopathy

-Insulin reaction There are many complications associated with diabetes. Many center on circulation issues and the effect of poor glucose control over time. Insulin reaction is another concerning complication of diabetes. -Coronary artery disease Coronary artery disease is a complication that often develops in a client with diabetes. This develops much faster when the client has poorly controlled glucose levels over time. -Cerebrovascular disease This is a complication often seen in clients with diabetes. -Fibromyalgia This is not associated with diabetes mellitus. -Diabetic retinopathy Diabetic retinopathy is a complication associated with diabetes mellitus.

The client is newly diagnosed with Hashimoto's thyroiditis. The client does not fully understand the disease so which of the following explanations should the nurse provide to the client about Hasmioto's thyroiditis? -It is an autoimmune disorder that occurs because the thyroid is absent -It is an autoimmune disorder that may be triggered by many different factors -It is caused by taking levothyroxine -It is caused by too many thyroid hormones in the body

-It is an autoimmune disorder that occurs because the thyroid is absent Hashimoto's thyroiditis is an autoimmune disorder where the thyroid is attacked and thyroid hormones decrease. This may be triggered by many different factors, not because the thyroid is absent. -It is an autoimmune disorder that may be triggered by many different factors Hashimoto's thyroiditis is an autoimmune disorder that may be triggered by many different factors. -It is caused by taking levothyroxine Hashimoto's thyroiditis is an autoimmune disorder that may be triggered by many different factors. Levothyroxine may be taken by someone with this disease to increase the thyroid hormones. -It is caused by too many thyroid hormones in the body Hashimoto's thyroiditis is not caused by too many thyroid hormones in the body. It is an autoimmune disorder where the thyroid is attacked and thyroid hormones decrease. This may be triggered by many different factors.

A 45-year-old client is preparing to undergo a thyroidectomy for a tumor on the thyroid gland. The nurse provides a decision aid tool for the client as part of surgery. Which best describes how a decision-making tool aids in the process of informed consent? -It provides the correct decision that the client should make and when to have the procedure -It explains how to control pain following the procedure -It guides the client in choosing which type of surgical procedure to have -It allows the client to see the risks and benefits of different choices about the procedure

-It provides the correct decision that the client should make and when to have the procedure The client makes the best decision for him or herself, whether it is to proceed with a treatment or surgery, or decline treatment. -It explains how to control pain following the procedure Pain control is managed by the nurse while the client is in the hospital. -It guides the client in choosing which type of surgical procedure to have This is the responsibility of the surgeon. -It allows the client to see the risks and benefits of different choices about the procedure A decision-making tool can be a helpful adjunct to teaching and education for a client who is preparing for a procedure. A client may be overwhelmed with choices and possible options for treatment and may have a hard time making a decision. This type of tool outlines the potential risks and benefits of different decisions that the client could make so that the client can compare possible outcomes to make the best decision.

The nurse is working on an oncology unit with a client who is currently receiving chemotherapy, and is finishing a bed bath. What is the priority? -Labeling and properly disposing of waste -Ensuring the IV pumps are plugged in to the wall to preserve battery life -Changing out the enteral feeding tubing -Letting the family know they can come back in the room?

-Labeling and properly disposing of waste A client who is actively receiving chemotherapy must have bodily waste labeled appropriately and disposed of in a proper manner. The nurse must ensure that this is done as a part of client care. Most facilities require chemotherapy waste to be handled with specific gloves and trash bags. -Ensuring the IV pumps are plugged in to the wall to preserve battery life This task is unrelated to the bed bath. The next action for the nurse to take is to dispose of the waste created by the bed bath for the client on chemotherapy precautions. -Changing out the enteral feeding tubing If the client has a feeding tube, changing the tubing is not a part of the bed bath process. This is not the priority. -Letting the family know they can come back in the room This is not a priority until the nurse is ready. The nurse is ready once the task is completed and the waste is disposed of in the correct manner.

A client's lab results revealed increased TSH. The nurse knows this means that the body is trying to tell the thyroid to produce more thyroid hormones. Which of the following medication would have increased the production of thyroid hormone? -Lactulose -Lamotrigine -Levofloxacin -Levothyroxine

-Lactulose This is an osmotic laxative that works by drawing water into the stool to soften the stool for easier passing. -Lamotrigine This medication is an anticonvulsant that is used to prevent seizures by inhibiting sodium transport in neurons. -Levofloxacin This is a fluoroquinolone anti-infective medication used to treat sinus infections, urinary tract infections, and pyelonephritis. -Levothyroxine Levothyroxine (Synthroid) is a medication that induces the thyroid to increase the amount of triiodothyronine production (thyroid hormone).

A client with leukemia is being discharged from the hospital and is going home with an infection. Which precautions would the nurse teach the client to implement at home that would best prevent him from transmitting the infection? -Launder clothing and dry in a cool dryer or air dry in the basement of the house -Wash the clothes of the infected person separately from the clothes of others in the family -Wash all dishes by hand and do not use a dishwasher -Disinfect contaminated surfaces in the home with hot water only

-Launder clothing and dry in a cool dryer or air dry in the basement of the house A high heat setting should be used to eliminate the microorganisms. -Wash the clothes of the infected person separately from the clothes of others in the family A client who has had treatment for infection may be sent home with an infection that is unresolved. When this occurs, the nurse should teach the client about how to prevent transmission of the infection to others in the home. This includes laundering the infected person's clothes and bedding separately from others and using a dishwasher or hot setting on the dryer to kill microorganisms while cleaning. -Wash all dishes by hand and do not use a dishwasher A dishwasher is effective at eliminating germs on dishes and is preferred to washing dishes by hand. -Disinfect contaminated surfaces in the home with hot water only A disinfectant solution should be used to clean contaminated surfaces throughout the home because hot water alone is not effective. When hot water touches a surface, it loses it's high temperature right away.

A nurse is reviewing the consent form for a blood transfusion for a client. Which of the following risks would the nurse need to explain as part of receiving a blood transfusion? Select all that apply. -Liver disease -Allergic reaction -Contracting HIV -Severe bleeding and DIC -Contracting tertiary syphilis

-Liver disease Liver disease, such as hepatitis B, is a risk associated with blood product transfusions and the nurse would be required to discuss this risk with the client. -Allergic reaction Having an allergic reaction is a risk for the recipient of a blood transfusion. The nurse would need to discuss this risk with the client. -Contracting HIV While all blood that is donated is screened carefully and blood products are carefully matched with correct donors, there are still risks associated with blood product transfusions that the nurse would need to explain to the client. These include the risk of contracting an infectious virus like HIV. -Severe bleeding and DIC Severe bleeding and DIC are reasons for the administration of a blood transfusion. They are not risks of receiving a blood transfusion. -Contracting tertiary syphilis Tertiary syphilis is not contracted through blood transfusions so the nurse does not need to address this disease with the client.

A 37-year-old client with pancreatic cancer is experiencing chemotherapy-induced nausea and vomiting (CINV) after his latest round of medication. Which drug would most likely be prescribed for the control of CINV? -Lorazepam (Ativan) -Tramadol (Ultram) -Metoclopramide (Reglan) -Morphine

-Lorazepam (Ativan) This benzodiazepine can be given for CINV, but not until other drugs have been attempted. -Tramadol (Ultram) This drug is not an antiemetic. -Metoclopramide (Reglan) CINV is a common and very debilitating side effect of chemotherapy treatment for cancer. A client may learn about lifestyle changes and methods to control CINV and to avoid complications, but sometimes medications are needed to best manage the condition. Anti-nausea medications such as dimenhydrinate, midazolam, and metoclopramide are commonly administered. -Morphine This drug does not have antiemetic properties.

The nurse is caring for a client who has recently finished chemotherapy. The client asks if it is appropriate to begin exercising. Under which conditions would exercise be contraindicated for this client? Select all that apply. -Low sodium -Low white blood cells -Low red blood cells -Low blood urea nitrogen -Low potassium

-Low sodium This is a contraindication for exertion in this client. -Low white blood cells This is a contraindication for exertion in this client. -Low red blood cells If a client has finished chemotherapy but their lab work shows low RBCs (anemia), low WBCs, or abnormal electrolytes such as sodium or potassium, it is contraindicated for the client to exert themselves. Once these blood levels became more stable, it is appropriate to begin an exercise program. -Low blood urea nitrogen Chemotherapy has the potential to increase BUN due to the effect on the kidneys, but a decrease in this lab value is not due to chemotherapy and is not a contraindication for exercise. -Low potassium This is a contraindication for exertion in this client.

