Concepts III

A nurse is instructing a client how to self-administer enfuvirtide. Which of the following instructions should the nurse include? A - "Allow the vial to sit until the solution is completely clear and without particulates." B - "After reconstituting with sterile water, vigorously shake the vial to mix the solution." C - "Use the medication immediately upon removing from the refrigerator." D - "Use the same location for five injections before rotating to a new site."

A - "Allow the vial to sit until the solution is completely clear and without particulates." Rational A- When administering enfuvirtide, the client should inject sterile water to reconstitute it and gently roll the vial between the hands. Then, the client should let the vial sit until the solution is completely clear and without particulates, which might take up to 45 min. The client should allow the vial to warm to room temperature before the injection and refrigerate any unused portion. B - When administering enfuvirtide, the client should inject sterile water to reconstitute it, and gently roll the vial between the hands. Then, the client should let the vial sit until the solution is completely clear and without particulates, which may take up to 45 min. The client should allow the vial to warm to room temperature before the injection and refrigerate any unused portion. C - When administering enfuvirtide, the client should inject sterile water to reconstitute it, and gently roll the vial between the hands. Then, the client should let the vial sit until the solution is completely clear and without particulates, which may take up to 45 min. The client should allow the vial to warm to room temperature before the injection and refrigerate any unused portion. D - The nurse should instruct the client to rotate injection sites and avoid injecting into any area with reddened, abraded, or scarred skin. The nurse should instruct the client to report tenderness, redness, swelling, hardened areas, itching, or other skin reactions.

A nurse is assisting with the administration of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions? A - "Has your son had a sore throat recently?" B - "Was your son born with this cardiac defect?" C - "Has your child had any injuries recently?" D - "Are you aware that your son will have to be in isolation?"

A - "Has your son had a sore throat recently?" Rational A- ​Rheumatic fever typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. It is appropriate to determine whether or not the child previously has a sore throat. B - ​Rheumatic fever is not a congenital heart defect, but without treatment it can progress to rheumatic heart disease, which involves cardiac valve damage. C - ​Although nurses should screen children for injuries, it is not an essential question for this child at this time. D - Isolation is unnecessary for treatment of rheumatic fever. In fact, after the child's acute stage of illness resolves, the parent can treat the child at home.

A nurse is caring for a client who has hepatitis A. The client asks the nurse how he might have contracted the virus. Before responding which of the following questions should the nurse first ask the client? A - "Have you eaten any shellfish lately?" B - "Did you have a blood transfusion recently?" C - "Have you traveled to a third world country in the past two months?" D - "Do you take any recreational drugs?"

A - "Have you eaten any shellfish lately?" Rational A - Hepatitis A is transmitted by the oral-fecal route and can by contracted by consuming shellfish which was in contaminated water. B - The nurse should understand Hepatitis A is contracted by the fecal to oral route, not through blood products. Hepatitis B or C can be contracted through blood and body fluids. C - The nurse should understand that Hepatitis E occurs most often in less developed countries and is transmitted through contaminated water or food. D - The nurse understands Hepatitis A is contracted by the fecal to oral route, not through contaminated needles or straws used in recreational drug administration. Intravenous drug use is a major cause of Hepatitis C.

A nurse is reinforcing teaching with a client who has genital herpes caused by herpes simplex virus type 2 (HSV 2). Which statement by the client indicates understanding of the teaching? A - "I can transmit the infection to another person even when I don't have symptoms." B - "I will need a 7 day course of antibiotics to treat this infection." C - "My partner and I will use a condom for sexual intercourse when I have lesions present." D - "The first indication of HSV 2 is a hard, red, painless sore."

A - "I can transmit the infection to another person even when I don't have symptoms." Rational A - Transmission of HSV 2 can occur even when the client has no symptoms. Viral shedding can occur even when lesions are no longer present. B - HSV 2 is a virus and antibiotic therapy will not treat the infection. The provider can prescribe a medication such as acyclovir which reduces pain and viral shedding, but does not cure the infection. C - A client who has HSV 2 should always use a condom and avoid intercourse when lesions are present. D - Blisters or vesicles on the genitals, fever, and headache are manifestations of HSV 2. Manifestations of syphilis include a hard, red, painless sore.

A nurse is teaching a client about maraviroc. Which of the following instructions should the nurse include? A - "It is important to report any noticeable rash immediately as it might indicate an issue with your liver." B - "Make sure you take this medication without any other medications first thing in the morning." C - "You might experience flu-like symptoms for which you can take any over-the-counter medication." D - "The side effects of this medication are minimal, so you can continue to work and drive as normal."

A - "It is important to report any noticeable rash immediately as it might indicate an issue with your liver." Rational A- Hepatic injury can manifest as a rash in clients who take maraviroc and should be reported to the provider regardless of how mild it appears. B - Maraviroc must be administered with other HIV drugs, which are determined and selected based on pre-testing for the HIV strain CCR5-tropic. C - It is not advised for clients to take any over-the-counter drugs without first consulting their provider to ensure there are no interactions. D - Side effects include central nervous system dysfunction such as dizziness, paresthesia, and sleep disorders, so clients should use caution when operating a motor vehicle or other equipment.

A nurse is teaching a client about immunizations. which of the following information should the nurse include in the teaching? A - "You should receive a tetanus booster every 10 years." B - "You should not receive the influenza immunization if you have a common cold." C - "You do not have to receive the shingles vaccine if you have received two doses of the varicella virus vaccine." D - "As long as you don't have risk factors, you will start receiving the pneumococcal vaccine when you are 50 years old."

A - "You should receive a tetanus booster every 10 years." Rational A - The nurse should inform the client that the tetanus-diphtheria (Td) vaccine is recommended every 10 years. B - The nurse should instruct the client to differ the influenza immunization if they have moderate to severe febrile illness. It is recommended to receive the influenza immunization with mild infections such as the common cold. C - The nurse should inform the client that it is recommended to receive the shingles vaccine regardless of previous varicella virus vaccine doses. D - The nurse should inform the client that the pneumococcal vaccine is recommended beginning at age 65.

A nurse is teaching a guardian of a child about the recommended age range to receive the HPV vaccine. Which of the following age ranges should the nurse include? A - 11 to 12 years old B - 7 to 9 years old C - 13 to 15 years old D - 15 to 17 years old

A - 11 to 12 years old Rational A - Three doses of the vaccine for HPV are recommended for adolescents ages 11 to 12 years old. B - Three doses of the vaccine for HPV are recommended for adolescents ages 11 to 12 years old. C - Three doses of the vaccine for HPV are recommended for adolescents ages 11 to 12 years old. D - Three doses of the vaccine for HPV are recommended for adolescents ages 11 to 12 years old.

A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a child. What type of immunity? A - Artificial active immunity B - Active C - Passive D - Artificial passive immunity

A - Artificial active immunity Rational A - The nurse should recognize that the MMR vaccine provides artificial active immunity to the child. A vaccine contains a form of the disease that is live, attenuated, or killed, which will allow the body to build up an active immunity against the disease. B - The nurse should recognize that active immunity occurs when the body produces its own antibodies in response to an antigen, such as the common cold. C - The nurse should recognize that passive immunity occurs when the body gets antibodies from an external source, such as through breastfeeding an infant. D - The nurse should recognize that artificial passive immunity occurs when the body receives artificial antibodies, such as immune globulins.

A nurse is collecting data from a 2 year-old toddler who has AIDS. The nurse should inspect inside the toddler's mouth for which of the following oppertunistic infections? Candidiasis. A - Candidiasis B - Gingivitis C - Canker sores D - Koplik spots

A - Candidiasis Rational A - Candidiasis, or oral thrush, is caused by the overgrowth of Candida albicans, an opportunistic fungus that typically infects the oral cavity of clients who have immature or compromised immune systems. Thrush is often the initial opportunistic infection noted in children who have AIDS. B - Gingivitis is not an opportunistic infection commonly associated with AIDS. C - Canker sores are shallow ulcers that often associated with minor trauma and dietary deficiencies. D - Koplik spots are oral lesions characteristic of measles (rubeola).

A nurse is teaching a client who has a new prescription for imatinib to treat chronic myeloid leukemia. Which of the following instructions should the nurse include? Select all A - Clean fruits and vegetables thoroughly. B - Increase calcium intake. C - Weigh yourself daily. D - Perform hand hygiene frequently. E - Avoid grapefruit and grapefruit juice.

