ATI Medical-Surgical Practice Test: Immune and Infectious, ATI Immune Test, ATI Endocrine
A nurse if caring for a client who has viral pneumonia and a history of COPD. Which of the following finding should the nurse report to the provider? A. Consolidation in lower lobes by chest x ray B. Left shift in the WBC differential C. Oxygen sat 91% D. Orthostatic hypotension
B. indicated that the pneumonia is of bacterial origin, rather than viral
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? (Select all that apply) -Subcutaneous nodules -Decreased urine output -Renal calculi -Butterfly rash -Joint inflammation
-decreased urine output -butterfly rash -joint inflammation
A nurse in the emergency department is assessing a newly admitted client. Which of the following places the client at increased risk for contracting hepatitis B? A. Residing in an institutional setting B. Engaging in unprotected sexual intercourse C. Working w/ hazardous chemical waste materials D. Traveling to a foreign country
B. transmitted by sexual contact
A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? A. Small purple-colored skin lesions B. Fever and diarrhea lasting longer than 1 month C. Persistent, generalized lymphadenopathy D. CD4 T-cells decreased to 750
A. means acquired Kaposi's sarcoma, which is an AIDS-defining illness.
A nurse is providing teaching for a client who has an allergy to peanuts. Which if the following instructions is the priority to include in the teaching? A. Inform other health care professionals of the allergy B. Wear a medical identification tag C. Carry an emergency anaphylaxis kit D. Read food labels
C. greatest risk to client is injury from an anaphylactic reaction
A nurse is caring for a client who has neutropenia. Which of the following findings indicates a need for intervention? A. The client's granddaughter is visiting and telling him about her first day of kindergarten. B. The client has a grilled ham and cheese sandwich, a banana, and yogurt on his lunch tray C. The client's family brings in a silk flower arrangement D. the client's assistive personnel places paper cups and plastic utensils in his room.
A. no no he gas immunocompromised status
A nurse is caring for a client who is HIV-positive is reinforcing teaching about the earliest manifestations of AIDS. The nurse explains that they include which of the following? A. Persistent fever, swollen glands, diarrhea, weight loss, and fatigue B. Elevated WBC count C. Increased blood pressure, tachycardia, dyspnea and edema D. Influenza-like symptoms including fatigue, sore throat, muscle pain, headache and swollen glands
A. Persistent fever, swollen glands, diarrhea, weight loss, and fatigue
A nurse is performing an assessment on a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessment data should the nurse report? A. Serum sodium 110 mEq/L B. 2+ deep-tendon reflexes C. Serum potassium 3.7 mEq/L D. Urine specific gravity 1.025
A - Correct - A client who has SIADH retains fluids, which causes dilutional hyponatremia. B - Incorrect - Deep-tendon reflexes of 2+ are within the expected reference range. C - Incorrect - This serum potassium level is within the expected reference range. D - Incorrect - This urine specific gravity is within the expected reference range.
A nurse is reviewing the daily laboratory results for a female client who has acute leukemia. Which of the following values is an expected finding? A. WBC 21,00 B. hgb 14 C. hct 40% D. Platelets 170,00
A. typically have an elevated WBC
A nurse is managing the care of a client who is postoperative and experiencing acute adrenal insufficiency. Which of the following actions should the nurse take? A. Administer IV hydrocortisone sodium succinate. B. Give oral spironolactone. C. Infuse 1 unit of platelets. D. Restrict daily fluid intake.
A - Correct - Hydrocortisone sodium succinate is necessary to replace the cortisol deficiency that occurs with adrenal insufficiency. B - Incorrect - Administering a potassium-sparing diuretic will further increase the client's potassium level, potentiating the state of hyperkalemia. C - Incorrect - Although this client needs to increase volume, infusing platelets is not indicated. D - Incorrect - Rapid fluid replacement is indicated for this client due to hypovolemia. ...
A nurse is monitoring a client's status 24 hr after a total thyroidectomy. Which of the following findings should the nurse report to the provider? A. Laryngeal stridor B. Productive cough C. Pain with hyperextension of the neck D. Hoarse, weak voice
A - Correct - Laryngeal stridor is a harsh, high-pitched sound upon inspiration that indicates respiratory obstruction. The nurse should take immediate action to preserve the client's airway. B - Incorrect - A productive cough can occur after endotracheal intubation and is caused by a buildup of secretions. C - Incorrect - Pain with hyperextension of the neck D - Incorrect - A hoarse and weak voice is common after general anesthesia as a result of endotracheal intubation. If hoarseness continues, it could indicate laryngeal nerve damage, which is usually transient.
A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following effects should the nurse include? (Select all that apply.) A. Osteoporosis B. Moon-shaped face C. Increased risk of infection D. Hearing loss E. Weight loss
A - Correct - Osteoporosis is an adverse effect of long-term corticosteroid therapy due to the suppression of bone formation and the acceleration of bone resorption that corticosteroid therapy can cause. B - Correct - Long-term corticosteroid therapy causes characteristics of the iatrogenic syndrome characterized by a moon-shaped face, a potbelly, and a buffalo hump. C - Correct - Increased risk of infection is an adverse effect of long-term corticosteroid therapy due to the decrease it causes in the number of circulating lymphocytes. D - Incorrect - Long-term corticosteroid therapy is more likely to cause cloudy or blurred vision than hearing loss. E - Incorrect - Long-term corticosteroid therapy is more likely to cause weight gain due to the fluid retention corticosteroids cause. ...
