MS 2 - Exam 3: Burns, HIV/AIDs, Anemias

When reviewing the chart of a client recently diagnosed with AIDS, the nurse should expect to find which assessment data? Select all that apply. 1. CD4+ count below 200 cells/μl 2. Infection with HIV 3. An alternative lifestyle 4. Opportunistic infection 5. T-cell count above 400 cells/μl

Answer: 1, 2, 4. According to the Centers for Disease Control and Prevention (CDC), three criteria must be met for an adult client to be diagnosed with AIDS. A person must be HIV-positive, have a CD4+ T-cell count below 200 cells/μl, and have an opportunistic infection such as tuberculosis, candidiasis, and cytomegalovirus. Because HIV attaches to the CD4+ receptor sites of the T cell, a T-cell value alone is incorrect.

A client is admitted to the burn unit with extensive full-thickness burns. What is the nurse's priority during the early phases of treatment? 1. Fluid status 2. Body image 3. Level of pain 4. Risk of infection

Answer: 1. In early burn care, the client's greatest need is fluid resuscitation, as a large-volume of fluid is lost through the skin. Body image, pain, and infection are important concerns in the nursing care of a burn client, but they do not take precedence over fluid management in the early phase of care.

A young female client with a history of sickle cell disease reports abdominal pain. What is the priority intervention by the nurse? 1. Obtaining a history of the sequence of symptoms 2. Keeping the client nothing by mouth (NPO) 3. Administering IV fluids 4. Preparing the client for a computed tomography (CT) scan of the abdomen

Answer: 1 Although the client may be in a sickle cell crisis and experiencing acute abdominal pain caused by sickling in the mesenteric circulation, it's important to remember that clients with sickle cell disease aren't spared from other intra-abdominal events. The history obtained from the client outlining the sequence of symptoms provides crucial assessment information. Other nursing interventions would include preparing the client for possible surgery by keeping her NPO and for diagnostic studies such as CT scanning. Administering IV fluids will help replenish fluid volume. Also, obtaining a history is a part of assessment. Nursing process always starts with assessment.

A woman arrives at the emergency department with a fractured arm. Her husband is constantly present, and the woman appears anxious. What is the nurse's priority action? 1.​ Privately ask the woman if she is being abused 2.​ During triage inquire if the woman is in a safe environment 3. ​Clearly state that all clients are asked about abuse prior to any treatment 4. ​Provide the woman with a written pamphlet about domestic abuse

Answer: 1 It is a priority to privately ask the client if she is being abused. Counseling, or printed resources should be given privately. Clarifying that all clients are asked about abuse prior to any treatment allows for the client to understand why these questions are being asked.

A client with HIV experiences frequent bouts of diarrhea. The nurse determines dietary teaching is effective when the client states the need to avoid which food? 1. Milk 2. Red licorice 3. Chicken soup 4. Broiled meat

Answer: 1 Clients with intolerance to lactose may develop chronic diarrhea. Although red licorice may be eaten, black licorice, which often contains glycyrrhizin, should be avoided. Other foods that the client should avoid include fatty foods, other lactose-containing foods, caffeine, and sugar. Chicken soup and broiled meat may be consumed.

A nurse is reviewing the laboratory results of a client with anemia. Which laboratory values are abnormal? 1. Erythrocyte count of 3.1 × 106/μl (3.10 × 1012/L) 2. Neutrophil count of 2,100/μl (2.10 × 109/L) 3. Leukocytes count of 2, 300/μl (2.30 × 109/L) 4. Platelets count of 115,000/μl (115 × 109/L)

Answer: 1 Anemia is defined as a decreased number of erythrocytes (red blood cells, RBC). The normal RBC count for an adult male is 4.6 × 106/μl (4.60 × 1012/L) to 6.2 × 106/μl (6.20 × 1012/L) and female is 4.2 × 106/μl (4.20 × 1012/L) to 5.4 × 106/μl (5.40 × 1012/L). The normal leukocyte (white blood cell, WBC) count is 4.500/μl (4.50 × 109/L) to 11,000/ μl (11.00 × 109/L), and the normal thrombocyte (platelet) count is 150,000/ μl (150 × 109/L) to 400,000/ μl (400 × 109/L). Normal neutrophil count is 2,500 and 6,000. Leukopenia is a decreased number of WBC. Thrombocytopenia is a decreased number of thrombocytes (platelets). Lastly, neutropenia is a decreased number of neutrophils (a type of WBC).