A - Clean fruits and vegetables thoroughly. C - Weigh yourself daily. D - Perform hand hygiene frequently. E - Avoid grapefruit and grapefruit juice. Rational A - Clean fruits and vegetables thoroughly is correct. Imatinib, a targeted antineoplastic drug, can cause bone marrow suppression. The nurse should instruct the client to clean fruits and vegetables carefully and completely to prevent transmission of bacteria. B - Increase calcium intake is incorrect. Imatinib is more likely to cause hypokalemia than hypocalcemia or bone loss. C - Weigh yourself daily is correct. Imatinib can cause fluid retention and weight gain. The nurse should instruct the client to record daily weights and monitor for edema. D - Perform hand hygiene frequently is correct. Imatinib can cause bone marrow suppression. The nurse should instruct the client to wash hands or use an alcohol-based hand rub frequently and to avoid exposure to illness. E - Avoid grapefruit and grapefruit juice is correct. Grapefruit and grapefruit juice can cause the blood levels of imatinib to be higher than normal. The nurse should instruct the client to avoid grapefruit and grapefruit juice during therapy.

A nurse is preparing to administer paclitaxel IV to a client who has ovarian cancer. Which of the following actions should the nurse take? Select all A - Give the client an antihistamine. B - Infuse the drug over 1 hr. C - Administer the drug through non-PVC tubing. D - Use an in-line filter. E - Add heparin to the paclitaxel solution.

A - Give the client an antihistamine. C - Administer the drug through non-PVC tubing. D - Use an in-line filter. Rational A - Give the client an antihistamine is correct. Prior to administering paclitaxel, an antimitotic drug, the nurse should give the client an antihistamine, such as diphenhydramine, a proton-pump inhibitor, such as cimetidine, and a glucocorticoid, such as dexamethasone, to prevent a hypersensitivity reaction. B - Infuse the drug over 1 hr is incorrect. The nurse should infuse paclitaxel over 3 hr, not 1 hr. C - Administer the drug through non-PVC tubing is correct. Paclitaxel is incompatible with PVC tubing. D - Use an in-line filter is correct. Paclitaxel requires administration through an in-line filter. E - Add heparin to the paclitaxel solution is incorrect. The nurse should not mix paclitaxel with any other drugs. Heparin and other anticoagulants increase the risk for bleeding.

A nurse is teaching the guardian of a 4 mo about the recommended immunizations for the infant. Which ones should she include? A - Haemophilus influenzae type B vaccine (Hib) B - Varicella vaccine C - Meningococcal conjugate vaccine (MCV4) D - Tetanus-diphtheria-acelluar pertussis vaccine (Tdap)

A - Haemophilus influenzae type B vaccine (Hib) Rational A - The nurse should inform the guardian that the Haemophilus influenzae type B vaccine (Hib) is recommended for infants and children to prevent a serious type of meningitis commonly seen in young children. B - The nurse should inform the guardian that the varicella vaccine is not given to infants under 12 months of age. The first dose is given at 12 months with a booster given between 4 and 6 years of age. C - The nurse should inform the guardian that the meningococcal conjugate vaccine is recommended for adolescents 11 to 18 years old. Adolescents should receive two doses of MCV4. The first dose should be given at 11 or 12 years old, with a booster dose at age 16. D - The nurse should inform the guardian that the Tdap vaccine is given to adolescents between the ages of 11 and 12 years old as a booster to the DTaP vaccine.

A nurse is caring for a client who is prescribed zidovudine. Which of the following lab values should the nurse report to the provider? A - Hemoglobin 7.1 g/dL B - RBC count 5.2/mm3 C - Neutrophil 57% D - Triglycerides 125 mg/dL

A - Hemoglobin 7.1 g/dL Rational A- The provider might consider dose reduction, discontinuation of therapy, or blood transfusions if the client's hemoglobin is less than 7.5 g/dL or has a reduction of greater than 25% from baseline. B - An RBC count of 5.2/mm3 is within the expected reference range and does not need to be reported to the provider. C - A neutrophil count of 57% is within the expected reference range and does not need to be reported to the provider. D - A triglyceride level of 125 mg/dL is within the expected reference range and does not need to be reported to the provider.

A nurse is teaching a client about recommended immunizations. which of the following immunizations should the nurse recommend the client receive starting at 50 years of age? A - Herpes zoster vaccine B - Human papillomavirus vaccine (HPV) C - Pneumococcal vaccine D - Haemophilus influenzae type B vaccine (Hib)

A - Herpes zoster vaccine Rational A - The herpes zoster, or shingles vaccine, is recommended for adults older than 50 years of age. B - Three doses of the human papillomavirus vaccine (HPV) are recommended for adolescents who are 11 to 12 years old. C - The pneumococcal vaccine, which prevents meningitis, pneumonia, and middle ear infections caused by Streptococcus pneumoniae, is recommended for children who are 0 to 6 years old. D - The Haemophilus influenzae type B vaccine (Hib), which prevents a serious type of meningitis, is recommended for children who are 0 to 6 years old.

A nurse is contributing to the plan of care for a client who has cirrhosis of the liver. Which of the following interventions should the nurse include in the plan? Select all A - Implement fall precautions. B - Obtain a weekly weight. C - Initiate a low sodium diet. D - Measure abdominal girth daily. E - Administer enemas to manage constipation.

A - Implement fall precautions. C - Initiate a low sodium diet. D - Measure abdominal girth daily. Rational A - Implement fall precautions is correct. The client who has cirrhosis of the liver has an increased risk of changes in mental status and confusion due to increased levels of serum ammonia and hepatic encephalopathy, which place the client at increased risk for falls. B - Obtain a weekly weight is incorrect. The client who has cirrhosis also has impaired salt and fluid regulation leading to fluid overload. Obtaining a daily weight would be an intervention that allows the nurse to more closely monitor fluid status. C - Initiate a low sodium diet is correct. The client who has cirrhosis also has impaired salt and fluid regulation leading to fluid overload. Regulating sodium intake by placing the client on a low sodium diet will assist in minimizing water retention. D - Measure abdominal girth daily is correct. The client who has cirrhosis develops fluid retention that manifests as ascites in the abdomen. Measuring abdominal girth daily is one measure the nurse can use to monitor fluid status. E - Administer enemas to manage constipation is incorrect. The client who has cirrhosis is at an increased risk for bleeding due to a lack of vitamin K and a low platelet levels. The nurse should place the client on bleeding precautions, which would exclude the use of enemas and intramuscular injections.

A nurse is preparing a client who has advanced cirrhosis for an abdominal paracentesis. Which of the actions should the nurse take? A - Instruct the client to empty his bladder. B - Place the client on his back. C - Assure the client that the procedure is painless. D - Have the client increase fluid intake after the procedure.

A - Instruct the client to empty his bladder. Rational A - The nurse should instruct the client to empty his bladder to reduce the risk of bladder damage. B - The nurse should place the client with the head of the bed elevated to promote drainage of fluid. C - The nurse should instruct the client that local anesthetics are administered prior to the procedure. D - Clients who have cirrhosis should limit fluid intake.

A nurse is caring for a client who has recurrent herpes simplex type 1 lesions. The nurse should perform a focused assessment of which of the following areas of the client's body? A - Mouth B - Genitalia C - Extremities D - Scalp

A - Mouth Rational A - Herpes simplex type 1 most commonly occurs on the client's mouth. B - Herpes simplex type 2 most commonly occurs on the client's genitalia. C - The client's extremities are not an area of the body associated with herpes simplex type 1. However, the client should perform good hand hygiene to prevent spreading the virus to other individuals. D - The client's scalp is not an area of the body associated with herpes simplex type 1. However, herpes zoster may locate on a neurological scalp pathway.

