Adult Health Exam 2- Ch 13-14, 22-23, 29-30

The nurse mentor is describing the phases of the immune response to a recent nursing graduate. The mentor determines that the graduate needs additional information if the graduate states that which is a phase of the immune response?

A. Effector phase B. Memory phase C. Activation phase D. Recognition phase Answer: B

The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding?

A. Elevate the patient's leg B. Press firmly on the lesion C. Check the temperature of the skin around the lesion D. Palpate the dorsalis pedis and posterior tibial pulses ANswer: B

The nurse is reviewing the diagnostic tests performed in an adult with a connective tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 35 mm/hr (35 mm/hr). How would the nurse interpret this finding?

A Normal B. Indicating severe inflammation C. Indicating moderate inflammation D. Indicating mild inflammation Answer: D

Healthcare provider prescribes topical 5-FU for a patient with actinic keratosis on the left ceek. The nurse should include which statements in the patients instructions?

A. 5-FU will shrink the lesion so that less scarring occurs once the lesion is excised B. You may develop nausea and anorexia, but good nutrition is important during treatment C. You will need to avoid crowds because of the risk for infection caused by chemotherpay D. Your cheek area will be painful and develop eroded areas that will take weeks to heal Answer: D

After receiving change-of-shift report on several patients with neutropenia, which patient should the nurse assess first?

A. 56n year old with frequent explosive diarrhea B. 33 year old with a fever of 100.8F C. 66 year old who has white pharyngeal lesions D. 23 year old complaining of sever fatigue Answer: B

It is important for the nurse providing care for a patient with sickle cell crisis to:

A. Limit the patient's intake of oral and IV fluids B. Evaluate the effectiveness of opioid analgesics C. Encourage the patient to ambulate nas much as tolerated D. Teach the patient about high-protein, high-calorie foods Answer: B

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minuites after the transfusion is started. After stopping the transfusion what action should the nurse take?

A. Draw blood for new crossmatch B. Send a urine sample to the lab C. Administer PRN acetaminophen D. Give the PRN diphenhydramine Answer: C

A nurse is providing discharge instructions to the partner of a client diagnosed with acquired immune deficiency syndrome (AIDS). Which of the following statements by the partner indicates a need for further teaching?

A. "I will dispose of soiled tissues in separate bags" B. "I'll clean blood spills with hot water" C. "I know that handwashing is an important preventative measure" D. I will wash soiled clothes in hot water Answer: B

The nursing instructor is evaluating a nursing student for knowledge of antibody classes. Which statement by the nursing student indicates that teaching has been effective?

A. "Immunoglobulin G (IgG) is the first antibody produced in response to antigen." B. "Immunoglobulin A (IgA) is the last antibody produced in response to antigen." C. "Immunoglobulin D (IgD) is the last antibody produced in response to antigen." D. "Immunoglobulin M (IgM) is the first antibody produced in response to antigen." Answer: D

The nursing student is presenting a clinical conference and discusses the cause of β-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

A. A child of Mexican descent B. A child of Mediterranean descent C. A child whose intake of iron is extremely poor D. A breast-fed/chest fed child of a parent with chronic anemia Answer: B

A nurse is planning care for a client with pernicious anemia. Which of the following interventions Should the nurse include in the plan?

A. Administer ferrous sulfate supplementation B. Increase dietary intake of folic acid C. Initiate weekly injections of vitamin B 12 D. Initiate a blood transfusion Answer: C

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a BP of 82/40, temperature of 102F, and severe back pain. WHich physician order will the nurse implement first?

A. Administer morphine sulfate 4mg Iv B. Give acetaminophen 650mg C. Infuse normal saline 500ml over 30 minutes D. Schedule complete blood count and coagulation studies Answer: C

Which activities can the nurse working in an outpatient clinic delegate to an LPN/LVN? (select all that apply)

A. Administer patch testing to patient with allergic dermatitis B. Interview a new patient about chronic health problems and allergies C. Apply a sterile dressing after the healthcare provider excises a mole D. Teach a patient about site care after a punch biopsy of an upper arm lesion E. Explain potassium hydroxide testing to a patient with a superficial skin infection Answer: A, C, D, E

A patient with atopic dermatitis has a new prescription for pimecrolimus. After teaching the patient about the medication which statement by the patient indicates that more teaching is needed?

A. After I apply the medication, I can go ahead and get dressed as usual B. I will need to minimize my time in the sun while using the Elidel C. I will rub the medication gently onto the skin every morning and night D. If the medication burns when I apply it, I will wipe it off and call the doctor Answer: D

Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage?