The nurse is assessing a postoperative client who is recovering from a partial gastrectomy. The nurse is aware that the client is at risk for developing: 1. anemia. 2. polycythemia. 3. purpura. 4. thrombocytopenia.

Answer: 1 Gastric surgery increases the risk of developing pernicious anemia. Polycythemia can occur from severe hypoxia due to congenital heart and pulmonary disease. Purpura and thrombocytopenia may result from decreased bone marrow production of platelets, and do not result from surgery.

Which client would be at highest risk? 1. A 22-year-old man with a history of mononucleosis 2. A 25-year-old man who smokes a pack of cigarettes a day 3. A 33-year-old man with a cousin with Hodgkin's lymphoma 4. A 40-year-old woman with HIV

Answer: 1 Malignant lymphoma has a peak incidence between ages 20 and 30, and after age 50. It's more common in men than women and is associated with a history of Epstein-Barr virus (which causes mononucleosis). There is also an increased incidence of the disease among siblings. There is no reported association between malignant lymphoma and smoking or HIV infection.

A client who received massive packed red blood cell (PRBC) blood transfusions due to trauma has a potassium level of 7.1 mEq/L (7.1 mmol/L). Which medication should the nurse expect to administer? 1. IV insulin 2. IV potassium chloride 3. Oral spironolactone 4. Oral lisinopril

Answer: 1 The client is experiencing transfusion-associated hyperkalemia. Storing packed red blood cell increases the potassium concentration. IV regular insulin pushes potassium from the blood into the cell decreasing the serum potassium level. Severe cases require hemodialysis. IV potassium chloride and spironolactone, a potassium-sparing diuretic, will further increase the potassium. Angiotensin-converting enzyme (ACE) inhibitor such as lisinopril causes hyperkalemia.

The nurse reviews the laboratory results of a postoperative female client two days following surgery, and notes a hemoglobin level of 11 g/dl (110 g/L). Which symptom would the nurse expect to see during assessment? 1. No abnormal symptoms 2. Pallor 3. Palpitations 4. Shortness of breath

Answer: 1 The normal hemoglobin for male is 14 to 18 g/dl (140 to 180 g/L) and female is 12 to 16 g/dl (120 to 160 g/L). Mild anemia usually has no clinical signs. Pallor, palpitations, and shortness of breath are associated with severe anemia.

A nurse is caring for a client diagnosed with Kaposi's sarcoma. The client's lesions have scant serous drainage. What personal protective equipment should the nurse wear? Select all that apply. 1. Gloves 2. Gown 3. Surgical mask 4. Particulate mask 5. Shoe cover

Answer: 1, 2 Kaposi's sarcoma is a type of skin cancer seen in clients with AIDS. It presents as a brownish-red to blue skin lesion. The nurse should wear gloves and gown when in contact with this client. All the other options are not necessary.

The nurse is gathering data on a client with pernicious anemia. Which data would support this diagnosis? Select all that apply. 1. Angular cheilitis 2. Smooth, bright-red tongue 3. Hemoglobin of 14 g/dl (140 g/L) 4. Sensitivity to cold 5. Dyspnea on exertion

Answer: 1, 2, 4, 5 Pernicious anemia is a vitamin B12 deficiency due to lack of the intrinsic factor produced by gastric mucosa. Intrinsic factor is necessary for the absorption of vitamin B12. Clinical manifestations include pallor, fatigue, dyspnea on exertion, angular chelitis (scaling of the surface of lips and fissures in the corner of the mouth), and sensitivity to cold. The client will also have a smooth, sore, bright red tongue because of the atrophy of the papillae of the tongue due to vitamin B12 deficiency. Hemoglobin of 14 g/dl (140 g/L) is normal.