A nurse is caring for a client who has a prescription for maraviroc therapy. The nurse should instruct the client to report which of the following adverse effects? A - Paresthesia B - Cough C - Tinnitus D - Jaundice E - Fever

A - Paresthesia B - Cough D - Jaundice E - Fever Rational A - Paresthesia is correct. Maraviroc, a chemokine receptor 5 antagonist, can cause paresthesia, dizziness, and musculoskeletal pain. B - Cough is correct. Maraviroc can cause a cough and upper respiratory infection. C - Tinnitus is incorrect. Maraviroc is unlikely to cause tinnitus. Cisplatin, a platinum compound, is an immune system drug that can cause ototoxicity and hearing loss. D - Jaundice is correct. Maraviroc can cause liver damage. The nurse should instruct the client to report an allergic reaction, such as a rash, because it can precede liver damage, manifested as jaundice or abdominal pain. E - Fever is correct. Maraviroc can cause a fever and sinus infection.

A nurse is caring for a client who has a new prescription for cisplatin to treat testicular cancer. The nurse should instruct the client to report which of the following adverse effects? (select all that apply) A - Paresthesia B - Sore throat C - Flank pain D - Tinnitus E - Conjunctivitis

A - Paresthesia B - Sore throat C - Flank pain D - Tinnitus Rational A - Paresthesia is correct. Cisplatin, a platinum compound, can cause peripheral neuropathy. The nurse should tell the client to report numbness, tingling, or decreased sensation in the hands or feet. B - Sore throat is correct. Cisplatin can cause bone marrow depression. The nurse should tell the client to report fever, sore throat, bruising, or fatigue. C - Flank pain is correct. Cisplatin can cause kidney toxicity. Prior to therapy, the nurse should hydrate the client with 1 to 2 L of IV fluid and continue for 24 hr following therapy to flush the kidneys and help prevent kidney toxicity. D - Tinnitus is correct. Cisplatin can cause ototoxicity. The nurse should monitor the client's hearing and instruct the client to report hearing loss, vertigo, or tinnitus. E - Conjunctivitis is incorrect. Cisplatin is unlikely to cause conjunctivitis, although it can cause blurred vision, papilledema, and optic neuritis.

A nurse is caring for a client who was diagnosed with HIV 6 months ago. The client came to the clinic for testing to determine disease progression. Which of the following laboratory tests should the nurse expect the provider to prescribe? A - Quantitative RNA assay B - Platelet count C - Enzyme-linked immunosorbent assay (ELISA) D - Western blot assay

A - Quantitative RNA assay Rational A - The quantitative RNA assay measures the viral load, or amount of HIV virus present. The nurse should expect this finding to be used to monitor disease progression and for treatment adjustment, as needed B - A client who has HIV can experience thrombocytopenia. However, this test does not indicate disease progression. C - The nurse should recognize the ELISA is performed to determine the presence of HIV in a client for initial diagnosis only. D - The nurse should recognize the Western blot assay is performed to confirm an HIV diagnosis when the results of an ELISA are positive.

A nurse is caring for a client who has a new prescription for delavirdine therapy to treat HIV-1. The nurse should instruct the client to report which of the following adverse reactions to the drug? A - Rash B - Insomnia C -Rhinitis D- Alopecia

A - Rash Rational A - Delavirdine, a non-nucleoside reverse transcriptase inhibitor, can cause a rash. The nurse should instruct the client to report a rash, which can occur 1 to 3 weeks after therapy, because it can develop into Stevens-Johnson syndrome, a potentially life-threatening complication. B - Delavirdine, a non-nucleoside reverse transcriptase inhibitor, is more likely to cause fatigue and dizziness than insomnia. C - Delavirdine, a non-nucleoside reverse transcriptase inhibitor, is more likely to cause bronchitis than rhinitis. D - Delavirdine, a non-nucleoside reverse transcriptase inhibitor, is unlikely to cause alopecia. Vincristine, an antimitotic, is an immune system drug that can cause alopecia.

A nurse is reinforcing discharge teaching with a client who has AIDS. Which of the following statements should the nurse make regarding home infection control? A - Soak sponges used for cleaning in a bleach solution after use. B - Disinfect blood spills with a hydrogen peroxide solution. C -Measure temperature weekly. D - Burn soiled dressings.

A - Soak sponges used for cleaning in a bleach solution after use. Rational A - The nurse should instruct the client to use 1:10 solution of household bleach to soak sponges and cloths for 5 min following household cleaning. B - The nurse should instruct the client to disinfect blood spills using a 1:10 solution of household bleach. C - The nurse should instruct the client to measure her temperature at least once per day to detect infection early. D - The client should dispose of soiled dressings in a tied plastic bag and place in regular trash.

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestation should the nurse expect to find? A - Spider angioma B - Dark colored stools C - Weak pulse D - Increased body hair

A - Spider angioma Rational A - The nurse should expect to find spider angioma, which indicates portal hypertension, on the client who has advanced cirrhosis. B - The nurse should expect to find clay colored stools, not dark colored stools. C - The nurse should expect to find a bounding pulse, not a weak pulse. D - The nurse should expect to find a decrease in body hair rather than an increase.

A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring for this client? A - Standard precautions B - Airborne precautions C - Contact precautions D - Droplet precautions

A - Standard precautions Rational A - HIV is transmitted by direct or indirect contact with infected blood or body fluids. It is not transmitted through cough or casual contact. Therefore, the nurse should plan to implement standard precautions when caring for this client. B - The nurse should plan to use airborne precautions when caring for a client who has measles. C - The nurse should plan to use contact precautions when caring for a client who has pertussis. D - The nurse should plan to use droplet precautions when caring for a client who has measles.

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? A - Take temperature once a day. B - Wash the armpits and genitals with a gentle cleanser daily. C - Change the litter boxes while wearing gloves. D - Wash dishes in warm water.

A - Take temperature once a day. Rational A - The nurse should reinforce to the client to take his temperature once a daily to identify if a temperature is present due to the client's altered immune system. B - The nurse should instruct the client to use an antimicrobial cleanser to wash his armpits and genitals twice daily. C - The client should avoid changing litter boxes. Litter boxes carry toxoplasmosis which can be life threatening to a client who has HIV. D - The nurse should instruct the client to wash dishes in hot soapy water to destroy the bacteria.

A nurse is considering drug therapy options for a client who has metastatic breast cancer that is positive for human epidermal growth factor receptor 2 (HER2). Which of the following drugs should the nurse expect the provider to prescribe? A - Trastuzumab B - Imatinib C- Leuprolide D - Flutamide

A - Trastuzumab Rational A- Trastuzumab, a monoclonal antibody and a pregnancy risk category D drug, treats and helps control the cell growth of metastatic breast cancer with tumors that overexpress HER2. This form of breast cancer accounts for up to 30% of metastatic breast tumors. B - Imatinib, a targeted antineoplastic drug, provides initial treatment of chronic myeloid leukemia, certain metastatic gastrointestinal tumors, and acute lymphoblastic leukemia, not metastatic breast cancer that is positive for HER2. C - Leuprolide, a gonadotropin-releasing hormone agonist, provides palliative treatment of prostate cancer, uterine fibroids, and endometriosis, not metastatic breast cancer that is positive for HER2. D - Flutamide, an androgen receptor blocker, treats early and metastatic prostate cancer, not metastatic breast cancer that is positive for HER2.

Which of the following instructions should the nurse include for mercaptopurine to treat leukemia? Which of the following instructions should the nurse include? Select all A - Use contraception if pregnancy is a risk. B - Perform oral hygiene frequently. C - Avoid activities that require mental alertness. D - Perform hand hygiene frequently. E - Avoid activities that can cause injury.

A - Use contraception if pregnancy is a risk. B - Perform oral hygiene frequently. D - Perform hand hygiene frequently. E - Avoid activities that can cause injury. Rational A - Use contraception if pregnancy is a risk is correct. Mercaptopurine, a purine analog, is a pregnancy risk category D drug. Clients of childbearing age who take the drug should use contraception, and the nurse should confirm nonpregnancy before starting therapy. B - Perform oral hygiene frequently is correct. Mercaptopurine can cause stomatitis. The nurse should instruct the client to perform frequent oral hygiene to help prevent or minimize this adverse effect. C - Avoid activities that require mental alertness is incorrect. Mercaptopurine is unlikely to cause sedation or dizziness. Trastuzumab, a monoclonal antibody, is an immune system drug that can cause dizziness, which would require the client to avoid activities that require mental acuity. D - Perform hand hygiene frequently is correct. Mercaptopurine can cause neutropenia. The nurse should instruct the client to wash hands thoroughly or use an alcohol-based hand rub frequently and to avoid crowds and contact with people who have communicable infections. E - Avoid activities that can cause injury is correct. Mercaptopurine can cause thrombocytopenia. The nurse should monitor the client's CBC throughout treatment and instruct the client to avoid activities that can cause injury and report any unexplained bruising or bleeding.