A nurse is preparing to administer propranolol by IV bolus to a client experiencing a thyroid storm. Which of the following findings indicates the client is having a therapeutic response? A. Reduction of the effects of thyroid hormone on the heart B. Blockage of the release of thyroid hormone from the thyroid gland C. Increase of the heart's sensitivity to thyroid hormone D. Increase of the uptake of thyroid hormone by the thyroid gland
A - Correct - Propranolol is a beta2-adrenergic blocking agent that decreases the rapid heart rate caused by excessive thyroid stimulation. B - Incorrect - Propranolol does not affect thyroid hormone release. C - Incorrect - Propranolol does not increase the heart's sensitivity to thyroid hormone. D - Incorrect - Propranolol does not affect the uptake of thyroid hormone by the thyroid gland.
A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy? A. Fasting blood glucose 96 mg/dL B. Postprandial blood glucose 195 mg/dL C. Casual blood glucose 210 mg/dL D. Preprandial blood glucose 60 mg/dL
A - Correct - This is within the expected reference range for a fasting blood glucose level and indicates that insulin therapy is effective. B - Incorrect - A postprandial blood glucose level of 195 mg/dL is above the expected reference range. C - Incorrect - A casual blood glucose level of 210 mg/dL is above the expected reference range. D - Incorrect - A preprandial blood glucose level of 60 mg/dL is below the expected reference range.
A nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid hormone replacement. Which of the following instructions should the nurse plan to include? A. "Take this medication on an empty stomach." B. "Take this medication with an antacid." C. "Change position slowly while taking this medication." D. "Limit your fluid intake while taking this medication."
A - Correct - To promote proper absorption, the client should take the medication on an empty stomach and not eat or drink anything for 30 to 60 min after taking it. B - Incorrect - Aluminum-containing antacids and calcium supplements can reduce the effectiveness of thyroid replacement therapy. C - Incorrect - This medication does not cause orthostatic hypotension. D - Incorrect - The client should drink 2 to 3 L of fluid daily.
A nurse is reviewing laboratory values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect? A. pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L B. pH 7.38, PaCO2 55 mm Hg, HCO3- 22 mEq/L C. pH 7.44, PaCO2 40 mm Hg, HCO3- 24 mEq/L D. pH 7.50, PaCO2 42 mm Hg, HCO3- 30 mEq/L
A - Correct - With DKA, the pH is low, carbon dioxide is within the expected reference range, and bicarbonate is low. B - Incorrect - Clients who have DKA have an acidic pH, not a pH within the expected reference range. C - Incorrect - Clients who have DKA have an acidic pH, not a pH within the expected reference range. D - Incorrect - Clients who have DKA have an acidic pH, not an alkaline pH. ...
A nurse is admitting a client who has hyperthyroidism. When assessing the client, the nurse should expect which of the following findings? A. Cold intolerance B. Lethargy C. Tremors D. Sunken eyes
A - Incorrect - A client who has hyperthyroidism has heat intolerance. B - Incorrect - A client who has hyperthyroidism is restless and irritable. C - Correct - Findings of hyperthyroidism include tremors, diaphoresis, and insomnia. D - Incorrect - A client who has hyperthyroidism can have exophthalmos, which causes a wide-eyed or startled appearance...
A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect? A. Moon face B. Weight gain C. Serum calcium 12.8 mg/dL D. Serum sodium 150 mEq/L
A - Incorrect - A rounded face is a finding of Cushing's disease. B - Incorrect - Weight loss is a finding of adrenal insufficiency. C - Correct - A client who has adrenal insufficiency has a serum calcium level above the expected reference range. D - Incorrect - A client who has adrenal insufficiency has a serum sodium level below the expected reference range. ...
A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following findings should the nurse expect? A. Decreased blood pressure B. Weight loss C. Hirsutism D. Increased skin thickness
A - Incorrect - Elevated blood pressure is an expected finding of Cushing's disease. B - Incorrect - Weight gain is an expected finding of Cushing's disease. C - Correct - Increased hair growth, or hirsutism, is an expected finding of Cushing's disease due to increased androgen production. D - Incorrect - Thinning of the skin is an expected finding of Cushing's disease.
A nurse is preparing a teaching plan for a client who has diabetes insipidus and is receiving intranasal desmopressin. Which of the following information should the nurse include in the teaching plan? A. Daily fluid intake should be at least 3 L. B. Obtain weight weekly while wearing similar clothing at the same time of day. C. Notify the provider if a weight loss of 0.45 kg (1 lb) or more per week is noted. D. Occurrence of nocturia indicates the need for a dosage adjustment.
A - Incorrect - Fluid intake should be limited to no more than 3 L per day. B - Incorrect - The client should obtain his weight daily to detect dehydration in the early stage. C - Incorrect - A weight gain or loss of 0.45 kg (1 lb) per week is not suggestive of overhydration or dehydration. D - Correct - The initial dose of desmopressin is administered in the evening; the provider will increase the dosage until the client no longer experiences nocturia.