The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. What is the most important action by the nurse? 1. Administer oxygen via nasal cannula 2. Assess the client's vital signs 3. Initiate cardiac monitoring 4. Draw blood for laboratory laboratory analysis

Answer: 2 Assessing vital signs would determine this client's hemodynamic stability. Monitoring the heart rhythm may be indicated based on assessment findings. Administering oxygen and drawing blood require a health care provider's order, and would not be part of a screening evaluation.

The nurse is reviewing the laboratory values of a client with aplastic anemia. Which diagnostic findings would be consistent with this diagnosis? 1. A decreased production of T-helper cells 2. A decreased level of white blood cells, red blood cells, and platelets 3. An increased levels of white blood cells, red blood cells, and platelets 4. The presence of Reed-Sternberg cells and lymph node enlargement

Answer: 2 The diagnostic findings for aplastic anemia include decreased levels of all the cellular elements of the blood (pancytopenia). T-helper cell production doesn't decrease in aplastic anemia. Reed-Sternberg cells and lymph node enlargement occur with Hodgkin's disease.

A nurse is caring for a client with AIDS. The client is receiving zidovudine. The client asked the nurse, "How does this drug work?" The nurse determines that teaching is effective when the client makes which statement? 1. "It kills HIV." 2. "It suppresses the replication of HIV virus." 3. "I won't infect anyone else when I take this drug." 4. "It's the only drug I need to take for HIV."

Answer: 2 Zidovudine is an antiviral drug that suppresses the replication of the HIV virus. It is most commonly used in conjunction with other anti-retroviral drugs. It also helps prevent the transmission of HIV from mother to fetus. Zidovudine is not a cure. It does not kill the HIV virus, and clients taking this medication remain infectious.

The nurse determines that teaching was successful when a client with a negative HIV antibody test states: 1. "I'm not infected with HIV." 2. "I haven't produced antibodies to HIV." 3. "I'm immune to HIV." 4. "I have antibodies to HIV."

Answer: 2 A negative HIV antibody test means that HIV antibodies weren't in the client's blood at the time the test was performed. Antibodies may take three weeks to six months or longer to develop. A negative test result doesn't indicate immunity. If antibodies to HIV are present, the test result is positive.

A nurse is reviewing the charts of four clients. Which client is at greatest risk for the development of anemia? 1. A client with Crohn's disease 2. A client with chronic renal failure (CRF) 3. A client with menorrhagia 4. A client with chronic obstructive pulmonary disease (COPD)

Answer: 2 Chronic renal failure will decrease the production of erythropoietin (EPO) which is needed for the production of red blood cells (RBC), thus resulting in anemia. A client with COPD will have polycythemia as hypoxia causes increased RBC production as a compensatory mechanism. Menorrhagia will cause hypovolemic anemia. As a result of blood loss, clients with Crohn's disease usually do not experience bleeding and, if they do, it is mild.

A nurse is teaching a client who has HIV about the adverse effects of saquinavir. What information is important to include? 1. Hypoglycemia 2. Thrombocytopenia 3. Leukocytosis 4. Hypolipidemia

Answer: 2 Saquinavir is an antiretroviral-protease inhibitor used in combination with other antiretroviral medications to help manage HIV. Adverse effects include hyperglycemia, bone loss, hypersensitivity reaction, hyperlipidemia, thrombocytopenia, and leukopenia.

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the priority intervention by the nurse? 1. Administer a bolus of normal saline solution 2. Maintain a patent airway 3. Administer epinephrine 4. Monitor vital signs

Answer: 2 The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.