The nurse is caring for client with diabetes. Which of the following are appropriate nursing interventions? Select all that apply. -Maintain a low protein diet -Give lipid lowering medications if indicated -Teach the client about the glycemic index -Encourage high caloric intake -Encourage aerobic exercise

-Maintain a low protein diet The client should be encouraged to limit carbohydrates, but protein is essential for a balanced healthy diet in the client with DM. -Give lipid lowering medications if indicated Lipid lowering medications are often necessary for a client with diabetes mellitus. -Teach the client about the glycemic index The diabetic client should have a balanced diet with all essential food constituents, be on lipid-lowering medication if indicated, and should be encouraged to engage in some form of aerobic exercise. -Encourage high caloric intake The client with diabetes mellitlus should eat enough calories to maintain an ideal weight, but not a high-calorie diet. -Encourage aerobic exercise A client with diabetes needs to be careful when first beginning an exercise program, in order to understand how the body's blood glucose level responds to exercise, but exercise is beneficial for a client with this condition.

A nurse works in a busy healthcare unit of the hospital which includes care of clients with many different types of chronic illnesses. Which of the following actions should the nurse implement to help prevent the spread of infection among clients who have diabetes? -Maintain tight control of client blood glucose levels -Avoid touching items in the client rooms -Cover all food trays with cling wrap before passing out meals -Set aside syringes that are only used for diabetic clients

-Maintain tight control of client blood glucose levels Diabetic clients are at higher risk of infection because of elevated blood glucose levels and changes in circulation as a result of the disease. When a nurse cares for diabetic clients, it is important to maintain good glucose control and avoid hyperglycemia. This practice reduces the risk of infection. -Avoid touching items in the client rooms The nurse should utilize standard precautions, including hand hygiene, when working with clients. -Cover all food trays with cling wrap before passing out meals Taking time to cover each tray with cling wrap is unnecessary, because the nurse is spending extra time handling the trays, which could actually spread germs rather than protect against germs. The food tray can go directly into the client's room when it becomes available. -Set aside syringes that are only used for diabetic clients Syringes and other supplies should never be used for more than one client.

The nurse is caring for a client with Cushing syndrome. The nurse knows to perform which daily activity? -Make sure the client is near the nurse's station -Make sure the scale is near the client's room -Medications need to be exactly on time -Linens need to be constantly changed, so make sure they are stocked

-Make sure the client is near the nurse's station Fluid retention is of primary concern to the nurse. -Make sure the scale is near the client's room Clients with Cushing syndrome are at risk for excessive fluid retention which can cause cardiac stress and hypokalemia. The nurse should anticipate daily weights as one way to monitor the client's fluid retention status. -Medications need to be exactly on time Fluid retention is of primary concern to the nurse. -Linens need to be constantly changed, so make sure they are stocked Fluid retention is of primary concern to the nurse.

A nurse is caring for a client with type 2 diabetes who has been prescribed an incretin mimetic medication for blood glucose control. Which medication is an example of an incretin mimetic? -Metformin (Glucophage) -Rosiglitazone (Avandia) -Exenatide (Byetta) -Chlorpropamide (Diabinese)

-Metformin (Glucophage) This drug is a biguanide, not an incretin mimetic. -Rosiglitazone (Avandia) This drug is a thiazolidinedione antidiabetic agent, not an incretin mimetic. -Exenatide (Byetta) An incretin mimetic medication is used for blood glucose control among clients with type 2 diabetes. This type of drug is given as an injection to stimulate the body to secrete insulin after eating. It also decreases the amount of sugar the liver makes and slows down food digestion in the stomach. -Chlorpropamide (Diabinese) This drug is a sulfonylurea, not an incretin mimetic.

Which of the following medications are for thyroid regulation? -Metoprolol -Levothyroxine -Lisinopril -Rifampin

-Metoprolol Metoprolol is a beta blocker that is given for hypertension. -Levothyroxine This is a medication that communicates to the body to release thyroid stimulating hormone (TSH). -Lisinopril Lisinopril is an ACE inhibitor that is given for hypertension. -Rifampin Rifampin is an antibiotic used to treat TB.

Which of the following oral diabetes agents would be classified as a biguanide medication? -Miglitol -Metformin -Pioglitazone -Acarbose

-Miglitol This is alpha-glucosidase inhibitors, which help in type 2 diabetes by slowing the digestion of carbohydrates in the body. -Metformin Biguanide medications are most commonly used in the treatment of type 2 diabetes. They lower blood glucose by decreasing glucose production in the liver and increasing the amount of sugar absorbed by cells. An example of a biguanide medication is metformin (Glucophage). -Pioglitazone This medication is a glitazone, and is commonly prescribed in combination with metformin. -Acarbose This is alpha-glucosidase inhibitors, which help in type 2 diabetes by slowing the digestion of carbohydrates in the body.

The nurse is caring for a client who was started on lisinopril at the beginning of the shift. The nurse notes that the client's tongue seems a bit swollen and their speech sounds "thick". What is the nurse's priority? -Monitor for hives -Maintain a MAP > 65 -Administering 2 units of PRBC's -Maintain a patent airway

-Monitor for hives While the presence of hives will further confirm an allergic reaction, there are already sufficient clinical symptoms that demonstrate an allergic reaction is occurring. Therefore, maintaining an airway is the highest priority. -Maintain a MAP > 65 Maintaining a MAP > 65 is necessary for adequate perfusion, but it is not the first priority. Without an airway, the client will have no oxygenation. -Administering 2 units of PRBC's The client is not hemorrhaging, and there is no indication of a low hemoglobin/hematocrit. Instead, the client would benefit from IV fluids to maintain adequate blood pressure. -Maintain a patent airway This is an emergency situation, because the client is experiencing an anaphylactic shock. When an anaphylactic response is suspected, maintaining a patent airway is the nurse's number one priority. If the client's tongue has enlarged, angioedema is a concern, which is swelling through multiple layers of the skin. This client can lose an airway, so monitoring and maintaining the airway is the priority.

A client is experiencing an adrenal crisis due to Addison's Disease. Which of the following would NOT be a priority nursing intervention for this client? -Monitor for hyponatremia -Monitor for fluid volume deficit -Monitor for hypoglycemia -Monitor for hypocalcemia

-Monitor for hyponatremia In adrenal crisis, it is difficult to excrete free water, meaning the blood becomes diluted - causing hyponatremia. -Monitor for fluid volume deficit These clients are at risk for volume deficit because of severe vomiting and diarrhea. -Monitor for hypoglycemia Adrenal crisis causes hypoglycemia due to the low levels of corticosteroids, especially cortisol. -Monitor for hypocalcemia Clients in adrenal crisis (severe adrenal insufficiency) are more likely to experience hypercalcemia, NOT hypocalcemia, due to less excretion by the kidneys and calcium being pushed out of the cells.

A nurse suspects a client has diabetes insipidus. What are the priority interventions? Select all that apply. -Monitor neuro status -Monitor urine specific gravity -Monitor strict I&O -Monitor for hyponatremia -Monitor for hypernatremia

-Monitor neuro status Diabetes insipidus causes a massive loss of water via the urinary tract due to insufficient secretion of ADH. This leads to cellular dehydration and hypernatremia. Both of these things can cause significant neurological changes, including confusion and seizures. Monitoring neuro status is a priority. -Monitor urine specific gravity Due to insufficient ADH, the body dumps large amounts of dilute urine. Monitoring urine specific gravity helps to monitor the dilution and/or concentration of the urine -Monitor strict I&O Clients with diabetes insipidus lose large amounts of dilute urine, monitoring strict I&O measurements is a priority to know the client's fluid status. -Monitor for hyponatremia Due to excessive loss of water, the client's blood will become concentrated, making the sodium level go UP, not down. The nurse should be monitoring for hypernatremia, not hyponatremia. -Monitor for hypernatremia Due to excessive loss of water, the client's blood will become concentrated, making the sodium level go UP. Monitoring for hypernatremia is a priority.

A nurse has an order to administer heparin to a client. Which steps would the nurse take to minimize the risk of the client developing heparin-induced thrombocytopenia (HIT)? Select all that apply. -Monitor the client's platelet count -Assess the client's extremities -Administer heparin flushes as ordered -Note if the client has a history of HIT in his chart -Avoid using heparin coated catheters

-Monitor the client's platelet count The nurse must monitor the client's platelet count. If the platelet count begins to fall, specifically to 50% below baseline, the client may be developing thrombocytopenia. -Assess the client's extremities The nurse needs to assess extremities to monitor for signs of blood clots. -Administer heparin flushes as ordered Any other source of heparin administration, like flushes, locks or heparin coated catheters should be avoided to minimize the amount of the drug that the client receives. -Note if the client has a history of HIT in his chart Documenting any client history of HIT will alert all providers to avoid the use of heparin. Another anticoagulant will be used instead. -Avoid using heparin coated catheters Heparin-induced thrombocytopenia (HIT) is a potential complication of heparin administration that occurs from very low platelet count. The nurse can minimize the risk of HIT by avoiding extra sources of heparin, such as with heparin-coated catheters, documenting any client history of HIT, monitoring the client's platelet count, and continuing to assess the client's circulatory status for signs of blood clots.