A nurse is caring for a client who is receiving vincristine to treat lung cancer. The nurse should monitor the client and recognize which of the following manifestations as an indication that the client is experiencing an adverse effect of the drug. A - Weak hand grasps B - Constricted pupils C - Bradycardia D - Crackles

A - Weak hand grasps Rational A - Vincristine, a vinca alkaloid, can cause peripheral neuropathy. The nurse should monitor deep-tendon reflexes and the strength and movement of the hands and feet. The nurse should instruct the client to report paresthesia or reduced sensation in the hands or feet. B - Vincristine is unlikely to cause constricted pupils, but it can cause ptosis and diplopia. C - Vincristine is unlikely to cause bradycardia, but it can cause hyperkalemia, as well as hypertension or hypotension. D - Vincristine is unlikely to cause crackles. Imatinib is an immune system drug that can cause pulmonary edema, manifesting as crackles.

A nurse is assessing a client following a trastuzumab infusion to treat metastatic breast cancer. Which of the following finding should the nurse recognize as an indication that the client is experiencing an adverse reaction to the drug? (select all that apply) A - Wheezing B - Dysrhythmias C - Hypotension D - Fever E - Ascites

A - Wheezing B - Dysrhythmias C - Hypotension D - Fever Rational A - Wheezing is correct. Trastuzumab, a monoclonal antibody, can cause a severe allergic reaction, manifesting as hives, bronchospasm, dyspnea, and wheezing. The nurse should have epinephrine ready to treat anaphylaxis. B - Dysrhythmias is correct. Trastuzumab can cause cardiotoxicity, manifesting as ventricular dysfunction, heart failure, and dysrhythmias. The nurse should monitor the client's ECG. C - Hypotension is correct. Trastuzumab can cause a severe allergic reaction, manifesting as hives, dyspnea, hypotension, and hypoxia. The nurse should have epinephrine ready to treat anaphylaxis. D - Fever is correct. Trastuzumab can cause flu-like reactions, manifesting as fever, chills, nausea, and headache. The nurse should monitor the client's temperature. E - Ascites is incorrect. Trastuzumab is unlikely to cause ascites, although it can cause abdominal pain, nausea, and vomiting. The nurse should monitor the client's fluid and electrolyte balance.

A nurse is assisting with the development of a community education course about the physical complications related to substance use disorder. Which of the following substances should the nurse identify as primary causes of cirrhosis? A - ​Alcohol ​B - Caffeine ​C - Cocaine D - Inhalants

A - ​Alcohol Rational A - Chronic alcohol use is one of the primary causes of cirrhosis of the liver. B - Chronic ingestion of caffeine can result in many physical complications; however, it is not associated with cirrhosis. C - Rationale C. Cocaine use can result in many physical complications; however, it is not associated with cirrhosis. D - Inhalant use can result in many physical complications; however, they are not associated with cirrhosis.

The nurse is contributing to the plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse recommend for inclusion in the plan of care? A - ​Decrease the client's fluid intake. ​B - Increase the client's saturated fat intake. ​C - Increase the client's sodium intake. ​D - Decrease the client's carbohydrate intake.

A - ​Decrease the client's fluid intake. Rational A- The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention. B - The nurse should limit the fat intake for a client who has cirrhosis due to the risk of malabsorption and steatorrhea. C - The nurse should limit the sodium intake for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention. D - It is not necessary for the nurse to decrease the carbohydrate intake for a client who has cirrhosis or ascites. Clients who have cirrhosis are typically malnourished and require sufficient calories to improve their nutritional status.

A nurse is preparing to administer enfuvirtide to a client. Which of the following actions should the nurse plan to perform? Select all A -Administer the drug subcutaneously. B - Discard the unused portion. C - Roll the vial gently to reconstitute the solution. D - Inject the solution at room temperature. E- Expect a cloudy solution.

A -Administer the drug subcutaneously. C - Roll the vial gently to reconstitute the solution. D - Inject the solution at room temperature. Rational A - Administer the drug subcutaneously is correct. The nurse should administer enfuvirtide, a fusion inhibitor, subcutaneously, twice per day. This is the only appropriate route of administration for the drug. B - Discard the unused portion is incorrect. The nurse should refrigerate the unused portion. The nurse should also warm the solution to room temperature prior to giving the next dose out of the vial. C- Roll the vial gently to reconstitute the solution is correct. The nurse should roll the vial of enfuvirtide gently between the palms of the hands after adding sterile water for injection. This reconstitutes the drug. D - Inject the solution at room temperature is correct. The nurse can store unused solutions of enfuvirtide in a refrigerator up to 24 hr but should restore it to room temperature before injection. E - Expect a cloudy solution is incorrect. Enfuvirtide should be clear and without particulates after reconstitution. The nurse should not administer a cloudy solution.

A nurse is teaching a client who has a new diagnosis of breast cancer about the drug tamoxifen. The nurse should tell the client that which of the following conditions is a contraindication? A -Deep-vein thrombosis B - COPD C - Diabetes mellitus D - Alcohol use disorder

A -Deep-vein thrombosis Rational A - Tamoxifen, an estrogen receptor blocker, can cause thromboembolism. Its use requires cautious use with clients who have deep-vein thrombosis. B - Clients who have COPD can take tamoxifen, an estrogen receptor blocker. Trastuzumab is an immune system drug that requires cautious use with clients who have pulmonary disease. C - Clients who have diabetes can take tamoxifen, an estrogen-receptor blocker. Interferon Alfa-2a is an immune system drug that requires cautious use with clients who have diabetes. D - Clients who have alcohol use disorder can take tamoxifen, an estrogen-receptor blocker. Zidovudine is an immune system drug that requires cautious use with clients who have alcohol use disorder.

A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? A - "I will not eat fried foods." B - "I will abstain from sexual intercourse." C - "I will refrain from international travel." D - "I will not order a salad in a restaurant."

B - "I will abstain from sexual intercourse." Rational A - A client who has cholecystitis should avoid fried and fatty foods. B - The client who has hepatitis A should abstain from sexual intercourse during the infectious period. C - Clients should receive the hepatitis A vaccine before international travel. However, international travel is not prohibited. D - Hepatitis A is transmitted by the fecal-oral route. The client who is infectious should not prepare food during the infectious period.

A nurse is reinforcing discharge teaching with a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include in the teaching? A - "Avoid using moisturizing lotions on your skin." B - "Wash your hair with a mild shampoo." C - "Apply powder liberally to sensitive areas of skin." D - "Use a sun-blocking agent with a sun protection factor of 10."

B - "Wash your hair with a mild shampoo." Rational A - The nurse should instruct the client who has SLE to apply non-perfumed moisturizing lotions liberally to the skin. B - Clients who have SLE are prone to hair loss. Therefore, the nurse should instruct the client to avoid products that can irritate the hair and scalp. C - The nurse should instruct the client who has SLE not use powder or other drying skin products on their skin. D - The nurse should instruct the client who has SLE to use a sun-blocking agent with a sun protection factor of at least 15.

A nurse is caring for a client who has AIDS-associated dementia and is confused. Which of the following actions should the nurse take? A - Explain provided care to the client in detail. B - Apply a bed alarm to the client's bed. C - Ensure that the client's room is well lit at night. D - Discourage the client's family from visiting the client.

B - Apply a bed alarm to the client's bed. Rational A - The nurse should use short, simple phrases with a client who is confused. B - To prevent falls, the nurse should apply an alarm to the bed of a client who is confused. C - A client who is confused requires minimal lighting at night. Excess lights can make the client confused about the difference between day and night time. D - The nurse should encourage the client's family and caregivers to visit. Seeing familiar faces can help to reorient the client.

