ATI - Medical-Surgical: Musculoskeletal, Gastrointestinal, Immune and Infectious

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin lesions on the face and neck. The client asks the nurse, "what should I do about these spots?" which of the following nursing responses should the nurse give? A. "Keep the lesions covered with a light sterile dressing when going outdoors" B. "There is not much you can do. The lesions will go away when your disease is in remission" C. "Apply moisturizer after bathing the lesions with warm water" D. "Apply antibiotic cream twice a day until scabs form on the lesions"

"Apply moisturizer after bathing the lesions with warm water." The nurse should instruct the client to clean, dry, and moisturize the skin using warm (not hot) water, along with an unscented lotion.

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

"HIV can be transmitted to anyone who has had contact with the infected blood." The concentration of the virus is highest in blood but also has been isolated in other body fluids, including sputum, saliva, cerebrospinal fluid, urine, and semen. Clients who have HIV are cautioned to practice safe sex, avoid donating blood, and abstain from sharing needles with others.

A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the affected arm adducted. Which of the following instructions should the nurse provide the client? A. "Keep your arm bent at the elbow." B. "Use a pillow to prop your shoulder up close to your ear." C. "Hold your arm against the side of your body." D. "Position your arm with the shoulder at a 90-degree angle."

"Hold your arm against the side of your body." ----- Adduction means to position toward the midline of the body. Therefore, the nurse should provide these instructions to explain the provider's prescription.

A nurse is teaching a client who has TB about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take this medication with food." B. "I need to take a B-complex vitamin while taking this medication." C. "I can expect this medication to turn my skin orange." D. "I can expect this medication to make my vision blurry."

"I can expect this medication to turn my skin orange." The nurse should instruct the client to expect his skin and urine to turn a reddish-orange tinge while taking rifampin.

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

"I can take this medication with aspirin." The nurse should instruct the client to avoid taking this medication with any other NSAIDs, such as aspirin, because this can increase the risk for bleeding and gastrointestinal ulceration.

A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following information should the nurse include about osteoarthritis? A. "Osteoarthritis is caused by autoimmune processes." B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." C. "Osteoarthritis affects other organ systems." D. "Osteoarthritis can impair a joint on a single side of the body."

"Osteoarthritis can impair a joint on a single side of the body." ------ The nurse should identify unilateral joint involvement as a finding of osteoarthritis. A client who has RA experiences symmetrical joint impairment.

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

"I should not smoke." Raynaud's disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities to feel numb and cool in response to cold temperatures or stress. During a Raynaud's attack, these arteries narrow, limiting blood circulation to affected areas. Strong emotion or exposure to the cold causes these areas to become white, due to a lack of blood flow in the area. They then turn blue, as tiny blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood returns, the area becomes red and then later returns to normal color. This can cause tingling, swelling and painful throbbing. The attacks can last from minutes to hours. If the condition progresses, blood flow to the area could become permanently decreased, causing the fingers to become thin and tapered, with smooth, shiny skin and slow-growing nails. If an artery becomes blocked completely, gangrene or ulceration of the skin can occur. Smoking cessation, not just reduction, is an action the client should take to prevent the onset of the manifestations of Raynaud's disease.

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

"I should stop eating raw clams." Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish. Individuals who eat raw or steamed shellfish are at increased risk for acquiring hepatitis A.

A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which of the following statements by the client should the nurse identify as understanding of the teaching? A. "I will wear a continuous movement machine on my knee for 24 hours a day." B. "I should avoid taking NSAID medications for pain after surgery." C. "I should wear elastic stockings on both of my legs." D. "I will begin exercising my legs the day after surgery."

"I should wear elastic stockings on both of my legs." ------ The purpose of elastic stockings is to prevent venous thromboembolism, which is a common complication following orthopedic surgery. Therefore, the nurse should identify this statement as understanding of the teaching.

A nurse is teaching a client who has tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergy when she states which of the following? A. "I will begin vacuuming once a week." B. "Carpeting the entire house will be very expensive, but it will be worth it." C. "I will apply a mattress cover to my bed." D. Installing curtains on the windows will help control the dust in the house."

"I will apply a mattress cover to my bed." The nurse should instruct the client to apply a hypoallergenic mattress cover that can be zipped over her bed to control the amount of dust. The client should remove the mattress cover periodically and machine wash to clean.