A nurse is working with a client brought to the emergency department in a comatose state after developing hyperosmolar hyperglycemic syndrome (HHS). The nurse ensures the client's airway is patent and vital signs are stable. What is the nurse's next priority in this situation? -Monitoring serum chloride levels -Administering insulin IM -Maintaining the client's cervical spine -Providing isotonic fluid replacement

-Monitoring serum chloride levels The first priority is rehydration.Serum electrolytes will need to be monitored, but will be initiated after fluids have been started for this client. -Administering insulin IM Before starting insulin therapy, fluid therapy is initiated in the client with HHS. When insulin is administered, it would be given IV rather than IM. -Maintaining the client's cervical spine The information given does not give us information about the client's cervical spine status. -Providing isotonic fluid replacement In this situation, the treatment goals are to vigorously rehydrate, correct the hyperglycemia, treat the underlying cause, and monitor cardiac, renal, CNS and pulmonary status. The nurse should first provide a fluid replacement by administering isotonic IV fluids such as normal saline or lactated Ringer's solution. This increases intravascular volume and dilutes the blood when glucose levels are high. Most clients respond to IV fluid replacement only, but the nurse may also administer insulin as ordered. Insulin would be given IV, not IM. Other measures include monitoring oxygen saturations and checking glucose and electrolyte levels such as potassium and sodium.

Which of the following is NOT caused by an autoimmune response? -Multiple sclerosis -Guillain-Barre syndrome -Type 2 diabetes -Type 1 diabetes

-Multiple sclerosis MS is an autoimmune disease. -Guillain-Barre syndrome This is an autoimmune disease. -Type 2 diabetes With type 2, beta cells do not produce enough insulin OR the body becomes resistant to insulin due to lifestyle choices. This is not caused from an attack by body's immune system. -Type 1 diabetes Type 1 diabetes occurs when the pancreas is not producing insulin because of an autoimmune attack. The immune system attacks pancreatic beta cells (islet cells), which takes away the body's ability to produce insulin.

The nurse is caring for a client with chronic diabetic neuropathy. The client requests non-pharmacological interventions to cope with the condition. Which of the following is NOT an appropriate intervention for this client? -Music therapy -Pet therapy visits -Aromatherapy -Heat packs to the feet

-Music therapy There is no risk involved with music therapy in regards to diabetic neuropathy. -Pet therapy visits This is an appropriate intervention for a client with neuropathy. -Aromatherapy This Iis an appropriate intervention for this client. -Heat packs to the feet The client with neuropathy may not be able to feel temperature changes, which puts him or her at risk for burning himself with a heat pack.

Which of the following sleep disorders has been most commonly associated with type 1 diabetes? -Night terrors -Sleepwalking -Insomnia -Delayed sleep phase syndrome

-Night terrors Not associated with a diagnosis of diabetes. -Sleepwalking Not associated with a diagnosis of diabetes. -Insomnia Sleep disturbances are associated with type 1 diabetes. The most common sleep disorder is insomnia, which has been correlated to uncontrolled blood glucose levels. When a person with diabetes has high blood glucose at bedtime, it is difficult for them to fall asleep. Other symptoms of diabetes that affect sleep are sleep apnea and restless leg syndrome. -Delayed sleep phase syndrome Not associated with a diagnosis of diabetes.

A client presents to the emergency department with thrombocytopenia. Likely nursing interventions include which of the following? Select all that apply. -Observe for purpura and open wounds -Withhold aspirin -Monitor urine output -Monitor for bleeding -Monitor for mental status changes

-Observe for purpura and open wounds A client with thrombocytopenia has reduced platelets in the blood and must be monitored carefully for signs of bleeding. Purpura would be a sign that the client has low platelets. -Withhold aspirin A client with thrombocytopenia has reduced platelets in the blood and must be monitored carefully for signs of bleeding. The client must avoid NSAIDs because this will increase the bleeding risk. -Monitor urine output A client with thrombocytopenia has reduced platelets in the blood and must be monitored carefully for signs of bleeding. Urine output should be monitored, and pink, red or brown urine should be noted as this means there is blood in the urine. -Monitor for bleeding A client with thrombocytopenia has reduced platelets in the blood and must be monitored carefully for signs of bleeding. -Monitor for mental status changes Unless the client has profound bleeding and loses 40% of their blood volume, they will not experience mental status changes. The question does not state the client is actively bleeding, so this nursing intervention is not likely.

A client who has been diagnosed with diabetes insipidus has been prescribed vasopressin as an antidiuretic replacement. The nurse caring for the client reviews his other medications. Which drug should not be taken with vasopressin? -Omeprazole -Diphenhydramine -Carbamazepine -Levothyroxine

-Omeprazole This drug does not have any known interactions with vasopressin. -Diphenhydramine This drug does not have any known interactions with vasopressin. -Carbamazepine Vasopressin is a medication that has the effects of anti-diuretic hormone. It can be used to control blood pressure and is used for the treatment of diabetes insipidus. Vasopressin should not be used with carbamazepine, as carbamazepine can decrease the overall effects of vasopressin in the bloodstream. -Levothyroxine This drug does not have any known interactions with vasopressin.

The nurse is reviewing a client's medications from home and notes that levothyroxine is listed as a daily medication. The nurse knows that which of the following times is best to take this medication? -One hour after a meal -Once a day with a meal -Thirty minutes before breakfast -With a bedtime snack

-One hour after a meal Calcium, iron, and certain other drugs and foods will decrease the absorption of levothyroxine, so clients are instructed to take this medication on an empty stomach. -Once a day with a meal To avoid malabsorption of this drug in the GI tract, it should be taken on an empty stomach. -Thirty minutes before breakfast Levothyroxine is best absorbed when taken on an empty stomach. One hour to 30 minutes before breakfast is appropriate. -With a bedtime snack This should not be taken with food because many foods will affect the absorption of this drug.

A nurse is caring for a client that delivered a fetal demise 3 hours ago is bleeding heavily. The providers believe she has disseminated intravascular coagulation and has ordered labs to be drawn. What results would the nurse expect to see if DIC is occurring? Select all that apply. -Platelets 50,000 -Hemoglobin 13.2 -INR 1.2 -PTT 56 seconds -PT 19 seconds

-PT 19 seconds Clotting times would be increased because of the body using up clotting factors and not being able to clot anymore. Normal PT is 11-14 seconds, this is prolonged, therefore would be evidence of DIC. -INR 1.2 This is a normal INR, but the nurse should expect it to be elevated. -PTT 56 seconds Clotting times would be prolonged because the body is no longer able to clot effectively. Normal PTT is 25-35 seconds. This result is lengthened, therefore possible evidence of DIC. -Platelets 50,000 Platelets would be decreased due to being used up. Normal platelets are 100K-450K. This is low, therefore would be evidence of DIC. -Hemoglobin 13.2 This is a healthy hemoglobin. We expect it to be low from bleeding.

A client reports pain at an intravenous site. What assessment findings would indicate phlebitis? Select all that apply. -Palpabale venous cord -Pain and coolness at site -Pain and edema at site -Temperature of 100.7 F -Redness and warmth at site

-Palpabale venous cord Phlebitis is an infection of a vein. Signs/symptoms include redness, pain, red streak (venous cord) and possibly purulent drainage. The client may also have a low grade fever. -Pain and coolness at site An infiltration is cool, edematous and painful without evidence of inflammation or infection. -Pain and edema at site An infiltration is cool, edematous and painful without evidence of inflammation or infection. -Temperature of 100.7 F Phlebitis is an infection of a vein. Signs/symptoms include redness, pain, red streak (venous cord) and possibly purulent drainage. The client may also have a low grade fever. -Redness and warmth at site Phlebitis is an infection of a vein. Signs/symptoms include redness, pain, red streak (venous cord) and possibly purulent drainage. The client may also have a low grade fever.

Which best describes how high stress levels can impact diabetes management? -Pancreatic failure requires the adrenal glands to work harder, leading to hypertrophy -Chronic stress can cause increased levels of blood glucose -Stress and anxiety are more likely to cause skin breakdown -Elevated glucose levels cause neurological impairment that affects stress management skills

-Pancreatic failure requires the adrenal glands to work harder, leading to hypertrophy Stress does not cause these effects in a person with diabetes. -Chronic stress can cause increased levels of blood glucose When stress occurs, such as during emotional stress, infections or a serious illness, the body releases specific hormones, including adrenaline, glucagon, growth hormone and cortisol. Blood sugar levels rise to prepare for 'fight or flight', and insulin production decreases to ensure the sugar is readily available for energy. This is counter-productive in the diabetic client, because as blood glucose levels rise, the client must take increasing amounts of insulin to control their glucose level. -Stress and anxiety are more likely to cause skin breakdown Stress does not cause these effects in a person with diabetes. -Elevated glucose levels cause neurological impairment that affects stress management skills Stress does not cause these effects in a person with diabetes.

