Med-Surg II Exam #2

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? A. The client's pain rating B. Nonverbal cues from the client C. The nurse's impression of the client's pain D. Pain relief after appropriate nursing intervention

A. The client's pain rating

Which laboratory results does the nurse expect to decrease in a client who has untreated HIV-III (AIDS)? (Select all that apply.) A. Total white blood cell count B. Viral load C. CD8+ T-cell D. HIV antibodies E. CD4+ T-cell F. Lymphocytes

A. Total white blood cell count E. CD4+ T-cell F. Lymphocytes

Which conditions or factors will the nurse teach at a community seminar as probable transmission routes for HIV? (Select all that apply.) A. Using injection drugs B. Sitting on public toilets C. Changing a diaper on an HIV positive child D. Having unprotected intercourse with multiple partners E. Breast-feeding F. Being bitten by mosquitos

A. Using injection drugs D. Having unprotected intercourse with multiple partners E. Breast-feeding

Which laboratory test does the nurse analyze to determine the effectiveness of combination antiretroviral drug therapy in an HIV-positive client? A. Viral load testing B. Enzyme-linked immunosorbent assay C. Fourth generation testing D. Western blot analysis

A. Viral load testing

A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply.) ATI 86.2 A. Western blot B. Indirect immunofluorescence assay C. CD4+ T-lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid (CSF) analysis

A. Western blot B. Indirect immunofluorescence assay

The nurse is teaching a client with erectile dysfunction about taking sildenafil to achieve an erection. Which client statement demonstrates an understanding of this drug? A. "I can have sex up to 8 hours after taking the drug." B. "I might get a headache or stuffy nose when this drug is used." C. "Taking this with a drink or two of alcohol will enhance my performance." D. "If one pill doesn't work, it is acceptable for me to quickly take another pill."

B. "I might get a headache or stuffy nose when this drug is used."

Which dietary change does the nurse suggest for the client who has esophageal candidiasis? A. "Avoid drinking alcoholic beverages." B. "Eat soft, cool food such as pudding and smoothies." C. "Limit your intake of fluid to no more than 1 L daily." D. "Increase your intake of cooked leafy green vegetables."

B. "Eat soft, cool food such as pudding and smoothies."

A nurse is teaching a client who has human immunodeficiency virus (HIV) about how the virus is transmitted. Which of the following statements should nurse include the teaching? A. "HIV can be transmitted as soon as a person develops manifestations." B. "HIV can be transmitted to anyone who has had contact with infected blood." C. "HIV is transmitted through the respiratory route via droplets." D. "HIV is transmitted only during the active phase of the virus."

B. "HIV can be transmitted to anyone who has had contact with infected blood."

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? A. Placing cool compresses on the affected arm B. Elevating the affected arm on a pillow above heart level C. Avoiding arm exercises in the immediate postoperative period D. Maintaining an intravenous site below the antecubital area on the affected side

B. Elevating the affected arm on a pillow above heart level

A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? A. Excessive salivation B. Finger contractures C. Periorbital edema D. Alopecia

B. Finger contractures

The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action? A. Take the medication with food. B. Increase fluid intake to 2000 to 3000 mL daily. C. Decrease sodium intake while taking the medication. D. Increase potassium intake while taking the medication.

B. Increase fluid intake to 2000 to 3000 mL daily.

With which antiretroviral drug class will the nurse teach clients to prevent harm by reporting any new onset muscle weakness and muscle pain to the immunity health care provider? A. Fusion inhibitors B. Integrase inhibitors C. Nucleoside reverse transcriptase inhibitors D. Protease inhibitors

B. Integrase inhibitors

A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options? A. Begin monthly breast self-examinations at age 40 B. Have a clinical breast examination each year after age 30 C. Begin annual mammograms at age 40 D. Have breast magnetic resonance imaging every 5 years after age 50

C. Begin annual mammograms at age 40

A nurse is planning care for a client who is postoperative following a radical mastectomy. Which of the following interventions should the nurse include plan? A. Rest the arm on the affected side on the bed when the client is sleeping B. Instruct the client to keep the affected arm flexed when ambulating C. Begin exercises with the client 1 day after the procedure D. Maintain the client on bed rest for 2 days after the procedure

C. Begin exercises with the client 1 day after the procedure

The nurse is caring for a postrenal transplantation client taking cyclosporine. The nurse notes an increase in one of the client's vital signs, and the client is com plaining of a headache. What vital sign is most likely increased? A. Pulse B. Respirations C. Blood pressure D. Pulse oximetry

C. Blood pressure

A patient with RA states, "I can't do as much as I used too because my joints hurt so much." What should the nurse teach to promote mobility? A. Avoid use of the painful joints B. Avoid the use of canes because they can increase range of motion C. Decrease range of motion exercises and any aerobic exercise D. Take medication as prescribed so that activities can be continued

D. Take medication as prescribed so that activities can be continued

The client who wants to use Truvada for preexposure prophylaxis (PreP) asks the nurse why testing is needed for HIV status before starting this drug. How does the nurse respond? A. "Although this drug can help prevent HIV infection, it is not enough by itself to control the disease if you are HIV positive." B. "The side effects of this drug are worse if you have a detectable HIV viral load." C. "If you take this drug and are HIV positive, your risk for co-infection with the hepatitis B virus is increased." D. "Some people have a genetic mutation that increases the risk for life-threatening reactions while taking this drug if they are also HIV positive."