A nurse is providing discharge instructions to a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of the STI? A. "I will bring my sexual partner in for treatment." B. "Now that I've had my first dose of medicine, I can resume sexual activity." C. "Once I have been treated, it is no longer necessary to use condoms." D. "Once treatment is completed and I am free of symptoms, I don't have to return to the clinic."

"I will bring my sexual partner in for treatment." The client should bring his partner in to be screened for genital warts and treated.

A nurse is teaching a client who has a new prescription for alendronate for treatment of osteoporosis. Which of the following statements by the client indicates understanding of the teaching? A. "I will take the medication in the evening." B. "I will drink a full glass of milk with the medication." C. "I will take the medication at mealtime." D. "I will sit upright after taking the medication."

"I will sit upright after taking the medication." ----- A client taking alendronate should sit upright for 30 min after administration to prevent esophageal irritation and ulceration. Therefore, the nurse should identify this statement as indicating an understanding of the teaching.

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

"I'll clean up blood spills immediately with hot water." The client's partner should clean blood or potentially contaminated body substances with a bleach solution and wear gloves when coming into contact with blood products.

A client who tests positive for the human immmunodeficiency virus (HIV) asks the nurse, " should i tell my partner that I am an HIV positive/" which of the following is appropriate nursing response? A. "That is your decision alone" B. "I would if I were you" C. "You sound like you are unsure what to say to your partner?" D. "We are required by law to notify your partner"

"It sounds like you are unsure what to say to your partner." This response uses the therapeutic communication tools of clarifying and restatement. It identifies that the client is unsure about if or how to approach the issue of being HIV positive with his partner, a common concern of clients due to fear of rejection. This response shows that the nurse is open to further communication with the client and encourages his expression of feelings.

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

"PCP results from an impaired immune system." The nurse should explain that the organism that causes PCP exists as part of the normal flora of the lungs and develops into a fungus. It becomes an aggressive pathogen when the immune system is compromised and the infection results from an impaired immune system.

A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the right foot. Which of the following statements should the nurse make? A. "This type of pain usually decreases over time as the limb becomes less sensitive." B. "Try to look at the surgical wound as a reminder the limb is gone." C. "Use a cold compress intermittently to decrease these pain sensations." D. "Grief over the lost limb can sometimes cause denial that the limb is really gone."

"This type of pain usually decreases over time as the limb becomes less sensitive." ----- The nurse should recognize that the client is reporting phantom limb pain, a frequent complication following amputation. The nurse should instruct the client that the sensation should decrease over time. The nurse should recognize the pain, provide treatment, and handle the limb gently to decrease the risk of triggering pain.

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

"Wash your genitalia using an antimicrobial soap." The nurse should instruct the client to bathe daily using an antimicrobial soap to prevent the spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap is recommended.

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

"You can expect a persistent fever and swollen glands." Clients who have AIDS can have persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of AIDS.

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? A. "You will need to apply a cold pack to the site three times a day." B. "Your provider might ask you to walk frequently to increase circulation to the area." C. "You will need to limit consumption of high-protein foods." D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

"Your provider might prescribe a central catheter line for long-term antibiotic therapy." ------- Osteomyelitis is an acute or chronic bone infection. The client will require weeks to months of IV antibiotic therapy for treatment. Therefore, the nurse should discuss the need for long-term IV access for antibiotic therapy.

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

A progressive, circular rash Early Lyme disease is characterized by fever, influenza-like manifestations, and erythema migrans, a distinct progressive circular or bulls-eye rash that often develops at the bite site, but can also develop at other sites, such as the thighs and knees.

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which patient statement to the nurse indicates that additional teaching is needed? A. "I can sleep in any position that is comfortable for me." B. "I should not cross my legs while sitting." C. "I will have someone else put on my shoes and socks." D. "I will use a toilet elevator on the toilet seat." The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching.

A. "I can sleep in any position that is comfortable for me." The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching.

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C Women who are pregnant D. Middle-aged men

A. Children The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact.

A nurse is caring for a client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-gluramyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT]

A. Gamma-glutamyl transferase (GGT) The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium

A. Prothrombin time A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 degrees C (101.1 degrees F) D. Oxygen saturation 92%

A. Right shoulder pain The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help with client comfort.

Which assessment information should indicate to the nurse that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? A. The patient's blood glucose is 165 mg/dL. B. The patient has experienced a recent 5-pound weight loss. C. The patient's erythrocyte sedimentation rate (ESR) has increased. D. The patient has joint pain and stiffness.

