Unit 3 Exam

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first?

Infuse metronidazole (Flagyl) 500 mg IV.

While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection?

Parasitic

Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Patient who has had 10 liquid stools in the last 24 hours

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?

Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient?

Avoid sharing razors and other personal items.

An infant's parents ask the nurse about preventing otitis media (OM). What should the nurse recommend?

Avoid tobacco smoke.

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

Patient's ability to follow a complex medication regimen

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?

Phenazopyridine may change the urine color

An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition?

Primary immunodeficiency

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?

Stock the patient's room with the necessary personal protective equipment.

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? Review foods that are higher in protein.

Talk about treatment with anti-fungal agents.

A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care?

Teach the patient about the use of antifungal medications.

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement?

The medications that I take will help prevent my body from attacking my new kidney.

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning?

Basic infection control techniques

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?

Blood pressure 90/48 mm Hg

The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations would be observed (Select all that apply)?

Vomiting Failure to gain weight Persistent diaper rash

A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI). Which urinalysis result should the nurse expect with these conditions?

WBC >2; specific gravity 1.030

What should the nurse recommend to prevent urinary tract infections in young girls?

Wearing cotton underpants

A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily.

2

The nurse should know that once human immunodeficiency virus (HIV) enters the body, seroconversion to HIV positivity usually occurs within:

6 to 8 weeks.

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)?

A 56-yr-old woman who works on an automotive assembly line

Chronic otitis media with effusion (OME) is differentiated from acute otitis media (AOM) because it is usually characterized by:

A feeling of fullness in the ear.

Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)?

Bulk-forming laxatives are an excellent source of fiber. Walking or cycling frequently will help bowel motility. A good time for a bowel movement may be after breakfast. Some over-the-counter (OTC) medications cause constipation.

Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)?

Burning on urination.

A patient who uses injectable illegal drugs ask the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?

Consider participating in a needle-exchange program

Which condition is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T-cells?

Acquired immunodeficiency syndrome (AIDS)

The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.)

Administration of intravenous fluids Strict monitoring of intake and output Use of personal protective equipment Patient teaching on methods to inhibit transmission.

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs?

Age

A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication?

An antibiotic helps to kill the infection causing the inflammation

The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition?

Anaphylactic Reaction

On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient's wound. The nurse realizes what information about this fluid?

Contains the materials used by the body in the initial inflammatory response.

The nurse plans a presentation for community members about how to decrease the risk for antibiotic- resistant infections. Which information will the nurse include in the teaching plan (select all that apply)?

Antibiotics are effective in treating influenza associated with high fevers. Continue taking antibiotics until all of the prescription is gone. Hand washing is effective in preventing many viral and bacterial infections.

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?

Applying petroleum jelly to the lips

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Viral load testing

In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide?

What specific type of pathogen is causing an infection.

1. The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.)

Are part of primary prevention for system disorders Help protect individuals and communities Are recommended by the Centers for Disease Control and Prevention (CDC)

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse?

Ask the patient about the concerns with stoma management.

A patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented?

Assist the patient to soak in a 15-minute sitz bath.

Which set of assessment data is consistent for a patient with severe infection that could lead to system failure?

BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?

Can you tell me more about the thoughts that you are having?

The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication?

Capsaicin cream (Zostrix)

The school nurse is informed that a child with human immunodeficiency virus (HIV) will be attending school soon. Which is an important nursing intervention?

Carefully follow universal precautions.

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

Check the patient's class schedule to help decide when the drugs should be taken.

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for

Cobalamin (B12) supplements.

A young child with human immunodeficiency virus is receiving several antiretroviral drugs. The purpose of these drugs is to:

Delay disease progression.

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee?

Discomfort with joint movement

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to

Discontinues the patient's oral food intake.

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should

Document stoma assessment findings.

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)?

Drain and measure the output from the ostomy.

The nurse reviews the patient's complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response?

Early stage acute

A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following?

Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?

Explain to the patient that this is an expected finding.

The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element?

Portal of entry

A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care?

Position patient with the knees flexed.

The nurse is planning care for an adolescent with acquired immunodeficiency syndrome. The priority nursing goal is to:

Prevent infection.

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?

Prevention of HIV transmission between sexual partners

Which diagnostic test allows visualization of the renal parenchyma and renal pelvis without exposure to external beam radiation or radioactive isotopes?

Renal ultrasound

The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider?

The patient has a temperature of 100.6° F.

Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to change in medication?

The patient has dark-colored stools.

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

The patient has developed acquired immunodeficiency syndrome (AIDS

The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient?

You will need to be retested in 2 weeks.

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)?

Gown Gloves

To detect human immunodeficiency virus (HIV), most laboratory tests focus on the:

HIV antibodies

The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)?

Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine

What is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus?

Crohn's disease

A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

Continue to use contraception while taking this medication.

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient?

Control Inflammation

What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis?

Coping with stress and avoiding triggers

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/μL and an undetectable viral load. What is the priority nursing intervention at this time?

Encourage adequate nutrition, exercise, and sleep.

A common clinical manifestation of Hodgkin's disease is:

Enlarged, firm, nontender lymph nodes.

Examples of sexual risk behaviors associated with exposure to a sexually transmitted infection (STI) include (Select all that apply):

Fellatio. Unprotected anal intercourse. Multiple sex partners

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction?

Fill the irrigation syringe with body-temperature solution.

Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS) (Select all that apply)?

Give supplemental vitamins as prescribed. Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed. Notify the physician if the child develops on a cough or congestion.

Which statement is characteristic of acute otitis media (AOM)?

It is treated with a broad range of antibiotics.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching?

Oatmeal with cream

What is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population?

Perinatal transmission

The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

The patient reports missing some doses of zidovudine (AZT).

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should

avoid activities requiring repetitive use of the same muscles and joints.

A young adult male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of

Gonococcal urethritis

The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition?

His immune system is functioning properly.

An 18-month-old child is seen in the clinic with AOM. Trimethoprim-sulfamethoxazole (Bactrim) is prescribed. Which statement made by the parent indicates a correct understanding of the instructions?

I should administer all the prescribed medication.

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching?

I will clean the ear canal daily with a cotton-tipped applicator.

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-yr-old female patient with cystitis when the patient states which of the following?

I will empty my bladder every 3 to 4 hours during the day

A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider?

Left-sided flank pain

Which information will the nurse teach a patient with lactose intolerance?

Live-culture yogurt is usually tolerated.

An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching?

Many drugs interact with antiretroviral medications.

A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

Remind the patient about the need to return for retesting to verify the results.

An inherited immunodeficiency disorder characterized by absence of both humoral and cell-mediated immunity is:

Severe combined immunodeficiency syndrome (SCIDS).

A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective?

The patient uses witch hazel compresses to soothe irritation.

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?

The patient will maintain intact perineal skin.

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include?

The site where the stoma will be located will be marked on the abdomen preoperatively.

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching?

This type of colostomy is usually temporary.

What is used to treat moderate-to-severe inflammatory bowel disease?

Corticosteroids

Which factor predisposes a child to urinary tract infections?

Short urethra in young girls

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis?

Use care when eating high-fiber foods to avoid obstruction of the ileum

The recommended treatment for the prevention of human immunodeficiency virus (HIV) transmission to the fetus during pregnancy is:

Zidovudine.

The nurse will instruct a patient who has undergone a left tympanoplasty to

Avoid blowing the nose

Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)?

Costovertebral tenderness

A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider?

Crackles are heard halfway up the posterior chest.

Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective?

I will need to use a sunscreen when I am outdoors.

After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching?

I will take 1 g of acetaminophen (Tylenol) every 4 hours.

A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse's best response?

Ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days.

A nurse is teaching a group of business people about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following?

If I don't feel sick, then I don't have to worry about transmitted diseases

A patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months. The nurse will plan to teach about

Medication use.

Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)?

Monitor stools for blood.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?

Most infants born to HIV-positive mothers are not infected with the virus.

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?

Needle stick with a needle and syringe used for a venipuncture

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?

Oral saquinavir (Invirase)

The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation.

Oral temperature 38.6° C/101.5° F WBC 20 cells/McL 109/L Patient reports, "I'm tired all the time. I haven't felt like myself in days."

Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.)

Uninsured or underinsured status High cost of medications Inadequate nutrition

The nurse is assisting the pediatric provider with a newborn examination. The provider notes that the infant has hypospadias. The nurse understands that hypospadias refers to:

Urethral opening along ventral surface of penis.

A child with secondary enuresis who complains of dysuria or urgency should be evaluated for what condition (Select all that apply)?

Urinary tract infection (UTI) Diabetes mellitus

Which immunization should be given with caution to children infected with human immunodeficiency virus?

Varicella