A. "Although this drug can help prevent HIV infection, it is not enough by itself to control the disease if you are HIV positive."

During a health history assessment, a patient with rheumatoid arthritis, chronic hypertension, and diagnosis of a recent cerebrovascular accident states that she takes 2 fish oil capsules (5 g) daily as a supplement for her RA. What additional question(s) should the nurse ask? (Select all that apply.) A. "Are you taking anticoagulant medications?" B. "Have you found the fish oil to help your RA?" C. "What other supplements do you currently take?" D. "How long have you been taking fish oil capsules?" E. "Have you notified your physician about taking fish oil capsules?"

A. "Are you taking anticoagulant medications?" B. "Have you found the fish oil to help your RA?" C. "What other supplements do you currently take?" D. "How long have you been taking fish oil capsules?" E. "Have you notified your physician about taking fish oil capsules?"

25. Which teaching will the nurse provide to a client who has been prescribed antibiotics for pelvic inflammatory disease (PID)? Select all that apply. A. "Finish all of the prescribed drug even if you begin to feel better" B. "If you feel nauseated from the antibiotics, take a dose of Tums or Maalox." C, "Take antibiotics with food to decrease the chance of stomach irritation." D. "You may resume intercourse once you have been on the antibiotic for 48 hours." E. "You will need to return to see the health care provider after finishing drug therapy."

A. "Finish all of the prescribed drug even if you begin to feel better" E. "You will need to return to see the health care provider after finishing drug therapy."

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to lie still in bed during my brachytherapy treatment." B. "I will have an implant placed once a month during my brachytherapy treatment." C. "I must stay at least 3 feet away from others between brachytherapy treatments." D. "I should expect some blood in my urine after each brachytherapy treatment."

A. "I need to lie still in bed during my brachytherapy treatment."

A nurse is providing teaching to a client with cancer who is receiving external radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to protect the area from sunlight." B. "I'm going to apply a heating pad to the area after each treatment." C. "I'll massage the area once per day." D. "I'll wash off the markings after each therapy treatment."

A. "I need to protect the area from sunlight."

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? A. "I should take hot baths because they are relaxing." B. "I should sit whenever possible to conserve my energy." C. "I should avoid long periods of rest because it causes joint stiffness." D. "I should do some exercises, such as walking, when I am not fatigued."

A. "I should take hot baths because they are relaxing."

A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to take methotrexate, even if I'm in remission." B. "I'm thankful that this type of lupus only affects the skin." C. "Each day, I should apply a sunblock with a sun protection factor of 15." D. "A mild fever is common with SLE and usually does not require medical intervention."

A. "I will need to take methotrexate, even if I'm in remission."

The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane, so he missed all of yesterday's dosages. What action does the nurse recommend? A. "Take today's dosages as normally prescribed and continue to follow your therapy program." B. "Don't worry. Unless you miss your drugs for 4 days consecutively, there is not a problem." C. "Take double doses of the drugs for the next 2 days and do not have sex for at least 4 days." D. "Go to the nearest emergency department and have an immediate blood test for assessment of viral load."

A. "Take today's dosages as normally prescribed and continue to follow your therapy program."

A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? A. "Wash your genitalia using an antimicrobial soap." B. "Rinse your dishes with cold water." C. "Clean your toothbrush once per month." D. "Incorporate raw fruits and vegetables into your diet."

A. "Wash your genitalia using an antimicrobial soap."

A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching? A. "You can expect a persistent fever and swollen glands." B. "You can expect an elevated white blood cell count." C. "You can expect increased blood pressure and edema." D. "You can expect weight gain."

A. "You can expect a persistent fever and swollen glands."

A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching? A. "You can suck on popsicles to numb your mouth." B. "Season food with spices instead of salt." C. "Avoid the use of a straw to drink liquids." D. "Eat foods at hot temperatures."