The nurse is reviewing the laboratory values of a 52-year-old client. The client's platelet count is 75,000/μl (75 × 109/L). How would the nurse interpret this value? 1. Normal platelet count 2. Thrombocytopenia 3. Thrombocytopathy 4. Thrombocytosis

Answer: 2 Thrombocytopenia is a decreased number of platelets. A normal platelet count ranges from 150,000/μl (150 × 109/L) to 400,000/μl (400 × 109/L). Thrombocytopathy is platelet dysfunction, and thrombocytosis is an excess number of platelets.

Which statement most appropriately identifies the nutritional needs of a client related to the physiologic processes that occur following a burn injury? 1. The client needs 100 cal/kg during hospitalization. 2. The hypermetabolic state after a burn injury contributes to poor healing. 3. Keeping the environment cool decreases caloric demand. 4. Maintaining a hypermetabolic rate decreases the client's risk of infection.

Answer: 2. A burn injury causes a hypermetabolic state that results in protein and lipid catabolism which affects wound healing. Calories should be one-and-a-half to two times the basal metabolic rate, with at least 1.5 to 2 g of protein/kg of body daily. An environmental temperature within normal range allows the body to function efficiently, and devote caloric expenditure to healing and normal physiologic processes. If the temperature is too warm or too cold, the body uses its energy on temperature regulation rather than tissue repair. High metabolic rates increase the risk of infection.

The nurse is caring for a client who was bitten by a brown recluse spider. Which assessment supports this finding? 1. Bull's-eye rash 2. Painful rash around a necrotic lesion 3. Patch of oval lesions 4. Line of papules and vesicles

Answer: 2. A necrotic, painful rash is associated with the bite of a brown recluse spider. A bull's-eye rash is a classic sign of Lyme disease. A slightly raised, oval lesion about two to six cm in diameter on the body is indicative of pityriasis rosea. A linear, popular, vesicular rash is characteristic of exposure to poison ivy.

A client with burns has a new donor site. What is the most important intervention by the nurse? 1. Keep the site dependent 2. Avoid pressure on the site 3. Keep the site tightly covered 4. Covered the site with antibiotic cream

Answer: 2. A universal concern in the care of donor sites for burn care is keeping the site away from sources of pressure. Placing the site in a position of dependence is not a justified aspect of donor site care. Tightly covering the site is not recommended. Covering the site with antibiotic cream is not recommended.

The nurse is planning care for a client with a late-stage burn. What is the most important intervention for the nurse to include to promote healing? 1. Removing eschar from the skin 2. Applying continuous-compression wraps 3. Wearing clothing to protect the burn from the sun 4. Maintaining wound care irrigation

Answer: 2. Applying continuous-compression wraps promotes skin healing, and prevents hypertrophied tissue from forming. The other interventions are appropriate for the client with a burn wound but don't necessarily help minimize scarring.

A client presents to a clinic with a second-degree sunburn on her face and arms. What is the first intervention by the nurse? 1. Administer analgesic medication as ordered 2. Apply cold, moist towels to the burns 3. Apply sterile, dry towels to the burns 4. Apply vitamin A, D, and E ointment to the burns

Answer: 2. Cold, moist towels help stop the burning process. Analgesics should be administered as ordered after the burning process has been controlled. Dry towels would retain the heat and aren't used. Ointments are applied during the healing phase but not initially.

What is the nurse's priority assessment for a client during the first 48 hours following a major burn injury? 1. Hyponatremia and hypokalemia 2. Hyponatremia and hyperkalemia 3. Hypernatremia and hypokalemia 4. Hypernatremia and hyperkalemia

Answer: 2. During the first 48 hours after a burn, capillary permeability increases, allowing fluids to shift from the plasma to the interstitial spaces. This fluid is high in sodium, causing a decrease in serum sodium levels. Potassium also leaks from the cells into the plasma, causing hyperkalemia.