A nurse is assessing a postpartum client who has a platelet count of 47,000 uL, D-dimer of 0.59 and a PT of 3 seconds. What findings would the nurse expect to assess? -Boggy uterus, pain -Headache, decreased urinary output -Petechiae, purpura -Lung crackles, hypertension

-Petechiae, purpura The low platelets and prolonged bleeding time will produce symptoms of hemorrhaging, as seen in clients with DIC. -Headache, decreased urinary output Headache is not an expected finding with DIC. The client might experience decreased urinary output due to hypovolemic shock from excessive bleeding, but it is a later sign. -Lung crackles, hypertension These are not expected findings of DIC. Hypotension may be seen with signs of hypovolemic shock from excessive bleeding. -Boggy uterus, pain These are not expected findings of DIC. A boggy uterus may indicate risk for postpartum hemorrhage and should be assessed further.

A nurse is caring for a client with essential thrombocythemia. What diagnostic finding will the nurse expect to see? -Platelet count greater than 450,000 -Decreased megakaryocytes in bone marrow -Elevated thrombin level -Elevated erythrocyte count

-Platelet count greater than 450,000 A thrombosis is a blood clot, and platelets clot blood. Therefore, thrombocythemia is a condition in which there are too many platelets in the blood. In essential thrombocythemia, the body produces excessive platelets, and diagnosis is confirmed when the number of platelets per microliter of blood is between 450,000 and 600,000. There are also increased megakaryocytes (which produce platelets) in bone marrow aspirate, but the thrombin level and erythrocyte count are normal. -Decreased megakaryocytes in bone marrow Megakaryocytes are increased in thombocythemia. -Elevated thrombin level These levels are normal with this condition. -Elevated erythrocyte count These levels are normal with this condition.

The nurse is caring for a client with thrombocytopenia. Which of the following substances would the nurse expect to administer for this client? -Platelets -Packed RBCs -Whole blood -Albumin

-Platelets If a client's platelet count drops below 100,000 cells/microliter, the client is considered to have thrombocytopenia and needs platelets. -Packed RBCs This is not given to correct thrombocytopenia. -Whole blood This is not given to correct thrombocytopenia. -Albumin This is not given to correct thrombocytopenia.

A client is admitted to the hospital with primary adrenal insufficiency. Which of the following drugs does the nurse anticipate giving for this condition? Select all that apply. -Prednisone -Growth hormone -Dexamethasone -Vasopressin -Prednisolone

-Prednisone Primary adrenal insufficiency symptoms are due to a hyposecretion of adrenal cortex hormones which are primarily glucocorticoids. These include dexamethasone, hydrocortisone, methylprednisolone and prednisone. -Growth hormone There is not a deficiency of growth hormone in adrenal insufficiency. -Dexamethasone Dexamethasone is given to treat primary adrenal insufficiency. -Vasopressin There is not a deficiency of vasopressin in adrenal insufficiency. -Prednisolone Prednisone is given to treat primary adrenal insufficiency.

While receiving a transfusion of packed red blood cells (PRBCs), a client reports feeling anxious and starts to form a rash on their hands and chest. Which of the following responses by the nurse would be appropriate? Select all that apply. -Prepare to administer diphenhydramine IV -Initiate infusion of 0.9% sodium chloride -Discard blood products -Remove contaminated IV catheter and replace IV access -Stop transfusion immediately

-Prepare to administer diphenhydramine IV Diphenhydramine, acetaminophen, and epinephrine are commonly used to treat a transfusion reaction. -Initiate infusion of 0.9% sodium chloride Sodium chloride is the only IV fluid compatible with blood products and that is why we hang blood products in tandem with 0.9% sodium chloride. Once the catheter has been flushed with Normal Saline, the existing IV catheter is safe to use. -Discard blood products While the transfusion should be stopped immediately, keeping the blood products to return to blood bank is an important step in investigating what caused the reaction. -Remove contaminated IV catheter and replace IV access Maintaining IV access is critical to administering life-saving drugs during a reaction. Once the catheter has been flushed with Normal Saline, the existing IV catheter is safe to use. -Stop transfusion immediately This is a transfusion reaction. Any sign of transfusion reaction should be assessed immediately and is an indication that the infusion must be stopped.

The nurse is admitting a client with newly diagnosed hypothyroidism receiving Synthroid. Which of the following items would the nurse expect to be monitored with this client? Select all that apply. -Presence of fatigue -TSH, T3, and T4 levels -Pulmonary function tests -Weight changes -Skin and hair condition

-Presence of fatigue Hypothyroidism is a common disorder affecting the endocrine system. In this condition, the client lacks sufficient thyroid hormone usually due to iodine deficiency or autoimmune causes. The client with hypothyroidism will be prescribed medication such as synthetic thyroid hormone, and monitored for signs of the disease which include fatigue, constipation, cold intolerance, dry skin, hair loss and weight gain among others. -TSH, T3, and T4 levels Thyroid levels will be monitored to assess the effectiveness of treatment. A low T3 and T4 and a high TSH indicates hypothyroidism. -Pulmonary function tests Hypothyroidism does not affect the lungs. -Weight changes Weight changes are monitored because hypothyroidism affects fat accumulation and fluid retention. And if Synthroid is prescribed, weigh loss is also a possibility if the dosage is too high for the client. -Skin and hair condition Dry skin and brittle hair and nails are side effects of hypothyroidism, and will be monitored to assess effectiveness of treatment.

A nurse is caring for a client who has just returned from a thyroidectomy. What would be the most appropriate position for this client? -Prone -Semi-Fowler's -Orthopneic -Supine

-Prone Lying prone (on the stomach) would not only add pressure to the incision, it would prevent the nurse from appropriately visualizing the incision site. -Semi-Fowler's Semi-Fowler's would be the best position after this surgery. The client is sitting upright, able to breathe well, and no pressure is being placed on the incision. -Orthopneic The orthopneic position is when the client is sitting upright and leaning forward over a table or pillows. This position is used to improve breathing. However, the client leaning head forward puts unnecessary pressure on the incision site. This position is not the most appropriate after a thyroidectomy. -Supine Lying flat (supine) would add pressure to the surgical site due to gravity. It could also cause unnecessary difficulty for the client's breathing.

The nurse is caring for a client who is having an anaphylactic reaction. The provider has placed orders. Which of the following orders is the priority? -Provide high flow oxygen -Place the client on the pulse oximeter -Administer IM epinephrine -Inspect the airway for airflow

-Provide high flow oxygen High flow oxygen should occur after the airway patency is determined -Place the client on the pulse oximeter Placing the client on a pulse oximeter will be important after the airway patency is determined. -Administer IM epinephrine While administering epinephrine is important, the nurse's priority is to assess for ABCs first. The nurse must assess the airway to determine if the client is able to breathe. -Inspect the airway for airflow With anaphylaxis, the ABCs are critical to assess in order.

A nurse is caring for a client who is infected with HIV. The nurse recognizes that the client is at risk for skin breakdown because of complications of his illness. Which intervention would the nurse most likely employ to reduce this risk? -Provide pain medication PRN as ordered -Ensure that the client gets adequate rest -Regularly take the client outside in a wheelchair -Encourage food and fluid intake

-Provide pain medication PRN as ordered Adequate pain relief, while an important responsibility of the nurse, will not lead to a reduced risk for pressure ulcers and may, in fact, INCREASE the risk due to the client's reduced ability to feel discomfort. -Ensure that the client gets adequate rest Rest is important, but too much time spent in a bed will increase the risk for skin breakdown. -Regularly take the client outside in a wheelchair Placing the client in a wheelchair increases the pressure on the client's buttocks, which can lead to skin breakdown. Rather, the nurse should encourage ambulation instead of offering a wheelchair. -Encourage food and fluid intake Up to 90% of clients who are infected with HIV experience some form of skin impairment, including skin breakdown and wounds. The nurse can take steps to prevent skin breakdown by utilizing the Braden Scale skin assessment tool, which includes nutrition status, mobility, activity, friction and sheer, moisture, and sensory perception. Encouraging food and fluid intake can help to prevent malnutrition that leads to wound development.

The emergency nurse is managing care for an assigned group of clients. The nurse receives a new admission that is becomes the priority. Which of the following is the priority? -RLQ pain -Chest pain -Bee sting with significant facial swelling -LUQ pain

-RLQ pain This could indicate appendicitis. However, airway and circulation issues would be stabilized before a client with appendicitis. -Chest pain Chest pain can indicate a myocardial infarction. However, loss of airway takes priority over loss of circulation. This client, although potentially in an emergent situation, would be seen second. -Bee sting with significant facial swelling The client with a bee sting is at risk for losing the airway, because this client is having an anaphylactic reaction. Everyone else may be uncomfortable, but they are more stable and can wait. -LUQ pain This client could be having digestive issues. This client would be seen last.

