Exam 2 EAQs

Which curative treatment would a nurse administer for a client reporting severe nighttime itching with burrows in the flexor surfaces of the wrists and in the anterior axillary folds?

Permethrin 5% topical lotion

Which statement by the student nurse demonstrates correct understanding of anemia related to chronic disease?

Red blood cells are normal in size and color; however, the number of cells produced is decreased

Which statement by a client with pruritus about personal care interventions indicates understanding of the interventions?

"I will trim my fingernails regularly"

Which statement regarding vitamin b12 injections by a client with pernicious anemia indicates that teaching was understood?

" I must take this medication for the rest of my life"

A client with cancer is scheduled for a bone scan. Which comment by the client indicates to the nurse that the teaching before the scan has been effective?

"A low radioactivity substance will be injected into my vein, and a machine will detect where it goes"

Which clinical indicator is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarrhea for 3 days?

Loss of body weight

Which medication is the likely cause of the symptoms in a client with hypokalemia reporting nausea, vomiting, and seeing a yellow light around objects?

Digoxin

Which physiological alteration would be expected with a higher than normal RBCS count?

Increased blood viscosity

Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries?

Incontinence; inability to move independently

In which category of fluids would the nurse classify an IV solution of 0.45% sodium chloride?

Hypotonic

Which response would the nurse suspect is being experienced by a client employed by a company manufacturing latex gloves who reports developing skin dryness, pruritus, and fissures 2 days ago and development of severe skin redness and inflammation in the past 24 hours?

Type IV contact dermatitis reaction

Which information about infection prevention would the nurse include when planning discharge teaching for a client being treated with chemo for leukemia?

Wash hands before eating and after using the toilet

Which clinical sign is the most important indication of an accurate degree of dehydration?

Weight loss

Cyanocobalamin (vit b12) 0.2mg IM is prescribed for a client with pernicious anemia. Each vial of the med contains 100mcg/ml. How many ml will the nurse admin?

2ml

During a 12 hour shift, a client has a 6oz cup of tea and 360ml of water. The client vomits 100 ml, and the instilled IV fluids equaled the urinary output. Which fluid balance would the nurse record for the 12 hour period?

440ml

Which value for hemoglobin would the nurse expect in a client who is experiencing sickle cell crisis?

6 to 8 g/100mL

When a client is seen in the ED with sudden onset severe dyspnea, coughing, wheezes, which prescribed to would the nurse administer first?

Albuterol via nebulizer

Which type of reaction is being experienced by a client who develops acute dyspnea, generalized urticaria, a HR of 128, and a BP of 70/38 while receiving a blood transfusion?

Anaphylactic

A client is admitted to the ED after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. The nurse would monitor the client for which life-threatening response?

Anaphylaxis

Which priority action would the nurse perform when caring for a client with suspected anaphylaxis?

Assess airway and oxygenation

Which definitive test confirms a diagnosis of multiple myeloma?

Bone marrow biopsy

Which prescribed medication would the nurse teach a client with Lyme disease who presents with displeasure, dizziness, and facial paralysis?

Ceftriaxone

The nurse is evaluating the effectiveness of a tx for a client with excessive fluid volume. Which clinical finding indicates that tx was successful?

Clear breath sounds

Which action would the nurse take next when a 78 year old client comes to the health clinic presenting with fatigue, and lab results indicate a hematocrit of 32% and a hemoglobin of 10.5?

Conduct a complete nutritional assessment of the client

Which action will the nurse take first when treating a client who is having an anaphylactic reaction?

Give epinephrine 0.5mg intramuscularly

Which meal is most appropriate for a client with a large pressure injury?

Grilled chicken, steamed spinach, and a side of orange slices

Which complication would the nurse suspect when a client who has just started a transfusion of packed RBCs reports chest pain, flank pain, difficulty breathing, and chills?

Hemolytic reaction

Which statement indicates the meaning of "a shift to the left" when evaluating the white blood cell count differential?

Increased immature neurtophils

Which statement about appropriate foods to consume when taking warfarin would indicate that the client needs further teaching?

"Dark green leafy vegetables are high in vitamin K, so I should eat them more often"

Which client statement about self-care measures to prevent dry skin indicates the need for further teaching?

"I will use deodorant soap in place of alkaline soap"

Which action would the nurse anticipate when admitting a client having a sickle cell crisis to the nursing unit?

-administer hydroxyurea -apply oxygen via nasal cannula -administer IV hydration

Which nursing assessment finding is consistent with fluid volume overload from a high flow IV fluid replacement therapy? SATA

-bounding pulse -presence of dependent edema -neck vein distention in the upright position

Which manifestation in a client who is having a third transfusion of packed red blood cells may be evident if the client experiences a febrile transfusion reaction? SATA

-chills -hypotension -tachycardia

The nurse administers two units of packed RBCs 250ml each, followed by 500ml of 0.9% sodium chloride. How many ml of solution has infused?

1000ml

Which instruction would the nurse teach a client about preventative measures for Lyme disease?

Tuck your shirt into your pants

Which type of hypersensitivity reaction is associated with systemic lupus erythematosus (SLE)?

Type III

Which lab result in a client who has just been admitted with anemia of unknown etiology requires the most rapid action by the nurse?

White blood cell count 950

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess?

distended jugular veins

Which clinical manifestation would the nurse expect to find in a client with hypokalemia? SATA

-anorexia -leg cramps

Which prescription would the nurse question when a clients serum sodium is 123 mEq?

Provide a 0.45% sodium chloride IV at 125 mL/h

After the nurse has taught self-care management to a client admitted with sickle cell crisis, which client action indicates a need for more education?

Raises the knee position of the bed

Which skin change supports the diagnosis of allergic contact dermatitis?