A. The patient's blood glucose is 165 mg/dL. Corticosteroids have the potential to cause diabetes. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication.

A nurse is caring for pt with celiac disease. which of the following foods should the nurse remove from clients tray? A) wheat toast B) tapioca pudding C) hard boiled eggs D) mashed potatoes

A. Wheat toast Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the client's tray.

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching? A. Use an alcohol-based soap to clean lesions. B. Wear a condom during sexual activity when lesions are present. C. Take a sitz bath once per day. D. Apply a warm compress to the lesions.

Apply a warm compress to the lesions. The nurse should instruct the client to apply a warm compress to the lesions to relieve discomfort.

A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? A. Perform passive range-of-motion exercises of the ankle hourly. B. Keep the affected extremity in a dependent position. C. Wrap a loose dressing around the affected ankle. D. Apply cold compresses to the extremity intermittently.

Apply cold compresses to the extremity intermittently. ------ Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply cold compresses for no more than 20 min at a time.

A nurse is caring for a client who is postoperative following a total knee arthroplasty and is prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first? A. Remind the client to push the button for the PCA device. B. Discuss activities the client may use to distract from the pain. C. Ask the client to describe the characteristics of the pain. D. Pause the CPM machine briefly to apply a cold pack to the client's knee.

Ask the client to describe the characteristics of the pain. ------ Answering this item requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to acquire further data by asking the client to describe the characteristics of the pain.

A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? A. Colchicine B. Naproxen C. Aspirin D. Prednisone

Aspirin ----- Aspirin can decrease the effectiveness of probenecid. The nurse should caution the client to avoid interaction between probenecid and salicylate medications.

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by earring foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

B. "A hepatitis B immunization is given to infants and children." Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age.

A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."

B. "This procedure can determine how well the lower part of your esophagus works." An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures.

A nurse is assessing a client who is in the early stages of hepatitis A. which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces

B. Anorexia Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

What suggestion should the nurse make to a group of women with rheumatoid arthritis (RA) about managing activities of daily living? Stand rather than sit when performing daily household and yard chores. A. Stand rather than sit when performing daily household and yard chores. B. Avoid activities requiring repetitive use of the same muscles and joints. C. Protect the knee joints by sleeping with a small pillow under the knees. D. Strengthen small hand muscles by wringing out sponges or washcloths.

B. Avoid activities requiring repetitive use of the same muscles and joints. Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.

Which finding should the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? A. Redness and swelling of the knee joint B. Discomfort with joint movement C. Stiffness that increases with movement D. Presence of Heberden's nodules

B. Discomfort with joint movement initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water. B. Place the client in semi-Fowler's position. C. Cleanse the skin around the tube site. D. Aspirate the tube for residual contents.

B. Place the client in semi-Fowler's position. The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse.

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? A. Pancakes with syrup and bacon B. Oatmeal with skim milk and fruit yogurt C. Egg-white omelet and a half grapefruit D. Whole wheat toast and fresh fruit

B. Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? A. To visualize polyps in the colon B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary tract D. To determine the presence of free air in the abdomen

B. To detect an ulceration in the stomach An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.

The nurse teaches a patient with osteoarthritis (OA) of the hip about how to manage the OA. Which patient statement indicates to the nurse a need for additional teaching? A. "A shower in the morning will help relieve stiffness." B. "I can use a cane to decrease the pressure and pain in my hip." C. "I will take 1 gram of acetaminophen (Tylenol) every 4 hours." D. "I can exercise every day to help maintain joint mobility."

C. "I will take 1 gram of acetaminophen (Tylenol) every 4 hours." No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient understands the nurse's teaching about the condition? A. "I should avoid nonsteroidal antiinflammatory drugs." B. "I should take birth control pills to avoid getting pregnant." C. "I will use sunscreen when I am outside." D. "I will exercise even if I am tired."

C. "I will use sunscreen when I am outside." Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

The nurse is advising a patient who was exposed 4 days ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen-antibody test has just been reported as negative for HIV. What information should the nurse give to this patient? A. "We won't know for about 10 years if you have HIV infection." B. "You do not need to fear infecting others." C. "You will need to be retested in 2 weeks." D. "With no symptoms and this negative test, you do not have HIV."