A client with full-thickness, circumferential burns to the chest has been intubated and is experiencing pressure from edema that is inhibiting chest wall expansion. What is the nurse's priority intervention for this client? 1. Cricothyrotomy 2. Escharotomy 3. Thoracentesis 4. Chest tube insertion

Answer: 2. Escharotomy is a surgical incision used to relieve the pressure from edema. It is sometimes needed with circumferential burns that prevent chest expansion or circulatory compromise. Cricothyrotomy is an emergency procedure that involves puncturing the trachea through the cricothyroid membrane to create an airway. This client is already intubated. Needle thoracentesis and insertion of a chest tube are performed to relieve a pneumothorax.

The client has sustained a burn. Which intervention will help to decrease hypertrophied scarring during the later stages of healing? 1. Remove all tissue in the wound area 2. Apply continuous pressure using elastic wraps 3. Wear clothing to protect the burn from the sun 4. Maintain wound dressing changes

Answer: 2. Using elastic wraps and bandages to apply continuous pressure during the early stages of wound healing can help prevent keloid scar formation. Removing tissue, especially eschar, promotes wound healing as do dressing changes, but neither directly decreases scar formation. Wearing clothing prevents sunburn but doesn't decrease scar formation.

A client arrives at the emergency department reporting chest and stomach pain and black, tarry stools for the past two months. Which orders should the nurse anticipate? 1. Cardiac monitoring, oxygen, creatine kinase, and lactate dehydrogenase (LD) levels 2. Prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and fibrin split product levels 3. An electrocardiogram (ECG), complete blood count (CBC), occult blood screening, and comprehensive serum metabolic panel 4. An electroencephalogram (EEG), alkaline phosphatase (ALP) and aspartate aminotransferase levels (AST), and basic metabolic panel (BMP)

Answer: 3 An ECG is used to evaluate chest pain, a CBC detects anemia, and the test for occult blood detects blood in the stool. Cardiac monitoring, oxygen, creatine kinase, and LD levels are appropriate for a cardiac primary problem. A BMP (includes glucose, electrolytes, BUN, creatinine), and ALP and AST levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.

A client asks the nurse about a common cause of aplastic anemia. Which reply would be best? 1. Lack of intrinsic factor 2. Blood loss 3. Bone marrow suppression 4. Inadequate intake of iron

Answer: 3 Aplastic anemia is caused by bone marrow suppression. Lack of intrinsic factor is the cause of pernicious anemia. Blood loss will cause hypovolemic anemia. Iron deficiency anemia is due to inadequate intake of iron.

Which intervention has the most impact in delaying the development of AIDS once a client has been infected with HIV? 1. Monthly plasmapheresis 2. Eating a balanced diet 3. Compliance to treatment 4. Adequate rest and sleep

Answer: 3 Compliance with the complete therapeutic regimen is the most important intervention in delaying the onset of AIDS. This includes adhering to a healthy lifestyle, taking prescribed medications, and reducing risks from other infections. Eating a balanced diet and getting adequate rest and sleep are part of the overall therapeutic regimen. Plasmapheresis isn't a treatment for HIV/AIDS.

Which factor increases a client's risk of developing anemia? 1. Colostomy following colon resection 2. Gastroesophageal reflux disease (GERD) 3. Gastrectomy 4. Bouts of dumping syndrome

Answer: 3 Lack of intrinsic factor following gastrectomy would cause pernicious anemia due to the client's inability to absorb vitamin B12. The presence of a colostomy, GERD, or dumping syndrome would not directly affect the red blood cells.

What assessment findings should the nurse expect in a client with thrombocytopenia? 1. Weakness and fatigue 2. Dizziness and vomiting 3. Bruising and petechiae 4. Light-headedness and nausea

Answer: 3 Petechiae and bruising are classic signs of thrombocytopenia. Weakness and fatigue are signs of anemia. Light-headedness, nausea, dizziness, and vomiting are not classic signs of thrombocytopenia.