A. Arthralgias B. Joint enlargement C. Erythematous rash D. Cardiac conduction deficits Answer: D

The nurse is reviewing lab resulysnand notes an aPTT level of 28 seconds. The nurse should notfiy the healthcare provider in anticipation of adjusting which medication?

A. Aspirin B. Heparin C. Warfarin D. Erythropoeitin Answer: B

When performing a skin assessment the nurse notes several angiomas on the chest of an older patient. WHich action should the nurse take first?

A. Assess the patient for signs of liver disease B. Discuss the adverse effects of sun damage on the skin C. Teach the patient about possible skin changes with aging D. Suggest that the patient make an appointment with a dermatologist ANswer: A

A nurse is teaching a patient who has polycythemia vera about self- care measures. Which of the following interventions should the nurse include?

A. Drink at least 1 liter of fluid daily B. Wear support hose continuously C. Elevate the legs when sitting D. use dental floss daily Answer: C

A nurse is planning care for a patient with acute myelogenous leukemia and a platelet count of 48000/mm^3. Which of the following instructions should the nurse include?

A. Avoid IM injections B. Assess the client for ecchymosis once a shift C. Do not allow visitors D. Encourage daily flossing between teeth Answer: A

Which action will be included in the care plan for a 30 year old woman who is neutropenic?

A. Avoid any injections B. Check temperature every 4 hours C. Omit fruits and vegetables D. Place a "No Visitors" sign on the door Answer: B

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

A. Avoid intramuscular injections B. Encourage increased oral fluids C. Check temperature every 4hrs D. Increase intake of iron-rich foods Answer: A

A nurse is providing discharge teaching to a client diagnosed with HIV. Which of the following instructions about infection prevention should be included? (Select all that apply)

A. Avoid large gatherings of people B. Clean toothbrush by running through dishwasher C. Change pet litter boxes with disposable gloves D. Consume fresh fruit and raw vegetables E. Avoid digging in the garden Answer: A, B, E

A routine complete blood count indicates that an active 80-year old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about:

A. Blood transfusion B. Bone marrow biopsy C. Filgrastim (Neupogen) D. Erythopoetin (Epogen) administration Answer: B

A pediatrician prescribes laboratory studies for the infant of a birthing parent positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant?

A. Chest x-ray B. Western blot C. CD4+ cell count D. p24 antigen assay Answer: D

A patient with an enlarging, irregular mole that is 7mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?

A. Curretage B. Cryosurgery C. Punch biopsy D. Surgical excision Answer: D

An older patient with a squamous cell carcinoma on the lower arm has a Mohs procedure, in the dermatology clinic. Which nursing action will be included in the postoperative plan of care?

A. Describe the use of topical fluorouracil on the incision B. Teach how to use sterile technique to clean suture line C. Schedule daily appointments for wet to dry dressing changes D. Teach about the use of cold packs to reduce bruising and swelling Answer: D

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

A. Discourage deep breathing to reduce risk for splenic rupture B. Teach the patient to use ibuprofen for left upper quadrant area C. Schedule immunization with the pneumococcal vaccine D. Avoid the use of acetaminophen Answer: C

A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). In planning care, the nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply.

A. Falls in response to a declining viral load B. Is a primary marker of immunocompetence C. Plays a role in the cell-mediated immune response D. Is a direct measure of the magnitude of HIV replication E. Guides decision making regarding timing of initiation of treatment Answer: B, C, E

A nurse is caring for a patient with a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe whoch of the following medications for the client?

A. Ferrous sulate B. Epoetin alfa C. Vitamin B12 D. Folic acid Answer: C

The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation?

A. Fever B. Cough C. Dyspnea at rest D. Dyspnea on exertion Answer: B

A nurse is assessing a client with deep vein thrombosis (DVT). Which of the following manifestations should the nurse expect to find? (Select all that apply)

A. Hardening along the blood vessel B. Absence of peripheral pulse C. Tenderness in the calf D. Cool skin on the leg E. Increased leg circumference Answer: A, C, E

A patient's CBC shpw hemoglobin of 19g/dL and hematocrit of 54%. What shoukld the nurse ask to determine possible causes of this findijg?

A. Have you had recent weight loss? B. Do you have any history of lung disease? C. Have you noticed any dark or tarry stools? D. WHat is your dietary intake of meats and proteins? Answer: B

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hrs ago. WHich lab result would the nurse expect to find?

A. Hematocrit of 46% B. Hemoglobin of 13.8mg/dl C. elevated reticulocyte count D. Decreased white blood cell (WBC) count Answer: C

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis?