A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia? A. Strong, bounding pulse B. Decreased bowel sounds C. Tingling and numbness of the hands and feet D. Diminished deep-tendon reflexes
A - Incorrect - Hypocalcemia causes a weak, thready pulse. B - Incorrect - Hypocalcemia increases gastrointestinal motility. C - Correct - Hypocalcemia causes paresthesias, usually starting in the hands and feet. D - Incorrect - Hypocalcemia causes hyperactive deep-tendon reflexes. ...
A home health nurse is assessing a client who is on lifelong hormone replacement therapy for treatment of hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect? A. Significant weight loss B. Persistent diarrhea C. Tachycardia D. Hypotension
A - Incorrect - Hypothyroidism is more likely to cause weight gain. B - Incorrect - Hypothyroidism is more likely to cause constipation. C - Incorrect - Hypothyroidism commonly causes bradycardia. D - Correct - Hypotension is an expected finding of hypothyroidism. ...
A nurse is providing teaching for a client who has diabetes mellitus. Which of the following findings associated with diabetic ketoacidosis (DKA) should the nurse include? A. Decreased urine output B. Weight gain of 0.45 kg (1 lb) in 24 hr C. Rapid, shallow respirations D. Blood glucose levels greater than 300 mg/dL
A - Incorrect - Increased urine output is an expected finding of DKA. B - Incorrect - Weight loss is an expected finding of DKA C - Incorrect - Deep Kussmaul respirations are an expected finding of DKA. D - Correct - Blood glucose levels above 300 mg/dL are an expected finding of DKA.
A nurse is caring for a client undergoing screening for primary Cushing's disease. The nurse should expect that which of the following laboratory findings to be elevated? A. Lymphocyte count B. Serum potassium C. Serum calcium D. Blood glucose
A - Incorrect - Lymphocyte count is below the expected reference range with Cushing's disease. B - Incorrect - Serum potassium is below the expected reference range with Cushing's disease. C - Incorrect - Serum calcium is below the expected reference range with Cushing's disease. D - Correct - Blood glucose is elevated with Cushing's disease. ...
A nurse is caring for a client who is taking propylthiouracil (PTU). The nurse should recognize that the client has met the treatment goals when she reports an increase in which of the following effects? A. Sweating B. Stools C. Weight D. Appetite
A - Incorrect - PTU should cause a decrease in diaphoresis. B - Incorrect - PTU should cause a decrease in bowel movements. C - Correct - PTU suppresses the production of thyroid hormones and, therefore, allows for weight gain. D - Incorrect - PTU should cause a reduction in appetite.
A nurse is assessing a client who has diabetes mellitus and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic? A. Rapid, deep respirations B. Cool, clammy skin C. Abdominal cramping D. Orthostatic hypotension
A - Incorrect - Rapid, deep respirations are an expected finding of hyperglycemia. B - Correct - Hypoglycemia causes cool, clammy skin, in addition to anxiety, nervousness, tachycardia, and confusion. C - Incorrect - Abdominal cramping is an expected finding of hyperglycemia. D - Incorrect - Hyperglycemia can cause dehydration, resulting in hypotension.
A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? A. Decreased heart rate B. Increased hematocrit C. High urine specific gravity D. Decreased BUN
A - Incorrect - Tachycardia is an expected finding of diabetes insipidus. B - Correct - An increased hematocrit level is an expected finding related to dehydration. C - Incorrect - Increased urine output leads to dilute urine and a low urine specific gravity. D - Incorrect - An increase in BUN levels is an expected finding related to dehydration.
To screen a client for pheochromocytoma, a nurse schedules a vanillylmandelic acid test. When teaching the client about this test, which of the following instructions should the nurse include? A. Start fasting at midnight prior to the day of the test. B. Begin the 24-hr urine collection with the first morning urination. C. Take low-dose aspirin for pain during the testing period. D. Restrict coffee intake 2 to 3 days prior to the test.
A - Incorrect - The client does not have to fast prior to the test. B - Incorrect - The client should discard the first morning urine, and then collect all urine after that for 24 hr. C - Incorrect - The client should avoid aspirin because it can affect test results. D - Correct - The client should avoid coffee and tea (even if they are decaffeinated), bananas, chocolate, and vanilla for 2 to 3 days prior to the test. ...
A nurse is providing teaching for a client who has a new prescription of amoxicillin to treat a respiratory infection. Which of the following statements by the client indicates an understanding of these teachings? A. "My birth control pills are less effective while I am on this medication" B. " I must take this medication on an empty stomach" C. "I should expect to have constipation while taking this medication" D. "I will keep taking this medication until I feel better"
A. antibiotics accelerate the elimination of oral contraceptives, making them less effective
A nurse is teaching a client about glycosylated hemoglobin (HbA1c) testing. Which of the following statements by the client indicates an understanding of the information about this test? A. "I need to fast after midnight the night before the test." B. "This test is a good indicator of my average blood glucose levels." C. "A level of 8% to 10% suggests adequate blood glucose control." D. "I will use my hemoglobin A1c level to adjust my daily insulin doses."