A client is admitted to the hospital with pallor, fatigue, dry lips, and a smooth, bright-red tongue. A preliminary diagnosis of pernicious anemia has been made. Which diagnostic test would confirm this diagnosis? 1. Bone marrow examination 2. Ventilation-perfusion scan 3. Schilling test 4. Tensilon test

Answer: 3 Schilling test is performed to evaluate vitamin B12 absorption. It is used to diagnose pernicious anemia. Pernicious anemia is caused by lack of intrinsic factor produced by gastric mucosa, which is necessary for vitamin B12 absorption. In Schilling test, a radioactive vitamin B12 is given PO and then urine is collected over the next 24 hours to measure whether vitamin B12 is normally absorbed. Bone marrow examination is used for aplastic anemia. Ventilation-perfusion scan is used to help diagnose a client with pulmonary embolism. Tensilon test is a test for myasthenia gravis.

A nurse is caring for client experiencing hypovolemic shock. Which findings should the nurse expect to assess? 1. Blood pressure of 132/85 mmHg, heart rate of 116, urine output of 45 ml/hr, and warm skin 2. Blood pressure of 149/92 mmHg, heart rate of 59, urine output of 57 ml/hr, and cold skin 3. Blood pressure of 87/58 mmHg, heart rate of 123, urine output of 20 ml/hr, and clammy skin 4. Blood pressure of 91/62 mmHg, heart rate of 99, urine output of 35 ml/hr, and pale skin

Answer: 3 Signs and symptoms of hypovolemic shock would include change in the level of consciousness, cool, clammy, and pale skin, hypotension, tachycardia, and tachypnea. The client will also have oliguria (decreased urine output) because of decreased circulation of fluid volume. Normal urine output is between 30 to 50 ml/hr.

A client diagnosed with anemia asks the nurse to explain the difference between anemia and thrombocytopenia. The nurse explains that anemia is caused by a decreased number of red blood cells and that thrombocytopenia results of: 1. an increase in red blood cells. 2. an increase in white blood cells. 3. a decrease in platelets. 4. a decrease in neutrophils.

Answer: 3 Thrombocytopenia is caused by decreased number of platelets. An increase in red blood cells is called polycythemia vera. An increase in white blood cells is called leukocytosis. A decrease in neutrophils is called neutropenia.

A client received burns to his entire back and left arm. The nurse uses the rule of nines to calculate the percentage of his body that is burned. What percentage of the client's body is burned? 1. 9% 2. 18% 3. 27% 4. 36%

Answer: 3. According to the rule of nines, the posterior trunk, anterior trunk, and legs are each 18% of the total body surface. The head, neck, and arms are each 9% of the total body surface, and the perineum is 1%. In this case, the client received burns to his back and one arm, which totals 27% of his body.

A client sustained partial-thickness burns to his trunk and both lower extremities. Which IV fluid will the nurse initiate? 1. Albumin 2. 5% dextrose in water 3. Lactated ringer's solution 4. 0.9% normal saline with 20 mEq potassium

Answer: 3. Lactated ringer's solution replaces lost sodium, and corrects metabolic acidosis, which commonly occurs following a burn. Albumin may be used as supportive therapy, but is not the primary fluid for replacement. Dextrose is not given to clients with burns during the first 24 hours as it may cause pseudodiabetes. The client is hyperkalemic due to the potassium shift from intracellular space to the plasma. Potassium would not be administered.

A nursing student is assigned to care for client with HIV. The student asks the staff nurse what precautions are necessary when measuring this client's blood pressure. What is the best information to give the student? 1. Wear gloves 2. Wear a gown 3. Use contact precautions 4. Wash hands

Answer: 4 Because measuring blood pressure doesn't involve contact with the client's blood or secretions, the nursing student should wash the hands before proceeding.