A. Home oxygen therapy is frequently used to decrease sickling B. There are no effective medications that can help prevent sickling C. Routine continuous dosage narcotics are prescribed to prevent a crisis D. Risk for a crisis is decreased ny having an annual influenza vaccine Answer: D

A nurse is teaching a patient with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the patient to monitor for which of the following adverse effects of this medication?

A. Hypoglycemia B. Tendinitis C. Infection D. Weight loss Answer: C

A nurse is caring for a client with a burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect?

A. Hypokalemia B. Hypernatremia C. Elevated HCT D. Decreased Hgb Answer: C

A 68-year old woman with acute myelogenous leukemia asks the nurse whether the planned chemotherapy will be worth undergoing. WHich response by the nurse is appropriate?

A. If you do not want to have chemotherapy, other treatment options include stem cell transplantation B. The side effects of chemotherapy are difficult but AML frequently goes into remission with chemotherapy C. The decision about treatment is one that you and the doctor need to make D. You dont need to make a decision about treatment right now because leukemias in adults tend to prgress slowly Answer: B

A nurse is monitoring a patient who had a myocardial infarction. For which of the following complications should the nurse monitor for the first 24 hours?

A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli Answer: C

A nurse is teaching a client with iron deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods?

A. Lentils B. Avocados C. Cabbage D. Broccoli Answer: A

The nurse asks a nursing student to identify the locations of macrophages in the body. The student responds correctly if the student indicates which organs and tissues contain a large number of these cells? Select all that apply.

A. Liver B. Tonsils C. Spleen D. Bone marrow E. Intestinal tract Answer: A, C, E

Which action will the nurse include in the plan of care for a 72 year old woman admitted with multiple myeloma?

A. Monitor fluid intake and output B. Administer calcium supplements C. Assess lymph nodes for enlargement D. Limit weight bearing and ambulation ANswer: A

A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse would take which action in caring for this client?

A. Monitor for signs of hyperglycemia. B. Administer the medication without food. C. Administer the medication with an antacid. D. Ensure that the client uses an electric razor for shaving. Answer: D

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result would the nurse anticipate in the presence of this disease?

A. Neutropenia B. Hyperglycemia C. Antigens of immunoglobulin A (IgA) D. Unusual antibodies of the IgG and IgM type Answer: D

A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study would the nurse be aware of before responding to the client?

A. No further diagnostic studies are needed. B. A Western blot will be done to confirm these findings. C. The client probably will have a bone marrow biopsy done. D. A CD4+ cell count will be done to measure T helper lymphocytes. Answer: B

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply.

A. Oliguria B. Hypotension C. Fluid retention D. Temperature of 99.6° F (37.6° C) E. Serum creatinine of 3.2 mg/dL (282 mcmol/L) Answer: A, C, E

A nurse is reviewing progress notes for a patient in cardiac failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters?

A. Percentage of blood the ventricles pump during each beat B. Amount of blood the left ventricle pumps during each beat C. Amount of blood in the left ventricle at the end of diastole D. The heart rate times stroke volume Answer: D

A critical action by the nurse when caring for a patient with an acute exacerbation of polycythemia vera is to:

A. Place the patient on bed rest B. Administer iron supplements C. Avoid use of aspirin products D. Monitor fluid intake and output ANswer: D

A 28 year old man with von Willebrand disease is admitted to the hospital for a minor knee srugery. the nurse will review the coagulation survey to check the:

A. Platelet count B. Bleeding time C. thrombin time D. prothrombin time ANswer: B

A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine. The nurse assesses the complete blood cell (CBC) count, knowing that which is an adverse effect of this medication?

A. Polycythemia B. Leukocytosis C. Thrombocytosis D. Granulocytopenia Answer: D

Which colloborative problem will the nurse include in the care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

A. Potential complication: seizures B. Potential complication: infection C. Potential complication: neurogenic shock D. Potential complication: pulmonary edema Answer: B

A nurse is caring for a patient with 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 Answer: C

A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result would be most closely monitored?

A. Protein B. Glucose C. Amylase D. Cholesterol Answer: C

A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse would include which measure in the dietary plan?

A. Provide large, nutritious meals. B. Serve foods while they are hot. C. Add spices to food for added flavor. D. Remove dairy products and red meat from the meal. Answer: D

A client arrives at the health care clinic and tells the nurse about just being bitten by a tick and would like to be tested for Lyme disease. The client reports that the tick was removed and flushed down the toilet. The nurse would take which nursing action?