C. "You will need to be retested in 2 weeks." HIV screening tests detect HIV-specific antibodies or antigens. However, there may be a delay between infection and the time a screening test is able to detect HIV. The typical "window period" for antigen-antibody combination assays is approximately 2 weeks. It is not known based on this information whether the patient is infected with HIV or can infect others. It would be best practice to have him return for repeat testing in approximately 2 weeks.

The day after a having a right below-the-knee amputation, a patient reports pain in the missing right foot. Which action is most important for the nurse to take? A. Tell the patient that the pain will diminish over time. B. Explain the reasons for the pain. C. Administer prescribed analgesics. D. Reposition the patient to assure good alignment.

C. Administer prescribed analgesics. Acute phantom limb sensation is treated as any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. Alignment is important but is unlikely to relieve the pain. Although the pain may decrease over time, it currently requires treatment.

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase

C. Amylase Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days.

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories

C. Foods high in fiber The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? A. Bending over the sink while brushing teeth B. Using crutches with a swing-to gait C. Leaning over to pull on shoes and socks D. Sitting upright on the edge of the bed

C. Leaning over to pull on shoes and socks Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement

C. Liver transplant Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food

C. Rigid abdomen Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure, or hypotension, results.

A nurse in the ER is caring for a pt who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A) famotidine B) esomeprazole C) vasopressin D) omeprazole

C. Vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? A. Rapid HIV antibody testing B. Enzyme immunoassay C. Viral load testing D. Immunofluorescence assay

C. Viral load testing The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as the treatment for this condition? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine

Celecoxib ------ Celecoxib is a type of NSAID, called cyclooxygenase-2 (COX-2) inhibitors, used to relieve some of the manifestations caused by RA in adults. The nurse should identify that the medication is also prescribed for osteoarthritis, spondylitis, and painful menstruation.

A nurse is teaching an assistive personnel about the standard precautions when caring for a client who has VRE of the urine. Which of the following images of PPE should the nurse recommend the AP to use when caring for this client? A. Mask B. Clean Gloves C. Eyewear D. Shoe Coverings

Clean Gloves The nurse should don clean gloves when caring for a client who has vancomycin-resistant enterococcus of the urine. This protects the nurse from coming in contact with bodily fluids contaminated with the bacteria of the client.

A nurse is providing discharge instructions for a client who is postoperative following inner maxillary fixation with wiring. Which of the following information should the nurse include? A. Cut the wiring if emesis occurs. B. Consume three meals daily as part of a low-protein diet. C. Swab the mouth with hydrogen peroxide if wiring produces oral irritation. D. Resume a soft diet in 3 to 5 days.

Cut the wiring if emesis occurs. ----- Inner maxillary fixation involves wiring of the teeth to support the fractured jaw by holding the jawbones together. The wires are left in place until the fracture is healed. To preserve the client's airway, the nurse should instruct the client to have wire cutters available to immediately cut wiring if emesis occurs. The client should return to the provider as soon as possible for re-wiring.

A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use

D. Alcohol use Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.

A nurse is assessing client who is experiencing perforation of a peptic ulcer. which of the following manifestations should the nurse expect? A) increased blood pressure B) decreased heart rate C) yellowing of the skin D) board like abdomen

D. Boardlike abdomen The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.

nurse is caring for a client who is 2 days postoperative following a gastric bypass. the nurse notes that bowel sounds are present. which of the following foods should the nurse provide at the initial feeding? A) vanilla pudding B) apple juice C) diet ginger ale D) clear liquids

D. Clear liquids Clear liquids, such as water or broth, can be given for the first oral feedings, but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar, which could cause diarrhea due to hyperosmolarity.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis

D. Diaphoresis The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? A. Assess the incision for redness. B. Reposition the left leg on pillows. C. Check the patient's blood pressure. D. Notify the health care provider.

D. Notify the health care provider. The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

A nurse is caring for a client who is dehydrated & receiving continuous tube feeding through a pump at 75ml/hr. when the nurse assess the client at 0800 , which of the following findings requires intervention by the nurse? A) a pitcher full of water is sitting at bedside within reach B) the disposable feeding bag is from the previous day at 1000 with 200ml of feeding C) client is lying on right side with a visible dependent loop in the feeding tube D) the HOB is elevated to 20 degrees

D. The head of the bed is elevated 20°. The head of the bed should be elevated at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move down through the digestive system and lessens the possibility of regurgitation.