A nurse in a provider's office is collecting data from a client who has systemic lupus erythematosus (SLE) and takes hydroxychloroquine to reduce skin inflammation. The nurse should identify that which of the following is an adverse effect of this medication? A -Mucosal ulcers B - Blurred vision C - Alopecia D - Wrist pain

B - Blurred vision Rational A - Mucosal ulcers are a manifestation of SLE. B - An adverse effect of hydroxychloroquine is retinopathy. C - Alopecia is a manifestation of SLE, not the medication. D - Arthritis in the wrist, fingers, hands, and knees is a manifestation of SLE.

A nurse is reviewing a recent laboratory report a client who has Human Immunodeficiency Virus (HIV). Which of the following laboratory values should the nurse report to the provider? A - Positive Western blot test B - CD4-T-cell count 140/mm3 C - Elevated C-reactive protein (CRP) D - WBC 4900/mm3

B - CD4-T-cell count 140/mm3 Rational A - A positive Western Blot is 99.9% accurate in detecting HIV infection. The client is already identified as being HIV positive. B - A CD4-T-cell count of less than 180/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. C - CRP levels are monitored to evaluate the effectiveness of therapy for inflammatory rheumatoid arthritis and lupus. This client is identified as HIV positive. Further testing is required to identify the source of the inflammation or infection. D - Although laboratory reference ranges will slightly vary, this WBC count is within an expected range of 4,800 to 10,800/mm3.

A nurse is assisting with the care of a client who has infective endocarditis. Which of the following manifestations should the nurse identify as a complication of this disorder? A - A heart murmur B - Dyspnea C - ​Fever D - Petechiae

B - Dyspnea Rational A - A heart murmur is a manifestation of infective endocarditis, but is not a complication. B - Emboli is a serious complication due to emboli arising in the right heart chambers which will terminate in the lungs, causing dyspnea, and left-chamber emboli may travel anywhere in the arteries, reaching the spleen, kidneys, brain, lungs, or extremities. C - Fever is a manifestation of infective endocarditis, not a complication. D - Petechiae is a manifestation of infective endocarditis, not a complication.

A nurse is contributing to a teaching plan about the prevention of hepatitis A. The nurse should include that which of the following activities can spread hepatitis A? A - Sharing personal hygiene items like razors. B - Eating uncooked foods. C - Getting a tattoo. D - Having vaginal intercourse.

B - Eating uncooked foods. Rational A- The nurse should identify sharing hygiene items as a risk factor for acquiring hepatitis B, C, or D, which are transmitted through blood and body fluids. B - The nurse should identify eating uncooked foods as a risk factor for acquiring hepatitis A. Food and shellfish can be contaminated with hepatitis A. The disease is spread through the fecal-oral route. C - The nurse should identify getting a tattoo as a risk factor for acquiring hepatitis B, C, or D, which are transmitted through blood and body fluids. D - The nurse should identify having vaginal intercourse as a risk factor for acquiring hepatitis B, C, or D, which is transmitted through blood and body fluids. Hepatitis A can be spread through oral-anal intercourse.

A nurse is caring for a client who has cirrhosis of the liver with ascites. Which of the following interventions should the nurse take? A - Restrict foods high in protein. B - Increase daily calorie intake. C - Increase foods high in sodium. D - Increase fluid intake.

B - Increase daily calorie intake. Rational A - The nurse should offer foods that are high in protein to prevent muscle loss in the extremities and regenerate liver cells, unless the client has signs of hepatic encephalopathy and if ammonia levels are elevated. B - The nurse should assist the client to increase daily calorie intake to help maintain the client's weight and promote liver regeneration. C - The nurse should restrict foods high in sodium to less than 2 g/day to decrease edema, especially if the client has ascites. D - The nurse should decrease the client's intake of fluids to control ascites, fluid retention, and heart failure.

A nurse is collecting a health history from a client. which of the following clients data should the nurse identify as a risk factor for contraindicating hepatitis C? A - Eating raw shellfish B - Presence of multiple tattoos C - Working in a child care center D - Recent travel to a second world E - country

B - Presence of multiple tattoos Rational A - The nurse should recognize that eating raw shellfish places a client at risk for contracting hepatitis A. B - The nurse should recognize that hepatitis C virus is spread through blood and contaminated needles. If unsanitary tattoo equipment was used for placement of the tattoos, the client could have been exposed to the virus. C - The nurse should recognize that the client at risk for contracting hepatitis A by working in a day care center, because it is spread through fecal-oral contamination. D - The nurse should recognize that a client who travels to certain second world countries is at risk for contracting hepatitis E, which is spread by fecal contamination of food and water.

The nurse is reinforcing teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following information should the nurse include in the teaching? A - SLE leads to progressive muscle weakness. B - SLE affects the connective tissue of the body. C - SLE causes painful urination. D - SLE resolves with several months of antiviral treatment.

B - SLE affects the connective tissue of the body. Rational A - The nurse should inform the client that SLE causes musculoskeletal stiffness and joint pain. B - The nurse should inform the client that SLE originates in the connective tissues of the body and affects all organ systems. C - The nurse should inform the client that SLE can cause kidney failure and should instruct the client to monitor for associated findings. D - The nurse should inform the client that SLE is a chronic illness that involves periods of remission and exacerbation.

A nurse should recognize that enfuvirtide can be prescribed to clients who have which of the following conditions? A - Advanced prostate cancer B - Primary brain tumors C - Advanced HIV D - Metastatic ovarian cancer

C - Advanced HIV Rational A - Enfuvirtide, a fusion inhibitor, does not treat advanced prostate cancer. Flutamide, an androgen receptor blocker, treats early or metastatic prostate cancer. B - Enfuvirtide, a fusion inhibitor, does not treat primary brain tumors. Carmustine, a nitrosourea drug, treats primary and metastatic brain tumors. C - Enfuvirtide, a fusion inhibitor, treats HIV that is advanced or resistant to other types of treatment. The nurse should always administer the drug with other antiretroviral drugs. D - Enfuvirtide, a fusion inhibitor, does not treat early estrogen-receptor-positive ovarian cancer. Topotecan, a topoisomerase inhibitor, treats metastatic ovarian cancer.

A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions? A - Xerostomia B - Gingivitis C - Candidiasis D - Halitosis

C - Candidiasis Rational A - Xerostomia, or dry mouth, is caused by Sjögren's syndrome or is an adverse effect of certain medications, such as atropine or sertraline. B - Gingivitis is inflammation of the gums or gingiva typically caused by irritation from dental plaque and poor oral hygiene. C - Oral candidiasis is a communicable, opportunistic yeast infection often affecting clients who have AIDS or immunosuppression. It causes creamy white lesions, usually on the client's tongue or inner cheeks (buccal mucosa). D - Halitosis, or foul-smelling breath, is the result of poor dental health, poor oral hygiene, or gastrointestinal problems.

A nurse is caring for a client who is HIV-positive and is 1 day postoperative following an appendectomy. Which of the following actions requires the nurse to wear a gown as personal protective equipment (PPE)? A - Talking with the client at the bedside B - Administering a medication by IV intermittent bolus C - Changing a wound dressing D - Administering an IM injection.

C - Changing a wound dressing Rational A - Standard precautions do not require the nurse to wear PPE while in the room of a client who is HIV-positive. B - Standard precautions require the nurse to wear PPE when there is a risk of contact with body fluids. The nurse will not come in contact with body fluids while administering a medication by IV intermittent bolus. C - Standard precautions require the nurse to wear PPE when there is a risk of contact with body fluids. While performing a dressing change for a client who is HIV-positive, the nurse is at risk for contact with body fluids, such as wound exudate or drainage, so the nurse should wear gloves and a gown. If the nurse irrigates the wound, she should also wear a face shield. D - Standard precautions require the nurse to wear PPE when there is a risk of contact with body fluids. The nurse should wear gloves when administering an IM injection to the client.

A nurse is preparing an in-service about HIV for a group of newly hired assistive personnel. Which of the following statements should the nurse include about HIV transmission? A - ​HIV is transmitted through casual contact. B - HIV is transmitted through contact with a contaminated toilet seat. C - HIV is transmitted through contact with infected body fluids. D - HIV is transmitted through mosquitoes.