The client needs replacement of the hormones necessary for the regulation of fluid and electrolyte balance within the body. Which hormones will the nurse expect to replace? Select all that apply. -Renin -Angiotensin -Aldosterone -Antidiuretic hormone (ADH) -Cortisol

-Renin Renin and angiotensin control blood pressure, but not fluid and electrolyte balance. -Angiotensin Angiotensin and renin control blood pressure, but not fluid and electrolyte balance. -Aldosterone Both ADH and aldosterone regulate the fluid and electrolyte balance through their action on the kidneys. Parathyroid hormone also regulates fluid and electrolyte balance. Medication such as fludrocoristone replace aldosterone. -Antidiuretic hormone (ADH) Both ADH and aldosterone regulate the fluid and electrolyte balance through their action on the kidneys. Parathyroid hormone also regulates fluid and electrolyte balance. Synthetic ADH medications are given to clients to help the kidneys retain water appropriately. -Cortisol Cortisol is a hormone involved in the metabolism of macronutrients, and also regulates sleep, stress response, and blood pressure. It is not involved in fluid and electrolyte balance.

A 79-year-old client with Cushing's disease has developed some cognitive effects that are impacting his ability to care for himself. Which cognitive effects are most likely to develop in a client with Cushing's disease? -Seizures -Aggression -Coma -Memory loss

-Seizures Seizures are not commonly associated with Cushing's syndrome. -Aggression Aggression is not a cognitive symptoms commonly seen in Cushing's syndrome clients. -Coma Coma is not coommonly associated with Cushing's syndrome. -Memory loss Cushing's disease occurs when the pituitary gland produces excess amounts of adrenocorticotropic hormone. The client can experience changes in body structure, as well as changes in skin, muscles, and cognition. One of the most common cognitive effects associated with Cushing's disease over time is memory loss.

A nurse is caring for a client who has been diagnosed with Addison's disease. The nurse is teaching about symptoms of Addisonian crisis in order to best manage and prevent it before it occurs. What symptoms should the client look for that the nurse should include as part of teaching? Select all that apply. -Severe headache -Generalized weakness -Sudden pain in the lower back or abdomen -Dehydration -High blood pressure

-Severe headache Severe headache is a symptom to teach this client regarding an Addisonian crisis. -Generalized weakness Generalized weakness could be a sign of an Addisonian crisis. -Sudden pain in the lower back or abdomen Addison's disease is a type of primary renal insufficiency in which the adrenal glands do not produce enough hormones. The client often has fatigue, muscle weakness, and weight loss. Addisonian crisis is another complication of the condition. It is characterized by sudden pain in the lower back, severe headache, generalized weakness, shock, and dehydration. -Dehydration Client teaching should include dehydration as one of the signs of an Addisonian crisis. -High blood pressure During Addisonian crisis, a client typically becomes severely hypotensive.

The nurse is caring for a client with breast cancer who underwent radiation therapy four weeks ago. The nurse should tell the client to look for what potential late effects of radiation therapy following the treatment? Select all that apply. -Softer breast tissue -Delayed wound healing -Broken blood vessels under the skin -Swelling of breast tissue -Lymphadema

-Softer breast tissue Fibrous tissue can occur, but softer tissue is not side effect of radiation. -Swelling of breast tissue Swelling of breast tissue is not side effect of radiation. -Lymphadema Radiation side effects are divided into two categories: Acute effects (from treatment time to 2-3 weeks after treatment) and chronic effects (from 3 weeks after treatment to years later). Acute effects include mucositis or ulceration of mucous membranes, yeast or bacterial infections, dry or darkening skin, and temporary cessation of function to the sweat and oil glands. Chronic effects include lymphadema, broken blood vessels under the skin, and delayed wound healing, as well as fibrotic muscle tissue in the area exposed to radiation. Dry mouth is a chronic effect if the radiation was placed near the neck. -Delayed wound healing Delayed wound healing can become a chronic issue after radiation. -Broken blood vessels under the skin This is one chronic side effect of radiation that may occur.

A client with lymphoma has developed septic shock after contracting a Clostridium difficile infection. Which type of isolation precautions should the nurse employ with this type of infection? -Standard precautions -Droplet precautions -Contact precautions -Airborne precautions

-Standard precautions Standard precautions are utilized when working with any client. This includes hand hygiene, gloves, and other personal protective equipment as needed. -Droplet precautions Droplet precautions are utilized when there is a risk for transmission of a disease from droplets that are >5 microns. -Contact precautions C. difficile is an infectious condition that can be spread when its spores are present on items or surfaces that are touched by others. A nurse should use contact precautions, which include frequent hand hygiene and using gloves and a gown when in contact with the client. The nurse may also need to wear a face shield if there is potential for splashing of blood or body fluids. -Airborne precautions Airborne precautions are utilized when there is a risk for transmission of disease from airborne droplets that are <5 microns.

A nurse is performing the initial assessment of a child with a history of acute leukemia who was brought into the emergency department. The nurse discovers the child has a temperature of 38.5C. Which action is the first priority in this situation? -Start an IV on the client -Begin cooling the client with ice packs -Assess for signs of dehydration -Check a stool sample

-Start an IV on the client A child with leukemia is immunocompromised, which means they are extremely susceptible to infections. If an immunocompromised client presents with a fever over 38C, they require prompt attention to prevent potentially life-threatening sepsis. The nurse's first priority would be to start an IV so the child can receive extra fluids and antibiotics. -Begin cooling the client with ice packs The child with a temperature of 38.5C is not high enough to be at risk for seizure and does not need to be cooled. -Assess for signs of dehydration The nurse knows this child will need IV access. Access should be established right away so IV therapy can begin. -Check a stool sample Checking a stool sample is not a high priority in this situation, and the chances that it would be immediately available are slim.

A nurse is caring for a client whose friend brings cupcakes to the hospital. After taking a bite, the client's face and neck begin to turn red and the client's lips start to swell. The client begins grabbing their throat as the client's mother reports a nut allergy. The nurse quickly retrieves Epinephrine 1:1,000. Which route is the appropriate route to administer this medication? -SubQ -IM -IV -PO

-SubQ This route would not be effective for anaphylaxis as it would not be absorbed quickly enough. -IM The client is experiencing an anaphylactic reaction. This is treated with Epinephrine 1:1,000 concentration and given IM only. -IV Epinephrine 1:10,000 is given IV in cardiac arrest, but in this case, the 1:1,000 concentration should be given IM only. -PO This route would be unsafe with oral swelling and is also not an effective route for any form of Epinephrine.

A client with lymphoma is preparing to undergo a bone marrow transplant. The client will be using bone marrow taken from their own body. Which type of transplant is this referred to? -Syngeneic -Allogeneic -Autologous -Xenogeneic

-Syngeneic This refers to tissue donated by an identical twin. -Allogeneic This refers to tissue donated by a sibling or relative with a similar tissue type, or from an unrelated person. -Autologous A client who undergoes a bone marrow transplant may use bone marrow taken from the client's own body as the donor marrow. This is known as an autologous transplant. The bone marrow is collected prior to the transplant and before administration of chemotherapy or radiation. The new marrow replaces the diseased marrow that has been destroyed by the chemotherapy and radiation prior to the transplant. -Xenogeneic This refers to transplantation of tissue from an animal to a human. An example would be a porcine heart valve transplantation.

The nurse is caring for a client who has been poorly managing their Graves' disease. Which additional factor would cause the nurse major concern? -Taking iron pills -Getting pregnant -Starting a new exercise program -Diagnosis of COPD

-Taking iron pills Graves' disease can be associated with anemia, so taking an iron pill would actually be helpful. This would not concern the nurse. -Getting pregnant Poorly controlled Graves' disease causes major complications during pregnancy. The fetus and baby can have a low birth weight, preterm birth, or still birth. -Starting a new exercise program Exercise is not contraindicated with Graves' disease. -Diagnosis of COPD Co-morbidities of COPD and Graves' disease would not cause a major concern, as Graves' disease does not affect the lungs.

A nurse is caring for a client who has a history of leukemia. The client's body is demonstrating systemic inflammatory response syndrome (SIRS). Which of the following signs or symptoms would the nurse see with SIRS? Select all that apply. -Temperature of 101.8 F -RR 28 breaths/minute -Heart rate of 95 beats/minute -WBC count of 10,000/mcL -Blood pressure of 98/62 mmHg

-Temperature of 101.8 F Systemic inflammatory response syndrome (SIRS) describes the process of inflammation that occurs in response to trauma or infection. If the client has an infection and then develops septicemia, the body undergoes the process of SIRS. Clinical parameters for SIRS include a fever of more than 38°C (100.4°F) or less than 36°C (96.8°F). -RR 28 breaths/minute A respiratory rate of greater than 20 breaths per minute meets SIRS criteria. -Heart rate of 95 beats/minute Clinical parameters for SIRS include a heart rate of more than 90 beats per minute. -WBC count of 10,000/mcL SIRS criteria for WBC is more than 12,000/mcL or less than 4,000/mcL. -Blood pressure of 98/62 mmHg Blood pressure is not part of the SIRS criteria.