A. Refer the client for a blood test immediately. B. Ask the client about the size and color of the tick. C. Tell the client to return to the clinic in 4 to 6 weeks. D. Inform the client that the tick is needed to perform a test. Answer: C

Which information obtained by the nurse assessing a patient admitted with mulitple myeloma is most important to report to the healthcare provider?

A. Serum calcium level is 15mg/dl B. Patient reports no stool for 5 days C. Urine sample has Bence-Jones protein D. Patient is complaining of severe back pain Answer: A

A patient in the dermatology clinic is scheduled for removal of a 15mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy?

A. Shave biopsy B. Punch biopsy C. Incisional biopsy D. Excisional biopsy Answer: C

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items shold the nurse gather for this procedure?

A. Sterile gloves B. Patch test instruments C. Cotton-tipped applicators D. Local anesthetic, syringe and intradermal needle Answer: C

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding?

A. Swelling in the genital area B. Swelling in the lower extremities C. Positive punch biopsy of the cutaneous lesions D. Appearance of reddish-blue lesions noted on the skin Answer: C

Which action will the nurse include in the plan of care for a patient who has thalassemia major?

A. Teach the patient tio use iron supplements B. Avoid the use of IM injections C. Administer iron chelation therapy as needed D. Notify healthcare provider of hemoglbin 11g/dl AnswerL C

A 19 year old woman with immune thrombocytopenic purpura has an order for a platelet transfusion. WHich information indicates that rhw nurse should consult with the healthcare provider before obtaining and administering platelets?

A. The platelet count is 42000/ml B. Petechiae are present on thje chest C. Blood pressure is 94/56mmHg D. Blood is oozing from venipuncture site Answer: A

Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the healthcare provider?

A. The platelet count is 52000/L B. The patient is difficult to arouse C. There are purpura on the oral mucousa D. There are large bruises on the patients back Answer: B

The nurse is caring for a client who has a dysfunction associated with the B lymphocytes in the immune system. The nurse plans care, knowing that which is a function of B lymphocytes?

A. They activate T cells. B. They produce antibodies. C. They initiate phagocytosis. D. They attack and kill the target cell directly. Answer: B

A patient with atopic dermatitis has been using a high potency topical corticosteroid ointment for several weelks. The nurse should assess for which adverse effect?

A. Thinning of the affected skin B. Alopecia of the affected areas C. Reddish-brown discoloration of the skin D. Dryness and scaling in areas of treatment Answer: A

A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma. WHich info should the nurse include?

A. Treatment plans include watchful waiting B. Screening for metastasis will be important C. Low dose systemic chemotherapy is used to treat D. Minimizing sun exposure will reduce risk for future BCC Answer: D

A client is diagnosed with Goodpasture's syndrome. The nurse determines that this client's renal disease is caused by a type II hypersensitivity response. Which laboratory result would be most important for the nurse to evaluate?

A. Urinalysis B. Electrolytes C. Glomerular filtration rate (GFR) D. Partial thromboplastin time (PTT) Answer: C

A nurse is teaching a patient with genital herpes about self-management. Which of the following teachings should they include?

A. Use an alcohol based soap to cleanse the lesions B. Wear a condom during sexual activity when lesions are present C. Take a sitz bath once daily D. Apply warm compress to the lesions Answer: D

When taking the health history of an older adult, the nurse discovers that the patient has worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self assess for which clinical manifestations? (select all that apply)

A. Vitiligo B. Alopecia C. Intertrigo D. Erythema E. Actinic keratosis Answer: D, E

The nurse is assessing a patient with pernicious anemia. WHich assessment finding would the nurse expect?

A. Yellow-tinged sclera B. Shiny, smooth tongue C. Numbness of the extremities D. Gum bleeding and tenderness Answer: C

The healthcare provider progress note states that the CBC shows a shift to the left. Which assessment finding would the nurse expect?

A. cool extremities B. pallor and weakness C. elevated temperature D. low oxygen saturation Answer: C

A nurse is assessing a patient with isotonic dehydration. Which of the following findings should the nurse expect?

A. increased hematocrit level B. bradycardia C. distended neck veins D. Decreased urine specific gravity Answer: A

A teenaged male patient who wrestles in highschool is examined by the nurse. Which assessment finding would prompt the nurse to teach the patient about the iportance of not sharing headgear to prevent the spread of pediculosis?

A. ringlike rashes with red, scaly borders over entire scalp B. Papular, wheal-like lesions with white deposits on the hair shaft C. Patchy areas of alopecia with small vesicles and excoriated areas D. Red, hivelike papules and plaques with sharply circumscribed borders Answer: B

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?