A. "You can suck on popsicles to numb your mouth."

A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient's pregnancy? 17.3 A. Abacavir B. Darunivir C. Tripanavir D. Raltegravir

A. Abacavir

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. A. Administer oxygen. B. Quickly assess the client's respiratory status. C. Document the event, interventions, and client's response. D. Leave the client briefly to contact a primary health care provider (PHCP). E. Keep the client supine regardless of the blood pressure readings. F. Start an intravenous (IV) infusion of D5W and administer a 500-ml bolus.

A. Administer oxygen. B. Quickly assess the client's respiratory status. C. Document the event, interventions, and client's response.

A nurse is providing discharge teaching to a client who has HIV. Which of the instructions about infection prevention should the nurse include? (Select all that apply.) A. Avoid large gatherings of people B. Clean toothbrush by running through the dishwasher C. Change pet litter boxes with disposable gloves D. Consume fresh fruit and raw vegetables E. Avoid digging in the garden

A. Avoid large gatherings of people B. Clean toothbrush by running through the dishwasher E. Avoid digging in the garden

Which statements about the transmission of HIV are true? (Select all that apply.) A. Clients with HIV-III and no drug therapy are very infectious. B. Even with appropriate drug therapy, most clients infected with HIV live only about 5 years after diagnosis. C. HIV may be transmitted only during the end stages of the disease. D. The most common transmission route is casual contact. E. Newly infected clients with a high viral load are very infectious. F. HIV-positive clients who have an undetectable viral load appear to not transmit the disease.

A. Clients with HIV-III and no drug therapy are very infectious. E. Newly infected clients with a high viral load are very infectious. F. HIV-positive clients who have an undetectable viral load appear to not transmit the disease.

A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is scheduled to begin treatment for systemic manifestation of the following types of medications should the nurse plan to administer? A. Corticosteroids B. Antimalarials C. Antidepressants D. Opioids

A. Corticosteroids

Which signs and symptoms does the nurse expect to find in a client diagnosed with Pneumocystis jiroveci infection? A. Dyspnea, tachypnea, persistent dry cough, and fever B. Substernal chest pain and difficulty swallowing C. Fever, persistent cough, and vomiting blood D. Cough with copious thick sputum, fever, and dyspnea

A. Dyspnea, tachypnea, persistent dry cough, and fever

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? A. Encouraging fluids. B. Providing frequent oral care C. Coughing and deep breathing D. Monitoring the red blood cell count

A. Encouraging fluids.

A nurse is teaching a female client with a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? A. Exercise B. Pregnancy C. Infection D. Sunlight

A. Exercise

A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while the client is taking this medication? A. Gait B. Appetite C. Level of consciousness D. Gastrointestinal function

A. Gait

A nurse is planning an educational program for a group of young adults about reducing the risk of cervical cancer. Which of the following interventions should the nurse include? A. Get the human papillomavirus (HPV) immunization B. Avoid the use of tampons on a routine basis C. Avoid drinking alcohol D. Get a Papanicolaou test every year starting at age 30

A. Get the human papillomavirus (HPV) immunization

A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify which of the following factors as increasing the client's breast cancer risk? (Select all that apply.) A. Increased breast density B. BMI of 32 C. Having given birth to 5 children. D. Undergoing hormonal replacement therapy for 10 years E. Having 1-2 alcoholic drinks per week

A. Increased breast density B. BMI of 32 D. Undergoing hormonal replacement therapy for 10 years

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? A. Increased calcium level B. Increased white blood cells. C. Decreased blood urea nitrogen level D. Decreased number of plasma cells in the bone marrow

A. Increased calcium level

A nurse is teaching a client about the manifestations of an allergic reaction. The release of histamine causes which of the following reactions? A. Increased mucus secretion B. Bronchial dilation C. Bradycardia D. Vertigo

A. Increased mucus secretion

A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. The client reports having a cough along with nausea and diarrhea. Their temperature is 38.1° C (100.6° F) orally. The client is concerned about the possibility of having HIV. Which of the following actions should the nurse take? (Select all that apply.) ATI 86.1 A. Perform a physical assessment. B. Determine when manifestations began. C. Teach the client about HIV transmission. D. Draw blood for HIV testing. E. Obtain a sexual history.

A. Perform a physical assessment. B. Determine when manifestations began. E. Obtain a sexual history.

A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors associated with this virus? (Select all that apply.) 86.4 A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult woman E. Occupational exposure

A. Perinatal exposure D. Older adult woman E. Occupational exposure

A nurse is teaching a client who has Raynaud's disease. Which of the following pieces of information should the nurse include in the teaching? A. Protect against the cold by wearing layers of clothing B. Begin an exercise program of 2-mile walks once per week C. Increase vitamin A in the diet D. Elevate the hands above heart level when resting

A. Protect against the cold by wearing layers of clothing

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? A. Protecting the client from infection B. Providing emotional support to decrease fear C. Encouraging discussion about lifestyle changes D. Identifying factors that decreased the immune function

A. Protecting the client from infection

A nurse is providing discharge teaching to a client following an open radical prostatectomy. The client is going home with an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be able to take a tub bath in 1 week B. "I will change the catheter drainage bag once each week." C. "I will use suppositories to prevent constipation." D. "I will regain my bladder control once the catheter is removed."