A pregnant client suffers from a pollen allergy and is being seen for management of symptoms. The nurse is teaching the client about how best to prevent an allergic reaction. Which of the following statements by the nurse is most appropriate? -The best way to protect yourself is to take regular doses of tetracycline during the time that you are pregnant -The best method of prevention is to avoid contact with specific allergens -You should take Sudafed or another cold preparation at the first sign of an allergic reaction -I would recommend that you undergo immunotherapy to reduce sensitivity to certain substances

-The best way to protect yourself is to take regular doses of tetracycline during the time that you are pregnant Tetracycline is harmful to the fetus during pregnancy. -The best method of prevention is to avoid contact with specific allergens Some people take allergy medications during times when exposure to substances that cause allergic responses are highest, such as during the spring when pollen is present. A pregnant client must avoid certain substances that can be damaging to the developing fetus, such as certain cold and allergy preparations and some antibiotics. The best recommendation for control of allergies in a pregnant client is for her to avoid contact with specific allergens if possible. -You should take Sudafed or another cold preparation at the first sign of an allergic reaction Sudafed should be avoided during pregnancy due to the possibility of damage to the fetus. -I would recommend that you undergo immunotherapy to reduce sensitivity to certain substances Immunotherapy is an option to desensitize a person's immune system to certain allergens, but this is a recommendation that comes from a licensed provider rather than a nurse. The nurse can explain immunotherapy to a client and tell them to discuss the possibility with their provider, but the provider will recommend this treatment.

A client with cancer has just had a Portacath placed by outpatient surgery. The nurse is discharging this client to go home. Which of the following instructions would the nurse give to this client about care of a Portacath? Select all that apply. -The dressing on the Portacath will need to be changed weekly -The client can shower and swim with the Portacath -The client will need a prescription for dressing supplies for the Portacath -The Portacath should be flushed at least once a month -The client should call the physician if infection develops around the Portacath site

-The client can shower and swim with the Portacath The Portacath is under the skin, therefore the client may swim or bathe as usual. -The Portacath should be flushed at least once a month A Portacath is a type of central line in which the access port is completely under the skin. It must be flushed every four weeks if it is not being used. -The client will need a prescription for dressing supplies for the Portacath A prescription is not needed for dressing supplies. Once the port site has healed, no dressing is necessary. -The dressing on the Portacath will need to be changed weekly The skin should be routinely inspected for redness or drainage, but once the site heals it does not need a dressing. -The client should call the physician if infection develops around the Portacath site The skin should be routinely inspected for redness or drainage, but once the site heals it does not need a dressing.

A client with leukemia will go home with a Groshong catheter placed in the right subclavian vein to use for long-term administration of chemotherapy. Which information would the nurse provide to the client regarding care of the Groshong catheter at home? Select all that apply. -The client should perform BID dressing changes -The client should use aseptic technique when handling the catheter ports -The client cannot bathe or shower until the catheter has been removed -The client should flush the catheter at least once per week -The client should avoid touching the open end of the catheter if the cap has been removed

-The client should perform BID dressing changes Each time the dressing is changed, there is a risk for pathogen introduction at the site. The frequency of dressing changes depends on the client's general health, type of dressing, medication being infused, and the condition of the client's skin. The most frequently a dressing would be changed is daily, or as infrequently as once per week. -The client should use aseptic technique when handling the catheter ports A Groshong catheter is a type of central venous catheter that is used for long-term administration of IV medications. It is important for the nurse to instruct the client on how to care for their catheter at home. Included in this teaching is aseptic technique for handling the catheter ports, proper dressing change and how to detect problems with the catheter. -The client cannot bathe or shower until the catheter has been removed The client may shower with this type of catheter, but must cover the catheter to avoid getting the dressing wet. -The client should flush the catheter at least once per week This is necessary to avoid catheter occlusion. -The client should avoid touching the open end of the catheter if the cap has been removed The client must use aseptic technique, which includes avoiding contact with the open end of the catheter.

A nurse is providing instructions and information to a client who has been recently diagnosed with HIV. What information would the nurse include as part of teaching this client about appropriate management of this condition? Select all that apply. -The client should wear sunscreen when outdoors -The client should tell all healthcare providers of the HIV status -The client should wash hands regularly -The client should not take medications that haven't been prescribed unless first discussed with the provider -The client cannot donate blood unless the recipient is also HIV positive

-The client should wear sunscreen when outdoors Clients with HIV should wear sunscreen because they're prone to photosensitivity from the virus and antiretroviral medications, and are also prone to developing skin cancers. -The client should tell all healthcare providers of the HIV status The client should inform all healthcare providers of their HIV status, because this may change the course of treatment for some conditions. -The client should wash hands regularly Clients with HIV are immunocompromised, which means they are extremely susceptible to infections. To protect themselves, practicing good hand hygiene will help avoid the spread of infection. -The client should not take medications that haven't been prescribed unless first discussed with the provider A client with HIV must take steps to care for themselves but also to protect others. This care includes taking medications as prescribed, and ensuring that new medications do not interact with the client's HIV medications. -The client cannot donate blood unless the recipient is also HIV positive HIV positive persons do not qualify for blood donation. Even if a person was HIV positive who would receive the blood, there are different strains of the virus and an HIV positive person could become more sick from HIV-containing blood.

A nurse is administering platelets to a client with leukemia. After completing the transfusion, the nurse should document which information? -The client's activity during the transfusion -The client's response to the transfusion -The signatures verifying the blood product -The type of product ordered for transfusion

-The client's activity during the transfusion This information is irrelevant to the blood transfusion. The nurse should document specific information related to the transfusion. -The client's response to the transfusion Platelets are a type of blood product that requires careful monitoring and documentation, just as with any other type of blood product administration. When a transfusion is complete, the nurse should document the time that it ended, the client's response to the transfusion, vital signs, and any reactions that occurred. -The signatures verifying the blood product This information is automatically gathered prior to starting the transfusion. -The type of product ordered for transfusion This information is automatically gathered prior to starting the transfusion.

A nurse is working with a family whose mother is dying of lymphoma. Which information would the nurse give to the family about respite care that is accurate? -The family may need respite just to get a break from the intensity of caregiving -The family can utilize respite care after the client has passed away -The family should know that respite care usually involves an inpatient hospital stay -The family should only use respite care for short periods in case the mother gets worse

-The family may need respite just to get a break from the intensity of caregiving Respite care is an option for some families who are struggling to care for a loved one. It involves placement of the client in an approved facility for the relief of the primary caregiver, for a maximum of 5 days each time. Respite provides a break from the intensity of care giving. The nurse in this situation may be able to give the family options about the type of respite care they need so they can take a break. -The family can utilize respite care after the client has passed away The purpose of respite care is to give the caregiver a break, so it does not apply after the client has passed away. -The family should know that respite care usually involves an inpatient hospital stay A respite care stay is not the same thing as an inpatient hospital stay, because the client does not have an acute illness or decline in health status -The family should only use respite care for short periods in case the mother gets worse The family can use respite care for the maximum time allowed. If the primary caregiver experiences burnout, the client will suffer, so respite is designed to alleviate this risk.

A 36-year-old client has developed hypothyroidism after having part of her thyroid removed because of a large nodule. The provider has ordered levothyroxine (Synthroid) for thyroid replacement and has been titrating the dose over several months to ensure that it is effective. Which of the following factors would most likely require an increase in titration of the dosage of this medication? -The patient has increased iodine-containing foods -The patient is having pain -The patient has developed muscle spasms -The patient is pregnant

-The patient has increased iodine-containing foods If the source of hypothyroidism is a lack of iodine and the client increases her intake of iodine-containing foods, the dose could potentially be decreased, not increased. -The patient is having pain Pain is not affected by levothyroxine. -The patient has developed muscle spasms Muscle spasms are associated with electrolyte imbalances and dehydration, but not thyroid hormone levels. -The patient is pregnant Administration of levothyroxine following surgery requires titration of the dose to adjust for the client's symptoms. A client may start on a low dose of the medication but then need to have the dose increased if the current dose is not able to control negative symptoms. A client who is pregnant may also need to have a dosage increase because low levels of thyroid hormone are associated with fetal harm and miscarriage.