The nurse is teaching a client about the transmission of HIV. Which statement demonstrates an understanding of the risks? 1. "I cannot have a routine teeth cleaning at the dentist's office." 2. "I may have intercourse with my spouse." 3. "I may engage in unprotected, non-insertive sexual contact." 4. "I should not engage in intercourse with a new partner without using a latex condom."

Answer: 4 Intercourse with a new partner is risky because of the unknown intravenous drug use or sexual history of this partner. Using a latex condom may provide increased protection against HIV exposure. Absolute safe sex practices include autosexual activities, abstinence, and intercourse within a monogamous, uninfected partner. Very safe practices include non-insertive sexual contact. Having your teeth cleaned is not a risk factor if the dental office properly sterilizes the equipment.

The nurse is teaching a client with iron-deficiency anemia about ferrous gluconate therapy. Which statement, if made by the client, would indicate a correct understanding of the teaching? 1. "I will take the medication with an antacid." 2. "I will take the medication with a glass of milk." 3. "I will take the medication with whole-grain cereal." 4. "I will take the medication on an empty stomach with orange juice."

Answer: 4 Preferably, ferrous gluconate should be taken on an empty stomach with orange juice. Ferrous gluconate shouldn't be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.

The nurse is performing mouth care on a client with AIDS. What is the most appropriate nursing intervention? 1. Use reverse isolation 2. Place the client in a private room 3. Put on a mask, gloves, and a gown 4. Wear gloves

Answer: 4 Standard precautions stipulate that a health care worker who anticipates coming into contact with a client's blood or body fluids must wear gloves. Reverse isolation is used to protect the client from the health care worker. A private room does not provide barrier protection, an essential step in standard precautions. A mask, gloves, and gown are needed only for anticipated contact with airborne droplets of blood or body fluids.

A client with sickle cell disease is discussing his therapeutic regimen. Which statement by the client indicates further teaching is needed? 1. "I should avoid vacationing vacationing or traveling in areas of high altitude." 2. "Cigarette smoking can cause a sickle cell crisis." 3. "I should drink 4 to 6 L of fluid each day." 4. "I should take one baby aspirin daily to help prevent sickle cell crisis."

Answer: 4 Aspirin inhibits platelet aggregation and won't help prevent sickle cell crisis. Hydroxyurea is prescribed for some people to help prevent sickle cell crisis. High altitude increases oxygen demand and therefore can also precipitate a crisis. Tobacco, alcohol, and dehydration can precipitate a sickle cell crisis and should be avoided.

A 32-year-old client is admitted with a tentative diagnosis of AIDS. The preliminary report of biopsies done on his facial lesions indicates Kaposi's sarcoma. What is the most appropriate action by the nurse? 1. Tell the client that Kaposi's sarcoma is common in people with AIDS 2. Pretend not to notice the lesions on the client's face 3. Inform the client of the biopsy results and support him emotionally 4. Explore the client's feelings about his facial disfigurement

Answer: 4 Facial lesions can contribute to decreased self-esteem and an altered body image. Discussing AIDS with a client whose diagnosis isn't final may be inappropriate and doesn't provide emotional support. Pretending not to notice visible lesions ignores the client's concerns. The health care provider—not the nurse—should inform the client of the biopsy results.

A client involved in a motor vehicle collision arrives in the emergency department unconscious, severely hypotensive, and with possible fractures of the pelvis and legs. Which parenteral fluid would the nurse expect to administer to this client? 1. Fresh frozen plasma 2. Normal saline solution 3. Lactated Ringer's solution 4. Packed red blood cells (RBCs)

Answer: 4 In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is often used to replace clotting factors. Normal saline or lactated Ringer's solution is used to increase volume and blood pressure, but too much colloid will hemodilute the blood and won't improve the oxygen-carrying capacity that RBCs would.