A - Incorrect - The client does not need to fast before blood sampling for HbA1c. In fact, what the client eats the day before has no effect on the results of this test. B - Correct - HbA1c reflects the client's glucose levels over a 120-day period, which is the life span of RBCs. C - Incorrect - Clients who have diabetes mellitus should keep their HbA1c below 7%. D - Incorrect - The client should use capillary blood glucose levels to adjust daily insulin doses with the provider's approval.
A nurse is providing teaching for a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements indicates that the client understands the teaching? A. "I should stop taking my insulin if I feel nauseous." B. "I will test my urine for protein when I start to feel ill." C. "I will call my doctor if my blood sugar is more than 250 mg/dL." D. "I should check my blood glucose level every 8 hours."
A - Incorrect - The client should continue taking the usual dose of insulin, even when not feeling well. B - Incorrect - The client should check urine for ketones when blood glucose levels are greater than 240 mg/dL. C - Correct - The client should call the provider if blood glucose levels exceed 250 mg/dL during illness. D - Incorrect - The client should check her blood glucose level every 4 hr during illness. ...
A nurse in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements by the client indicates an understanding of the teaching? A. "I will let my feet air dry after washing." B. "I will wear sandals to allow air to circulate around my feet." C. "I will buy over-the-counter medicine to treat the calluses on my feet." D. "I will apply lotion to the dry areas of my feet, avoiding application between my toes."
A - Incorrect - The client should dry her feet thoroughly after washing to prevent bacterial growth between the toes. B - Incorrect - The client should wear closed-toe shoes to prevent injury to her feet. C - Incorrect - Over-the-counter medications can impair skin integrity and lead to further injury. D - Correct - Lotion is appropriate for dry areas of the feet, but the client should avoid applying lotion between the toes, as this area is prone to bacterial growth.
A nurse is caring for a client who has diabetes mellitus and developed peripheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to his feet? A. Examine the skin and feet weekly for alterations in skin integrity. B. Monitor the temperature of bath water with a thermometer. C. Shop for shoes early in the day. D. Round the edges of toenails when trimming.
A - Incorrect - The client should examine his skin and feet daily. B - Correct - Peripheral neuropathy makes it difficult to determine if bath water is too hot. Therefore, to prevent injury, the client should use a bath thermometer to ensure the water temperature is less than 43.3° C (110° F). C - Incorrect - The client should shop for shoes later in the day when his feet are slightly swollen to make sure the shoes fit. D - Incorrect - The client should trim his toenails straight across and smooth the edges with an emery board. ...
A nurse is planning dietary teaching for a client who has type 1 diabetes mellitus. Which of the following information should the nurse include regarding alcohol consumption? A. Substitute two carbohydrate exchanges for every one alcoholic beverage. B. Ingest alcohol with meals to reduce alcohol-induced hypoglycemia. C. Consuming alcohol decreases blood triglyceride levels. D. Expect to increase insulin dosage when consuming alcohol.
A - Incorrect - The client should substitute two fat exchanges for every beverage containing alcohol. B - Correct - Alcohol prevents liver production of glucose. Consuming carbohydrates while drinking alcoholic beverages helps prevent hypoglycemia. C - Incorrect - Consuming alcohol increases triglyceride levels. D - Incorrect - The client might need to decrease insulin dosage due to the hypoglycemic effect of alcohol.
A nurse is providing discharge teaching for a client who has diabetes insipidus and has a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching? A. Breathe deeply while using the nasal spray. B. Blow nose gently prior to using the nasal spray. C. Administer the nasal spray while in a side-lying position. D. Instill the medication four times per day.
A - Incorrect - The medication is absorbed through the nasal mucosa. The client should hold his breath while spraying the medication. B - Correct - By blowing the nose gently prior to use of the spray, the client avoids dilution of the medication by nasal secretions or improper absorption of the medication due to nasal blockage. C - Incorrect - The client should sit upright when administering the spray. This helps to keep the spray from going down the throat. D - Incorrect - The client should instill the medication every 8 hr to 24 hr as prescribed by the provider. ...
A nurse is planning preoperative care for a client who has pheochromocytoma. Which of the following interventions should the nurse anticipate as being the priority? A. Use same arm for BP measurement. B. Avoid palpating the abdomen. C. Manage headaches with analgesics. D. Provide a private, darkened room.
A - Incorrect - The nurse should measure the client's BP in the same arm to obtain accurate readings. However, this is not the priority intervention. B - Correct - The greatest risk to this client is injury from hypertensive crisis. Therefore, the priority intervention is to avoid palpating the abdomen, which can cause a sudden release of catecholamines, causing a hypertensive crisis. C - Incorrect - The nurse should administer analgesics to treat the client's headaches. However, this is not the priority intervention. D - Incorrect - The nurse should provide a private, darkened room to promote rest and comfort. However, this is not the priority intervention. ...