A client with diabetes insipidus must start taking vasopressin. Which information from the nurse is correct when providing teaching about this medication? -The physician may order a routine ECG while the client is taking vasopressin -Vasopressin is taken as an oral tablet or in syrup form -The client will need to increase his or her fluid intake while on this medication -Vasopressin can cause severe hypomagnesemia as a potential side effect

-The physician may order a routine ECG while the client is taking vasopressin Vasopressin is a synthetic form of an anti-diuretic hormone that works by helping the body reabsorb water through the kidneys and by improving blood pressure. When a client must take this medication, the nurse should let the client know that some tests are required while the client is taking the drug. For example, the client may need routine ECG testing to monitor heart function while on this drug, due to the risk of arrhythmias. -Vasopressin is taken as an oral tablet or in syrup form This medication is available as a tablet or IV form, but not a syrup. -The client will need to increase his or her fluid intake while on this medication Too much fluid intake while on vasopressin can lead to serious complications. -Vasopressin can cause severe hypomagnesemia as a potential side effect Hypomagnesemia is not associated with vasopressin use.

A client with a spinal tumor has been having a difficult time sleeping. Which best explains how a tumor can make sleep more difficult for a client with cancer? -The tumor disrupts melatonin production, which prevents sleep -The tumor increases the risk of insomnia, which can lead to depression -The tumor causes cognitive changes that can affect the ability to fall asleep -The tumor may place pressure on parts of the body that can be uncomfortable

-The tumor disrupts melatonin production, which prevents sleep A spinal tumor has not been reported to disrupt melatonin production. -The tumor increases the risk of insomnia, which can lead to depression Cancer can result in a difficult time coping in many clients. However, depression can lead to insomnia, rather than insomnia leading to depression in this situation. -The tumor causes cognitive changes that can affect the ability to fall asleep A tumor on the spine does not normally cause cognitive changes in a client, unless there is neurological metastatic activity. -The tumor may place pressure on parts of the body that can be uncomfortable Sleep problems are common among cancer clients. The medications, treatments, and the illness itself can cause multiple problems with a client getting to sleep and staying asleep. When a client has a tumor, the growth can make sleep difficult when it compresses some parts of the body, leading to discomfort. A tumor may also be painful, it can cause a fever, or itching, or it may leave a person feeling very tired but unable to sleep.

A client is afraid that she has been exposed to HIV. The HIV antibody screening test is positive. The client is upset. Which of the following responses from the nurse is most appropriate? -This test determines that you have an autoimmune disease, not necessarily HIV -The test only says that you have been exposed to an organism, but it does not mean you are currently infected -A positive result on this test actually means that you do not have HIV, so you do not need to worry -I regret to inform you that the test indicates that you are positive for HIV.

-This test determines that you have an autoimmune disease, not necessarily HIV The test is specifically for HIV. -The test only says that you have been exposed to an organism, but it does not mean you are currently infected A positive test result means the client has the virus in the body -A positive result on this test actually means that you do not have HIV, so you do not need to worry A positive result means the client has the virus in the body. -I regret to inform you that the test indicates that you are positive for HIV. When determining if an infection is present, there are several types of antibody testing that can be performed. An HIV antibody screening test can detect if the body has released antibodies against the HIV virus. If the test is positive, it means the client has the HIV virus in the body.

The nurse is caring for a client with AIDS. The nurse enters the room prepared to do an assessment, take vital signs, and give scheduled medications. After performing these nursing interventions, the nurse assists the client into the shower and changes the client's linens while the client sits on the shower bench. Which of the following describes the most appropriate reasoning behind this? -To cluster care in order to conserve the client's energy -To prevent exposing multiple staff members to the virus -To ready the client for an intense physical therapy session -To ensure the client is ready and able to eat when their breakfast tray arrives

-To cluster care in order to conserve the client's energy Clustering care is extremely important when caring for a client with AIDS. Due to opportunistic infections, malnutrition, dehydration, and mental fatigue, a client with AIDS will become fatigued quickly. It is best practice to cluster care and minimize disturbances so the client can conserve energy. -To prevent exposing multiple staff members to the virus A client with AIDS is susceptible to infections, and it is much more dangerous for the client to be exposed to a healthy person than it is for a healthy person to be exposed to a client with AIDS. -To ready the client for an intense physical therapy session A client with AIDS may receive some physical therapy, but aggressive physical therapy is contraindicated because the goal for an AIDS client is to maintain strength, not increase their strength and physical stamina. A client with AIDS is not well enough to sustain aggressive PT and could become increasingly ill when energy reserves are depleted. -To ensure the client is ready and able to eat when their breakfast tray arrives Maintaining adequate nutrition is an important concept for a client with AIDS. However, the purpose of the nurse's actions are to cluster care in order to conserve the client's limited energy.

Which best describes the purpose of the type and crossmatch blood test? -To determine the patient's blood type and whether any infectious diseases are present -To determine the patient's blood type and whether he will need blood in the next 24 hours -To determine the patient's blood type and his hemoglobin and hematocrit level -To determine the patient's blood type and whether it is ABO compatible with another sample of blood

-To determine the patient's blood type and whether any infectious diseases are present Blood is not tested for infectious diseases during a type and crossmatch. Fortunately the donor's blood has already been tested using a standard screening process. -To determine the patient's blood type and whether he will need blood in the next 24 hours Information gained from blood type and crossmatching do not show whether the client needs blood now or will need blood in the next 24 hours. This is determined by a CBC and provider judgment. -To determine the patient's blood type and his hemoglobin and hematocrit level The H&H is determined by a complete blood count, or CBC. -To determine the patient's blood type and whether it is ABO compatible with another sample of blood A type and crossmatch is a lab test performed to determine what type of blood may be administered to a client if it is needed. This test confirms the client's blood type as well as its ABO compatibility with another kind of blood. To test the crossmatch, a small amount of blood is mixed with a sample to determine compatibility. If no red blood cell agglutination occurs, the blood is compatible.

The oncology nurse is caring for a client with leukemia. The nurse knows that the purpose of chemotherapy in this client is for which reason? -To reduce the size of the tumor -To eliminate cancer cells in the blood to prepare the client for targeted radiation therapy to the bone marrow -To wipe out the bone marrow completely -To catch the microscopic cancer cells that could have been missed during surgery

-To reduce the size of the tumor A solid tumor is not present with this type of cancer. -To eliminate cancer cells in the blood to prepare the client for targeted radiation therapy to the bone marrow Radiation therapy is sometimes used in blood cancers, but is not the reason that a client receives chemotherapy. When radiation is given, it is usually for comfort. -To wipe out the bone marrow completely A client with a blood cancer such as leukemia receives chemotherapy to completely wipe out their bone marrow so that the bone marrow can be replaced with healthy bone marrow cells. -To catch the microscopic cancer cells that could have been missed during surgery A client does not undergo surgery to remove cancer, because a solid tumor does not exist with leukemia.

The nurse is caring for a client with diabetes insipidus and is preparing to administer a scheduled vasopressin injection. Which of the following is an anticipated outcome for a client with diabetes insipidus receiving this drug? -Urine output of 2000 cc/day -Oral intake of 4500 mL per day -Weight loss of 4 pounds in a week -Urine specific gravity of 1.001

-Urine output of 2000 cc/day When a client has diabetes insipidus (DI) they can have a urine output of up to 15,000 mL per day. With vasopressin injection, there should be less polyuria and polydipsia. A urine output of 2000 cc/day is a normal urine output, which indicates that the vasopressin is effective. -Oral intake of 4500 mL per day If the oral intake is 4500 cc/day, the diabetes insipidus is not being treated adequately because the client's intake of fluids is much higher than normal. -Weight loss of 4 pounds in a week A client's response to vasopressin treatment cannot be measured in weight loss, because the client's weight may not change based on the severity of the DI. The client may be losing fluid at a rapid rate, but may also be taking in fluid to compensate for the loss, so their weight would not change. -Urine specific gravity of 1.001 A normal urine specific gravity is between 1.003 to 1.03. If the urine specific gravity is below this number, the urine is not concentrated enough which means the treatment is not working properly.

A 41-year-old client has been diagnosed with type 2 diabetes. The nurse is teaching the client about how to perform self-monitoring of blood glucose (SMBG) at home. The nurse instructs the client about how to use a lancet to obtain a blood sample. Which technique would the nurse most likely include? -Use the lancet on the side of the pad of the finger -Use the lancet on the tip of the finger to provide the most blood -Use the lancet to puncture deep enough to reach the subcutaneous tissue -Use the same two fingers to check glucose to provide consistency in blood samples

-Use the lancet on the side of the pad of the finger When checking blood glucose at home, the client should learn the most appropriate and easiest method of obtaining a blood sample, as he or she will likely need to check the blood multiple times per day. The nurse should teach the client to use a lancet on the side of the pad of the finger. This location is the least painful for the client and will be less likely to interfere with use of the pad of the finger after the blood draw. -Use the lancet on the tip of the finger to provide the most blood The client only needs one drop of blood, so any location that can provide one drop is appropriate. The side of the pad of the finger is best because the client keeps the most used part of the finger intact for use. -Use the lancet to puncture deep enough to reach the subcutaneous tissue The lancet needs only to puncture the capillary layer, which is deep enough to draw one drop of blood. -Use the same two fingers to check glucose to provide consistency in blood samples The client should evenly distribute the sites used to obtain blood to avoid excess fingersticks to one or two sites. Additionally, the blood glucose level is uniform throughout the body, so the number does not vary based on where the sample is obtained.