Which of the following findings should alert the nurse to the possibility that a client who is 2 days postop is developing an infection? A. Temperature of 37.8 (100.2) B. Erythema at the incision site C. WBC count of 9,000/mm D. Pain reporter as 6 out of 10

Erythema at the incision site Redness, or erythema, at the incision site is an initial sign of a wound infection and requires intervention by the nurse.

A nurse is teaching a female client who has a new diagnosis of Systemic Lupus Erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE? A. Exercise B. Pregnancy C. Infection D. Sunlight

Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and the manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with her provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active.

A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, has a SaO2 of 87%, and the nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis

Fat embolism syndrome ----- The nurse should identify the triad of neurologic changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and fracture of a long bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude small blood vessels.

A nurse is assessing a client who has systemic Scleroderma. In addition to skin changes, which of the following findings should the nurse expect? A. Excessive salivation B. Finger contractures C. Periorbital edema D. Alopecia

Finger contractures Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are two types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs. The manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma, the body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma unless clients follow a regimen of range-of-motion and muscle-strengthening exercises.

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.) A. Gloves B. Eye protection C. Shoe covers D. Gown D. Mask

Gloves, Gown Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.

A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed and the traction weight is resting on the floor. Which of the following actions should the nurse take? A. Remove the weight temporarily to reposition the client to the correct alignment in bed. B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely. C. Lift the rope off the pulley while the client rocks back and forth to reposition. D. Lift the weight manually while another staff member moves the client up in bed.

Have the client use a trapeze to pull himself up while ensuring the weight hangs freely. ----- The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client up, making sure to maintain proper alignment of the extremity.

A nurse is monitoring a new licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a CXR. The nurse should instruct the newly licensed nurse to take which of the following actions? A. Have the client wear a surgical mask. B. Wear a gown for protection from the client's infection. C. Ask the radiology staff to perform a portable chest x-ray in the client's room. D. Place an N95 respirator on the client.

Have the client wear a surgical mask. The nurse should instruct the client to wear a surgical mask. The mask will protect anyone who comes into contact with the client, including the nurse.

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? A. An assistive device to use when the client is ambulating B.Heat paraffin therapy applied to the client's joints C. Gentle massage of the client's hands D. Active range-of-motion exercises on the client's affected joints

Heat paraffin therapy applied to the client's joints The nurse should anticipate the use of heat paraffin to be prescribed as a nonpharmacologic intervention. The elevated ESR indicates an acute inflammatory process due to client's rheumatoid arthritis. The use of the warm paraffin relives the stiffness of the client's joints and provides comfort.

A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? A. Decreased intake of phosphate-containing foods B. Spending several hours in the sun daily C. Increased estrogen levels D. History of anorexia nervosa

History of anorexia nervosa ----- The nurse should identify anorexia nervosa as a risk factor for osteoporosis. Inadequate protein intake can lead to a decreased bone density, increasing the risk for fractures

A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that the purpose of a Mantoux skin test using purified protein derivative (PPD) is to do which of the following actions? A. Identify if a client lacks immunity to tuberculosis. B. Find out if a client has active tuberculosis. C. Decrease the hypersensitivity of the client's reaction to PPD. D. Identify if a client has been infected with mycobacterium tuberculosis.

Identify if a client has been infected with mycobacterium tuberculosis. The nurse should inform the client that the Mantoux test is used to identify individuals who have been infected with mycobacterium tuberculosis.

A nurse is caring for a client who has seasonal allergy symptoms and had radioallergosorbent (RAST) testing completed during a previous clinic visit. The nurse recognize that a positive result is indicated by an elevation of which of the following? A. IgM (Immunoglobulin M) B. IgA C. IgG D. IgE

IgE (immunoglobulin E) RAST testing involves measuring the quantity of IgE present in serum after exposure to specific antigens selected on a basis of the client's symptom history. An elevated IgE indicates a positive response and is common among clients who have a history of allergic manifestations, anaphylaxis, and asthma.

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

Increased mucus secretion The nurse should instruct that the client that increased mucus secretion is a manifestation of histamine release. Histamine is the neurotransmitter the body produces during an allergic reaction.