A nurse is caring for a client who has type 2 diabetes mellitus and is admitted with hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect? A. Blood glucose of 496 mg/dL and serum pH of 7.32 B. Blood glucose of 550 mg/dL and serum pH of 7.02 C. Blood glucose of 702 mg/dL and serum pH of 6.11 D. Blood glucose of 846 mg/dL and serum pH of 7.40
A - Incorrect - These laboratory values indicate diabetic ketoacidosis. B - Incorrect - These laboratory values indicate diabetic ketoacidosis. C - Incorrect - These laboratory values indicate diabetic ketoacidosis. D - Correct - With HHS, the client produces enough insulin to prevent ketosis, but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range, but the blood glucose is greater than 600 mg/dL. ...
A nurse is preparing to give a client information about an adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders? A. Cushing's syndrome B. Hyperthyroidism C. Pheochromocytoma D. Addison's disease
A - Incorrect - Urine and serum cortisol levels are checked to test for Cushing's syndrome. B - Incorrect - In clients who have hyperthyroidism, T3 and T4 are high. Thyroid-stimulating hormone is low in clients who have Graves' disease and high in clients who have secondary or tertiary hyperthyroidism. C - Incorrect - A 24-hr urine collection is used to detect catecholamines and other substances that can indicate pheochromocytoma. D - Correct - The ACTH stimulation test is the standard test for Addison's disease. It measures the cortisol response to ACTH. The response is absent or very decreased in clients who have primary adrenal insufficiency. ...
A nurse is preparing insulin for a client who has diabetes mellitus. The client is to receive evening doses of insulin glargine and regular insulin. Which of the following actions should the nurse take to administer these two medications safely? A. Draw up the insulin glargine into the syringe first, and then draw up the regular insulin. B. Draw up the regular insulin into the syringe first, and then draw up the insulin glargine. C. Draw up the insulin glargine and the regular insulin into separate syringes. D. Draw up either insulin into the syringe first because both insulins are clear.
A - Incorrect - When mixing insulins, the nurse should draw up the short-acting insulin first. However, there is only one longer-acting insulin, NPH insulin, that is safe to mix with short-acting insulin. B - Incorrect - When mixing insulins, the nurse should draw up the short-acting insulin first. However, there is only one longer-acting insulin, NPH insulin, that is safe to mix with short-acting insulin. C - Correct - The nurse should not mix insulin glargine with any other insulin in the same syringe due to the low pH of its diluent. D - Incorrect - Whether a particular type of insulin is clear or cloudy does not determine its suitability for mixing. Acceptable mixtures include mixing clear, short-acting insulin with cloudy, longer-acting insulin, NPH insulin.
A nurse id providing teaching for a group of clients regarding prevention of skin cancer. Which of the following risk factors should the nurse include in the teaching? A. Light skin pigmentation B. Psoriasis C. history of frostbite D. Immunodeficiency disorder
A.
A nurse is helping to prepare a client treated for sexually transmitted disease (STD) for discharge. which of the following statements indicates that the client understands what the nurse explained about preventing infection transmission? A. "I will bring my sexual partner in for treatment" B. "Now that I've had my 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"
A. "I will bring my sexual partner in for treatment" Any sexual partner of this client should receive antibiotics to keep the client and his partner from transmitting the infection back and forth to each other
A nurse is providing teaching for a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following should the nurse include in the teaching? A. Avoid crowds B. Expect symptoms to subside in 1 to 2 weeks C. Increase intake of vitamin D D. Anticipate constipation
A. can decrease WBC and platelet levels, thus increasing risk for infection
A nurse is caring for a client who has a latex allergy. the nurse is aware that which of the following items may be unsafe to use while performing this client's care? A. Cartoon-character adhesive bandages B. Vinyl gloves C. Mylar balloons D. Silicone urinary catheters
A. Cartoon-character adhesive bandages
A nurse is teaching a female client newly diagnosed with systemic lupus erythematosus (SLE) about factors that might trigger an exacerbation of SLE. The nurse determines that the client needs more teaching when she identifies which of the following as a factor? A. Exercise B. Pregnancy C. Infection D. Sunlight
A. Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks normal body tissue. This attack may result in generalized inflammation and the symptoms associated with the specific involved tissues. most clients with 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.
A client admitted to the hospital with active pulmonary tuberculosis (TB) is placed on airborne precautions, prescribed medication and scheduled for a chest xray. While transporting the client to the radiology department the nurse should do which of the following? A. Have the client wear a mask B. Wear a mask and gown for protection from the clients infection C. Ask the radiology staff to do a portable chest xray in the clients room D. Take no special precautions
A. Have the client wear a mask This intervention protects anyone who may come in contact with the client, including the nurse.
A nurse is reinforcing teaching for a client who has frequent allergic reactions about how his symptom develop. the nurse should explain that histamine release causes which of the following? A. Increased mucous secretion B. Bronchial dilation C. Tachycardia D. Vertigo
A. Increased mucous secretion Histamine is the neurotransmitter the body produces during an allergic reaction. with extreme cases, histamine levels are high enough to cause anaphylactic shock. increase mucus secretion is a common manifestation of histamine release.