A nurse has an order to administer cryoprecipitate to a client. Which of the following is an indication for administering this type of blood product? Select all that apply. -Von Willebrand's disease -Hypokalemia -Hypovolemic shock -Disseminated intravascular coagulation -Hemophilia A

-Von Willebrand's disease This is a condition for which cryoprecipitate is given. -Hypokalemia This condition is not related to bleeding or clotting disorders. -Hypovolemic shock This condition is not related to bleeding or clotting disorders. -Disseminated intravascular coagulation This is a condition for which cryoprecipitate is given. -Hemophilia A Cryoprecipitate contains clotting factors and is typically given for bleeding disorders where fibrinogen is lacking. Some examples of conditions that warrant cryoprecipitate administration are hemophilia, DIC, and Von Willebrand's disease.

A 63-year-old female client complains of urinary retention and an inability to empty her bladder. The nurse understands that the client is likely experiencing which of the following conditions? Select all that apply. -Bladder tumor -Vulvovaginitis -Uterine prolapse -Vaginal pemphigus -Urethral stricture

-Vulvovaginitis This is an infection of the vagina that does not lead to urinary tract obstruction. -Vaginal pemphigus This is an infection that causes blisters and lesion, but does not lead to urinary tract obstruction. -Urethral stricture A urethral stricture is one of the common causes of urinary tract obstruction in women. -Uterine prolapse Uterine prolapse can lead to urinary tract obstruction. -Bladder tumor Based on the client's symptoms of retention and an inability to empty the bladder completely, the nurse knows she is experiencing urinary tract obstruction. Urinary tract obstruction develops as a result of something blocking the flow of urine. Some common causes of obstruction in women include uterine prolapse, urethral stricture, a bladder tumor, an ovarian cyst, uterine fibroids, or a cystocele. Treatment of urinary tract obstruction centers on correcting the cause of the blockage, and often involves surgical correction of the underlying cause.

A client has a TSH level of 5.23 mIU/L and a T4 of 3.4 ug/dL. What signs and symptoms would the nurse expect to assess? Select all that apply. -Weight loss -Constipation -Heart rate of 56 bpm -Diarrhea -Heart rate of 126 bpm

-Weight loss The signs and symptoms of hyperthyroidism include tachycardia, diarrhea, heat intolerance, weight loss, muscle weakness and anxiety. -Constipation The client has a diagnosis of primary hypothyroidism. Signs and symptoms would include constipation, bradycardia, sensitivity to cold, memory problems, severe PMS, dry skin and fatigue. -Heart rate of 56 bpm The client has a diagnosis of primary hypothyroidism. Signs and symptoms would include constipation, bradycardia, sensitivity to cold, memory problems, severe PMS, dry skin and fatigue. -Diarrhea The signs and symptoms of hyperthyroidism include tachycardia, diarrhea, heat intolerance, weight loss, muscle weakness and anxiety. -Heart rate of 126 bpm The signs and symptoms of hyperthyroidism include tachycardia, diarrhea, heat intolerance, weight loss, muscle weakness and anxiety.

A 38-year-old client has been diagnosed with type 2 diabetes and must take injectable insulin to manage the disease. The nurse is teaching the client about how to inject insulin and the client becomes very upset and anxious at the thought of giving herself an injection. Which response from the nurse is most appropriate? -You are obviously upset, so I will ask the provider if we can get you a prescription for oral insulin -This is part of your daily routine and you will get used to it -Let's talk about how we can make this as easy as possible for you -I think you should come to the healthcare clinic for your injections so you do not have to do it yourself

-You are obviously upset, so I will ask the provider if we can get you a prescription for oral insulin The client must give herself injections. Oral insulin is not an option. -This is part of your daily routine and you will get used to it This information is true but does not come across as supporting the client and acknowledging her fears. -Let's talk about how we can make this as easy as possible for you Some clients, after being diagnosed with diabetes, become very fearful or upset at the thought of administering insulin injections. The nurse can help a client in this situation by reassurance and discussing how to make it easier for the client to accept. By coming up with methods that could improve the situation, the nurse can help the client to accept the diagnosis and the need to administer insulin. -I think you should come to the healthcare clinic for your injections so you do not have to do it yourself A clinic is not set up to give insulin injections multiple times per day for clients.

A nurse reads in a client's H&P that the client is deficient in a hormone that stimulates the adrenal cortex. What is an appropriate term for this hormone? adrenocorticotropic hormone corticosteroid hormone adrenal cortectomy adrenotropin

-adrenocorticotropic hormone "Adrenocortico-" refers to the adrenal cortex specifically. "tropic" refers to a hormone that stimulates a gland to release other hormones. -corticosteroid hormone This is a type of steroid released by the adrenal cortex, but is not the hormone that causes stimulation of it. -adrenal cortectomy "-ectomy" refers to surgical removal. -adrenotropin This term does not account for specifically stimulating the adrenal cortex.

45 minutes after receiving a transfusion of whole blood, a client develops an anaphylactic transfusion reaction. During this reaction, the nurse would most likely expect to see: -trouble breathing -fever -hypertension -increased oxygen saturation

-trouble breathing The signs and symptoms of an anaphylactic transfusion reaction include: a feeling of apprehension and impending doom, generalized flushing, nausea, vomiting, diarrhea and abdominal cramps, laryngeal edema, bronchospasm and dyspnea, profound hypotension, shock, and potential cardiopulmonary arrest. An anaphylactic reaction to a blood transfusion occurs when the client's body develops an immune response against the blood product. -fever This can occur during a hemolytic reaction, not an anaphylactic reaction. -hypertension During an anaphylactic transfusion reaction, the client develops hypotension. -increased oxygen saturation During an anaphylactic reaction the client typically experiences a decrease in oxygen levels, not an increase.

A nurse is caring for a 34-year-old client who has been infected with HIV for 11 years. The client presents with diarrhea, weight loss and a fungal infection in the mouth. Which of the following are appropriate interventions for this client? Select all that apply. -Initiate isolation precautions to protect the client from infection -Teach the client wear a mask to protect visitors from infection -Encourage nutritional supplements -Monitor red blood cell count -Provide meticulous skin care

Initiate isolation precautions to protect the client from infection check_circle This client has signs of progression of HIV to AIDS. Assessment findings in the client with AIDS include malaise, fever, weightloss, diarrhea, fatigue, night sweats, opportunistic infections, neoplasms, fungal/bacterial/viral infections and lymphadenopathy. Once the client's condition has progressed to AIDS, they have a profound susceptibility to infection and malignancy. The goal of isolation precautions for an immunocompromised client is to protect the client, not visitors. -Teach the client wear a mask to protect visitors from infection The client and visitors should be educated on how to prevent the spread of infection, but the pathogens from other people pose a much greater risk to the client with AIDS than the risk the client poses for infecting others. -Encourage nutritional supplements The client may not feel like eating, so adequate nutritional support is helpful, as well as maintaining fluid and electrolyte balance. -Monitor red blood cell count White blood cells, lymphocytes and platelets should be monitored. -Provide meticulous skin care Meticulous skin care of the client will help prevent the spread of infection.

A nurse recognizes that the last two clients who received blood products developed some form of transfusion reaction. Which of the following steps could the nurse perform that would most likely prevent a transfusion reaction in the next client? Select all that apply. -Verify client identification with type and crossmatch -Use proper blood administration tubing with a filter -Warm the blood before transfusing -Inspect blood for any signs of abnormalities -Start the transfusion quickly and run over a period of one hour

Verify client identification with type and crossmatch Not all blood transfusion reactions can be prevented, but the nurse can take steps to reduce the risk of one occurring by carefully checking the client and the blood that is going to be administered. The nurse should also be familiar with signs of a transfusion reaction and know when to discontinue the blood. Use proper blood administration tubing with a filter The nurse should check if proper blood administration tubing with filter is use. Warm the blood before transfusing The nurse should inspect the blood product, but not warm the blood before transfusing. Inspect blood for any signs of abnormalities This is appropriate to avoid giving blood inappropriately. Start the transfusion quickly and run over a period of one hour The proper method to administer blood is to start slowly. *IF* there is a reaction, it usually occurs within the first few minutes of the transfusion, so the LESS amount of blood that has transfused into the client the better.