A. the patient applies corticiosteroid cream to pruritic areas B. The patient uses Neosporin ointment on minor cits and abrasions C. The patient uses oilated oatmeal (Aveeno) to the bathwater every day D. The patient takes diphenhydramine nightly if itching occurs Answer: B

A patient reports chronic itching of the ankles and continuously scratches at the area. Which assessment finding will the nurse expect?

A> Hypertrophied scars on both ankles B. Thickening of the skin around the ankles C. Yellowish-brown skin around both ankles D. Complete absence of melanin in both ankles Answer: B

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

a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patients class schedule to help decide when the drugs should be taken. Answer: D

24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon?

a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is low Answer: C

5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching?

a. I need to find another way to earn extra money. b. I will get a prescription for epinephrine and learn to self-inject it. c. I will plan to take oral antihistamines daily before going to work. d. I should wear a Medic-Alert bracelet indicating my allergy to bee stings. Answer: C

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

a. Instruct the patient to apply ice to the neck. b. Advise the patient that this is probably the flu. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient. Answer: C

21. An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching?

a. Many medications have interactions with antiretroviral drugs. b. Less frequent CD4+ level monitoring is needed in older adults. c. Hospice care is available for patients with terminal HIV infection. d. Progression of HIV infection occurs more rapidly in older patients. Answer: A

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

a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection Answers: B, C

16. 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 right time?

a. Oral acyclovir (Zovirax) b. Oral saquinavir (Invirase) c. Nystatin (Mycostatin) tablet d. Aerosolized pentamidine (NebuPent) Answer: B

11. Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing?

a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation Answer: A

3. 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)?

a. Continue taking antibiotics until all the medication is gone. b. Antibiotics may sometimes be prescribed to prevent infection. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections. Answers: A, B, E

The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time?

a. "Do you have a productive cough?" b. "How often do you brush your teeth?" c. "Are you taking any medications at present?" d. "Have you ever had an oral herpes infection?" ANswer: C

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

a. 44-year-old with sickle cell anemia who says "my eyes always look sort of yellow" b. 23-year-old with no previous health problems who has a nontender lump in the axilla c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement Answer: B

18. The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant?

a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant Answer: C

19. A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first?

a. Administer epinephrine. b. Apply topical hydrocortisone. c. Monitor the patient for lower extremity edema. d. Ask the patient about exposure to any new lotions or soaps. Answer: A

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family Answer: B

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

a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/L c. HIV-positive patient with a CD4+ count of 160/L who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis Answer: D

12. Which patient should the nurse assess first?

a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness Answer: C

22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method. Answer: D

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count Answer: D

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?

a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time Answer: D

21. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first?

a. Remind the patient to remain calm. b. Administer subcutaneous epinephrine. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site. Answer: C

15. 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 instructions will the nurse give to the patient?

a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents. Answer: C

1. The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient?

a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders Answer: B

10. The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation?

a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Numbness and tingling Answer: D

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis?

a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily. Answer: C

3. A patient with 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?

a. Teach the patient about the medications available for treatment. b. Inform the patient how to protect sexual and needle-sharing partners. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to notify individuals who have had risky contact with the patient. Answer: C

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's best action?

a. Teach the patient about the treatment of fungal infection. b. Discuss the use of drying agents to minimize infection risk. c. Instruct the patient about the use of mild soap to clean skinfolds. d. Ask the patient about type 2 diabetes or if there is a family history of it. Answer: D

1. A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient?

a. The EIA test will need to be repeated to verify the results. b. A viral culture will be done to determine the progression of the disease. c. It will probably be 10 or more years before you develop acquired immunodeficiency syndrome (AIDS). d. The Western blot test will be done to determine whether acquired immunodeficiency syndrome (AIDS) has developed. Answer: A

5. A pregnant woman with a history of 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?

a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART). Answer: B

13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patients skin rash?

a. The donor T cells are attacking the patients skin cells. b. The patients antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection. Answer: A

2. 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/mL.Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

a. The patient meets the criteria for a diagnosis of an acute HIV infection. b. The patient will be diagnosed with asymptomatic chronic HIV infection. c. The patient has developed acquired immunodeficiency syndrome (AIDS). d. The patient will develop symptomatic chronic HIV infection in less than a year. Answer: C

16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patients health history has the most implications for planning patient teaching about the medication at this time?

a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast. Answer: D

14. 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?

a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin. Answer: D

Which patient requires the most rapid assessment and care by the emergency department nurse?

a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours d. The patient with thrombocytopenia who has oozing after having a tooth extracted Answer: C

The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will

a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee. Answer: A