B. "I will change the catheter drainage bag once each week."

A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? A. "I will use a soft toothbrush or foam swab for oral care." B. "I will use lemon and glycerin swabs after meals." C. "I will remove my dentures except while eating." D. "I will rinse my mouth frequently with hydrogen peroxide solution."

B. "I will use lemon and glycerin swabs after meals."

The nurse has provided teaching to a client with vulvovaginitis. Which client statement indicates that nursing intervention is required? Select all that apply. A. "I will wipe from the front to the back." B. "I will wash with fragranced soap to prevent odor." C. "I am going to the store now to buy cotton underwear." D. "I will use fragrance-free laundry detergents in the future." E. "I am going to take all of the medicine the provider prescribed."

B. "I will wash with fragranced soap to prevent odor."

A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome (AIDS). Which of the following statements the client's partner indicates a need for further teaching? A. "I will dispose of soiled tissues in separate plastic bags." B. "I'll clean up blood spills immediately with hot water." C. "I know that handwashing is an important preventive measure." D. "I will wash soiled clothes in hot water."

B. "I'll clean up blood spills immediately with hot water."

A client with a history of BPH calls the telehealth nurse reporting the sudden onset of testicular pain after moving heavy furniture. What is the appropriate nursing response? A. "Taking ibuprofen may help alleviate the pain." B. "Please go to your closest emergency department right away." C. "This is a common reaction when performing labor; the pain will go away." D. "Your BPH is probably giving you difficulty because you were moving furniture."

B. "Please go to your closest emergency department right away."

A nurse is caring for a client who has breast cancer and is receiving a combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide? A. "The risk of renal toxicity is lessened when a combination of chemotherapy medications is used." B. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed." C. "The use of more chemotherapy medications will shorten the time you have to be in treatment." D. "The combination of chemotherapy medications will eliminate the potential for bone marrow suppression."

B. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed."

Which statement made to the nurse by an assistive personnel (AP) assigned to care for an HIV-positive client indicates a breach of confidentiality and requires further education by the nurse? A. "The client's spouse told me she got HIV from a blood transfusion." B. "The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client." C. "I told family members they need to wash their hands when they enter and leave the room." D. "Yes, I understand the reasons why I have don't need to wear gloves when I feed the client."

B. "The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client."

What teaching will the nurse provide to a 30-year-old female client who has never been sexually active about decreasing her risk of developing cervical cancer? Select all that apply. A. "You cannot lower the risk for cervical cancer." B. "You cannot receive the Gardasil-9 immunization." C. "Use condoms when you plan to be sexually intimate." D. "Over-the-counter contraceptive methods can be used to prevent HPV" E. "Having an annual Pap test will decrease your chances of cervical cancer."

B. "You cannot receive the Gardasil-9 immunization." C. "Use condoms when you plan to be sexually intimate."

The nurse is caring for four patients, and understands that which is at greatest risk of infection? A. 19-year-old with stomach pain B. 24-year-old with chronic kidney disease C. 36-year-old prescribed a 10-day steroid taper D. 64-year-old with history of prostate hyperplasia

B. 24-year-old with chronic kidney disease

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? A. Maintain bed rest as much as possible. B. Administer corticosteroids as prescribed for inflammation. C. Advise the client to remain supine for 1 to 2 hours after meals. D. Keep the room temperature warm during the day and cool at night.

B. Administer corticosteroids as prescribed for inflammation.

Which activities can the nurse postpone or eliminate for the client who has extreme fatigue today? Select all that apply. A. Administering prescribed drug therapy B. Ambulating in the hall C. Culturing suspected infectious drainage D. Performing pulmonary hygiene E. Performing oral care F. Providing a complete bed bath G. Teaching about nutrition therapy

B. Ambulating in the hall F. Providing a complete bed bath G. Teaching about nutrition therapy

A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which lab oratory value while the client is taking this medication? A. Glucose level B. Calcium level C. Potassium level D. Prothrombin time

B. Calcium level

A patient with AIDS is having difficulty maintaining body weight. Which nursing interventions are most appropriate for this patient? (Select all that apply.) A. Encourage the patient to drink at least 1 L of fluid per day. B. Collaborate with the dietician. C. Provide foods that are high in calories. D. Encourage low fat food choices. E. Provide three large meals a day. F. Ensure regular mouth care.

B. Collaborate with the dietician. C. Provide foods that are high in calories. D. Encourage low fat food choices. F. Ensure regular mouth care.