C - HIV is transmitted through contact with infected body fluids Rational A - The nurse should include in the teaching that HIV is not transmitted by casual contact, but through infected seminal fluid, vaginal secretions, amniotic fluid, breast milk, and other body fluids. B - The nurse should include in the teaching that HIV is not transmitted from contact with a contaminated toilet seat, but through infected seminal fluid, vaginal secretions, amniotic fluid, breast milk, and other body fluids. C - The nurse should include in the teaching that HIV is transmitted through contact of infected body fluids such as seminal fluid, vaginal secretions, amniotic fluid and breast milk and other body fluids. D - The nurse should include in the teaching that HIV is not transmitted through mosquitoes, but through infected seminal fluid, vaginal secretions, amniotic fluid, breast milk, and other body fluids.

A nurse is caring for a client who has a new prescription for topotecan therapy to treat resistant, small-cell lung cancer. The nurse should advise the client against taking which of the following types of OTC drugs? A - Folic acid B - St. John's wort C - Ibuprofen D - Aluminum hydroxide

C - Ibuprofen Rational A- Folic acid does not specifically interact with topotecan, a topoisomerase inhibitor. It can, however, change the response to methotrexate, another immune system drug. B - St. John's wort does not specifically interact with topotecan, a topoisomerase inhibitor. It can, however, decrease the levels of maraviroc, another immune system drug. C - NSAIDs, anticoagulants, and antiplatelet drugs increase the client's risk for bleeding while receiving topotecan, a topoisomerase inhibitor. The nurse should advise the client against taking aspirin, ibuprofen, and other NSAIDs during therapy. D - Antacids, such as aluminum hydroxide, do not specifically interact with topotecan, a topoisomerase inhibitor. Antacids decrease the absorption of delavirdine, another immune system drug.

A nurse is a clinic is caring for a female client who has gonorrhea. Which of the following actions should the nurse take? A - Instruct the client about preventing reinfection by using a diaphragm. B - Remind the client that gonorrhea is a virus, therefore it cannot be cured. C - Obtain information about the client's recent sexual partners. ​D - Check for the presence of a primary lesion or chancre.

C - Obtain information about the client's recent sexual partners. Rational A - Clients are instructed to use condoms to prevent reinfection. B - Gonorrhea is a bacterium and can be cured with antibiotics. The nurse should anticipate a prescription for ceftriaxone 1 mg IM once combined with azithromycin 1 gm PO once. C - Sexual partners should be examined, cultured, and treated due to the risk of reinfection. D - Most women with gonorrhea are asymptomatic; a primary lesion or chancre is a symptom of primary syphilis.

A nurse is collecting data from a client who has systemic lupus erythematosus. Which of the following findings is the highest priority to report to the provider? A - Client reports feeling depressed B - Dry, raised rash on the face C - Presence of peripheral edema D - Joint pain in hands and knees

C - Presence of peripheral edema Rational A - The client who has systemic lupus erythematosus commonly reports feelings of depression; however, another finding is the priority. B - The client who has systemic lupus erythematosus commonly has a classic "butterfly" rash on the face; however, another finding is the priority. C - The client who has systemic lupus erythematosus is at greatest risk for death from lupus nephritis; therefore, according to the safety and risk reduction priority-setting framework, findings that indicate an impairment of renal function are the highest priority to report. D - The client who has systemic lupus erythematosus commonly reports joint pain; however, another finding is the priority.

A nurse is reinforcing teaching with a community group about he preventions of viral hepatitis. Which of the following information should the nurse include in the teaching? A - Wear a mask when in crowded places. B - Avoid washing fresh vegetables to prevent the removal of nutrients. C - Thoroughly cook foods prepared with tap water. D - Limit time spent around individuals who have a productive cough.

C - Thoroughly cook foods prepared with tap water. Rational A - Viral hepatitis is not spread through airborne or droplet routes; therefore, the nurse should not include this information. B - The nurse should instruct the group to wash vegetables before eating because contaminated food can spread the hepatitis A virus. C - Water can be contaminated with hepatitis A. Therefore, the nurse should remind the group to prepare foods with purified water. D - Viral hepatitis is not spread through airborne or droplet routes; therefore, the nurse should not include this information.

A nurse is reinforcing teaching with a client who has genital herpes. Which of the following clients statements should the nurse identify as understanding of the teaching? A - "I am not contagious if no lesions are present." B - "The provider can do weekly treatment to remove the lesions." C - "I should use condoms during the prodromal phase of infection." D - "The lesions can spread to other areas of my body."

D - "The lesions can spread to other areas of my body." Rational A- The nurse should inform the client to avoid direct contact with lesions, but that herpes simplex can still be transmitted when there are no active lesions. B - The nurse should explain that weekly treatment with podophyllin resin is used to treat genital warts. C - The nurse should instruct the client to abstain from intercourse from the onset of the prodromal period until 10 days after lesions are healed. D - Herpes simplex lesions can spread through autoinoculation, when a client touches an active lesion then touches another area of the body. Therefore, the nurses should identify this statement as understanding of the teaching.

A nurse should recognize that maraviroc is used in the treatment of which of the following conditions? A - Diabetes mellitus B - Meningeal infection C - Pancreatitis D - Chemokine receptor 5 (CCR5)-tropic HIV-1

D - Chemokine receptor 5 (CCR5)-tropic HIV-1 Rational A - Maraviroc, a chemokine receptor 5 (CCR5) antagonist is used in the treatment of drug resistant HIV to block the entry of HIV into host cells. It is not used to treat diabetes. The treatment of diabetes involves antidiabetic drugs. B - Maraviroc, a chemokine receptor 5 (CCR5) antagonist is used in the treatment of drug resistant HIV to block the entry of HIV into host cells. It is not used to treat meningeal infections. The treatment of meningeal infections involves anti-viral drugs or antibiotics. C - Maraviroc, a chemokine receptor 5 (CCR5) antagonist is used in the treatment of drug resistant HIV to block the entry of HIV into host cells. It is not used to treat pancreatitis. The treatment of pancreatitis involves analgesics and acid-suppressive drugs in addition to parenteral nutrition. D - Maraviroc, a CCR5 antagonist, acts by binding to CCR5 and preventing HIV-1 from entering the cell. It is used in the treatment of clients who have CCR5-tropic HIV-1.

A nurse is caring for a client who has a new prescription for intrathecal cytarabine therapy to treat meningeal leukemia. The nurse should inform the client that they will also receive which of the following drugs to reduce the risk of neurotoxicity? A - Diphenhydramine B - Leucovorin C - Folic acid D - Dexamethasone

D - Dexamethasone Rational A - Diphenhydramine, an antihistamine, prevents or minimizes allergic reactions. It does not reduce the risk of neurotoxicity for clients who are receiving intrathecal cytarabine, an antimetabolite. B - Leucovorin, a chemotherapeutic protectant, protects cells from the actions of folic acid antagonists, such as methotrexate. It does not reduce the risk of neurotoxicity for clients who are receiving intrathecal cytarabine, an antimetabolite. C - Folic acid supplements help reduce the risk of toxicity from folic acid antagonists, such as methotrexate. It does not reduce the risk of neurotoxicity for clients who are receiving intrathecal cytarabine, an antimetabolite. D - Clients who have a prescription for the intrathecal form of cytarabine should also receive dexamethasone, a glucocorticoid, to help decrease the inflammation of the arachnoid that the drug can cause. IV dexamethasone reduces the client's risk for neurotoxicity.

A Nurse is preparing to dispose of a needle after administering an intramuscular injection to the client who has hepatitis C. Which of the following actions should the nurse take? A - Recap the needle. B - Place the cap on the table and slide the needle into the cap. C - Ask another nurse to recap the needle. D - Dispose of the needle uncapped.

D - Dispose of the needle uncapped. Rational A - Recapping a needle is an unsafe practice because it creates a high risk for a needlestick injury. B - Recapping a needle is an unsafe practice because it creates a high risk for a needlestick injury. C - Transferring a needle to another nurse is an unsafe practice because it creates a high risk for a needlestick injury. D - The nurse should place the uncapped needle in a puncture-resistant container to prevent a needlestick injury with the contaminated needle.

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following finding should the nurse expect? A - Apical pulse rate different than the radial pulse rate B - Increase in heart rate by 20% when standing C - Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position D - Drop in systolic BP more than 10 mm Hg on inspiration

D - Drop in systolic BP more than 10 mm Hg on inspiration Rational A - An apical pulse rate different than the radial pulse rate is called a pulse deficit and needs further investigation by the nurse. B - The nurse should check the client for orthostatic hypotension when the pulse rate increases by 20% when standing. C - The nurse should check the client for orthostatic hypotension when the client's systolic BP drops by 20 mm Hg when moving from a lying to a sitting position. D - The nurse should expect the client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or pericardial tamponade.