A nurse is caring for client who has a new prescirption for clindamycin to treat acute pelvic inflammatory disease. The nurse should monitor for and report which of the following finding immediately to the provider? A. Watery diarrhea B. Vaginitis C. fever D. N/V
A. greatest risk is pseudomembranous colitis, immediately discontinue the medicstion
A client has been diagnosed with Raynaud's disease, when reinforcing teaching with the client, the nurse should include information about which of the following? A. Protecting against cold with layers of clothing B. Starting a regular exercise program of 2-mile walks daily C. Increasing niacin and pyridoxine in the diet D. Elevating the hands above heart level during an acute attack
A. Protecting against cold with layers of clothing Extreme cold can lead to tissue damage, and clients with Raynaud's are prone to more frequent attacks during cold weather.
A nurse is caring for a client who reports a skin change on her arm. Which of the following findings should the nurse report to the provider? A. An asymmetrical papule that is pigmented B. A patch of silvery-white scales with a red epidermal base C. A collection of irregular dry papules that are black D. An elevated red lesion that arises from a scar
A. indicates malignant melanoma
A nurse is providing teachings for a client who is scheduled for a Pap test. The nurse should instruct the client that she is being tested for which of the following? A. Uterine cancer B. Cervical cancer C. Ovarian cyst D. Fibroids
B.
A nurse is preparing the family of an infant with acquired immune deficiency syndrome (AIDS) for discharge. which statement by the child's parent should alert the nurse to a need for further instruction? A. "I'll use disposable diapers, discarding them in separate plastic bags" B. "I'll clean up blood spills immediately with hot soapy water" C. "I know that handwashing is an important preventive measure" D. "Anybody changing the baby's diapers must wear gloves"
B. "I'll clean up blood spills immediately with hot soapy water"
Allergy testing indicates that a client has several environmental allergies and the provider recommends allergy desensitization. after explaining the procedure, the nurse determines that the reinforcement of teaching has been effective when the client states which of the following? A. "At each visit, I'll receive an allergy shot with a little bit less of the allergen than I received before" B. "I'll need to remain in the clinic for 30 minutes after each shot in case I have a bad reaction" C. "Any type of reaction at the injection site is abnormal, and I will need to receive an epinephrine shot" D. "Once my dose is established, I'll be taught how to give myself the allergy shots at home daily"
B. "I'll need to remain in the clinic for 30 minutes after each shot in case I have a bad reaction" After desensitization injection is administered, observation for a minimum of 30 minutes is required to monitor the client for any manifestations of an anaphylactic reaction
A nurse in the health clinic is evaluating the effectiveness of naproxen (naprosyn) following a client's exacerbation of rheumatoid arthritis, which comment by the client requires further intervention with the nurse? A. "I signed up for a swimming class, starting tomorrow" B. "I've been buying an acid reducer to help with the indigestion I've had" C. "I've lost 2 pounds since my last appointment 2 weeks ago" D. "The naprosyn goes down easier when I crush it and put it in applesauce"
B. "I've been buying an acid reducer to help with the indigestion I've had" NSAIDs like naprosyn can cause serious adverse GI reactions such as ulcerations, bleeding, perforation.
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
B. Erythema at the incision site
A nurse is collecting data from a client who has had systemic scleroderma for 5 years. 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
B. Finger contractures Scleroderma is a chronic disease that can cause thickening, hardening or tightening of the skin, blood vessels and internal organs. There are 2 types: localized scleroderma, which mainly affects the skin, and systemic scleroderma which may affect many internal organs. The symptoms include skin changes, Raynaud's disease, 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 clients skin and subcutaneous tissues becoming increasing 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
A client with an acute exacerbation of rheumatoid arthritis has an erythrocyte sedimentation rate (ESR) of 65 mm/hr. based on this finding, the nurse anticipates that the client's affected joints will require which of the following? A. Assistive devices B. Heat or cold therapy C. Gentle massage D. Active ROM exercises
B. Heat or cold therapy Elevated ESR indicates an acute inflammatory process. The client will most likely need thermal interventions to control inflammation, as well as activity limitations to rest inflamed joints
A client reports bilateral pain and swelling in her finger joints, with stiffness in the morning. the finger joints are erythematous and warm to touch. the clients tells the nurse she has a long family history of arthritis. to help diagnose this client's condition, the nurse anticipates an order for which laboratory study? A. C-Reactive protein (CRP) B. Rheumatoid factor (RF) C. WBC count D. Erythrocyte sedimentation rate (ESR)
B. Rheumatoid factor (RF) Likely RA; RF is found in the serum of most clients who have RA
When planning to reinforce teaching for a client who is HIV-positive, the nurse should explain to the client that the virus can be transmitted A. As soon as the client develops manifestations B. To anyone having contact with the clients blood C. Via the respiratory route through droplets D. Only during the active phase of the virus
B. To anyone having contact with the clients blood The concentration of the virus is highest in blood and has been isolated in several body fluids; including sputum, saliva, CSF, urine and semen. Clients with HIV are cautioned to practice safer sex, avoid donating blood, and abstain from sharing needles with others
A nurse is caring for a client who has hodgkin's lymphoma. Which of the following fidnings should the nurse expect? A. Overgrowth of B-lymphocyte plasma cells B. Reed-Sternberg cells C. Epstein-Barr virus D. Overproduction of blast phase cells
B. are cancer cells specific to Hodgkin's lymphoma and are found in lymph nodes
A nurse is providing discharge teaching for a client who is HIV-positive. Which of the following instructions should the nurse include int he teaching? A. Clean bathroom surfaces with full-strength bleach B. Discard beverages that have been unrefrigerated for 1 hour C. Wash laundry soiled with a body fluid in warm water. D. Work in the garden for exercise
B. b/c they can support bacteria
A nurse is performing a breast examination on a client. Which of the following should the nurse report to the provider? A. Asymmetrical breast size B. Breast tissue with an orange-peel appearance C. Presence of Montgomery's tubercles on the aureola D. Moveable mass in the left-lower breast quadrant
B. d/t lymph channels indicates advanced breast cancer
A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to the nurse that medication therapy is effective? A. WBC 3,500 B. Lymphocyte 1,500 C. Decreased viral load D. Low CD4/CD8 ratio
C.