When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. A. Limiting the time with the client to 1 hour per shift. B. Keeping pregnant women out of the client's room. C. Placing the client in a private room with a private bath. D. Wearing a lead shield when providing direct client care. E. Removing the dosimeter film badge when entering the client's room. F. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client.

B. Keeping pregnant women out of the client's room. C. Placing the client in a private room with a private bath. D. Wearing a lead shield when providing direct client care.

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. A. Restrict fluid intake. B. Monitor liver function studies. C. Instruct the client to avoid alcohol. D. Administer the medication with an antacid. E. Instruct the client to avoid exposure to the sun. F. Administer the medication on an empty stomach.

B. Monitor liver function studies. C. Instruct the client to avoid alcohol. E. Instruct the client to avoid exposure to the sun.

The nurse caring for a client who is taking an amino glycoside should monitor the client for which adverse effects of the medication? Select all that apply. A. Seizures B. Ototoxicity C. Renal toxicity D. Dysrhythmias E. Hepatotoxicity

B. Ototoxicity C. Renal toxicity D. Dysrhythmias

A nurse is planning a presentation at a community center about risk factors for cancer. Which of the following types of cancer should the nurse include when discussing familial clustering of specific types of cancer? A. Skin B. Prostate C. Bone D. Bladder

B. Prostate

Which nursing intervention is appropriate when caring for a female client who has undergone a mastectomy and will receive chemotherapy? Select all that apply. A. Encourage client to accept her new body image. B. Provide self-care resources to the primary caretaker. C. Teach client about birth control options that are available. D. Refer to support groups for people who have had mastectomy. E. Involve partner in discussions about sexuality if client desires.

B. Provide self-care resources to the primary caretaker. C. Teach client about birth control options that are available. D. Refer to support groups for people who have had mastectomy. E. Involve partner in discussions about sexuality if client desires.

A nurse is planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? A. Monitor visitors for manifestations of infection B. Remind the client to use an electric razor C. Encourage frequent rest periods D. Instruct the client to rinse mouth daily with normal saline

B. Remind the client to use an electric razor

A nurse is administering a new medication intravenously to a patient. The patient becomes short of breath and begins to experience itching and hives. What is the priority nursing response? A. Assess blood pressure B. Stop the intravenous infusion C. Discuss anxiety with the patient D. Review the patient's allergies

B. Stop the intravenous infusion

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? A. To examine the testicles while lying down B. That the best time for the examination is after a shower C. To gently feel the testicle with one finger to feel for a growth D. That TSEs should be done at least every 6 months

B. That the best time for the examination is after a shower

Which specific information will the nurse teach to the client. with systemic lupus erythematosus newly prescribed belimumab therapy? 18.3 A. Avoid injecting it in a site near a cutaneous lesion. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because it causes extreme drowsiness.

B. The drug can only be given by a health care professional.

A nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an adverse effect of chemotherapy. Which of client manifestations is an expected finding of peripheral neuropathy? A. Thinning of the scalp hair B. Tingling of the hands and feet C. Reduced ability to concentrate D. Sores in mucous membranes

B. Tingling of the hands and feet

Which assessment finding in a client who recently had a right mastectomy 2 days ago will the home health nurse report to the health care provider? A. Temperature of 99°F B. Tingling sensation in the right arm C. Impaired range of motion in the right arm D. Drainage of 20 mL collected over 24 hours

B. Tingling sensation in the right arm

A nurse is conducting dietary teaching for a client who has AIDS. Which of the following instructions should the nurse include in the teaching? A. Discard leftovers after 8 hr B. Use a separate cutting board for poultry C. Thaw frozen foods at room temperature D. Store cold foods at 10°C (50°F) or less

B. Use a separate cutting board for poultry

Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm³ (0.2 x 109/L) to 400 cells/ mm³ (0.2x 109/L) indicates to the nurse that more teaching is needed? A. "Now my viral load is also probably lower." B. "I am so relieved that my drug therapy is working." C. "Although I am still HIV positive, at least I no longer have AIDS." D. "This change means I am less likely to develop an opportunistic infection."

C. "Although I am still HIV positive, at least I no longer have AIDS."

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses should the nurse give? A. "Keep the lesions covered with a light sterile dressing when going outdoors." B. "Rub lesions with a washcloth to dry after washing." C. "Apply moisturizer after bathing the lesions with warm water." D. "Apply antibiotic cream twice per day until scabs form on the lesions."

C. "Apply moisturizer after bathing the lesions with warm water."

What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed this drug? A. "Do you have glaucoma or any other problem with your eyes?" B. "Do you take medications for a seizure disorder?" C. "Are you allergic to sulfa drugs?" D. "Are you a diabetic?"