A nurse is assisting with the care of a client who has cirrhosis of the liver with ascites. Which of the following actions should the nurse take? A - Position the client flat in bed. B - Medicate the client with acetaminophen for discomfort. C - Weigh the client weekly. D - Measure the client's abdominal girth every 8 hr.

D - Measure the client's abdominal girth every 8 hr. Rational A - The nurse should elevate the client's head of bed to 30° to relieve pressure from the ascites and promote respiratory effort. B - The nurse should not administer acetaminophen or medications that are toxic to the liver to a client who has cirrhosis of the liver and ascites. C - The nurse should weigh the client daily to determine whether the ascites is resolving or worsening. D - The nurse should measure the client's abdominal girth every 8 hr to determine whether the ascites is resolving or worsening.

A nurse is assisting with the plan of care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan? A - Provide a low calorie diet. B - Administer acetaminophen for pain. C - Encourage eating three large meals daily. D - Provide periods of rest.

D - Provide periods of rest. Rational A - A client who has hepatitis should have a diet high in calories to promote healing. B - A client who has hepatitis should avoid acetaminophen, which is metabolized in the liver, to allow the liver time to heal. C - A client who has hepatitis should eat small frequent meals daily to provide adequate calories and nutrition. Nausea and anorexia are manifestations of hepatitis; therefore, the client may tolerate four to six small meals better than three large meals. D - A client who has hepatitis should alternate periods of rest with activity to promote healing.

A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend? A - Prepare the client to begin highly active antiretroviral therapy (HAART) B - Promote client weight gain of one to two pounds per week C - Encourage the client to increase participation in community social activities D - Provide routine analgesia to minimize episodes of breakthrough pain

D - Provide routine analgesia to minimize episodes of breakthrough pain Rational A - The nurse should recognize that HAART is initiated in the early stages following HIV diagnosis. At this advanced stage, the client may be taking minimal medications, limited to only those that will promote comfort. B - The nurse should recognize that a client who has advanced stage HIV commonly experiences unintentional weight loss and is at risk for wasting syndrome. The nurse should promote client choice for food or beverages as an end-of-life comfort measure. C - The nurse should recognize that a client who has advanced stage HIV experiences opportunistic infections and weakness, and is unlikely to be as active outside the home. The nurse should assist the client in interactions with significant others as a means to promote psychological support for the client. D - The nurse should plan to provide analgesia on a routine basis to best manage pain control and prevent unnecessary suffering.

A nurse should recognize that raltegravir is used to treat clients who have which of the following conditions? A - Hairy cell leukemia B - Thyroid cancer C - Kaposi's sarcoma D - Resistant HIV Rational

D - Resistant HIV Rational A - Raltegravir, an integrase inhibitor, does not treat hairy cell leukemia. Interferon alfa-2a treats hairy cell leukemia and chronic myelogenous leukemia. B - Raltegravir, an integrase inhibitor, does not treat thyroid cancer. Doxorubicin, an anthracycline, treats thyroid cancer. C - Raltegravir, an integrase inhibitor, does not treat Kaposi's sarcoma. Paclitaxel, a taxane, treats Kaposi's sarcoma. D - Raltegravir, an integrase inhibitor, along with other antiretroviral drugs, treats HIV that is resistant to other drugs. The nurse should administer raltegravir with other antiretroviral drugs.

A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the clients renal function? A - Antinuclear antibody B - C-reactive protein C - Erythrocyte sedimentation rate D - Serum creatinine

D - Serum creatinine Rational A - The nurse should identify the antinuclear antibody test is used in the diagnosis of SLE and indicates the presence of an autoimmune disease; however, this test does not reflect renal function. B - Although this test is elevated during acute exacerbations of SLE, it is reflective of inflammation but does not indicate renal function C - Although the client's erythrocyte sedimentation rate might be prolonged during exacerbations (indicating active inflammation), the nurse should recognize that this test does not reflect renal function. D - Many clients with SLE have deposits of protein within the glomeruli of the kidneys and may develop lupus nephritis (persistent inflammation in the kidneys) or chronic renal failure. A disorder of renal function reduces the excretion of creatinine, resulting in increased levels of serum creatinine. The nurse should identify serum creatinine as a sensitive indicator of renal function.

A nurse is caring for a client who has a new prescription for Ritonavir and zidovudine therapy to treat HIV-1. The nurse should inform the client that zidovudine is prescribed with ritonavir for which of the following reasons? A - To prevent an infusion reaction B - To increase platelet production C - To protect healthy cells from the toxic effects of ritonavir D - To prevent drug resistance

D - To prevent drug resistance Rational A - Zidovudine, a nucleoside reverse transcriptase inhibitor, is unlikely to prevent an adverse reaction to an infusion of ritonavir, a protease inhibitor. Prior to the administration of paclitaxel, an antimitotic drug, administering an antihistamine, a proton-pump inhibitor, and a glucocorticoid can prevent a hypersensitivity reaction. B - Zidovudine, a nucleoside reverse transcriptase inhibitor, is unlikely to increase the production of platelets. Filgrastim, a colony-stimulating drug, can increase neutrophil production. C - Zidovudine, a nucleoside reverse transcriptase inhibitor, is unlikely to protect healthy cells from the toxic effects of ritonavir. The nurse should administer leucovorin rescue within 12 hr of high doses of methotrexate to protect healthy cells from the toxic effects of that drug. D - The nurse should explain that zidovudine, a nucleoside reverse transcriptase inhibitor, is administered along with ritonavir, a protease inhibitor, to reduce the risk for drug resistance and to increase drug effectiveness. Monotherapy with zidovudine quickly results in drug resistance, as is also the case with monotherapy with ritonavir.

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor the client for which of the following conditions? A - Dehydration B - Bacterial infection C - Compartment syndrome D - Pleural effusion

B - Bacterial infection Rational A - The nurse does not need to monitor the client for dehydration. B - The nurse should monitor the client for bacterial infections due to the impairment of neutrophils to fight fungal or bacterial infections, which is a primary result of the disorder. C - The nurse does not need to monitor the client for compartment syndrome. D - The nurse does not need to monitor the client for a plural effusion.

A client arrives for initial evaluation following a diagnosis of systemic lupus erythematosus (SLE). The nurse understands that which of the following is a classic cutaneous manifestation of SLE? A - Facial pallor B - Brittle nails C - Foot ulcers D - Butterfly rash on face

D - Butterfly rash on face Rational A- Pallor may be noted in a client who has anemia. However, it is not a manifestation of SLE. B - Brittle nails may be noted in an older adult client as a physiological change noted with aging. However, it is not a manifestation of SLE. C - Foot ulcers may be noted in a client who has peripheral arterial disease or diabetes mellitus. However, this is not a manifestation of SLE. D - The nurse should identify a butterfly rash as a common cutaneous manifestation for the client who has SLE. Other common findings include hair loss, weakness, and sun sensitivity resulting in a widespread rash.

A nurse is caring for a child who has rheumatic fever. When obtaining the client's medical history from the patient, the nurse should recognize which of the following findings as significant? A - ​A classmate has fifth disease. ​B - A sibling had a sore throat 3 weeks ago. ​C - The father had gastritis 2 weeks ago. D - A neighbor's child has chickenpox.

​B - A sibling had a sore throat 3 weeks ago. Rational A- ​Fifth disease, or erythema infectiosum, is a viral illness common in school-age children. The causative agent is human parvovirus. Transmission of this infection does not result in rheumatic fever. B - ​Rheumatic fever typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. If the sibling had a respiratory infection, it is likely the client might also have had a streptococcal respiratory infection. C - There are a wide variety of possible causes of gastritis, but it is unlikely that the bacteria that causes rheumatic fever also caused the parent's gastritis. D - The varicella virus causes chickenpox. It does not cause rheumatic fever.