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

Monitor your body temperature and report any elevations promptly." SLE is a chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temperature and report any elevations promptly, as fever can suggest either an exacerbation or a potentially life-threatening infection.

The health care provider asks the nurse to evaluate whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? A. Observe for swelling of the patient's lips and tongue. B. Obtain the patient's blood pressure and heart rate. C. Assess the patient's extremities for wheal and flare lesions. D. Question the patient about any clear nasal discharge.

Observe for swelling of the patient's lips and tongue. Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? A. Sensation of heat on the surface of the cast B. Paresthesias of the extremity C. Pruritus of the extremity D. Musty odor noted from cast materials

Paresthesias of the extremity ------ The nurse should identify paresthesias as a finding of compartment syndrome. Compartment syndrome involves the compression of nerves and blood vessels in an enclosed space, leading to impaired blood flow and nerve damage. Other findings include numbness, tingling, weakness, and pain that does not respond to medication.

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understandings of the teaching? A. Protect against the cold by wearing layers of clothing. B. Begin an exercise program of 2-mile walks once per week. C. Increase vitamin A in the diet. D. Elevate the hands above heart level when resting.

Protect against the cold by wearing layers of clothing. Clients who have Raynaud's disease are prone to attacks during cold weather. Extreme cold can lead to tissue damage. Therefore, the client needs to be protected with layers of clothing to promote warmth and increase circulation to the extremitie

A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of the following complications? A. Pneumonia B. Pulmonary embolus C. Tension pneumothorax D. Tuberculosis

Pulmonary embolus ----- Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary embolus. The client might also exhibit tachycardia, chest petechiae, and have a decreased SaO2. The nurse should notify the rapid response team immediately.

When assessing a client with Kaposi's sarcoma, the nurse would expect to see which of the following? A. A nonproductive cough with fever and shortness of breath B. Lesions on the retina that produce blurred vision C. Insidious onset of progressive dementia D. Reddish-purple skin lesions

Reddish-purple skin lesions Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following biopsy, the lesions are treated with radiation and/or chemotherapy.

A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority? A. Report of muscle spasms B. Inability to get dressed without assistance C. Report of feelings of anger D. Refusal to look at the affected limb

Report of muscle spasms ----- The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, the nurse should identify the report of muscle spasms, a physiological need, as the priority client finding.

A nurse is reviewing the lab results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following lab tests can indicate arthritis? A. Reticulocyte count B. Rheumatoid factor C. Direct Coombs' test D. Platelet count

Rheumatoid factor An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective tissue diseases.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? A. Decreasing blood pressure B. Muscle cramps C. Rising body temperature D. Skin flushing

Rising body temperature The patient's report of feeling cold and shivering indicate that the hypothalamic set point for temperature has increased and the temperature will be increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature.

A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? A. Bulging in the area over the surgical incision B. Shortening of the right leg C. Sensation of warmth over the surgical incision D. Pallor following elevation of the right leg

Shortening of the right leg ----- The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. Other findings include increased hip pain, inability to move the extremity, and rotation of the hip internally or externally.

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

Standard precautions Standard precautions should be implemented with every client, to prevent the spread of infection transmitted by direct or indirect contact with infectious blood or body fluids. Because HIV is spread through blood and bodily fluids, standard precautions are appropriate.

A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which the following findings should the nurse report to the provider? A. Toes cold to the touch B. Serous drainage from the pin sites C. Blanching of the toenail beds with pressure D. Pink tissue around the fixator insertion sites

Toes cold to the touch ------ The nurse should monitor for and report manifestations of compartment syndrome following internal fixation. Therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch.

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? A. Confluent, honey-colored, crusted lesions B. Large, tender nodule located on a hair follicle C. Unilateral, localized, nodular skin lesions D. A fluid-filled vesicular rash in the genital region

Unilateral, localized, nodular skin lesions Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces unilateral, localized, nodular skin lesions.

A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? A. Use a hair dryer on a cool setting to blow air into the cast. B. Ask the provider to bivalve the cast. C. Provide the client with a sterile cotton swab to rub the affected skin. D. Wrap the extremity with a dry heating pad.

Use a hair dryer on a cool setting to blow air into the cast. ------ The nurse should provide relief for the report of itching by blowing cool air into the cast using a hair dryer on a cool setting or an empty 60-mL plunger syringe.