C. "Are you allergic to sulfa drugs?"

Which statement made by the nurse during an admission assessment for a client who is HIV positive demonstrates a nonjudgmental approach in discussing sexual practices and behaviors? A. "You must tell me all of your partners' names, so I can let them know about possibly being infected." B. "I hope you use condoms to protect your partners." C. "Have you had sex with men or women or both?" D. "You don't participate in anal intercourse, do you?"

C. "Have you had sex with men or women or both?"

A nurse in a provider's office is teaching a client with a recent diagnosis of rheumatoid arthritis who has a new prescription for naproxen tablets. Which of the following statements by the client indicates the need for further teaching? A. "After taking this medication for 4 weeks, I'll start to notice relief in my joints." B. "I can take an antacid with this medication for indigestion." C. "I can take this medication with aspirin." D. "The naproxen goes down easier when I crush it and put it in applesauce."

C. "I can take this medication with aspirin."

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my exposure to sunlight." B. "I should avoid drinking alcohol." C. "I should not smoke." D. "I should limit of intake of foods that are high in purine."

C. "I should not smoke."

A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? A. "I am unable to donate blood." B. "I will need to get a booster shot of immune serum globulin every year." C. "I should stop eating raw clams." D. "I can develop this disease by getting a tattoo."

C. "I should stop eating raw clams."

A nurse is providing teaching to a client who is receiving chemotherapy and has developed neutropenia. Which of the following statements indicates that the client needs further instructions? A. "I'll keep an antibacterial hand gel in my purse." B. "My partner will have to take care of the cat's litter boxes for a while." C. "I'm planning a large gathering of friends and family for the holidays." D. "I will eat canned fruits and vegetables."

C. "I'm planning a large gathering of friends and family for the holidays."

A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse provide? A. "That is your decision alone." B. "I would if I were you." C. "It sounds like you are unsure what to say to your partner." D. "Your provider is required by law to notify your partner."

C. "It sounds like you are unsure what to say to your partner."

A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following pieces of in should the nurse include in the teaching? A. "PCP is sexually transmitted from person to person." B. "You were most likely exposed to a contaminated surface such as a drinking glass." C. "PCP results from an impaired immune system." D. "You might have contracted PCP from a family pet."

C. "PCP results from an impaired immune system."

A nurse is providing discharge teaching to a client who is post-operative following a right mastectomy for breast cancer. The client will be discharged with 2 Jackson-Pratt drains. Which of the following pieces of information should the nurse include in the teaching? A. "Empty the drainage tubes once per day." B. "Showering is permitted before the drainage tubes are removed." C. "The drainage tubes often are removed at the same time as the stitches." D. "Do not begin exercising your arm until the provider removes the drainage tubes."

C. "The drainage tubes often are removed at the same time as the stitches."

Tamoxifen citrate is prescribed for a client with meta static breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement? A. This medication can be used only to treat breast cancer." B. "Yes, your family member can take this medication for bladder cancer as well." C. "This medication can be taken to prevent and treat clients with breast cancer." D. "This medication can be taken by anyone with cancer as long as their health care provider approves it."

C. "This medication can be taken to prevent and treat clients with breast cancer."

Which point is most important for the nurse to include when teaching assistive personnel (AP) about protecting themselves from HIV exposure when caring for HIV-positive clients? A. "Always wear a mask when entering an HIV-positive client's room." B. "Talk to the employee health nurse about starting preexposure prophylaxis." C. "Wear gloves when in contact with clients' mucous membranes or nonintact skin." D. "Wear full protective gear when providing any care to HIV-positive clients."

C. "Wear gloves when in contact with clients' mucous membranes or nonintact skin."

Immune function is most efficient when people are which age? A. Infancy B. Teen years C. 20 to 30 years D. 50 years and older

C. 20 to 30 years

A charge nurse is observing a newly licensed nurse provide care for a client who is receiving internal radiation therapy for the treatment of cervical cancer. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Leaving soiled linens in a container in the client's room B. Instructing visitors to remain 2 m (6 feet) away from the client C. Borrowing a dosimeter film badge from another nurse before entering the client's room D. Removing an extra IV pole from the client's room to be used for another client

C. Borrowing a dosimeter film badge from another nurse before entering the client's room

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? 17.1 A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

C. Clipping the newly generated viral proteins into smaller functional pieces

Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

C. Clipping the newly generated viral proteins into smaller functional pieces

Which concept is the highest priority for the nurse to consider in planning care for the client with HIV-III who has candidial stomatitis? A. Cellular regulation B. Gas exchange C. Comfort D. Nutrition

C. Comfort

A patient is fearful that he has been infected with HIV. The nurse recognizes which as the first symptom associated with possible HIV infection? A .Lymphocytopenia B. Opportunistic infection C. Fever, night sweats, muscle aches D. Reduced numbers of CD4+ T-cells

C. Fever, night sweats, muscle aches

Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs? A. Nausea B. Lethargy C. Hearing loss D. Muscle aches

C. Hearing loss

The nurse notes bright red urinary drainage from a client who had a trans urethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. What is the appropriate initial nursing action? A Calculate intake and output. B. Monitor hemoglobin and hematocrit. C. Increase the rate of the bladder irrigation. D Document findings in the electronic health record.