A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects? A - Dry mouth ​B - Diarrhea ​C - Headache ​D - Peripheral edema

​B - Diarrhea Rational A - Dry mouth is not an adverse effect associated with lactulose. B - The nurse should monitor for diarrhea. Lactulose is a synthetic disaccharide that the small intestine cannot utilize. It causes diarrhea by lowering the pH, so the bacterial flora are changed in the bowel. C - Headache is not an adverse effect associated with lactulose. D - Peripheral edema is not an adverse effect associated with lactulose.

A nurse is contributing to a plan of care for a client who has Hepatitis B. Which of the following should the nurse include in the plan? 1)Administer antibiotics. 2)Provide a high-fat diet. 3)Use disposable plates and utensils. 4)Limit activity.

1)Limit activity. Rational 1 - The treatment for Hepatitis B is largely supportive. Although, in extreme cases of illness, antiretroviral medications may be used. 2 - The nurse should plan a diet with small, frequent meals that are low-fat because this is better tolerated by the clients who have Hepatitis B. 3 - The nurse should recognize that Hepatitis B is transmitted through contact with blood and body fluids. There is no need to provide disposable plates and utensils for the client. 4 - The nurse should recognize that the client who has hepatitis experience fatigue and weakness. It is necessary to limit activity for this client to promote immune function and recovery for the client who has Hepatitis B.

A nurse is caring for a client who has cirrhosis. When delivering the client's lunch tray, which of the following food selection requires intervention by the nurse? A - 1 medium baked potato B - 1 cup of sliced cucumbers in vinegar C - 1 slice of ham on whole wheat bread D - 1 240 mL (8 oz) milkshake

C - 1 slice of ham on whole wheat bread Rational A - Clients who have cirrhosis are at risk for fluid retention. A baked potato is an appropriate food choice for this client. B - Clients who have cirrhosis are at risk for fluid retention. Cucumbers in vinegar are an appropriate food choice for this client. C - Ham is high in sodium and can increase fluid retention, leading to edema. Clients who have cirrhosis are prone to edema as the osmotic pressures change due to a decrease in plasma albumin. D - Clients who have cirrhosis are at risk for fluid retention. A milkshake is an appropriate food choice for this client.

A nurse is reviewing the laboratory reports for a client who has cirrhosis. Which of the following results should the nurse expect for the client? A - Elevated albumin level B - Decreased liver enzymes C - Elevated sodium levels D- Decreased platelets

D- Decreased platelets Rational A - The nurse should expect a decreased albumin level in a client who has cirrhosis, as the damaged liver is unable to synthesize the protein. B - The nurse should expect liver enzymes to be elevated in cirrhosis as inflammation to the liver occurs. C - The nurse should expect low sodium levels, or hyponatremia, in a client who has cirrhosis due to the dilutional effect of the renal retention of water. D - The nurse should expect decreased platelets, or thrombocytopenia, in a client who has cirrhosis due to the impairment of the spleen.

the nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider? A - ​Anorexia ​B - Dyspnea ​C - Fever ​D - Malaise

​B - Dyspnea Rational A - The nurse should monitor the client for anorexia to prevent malnutrition; however, another finding is the priority. Anorexia is a manifestation associated with infective endocarditis. B - When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority finding is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization; therefore it is the priority finding to report. C - nurse should monitor the client for fever, which can indicate a need for a change in therapy; however, another finding is the priority. D - The nurse should monitor the client for malaise, which can indicate a need for a change in therapy; however, another finding is the priority.

A nurse is caring for a client who has liver cirrhosis with ascites and bleeding esophageal varices. Which of the following laboratory findings indicates that the client's gastrointestinal (GI) tract is digesting and absorbing blood? Rational A - ​Elevated BUN ​B - Elevated HbA1c ​C - Decreased chloride ​D - Decreased bilirubin

A - ​Elevated BUN Rational A- The nurse should identify that as the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding. B - Chronic blood loss can lower HbA1c and alcohol toxicity can raise it. Digestion of blood does not elevate HbA1c. C - Neither liver disease nor GI bleeding affects chloride levels, however severe vomiting and GI suction can decrease chloride levels. D - Bilirubin levels rise with cirrhosis along with hemolysis of red blood cells.

A nurse is assisting in preparing a presentation at a community center about systemic lupus erythematosis (SLE). The nurse should identify which of the following groups of people as having the highest risk for developing this disorder? A - ​Asian men ​B - Caucasian women ​C - Native American men ​D - African American women

​D - African American women Rational A - Although SLE is prevalent among Asian populations, there is another group at higher risk. B - Although SLE is prevalent among Caucasian women, there is another group at higher risk. C - Native American men have a risk for SLE equivalent to that of the general population. D - The nurse should identify that African American women are at greatest risk for developing SLE.

The nurse is collecting data from a client who has systemic lupus erythematosus ( SLE). which of the following findings should the nurse expect? Facial Rash. A - ​Thickened skin ​B - Spinal deformity ​C -Iritis ​D - Facial rash

​D - Facial rash Rational A - The nurse should identify hardened, thickened skin as a manifestation of scleroderma. B - The nurse should identify spinal deformity as a manifestation of ankylosing spondylitis. C - The nurse should identify iritis (inflammation of the iris) as a manifestation of ankylosing spondylitis. D - The nurse should expect the client who has SLE to have a characteristic facial ("butterfly") rash. The rash is often dry, scaly, red, and raised in appearance.

A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). the client states, "I don't care what the doctor says, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse should identify that the client is experiencing which of the following forms of crisis? A - ​Adventitious ​B - Internal ​C - Maturational ​D - Situational

​D - Situational Rational A - An adventitious crisis is one that is not a part of regular life, such as a natural disaster or act of terrorism. B - An internal crisis is one that results from the inability to cope with life changes, such as the marriage of a child or age-related changes. C - A maturational crisis is one that results from the inability to cope with life changes, such as moving away from home to go to college. D - A diagnosis of HIV is a situational crisis which is one that is unexpected but is part of regular life, such as a serious illness or financial loss.

A nurse is collecting data from a client who has AIDS. The nurse notes that the client has multiple, widespread purplish-brown skin lesions. The nurse should suspect that the client has developed which of the following types of skin lesions? A - Actinic keratosis B - Kaposi's sarcoma C - Actinic dermatitis D - Basal cell carcinoma

B - Kaposi's sarcoma Rational A - Actinic keratosis is not cancerous. However its lesions can evolve into skin cancer. This disorder appears as rough, red, or brown scaly patches on the skin, usually in areas of sun exposure. B - Kaposi's sarcoma manifests as AIDS-related malignant skin and mucous membrane lesions that are usually purplish-brown in color. C - Actinic dermatitis is a histamine reaction to an allergen. It manifests as an area of redness, swelling, and vesicle formations that itches. D - Basal cell carcinoma can appear as a small raised bump that has a smooth, pearly appearance. It can also be scar-like and firm to the touch. Prolonged exposure to sunlight's ultraviolet radiation is the most common cause of this type of skin cancer.

A nurse is caring for a client who has AIDS and anorexia. Which of the following actions should the nurse take to increase the client's body weight? A - Offer the client fluids with meals. B - Increase fiber in the client's diet. C - Encourage the client to eat less protein. D - Provide supplemental vitamins.

D - Provide supplemental vitamins. Rational A - The nurse should limit fluids before and with meals. Fluid intake creates a feeling of fullness that decreases food intake. B - High fiber foods can increase the client's motility, resulting in diarrhea. C - The nurse should increase the amount of protein in the client's diet to assist with building lean muscle mass and meeting the client's metabolic needs. D - The nurse should offer the client supplemental vitamins to improve the client's immune system and nutritional status.

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain to the client that, after the laboratory has the enzyme immunoassay (EIA) results, it will use which of the following tests to confirm the diagnosis? A - ​CD4+ T-cell count ​B - Western blot assay ​C - Quantitative RNA assay ​D - Viral load test

​B - Western blot assay Rational A - ​After confirmation of HIV infection, the CD4+ T-cell count helps providers decide when to initiate antiretroviral medication therapy. B - ​The Western blot assay confirms seropositivity when the EIA (formerly, the enzyme-linked immunosorbent assay, or ELISA) has a positive result. C - After confirmation of HIV infection, quantitative RNA assays use gene amplification to determine the amount of HIV RNA in the client's serum. D - After confirmation of HIV infection, a viral load test helps determine the client's response to HIV infection.