A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. To confirm a diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic tests? A. Indirect laryngoscopy B. chest x ray C. throat culture D. monospot test
C.
A client diagnosed with systemic lupus erythematosus (SLE) 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 is appropriate? 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"
C. "Apply moisturizer after bathing the lesions with warm water"
A nurse is reinforcing teaching for a female client 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. "Its best for me to minimize exercise" B. "I shouldn't drink any alcohol" C. "I must not smoke" D. "I'd better not plan to become pregnant"
C. "I must not smoke" Raynauds disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities and the tips of the nose and ears 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 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 returns to normal color. There may be associated tingling, swelling, and painful throbbing. The attacks may 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 may occur. Smoking cessation is an action the client should take to prevent the onset of the manifestations of Raynaud's disease.
A client receives instructions about behaviors that increase the risk of developing Hepatitis A. Which statement by the client indicated to the nurse an accurate understanding of the information? A. "I won't donate blood anymore" B. "I'll get a booster shot of immune serum globulin every year" C. "I'll stop eating raw clams even though I enjoy them" D. "I won't touch another drop of alcohol"
C. "I'll stop eating raw clams even though I enjoy them" Hep A is transmitted via fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, uncooked shellfish. Those who eat raw or steamed shellfish are at an increased risk
Which of the following explanations should the nurse offer to an immunosuppressed client concerned about acquiring pneumocystis carinii pneumonia (PCP) 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"
C. "PCP results from an impaired immune system" The organism that causes PCP exists as part of the normal flora of the lungs. It becomes aggressive pathogen when the immune system is compromised.
A client with reactive airway disease is tested and found to have an allergy to dust mites. The nurse determines that the client understands how to reduce her exposure to this allergen when she states which of the following? A. "I'll run a room humidifier in my bedroom every night" B. "Carpeting the entire house will be very expensive, but it will be worth it" C. "Washing all the bed linens in hot water every week will be time-consuming" D. "I'll apply insect repellent sparingly to any exposed parts when I'm outdoors"
C. "Washing all the bed linens in hot water every week will be time-consuming" Dust mites are vulnerable to high temperatures and because a client may spend up to 1/3 of the day in bed, actions to reduce exposure in bedroom are essential
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 aren't sure what to say to your partner?" D. "We are required by law to notify your partner"
C. "You aren't sure what to say to your partner?"
A nurse has prepared a sign to hang outside of the room of a client who is on contact precautions because of a confirmed MRSA infection. Which sign, if prepared by the nurse, would indicate a knowledge deficit?
Graphic 4: isolation mask is not necessary with contact precautions
A nurse is educating a client who is scheduled for a kidney transplant. Which of the following information regarding hyper-acute rejection should the nurse include in the teaching? A. Hyperacute rejection can occur during the first few weeks after the transplant. B. If hyperacute rejection occurs, the kidney can become enlarged. C. The organ will need to be removed if hyeracute rejection occurs. D. Immunosupressive therapy is given to reverse hyperacute rejection.
C. It's the only treatment
A human immunodeficiency virus (HIV) - positive client is admitted to the hospital with lung infection. which isolation category should the nurse implement to prevent transmission of the HIV virus? A. Protective isolation B. Droplet precautions C. Standard precautions D. Contact precautions
C. Standard precautions - standard precautions Implemented with every client, prevent the spread of infection transmitted by direct or indirect contact with infectious blood or bodily fluids. since this is the mode of transmission of HIV, this is appropriate isolation precaution.
A nurse is assessing a client who has an exacerbation of herpes zoster. the nurse should observe the client's skin for which of the following? A. Confluent, honey-colored, crusted lesions B. Papules, vesicles, pustules and crusts C. Unilateral, localized, nodular skin lesions D. Fluid-filled vesicular rash in the genital region
C. Unilateral, localized, nodular skin lesions
A nurse is planning an education program about testicular cancer for a group of male adolescents. Which of the following information should the nurse include? A. Testicular cancer is more common in men older than 65. B. With early treatment, the survival is 50% C. Examine your testicles immediately after showering. D. Schedule a yearly ultrasound to screen for testicular cancer.