C. Increase the rate of the bladder irrigation.

A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? A. Hypoglycemia B. Tendinitis C. Infection D. Weight loss

C. Infection

Which action will the nurse perform first for a client in anaphylaxis to prevent harm? 18.2 A. Applying oxygen by nonrebreather mask B. Administering IV diphenhydramine C. Injecting epinephrine D. Initiating IV access

C. Injecting epinephrine

A nurse is caring for a client who is receiving brachytherapy. Which of the following measures should the nurse include in the client's plan of care? A. Plan to spend extra time with the client to provide emotional support. B. Ensure that chemotherapy medications do not extravasate into the client's tissues. C. Keep the door to the client's room closed. D. Encourage family members and friends to visit for at least 1 hr per day.

C. Keep the door to the client's room closed.

Which practices are generally recommended to prevent sexual transmission of HIV? (Select all that apply.) A. Oral contraceptives taken consistently B. Natural-membrane condoms for genital and anal intercourse C. Latex gloves for finger or hand contact with the vagina or rectum D. Latex dental dam genital and anal intercourse E. Water-based lubricant with a latex condom F. Latex or polyurethane condoms for genital and anal intercourse

C. Latex gloves for finger or hand contact with the vagina or rectum D. Latex dental dam genital and anal intercourse E. Water-based lubricant with a latex condom F. Latex or polyurethane condoms for genital and anal intercourse

The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs and symptoms of which adverse effects of the medication? Select all that apply. A. Ototoxicity B. Palpitations C. Nephrotoxicity D. Bone marrow suppression E. Gastrointestinal (GI) effects F. Increased white blood cell (WBC) count

C. Nephrotoxicity D. Bone marrow suppression E. Gastrointestinal (GI) effects

A nurse is caring for client who has human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? A Protective isolation B. Droplet precautions C. Standard precautions D. Airborne precautions

C. Standard precautions

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? A. Restrict all visitors. B. Restrict fluid intake. C. Teach the client and family about the need for hand hygiene. D. Insert an indwelling urinary catheter to prevent skin breakdown.

C. Teach the client and family about the need for hand hygiene.

What is the first action a nurse should take after sustaining a needlestick injury after injecting a client who is known to be HIV positive? A. Send the syringe and needle to the laboratory for analysis of viral load. B. Inform the charge nurse. C. Thoroughly scrub and flush the puncture site. D. Go to the employee clinic for postexposure prophylaxis.

C. Thoroughly scrub and flush the puncture site.

A nurse is obtaining a client's health history who has cancer of the cervix. Which of the following manifestations should the nurse expect? A. Weight gain B. Oliguria C. Vaginal bleeding D. Back pain

C. Vaginal bleeding

A client who has stage II breast cancer asks the nurse about sites of metastasis for this cancer. Which of the following responses should the nurse provide? A. "It's too soon to worry about something that might not happen." B. "Breast cancer tends to metastasize to the stomach." c. "Metastasis is unlikely since we detected your cancer early." D. "Breast cancer tends to metastasize to the bones."

D. "Breast cancer tends to metastasize to the bones."

A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? 86.5 A. "I will choose a diet high in fat to help gain weight." B. "I will be sure to eat three large meals daily." C. "I will drink up to 1 liter of liquid each day." D. "I will add high-protein foods to my diet."

D. "I will add high-protein foods to my diet."

A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? 86.3 A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C. "I will wear a mask when around family members who are ill." D. "I will cook vegetables before eating them."

D. "I will cook vegetables before eating them."

Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid? 17.2 A. Caffeinated beverages B. Grapefruit juice C. Dairy products D. St. John's wort

D. St. John's wort

A 37-year-old man with polycystic kidney disease is on the kidney transplant list. He is to receive 2 units of leukocyte-poor packed red blood cells to treat a low hemoglobin. He asks the nurse why he needs this type of blood. What is the nurse's best response? A. "It causes fewer blood reactions for pre-transplant patients." B. "It is less likely to causes hemolysis, or destruction of the blood cells, after transfusion." C. "All pre-transplant patients receive leukocyte-poor blood because it is absorbed better by the body." D. "It will decrease the risk of obtaining white blood cells from the donor that could make it harder for your transplanted kidney to function."