Which assessment data would the nurse expect to see in the chart of a client admitted with Pneumocystis jiroveci pneumonia? 1. Blood pressure of 108/72 mmHg 2. Oxygen saturation 95 percent 3. Respiratory rate of 20 4. CD4 count below 200

Answer: 4 Pneumocystis jiroveci pneumonia (PJP) is a type of pneumonia caused by a Pneumocystis jiroveci fungus. It is an opportunistic infection seen in clients who are immunocompromised with a CD4 count below 200, particularly in clients with HIV/AIDS.

The nurse is assessing a client admitted to the emergency department with a deep partial-thickness burn on his arm. What is the most accurate way for the nurse to document this finding? 1. Pain and redness 2. 10% damage to the epidermis 3. Necrotic tissue through all layers of skin 4. Necrotic tissue through most of the dermis

Answer: 4. A deep partial-thickness burn causes necrosis of the epidermal and dermal layers. Redness and pain are characteristics of a superficial injury. Superficial burns cause slight epidermal damage. Necrosis through all skin layers is seen with full-thickness injuries.

The client is experiencing the initial phase of a burn injury. What is the nurse's priority intervention? 1. Decrease anxiety 2. Promote hygiene 3. Turn frequently 4. Prevent infection

Answer: 4. Because the body's protective barrier is damaged, and the immune system is compromised, preventing infection is the primary action. Decreasing anxiety, promoting hygiene, and turning frequently are important but are not the primary focus. Physiologic needs take precedence.

A client has multiple blisters from a superficial burn. What intervention will the nurse perform when the blisters break? 1. Remove the raised skin 2. Wash the area vigorously with soap and water 3. Apply silvadene cream 4. Clean the area with normal saline solution and cover it with a dressing

Answer: 4. To maintain asepsis, the nurse should clean the area with normal saline solution and cover it with a dressing. Removing the raised skin would cause further skin damage. Washing the area vigorously with soap and water would damage the tissue and cause drying. Silvadene cream is used as an antimicrobial, and not currently needed.

The nurse is reviewing a client's complete blood count (CBC) and notes an erythrocyte count of 2.7 × 106/μl (2.70 × 1012/L), leukocytes of 2,100/μl (2.10 × 109/L), and platelets of 90,000/μl (90 × 109/L). The nurse interprets this as indicative of what condition? 1. Pernicious anemia 2. Aplastic anemia 3. Sickle cell anemia 4. Polycythemia

Answer:2 Aplastic anemia is a pathology of bone marrow dysfunction. Clients with aplastic anemia may have pancytopenia. Red blood cells, white blood cells, and platelets are all decreased. Bone marrow produces red blood cells, white blood cells, and platelets. The normal erythrocyte (red blood cells) count for an adult male is 4.6 × 106/μl (4.60 × 1012/L) to 6.2 × 106/μl (6.20 × 1012/L) and female is 4.2 × 106/μl (4.20 × 1012/L) to 5.4 × 106/μl (5.40 × 1012/L). The normal leukocyte (white blood cells) count is 4.500/μl (4.50 × 109/L) to 11,000/μl (11.00 × 109/L), and the normal thrombocytes (platelet) count is 150,000/μl (150 × 109/L) to 400,000/μl (400 × 109/L). Polycythemia is an abnormal increase in red blood cells, Sickle cell anemia results from defective hemoglobin with a sickle presence and pernicious anemia is the inability to absorb B12 from lack of intrinsic factor.

A client is receiving epoetin alfa. Which findings indicate the effectiveness of the drug? 1. Increase in white blood cells 2. Decrease in blood glucose 3. Increase in red blood cells 4. Decrease in blood coagulation

Answer:3 Epoetin alfa is a man-made form of the protein human erythropoietin used to lessen the need for red blood cell transfusions. It stimulates the bone marrow to produce more red blood cells. The drug is used to treat anemia caused by chronic kidney disease, chemotherapy, and zidovudine, which is a drug used to treat HIV infection. The drug does not affect white blood cells or coagulation, nor does it cause blood glucose to decrease.