C. b/c it's easier to palpate
A nurse is caring for a pt who has an elevated prostate-specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic tests? A. Palpation of testes and lymph nodes B. Human chorionic gonadotropin level C. Digital rectal examination D. Pelvic ultrasound
C. determines size and consistency of the prostate
A nurse is providing teaching for a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I should use a suncreen with an SPF of at least 15" B. "Long-term immunosuppresive therapy could cure this disease" C. " I should wear gloves when it is cold outside" D. "SLE should not affect my lungs or breathing"
C. raynaud's syndrome commonly accompanies SLE and can cause painful vasoconstriction in the fingers when they are exposed to cols temps
A nurse is caring for a client who is receiving chemotherapy and has laboratory data revealing bone marrow suppression. The nurse should include which of the following instructions in the teaching? A. take aspirin for minor aches and pains B. Rinse the toothbrush with warm water and after each use C. Avoid eating fresh fruit and vegetables D. Wear clothing that will minimize sun exposure
C. they can contain bacteria
A nurse is providing care for four clients. Which of the following clients is at the greatest risk for pneumonia? A. A school-age child who has a history of allergies and asthma B. A young adult client living in a college dormitory C. A middle-age adult using an incentive spirometer following surgery D. An older adult client transferred from a long-term care facility who has dysphagia
D.
A nurse is helping to prepare a client with systemic lupus erythematosus (SLE) for discharge. which of the following instructions should the nurse include in the client's discharge teaching plan? A. "Avoid the use of NSAIDs" B. "Stop taking the corticosteroids when your symptoms are resolved" C. "Exposure to UV light will help control the skin rashes" D. "Monitor your body temperature and report any elevations promptly"
D. "Monitor your body temperature and report any elevations promptly" SLE is a chronic autoimmune disorder that can affect virtually any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack normal 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 temp and report any elevations as fever could suggest an exacerbation or a potentially life-threatening infection
A client is concerned about the possibility of contracting lyme disease after being bitten by a tick. the nurse should observe the client for the common early manifestations of lyme disease, including which of the following? A. A diffuse maculopapular rash B. Stiff, swollen, painful joints C. Double vision D. A progressive, circular rash
D. A progressive, circular rash Early Lyme disease is characterized by fever, flu-like manifestations, and erythema migrans, a distinct progressive circular rash that develops often at the bite site.
A nurse checks the morning laboratory results for a client admitted with status asthmaticus. the nurse knows that which result, if elevated on the white blood cell (WBCC) differential, would suggest an allergic basis for the client's illness? A. Neutrophils B. Lymphocytes C. Monocytes D. Eosinophils
D. Eosinophils Typical with asthma, especially when the disorder is associated with a hypersensitivity reaction. Eosinophils can also be elevated with several autoimmune disorders
A nurse is providing teaching for a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses by the nurse is appropriate? A. "Take a cool bath in the evening." B. "Exercise every other day" C. "Use pillows to support your joints while in bed" D. "Ask family members to help with household chores"
D. Gives the client an opportunity for rest
A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding? A. Loss of body hair B. Report of anorexia C. Mucositis of the oral cavity D. Erythema at the IV insertion site
D. Greatest risk is injury to the tissue due to extravasation and infection
A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that the purpose of mantoux skin test using purified protein derivative (PPD) is to do which of the following? A. Identify clients who lack immunity to tuberculosis B. Find out if a client has active tuberculosis C. Decrease hypersensitivity to purified protein derivative D. Identify clients who have been infected with mycobacterium tuberculosis
D. Identify clients 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
D. IgE RAST testing involves measuring the quantity of IgE present in the serum after exposure to specific antigens selected on a basis of the clients symptom history. An elevated IgE indicates a positive response and is common among clients with a history of allergic manifestations, anaphylaxis and asthma
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
D. Reddish-purple skin lesions KS is commonly associated with AIDS
A nurse is planning an education program for a grp of high school teachers who will be taking students on a hike. Which of the following info should the nurse unclouded regarding Lyme disease? A. "If bitten by a tick, you should get tested immediately" B. "If you have a tick embedded in your skin, apply a lit match to remove it" C. "You should wear dark-colored clothing to deter ticks from biting" D. "If you develop pain and stiffness in your joints, you should see your doctor"
D. Stage 1 lyme disease, "bull's eye" rash, muscle and joint pain and stiffness
A nurse is caring for a client who has leukemia and a platelet count of 48.000. Which of the following actions should the nurse take? A. Provide a diet low in vit K B. Place the client on contact precautions C. Admin SQ epoetin alfa D. test urine and stool for occult blood
D. Thrombocytopenic is at risk for occult bleeding
A nurse is providing teaching for a client who has Hodgkin's lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include? A. Use an antibacterial soap to cleanse the skin. B. wash the ink marking off when showering C. Rub the skin with a towel when drying D. Avoid direct sunlight exposure to the skin
D. it can be damaging to skin being exposed to additional radiation
A nurse is providing education for the parent of a child about administration guidelines for the human papilloma virus (HPV) vaccine. Which of the following info should the nurse include? A. One dose should be given at birth and another at 5 years B. The vaccine does not protect males C. The vaccine protects against chlamydia D. Three doses should be given starting at age 11 or 12
D. second given 1 to 2 months after 1st dose and third given 6 months after 1st dose