D. "It will decrease the risk of obtaining white blood cells from the donor that could make it harder for your transplanted kidney to function."

A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? A. "Avoid the use of NSAIDs." B. "Stop taking the corticosteroids when your symptoms resolve." C. "Exposure to ultraviolet light will help control the skin rashes." D. "Monitor your body temperature and report any elevations promptly."

D. "Monitor your body temperature and report any elevations promptly."

A nurse is teaching a client how to perform a breast self-examination (BSE). The nurse should identify which of the following findings as an indication of breast cancer? A. Lumps that are mobile and tender on palpation prior to a menstrual period B. Multiple round masses that are tender and found in both breasts C. Bilaterally darkened areolas D. A nontender, hard lump that is palpated in a breast

D. A nontender, hard lump that is palpated in a breast

A nurse is collecting a health history from a female client who is undergoing screening for breast cancer. Which of the following factors increases the client's risk of developing breast cancer? A. Obesity B. Oral contraceptive use C. Alcohol use D. Age over 50 years

D. Age over 50 years

A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse in care? A. Rinse the mouth with chlorhexidine solution every 2 hr B. Limit fluid intake with meals C. Provide oral hygiene with a firm-bristled toothbrush after each meal D. Avoid salty foods

D. Avoid salty foods

A home health nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following foods should the nurse include in the client's plan of care? A. Soft-boiled eggs B. Brie cheese made with unpasteurized milk C. Cold deli-meat sandwiches D. Baked chicken

D. Baked chicken

A nurse is reviewing the laboratory data of a client who reports manifestations suggesting systemic lupus erythematosus (SLE). The nurse should expect an increase in which of the following parameters for a client who has SLE? A. Platelet count B. RBC count C. Hct D. Erythrocyte sedimentation rate (ESR)

D. Erythrocyte sedimentation rate (ESR)

Which part of the HIV infection process is disrupted by the antiretroviral drug class of nucleoside reverse transcriptase inhibitors (NRTIs)? A. Clipping the newly generated viral proteins into smaller functional pieces B. Activating the viral enzyme "integrase" within the infected host's cells C. Binding of the virus's gp120 protein to one of the CD4+ coreceptors D. Forming counterfeit bases that prevent DNA synthesis and viral replication

D. Forming counterfeit bases that prevent DNA synthesis and viral replication

A nurse is caring for a client who underwent radioallergosorbent (RAST) testing due to seasonal allergies. The nurse should anticipate an elevation in which o the following immunoglobulin laboratory values? A. IgM B. IgA C. IgG D. IgE

D. IgE

A nurse is preparing a plan of care for a client who is postoperative following a modified radical mastectomy. Which of the following invasive devices nurse expect the client to have? A. Chest tube B. Indwelling urinary catheter C. Nasogastric tube D. Jackson-Pratt drain

D. Jackson-Pratt drain

A nurse is caring for a client who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. Which of the following dietary recommendations should the nurse share with the client? A. Eat with metal utensils B. Limit coffee C. Avoid citrus foods D. Offer mints

D. Offer mints

The community health nurse is instructing a group of young female clients about breast self examination. The nurse should instruct the clients to perform the examination at which time? A. At the onset of menstruation B. Every month during ovulation C. Weekly at the same time of day D. One week after menstruation begins

D. One week after menstruation begins

A client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication? A. Diarrhea B. Hair loss C. Chest pain D. Peripheral neuropathy

D. Peripheral neuropathy

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? A. Call the primary health care provider (PHCP). B. Reinsert the implant into the vagina. C. Pick up the implant with gloved hands and flush it down the toilet. D. Pick up the implant with long-handled forceps and place it in a lead container.

D. Pick up the implant with long-handled forceps and place it in a lead container.

A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client? A. Diffuse maculopapular rash B. Dyspnea C. Double vision D. Progressive circular rash

D. Progressive circular rash

A nurse is caring for a client who will receive brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions? A. Chemotherapy via a central venous access device B. Radiation to the tumor from an external source C. Precise delivery of high-dose radiation after tumor imaging D. Radioactive infusions or insertions into or near the tumor

D. Radioactive infusions or insertions into or near the tumor

The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication? A. CD4+ T cell count B. Lymphocyte count C. Serum albumin level D. Serum creatinine level

D. Serum creatinine level

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition? A. That the dose of the medication is too low B. That the client is experiencing toxic effects of the medication C. That the client has developed inadequacy of thermoregulation D. That the client has developed another infection caused by leukopenic effects of the medication

D. That the client has developed another infection caused by leukopenic effects of the medication

Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the primary health care provider if which diagnosis is documented in the client's history? A. Gout B. Asthma C. Myocardial infarction D. Venous thromboembolism

D. Venous thromboembolism