Red papules and plaques

Which action will the nurse take to determine whether therapy for vitamin b12 deficiency is effective?

Review hemoglobin and hematocrit levels

Which insect is responsible for a condition with erythematous papules in the interdigital spaces and severe itching at night?

Sarcoptes scabiei (scabies)

Which diagnostic test will the nurse use to confirm the diagnosis when hypokalemia is suspected?

Serum potassium level

Which sign of hypokalemia will the nurse monitor for in a client receiving furosemide?

Muscle weakness

Which topic will the nurse include when teaching a client who has a new diagnosis of polycythemia Vera?

Need for high fluid intake

Which finding would be most important to communicate to the hcp when the nurse is assessing a 20 year old client who has come to the clinic reporting recent unintended weight loss and fatigue?

No tender enlarged cervical lymph node

Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? SATA

-decreased urine -hypotension -dry mucous membranes -poor skin turgor

Which second-line medication would the nurse prepare to give after administering epinephrine to a client experiencing an anaphylactic reaction? SATA

-dexamethasone -diphenhydramine hydrochloride -hydrocortisone sodium succinate

Which signs of hypokalemia would the nurse monitor in the postoperative surgical client with a ng tube attached to continuous low suction? SATA

-dysrhythmias -muscle weakness

Which finding would the nurse expect when assessing a client hospitalized for dehydration? SATA

-postural hypotension -skin on forehead remains tenets after being pinched

Which symptom would the nurse monitor for when caring for a client who has hyponatremia?

Change in level of consciousness

Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration?

Change in mental status

Which intervention would the nurse expect to be included in the plan of care of a client diagnosed with multiple myeloma?

Chemotherapy employing a combination of medications

Which client would a nurse a nurse recognize as having an age-related impairment of the thirst mechanism when reviewing the lab reports of a group of older adult clients?

Client A -167 mEq/L

Which prescribed treatment would the nurse question when a client who has sickle cell anemia has been admitted with acute chest syndrome?

Daily iron supplement

A 60 year old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The lab results show cobalamin levels of 125pg/mL. Which med would the nurse expect to be prescribed for the client?

Vitamin b12 injections

Which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia?

"I have abnormal hemoglobin."

List the nurses activities in the order that they will be performed when administering a blood transfusion.

1. Verify that a type and cross match blood sample has been sent to the lab. 2. Obtain venous access, preferably with a 19 gauge needle or larger. 3. Prime the blood infusion set tubing with NS at the bedside. 4. Ask another nurse to check the blood identification at the clients bedside. 5. Run the blood at a slower rate during the first 10 minutes of the transfusion.

Which IV fluid is a hypertonic solution?

5% dextrose in NS

Which action is the priority before administering the antibiotics when a client is admitted with cellulitis of the left leg and a temp of 103 and the primary hcp prescribes IV antibiotics?

Determine the clients allergies

Which statement would the nurse use to respond to an older adult client who states "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated"?

Fluids should be increased if the urine becomes darker

Which abnormal lab value will the nurse expect when caring for a client with iron deficiency anemia?

Increased total iron binding capacity (TIBC)

Which condition would a nurse expect to teach about when a client with a reddish-blue generalized skin alteration is hospitalized and lab findings show an increase in the overall amount of hemoglobin?

Polycythemia Vera

Which nursing action is the priority for a client who has a serum potassium level of 6.7mEq

Monitor for cardiac dysrhythmias

Which reason would an IV infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a NG tube set to low intermittent suction?

Prevent electrolyte imbalance

Which adverse response to chemotherapy would a nurse teach a client with Hodgkin's disease to report to the HCP?

Sores in the mouth

Which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons?

Stage IV

Several minutes after the start of a red blood cell infusion, the client reports itching. The nurse observes hives on the clients chest. Which action would the nurse take?

Stop the transfusion

Which topic would the nurse include when teaching a client with Hodgkin disease about responses to whole-body radiation?

Susceptibility to infection

Which disorder would the nurse suspect in a client who reports hair loss, joint pain, and a facial rash and has a medical record showing the presence of a butterfly rash?

Systemic lupus erythematosus

Which assessment would be brought to the HCP's attention before administration of IV potassium chloride?

Urinary output of 200ml during previous 8 hrs

Which condition may be present in the client with localized vasodilation, transduction of fluid, and erythema?

Urticaria

Which assessment finding in a client reporting sever itching with redness and wheals on the uncovered parts of the legs after sleeping in an old bed supports the primary hcp prescribing antihistamines and topical corticosteroids?

Urticaria grouped in threes surrounded by vivid flare, transforming into a persistent lesion

Which action would the nurse implement when a client develops an anaphylactic reaction?

-initially, apply O2 at 90% to 100% per NC -call the rapid response team and have the crash cart retrieved -elevate the head of the bed to 45 degrees -ensure emergency airway equipment is at the bedside table

Which factor is a likely cause of hyponatremia? SATA

-profuse diaphoresis -rapid IV infusion of 5% dextrose in water (D5W)

When monitoring a client for hyponatremia, which assessment findings would the nurse consider significant? SATA

-seizures -confusion

Which IV solution would a nurse anticipate administering when caring for a client with a history of severe diarrhea for the past 3 days who is admitted for dehydration?

0.9% sodium chloride

Which hypersensitivity condition would the nurse suspect when a client presents with cutaneous lesions, swelling of the face, eyelids, and lips from dilation and engorgement of the capillaries but no observable welts or vesicles?

Angioedema

Which nursing action is important when transfusing packed RBCs to a client with a diagnosis of anemia?

Monitoring the clients response, particularly with in the first 10 minutes

Which action will the urgent Clare clinic nurse anticipate taking for a 24 year old client who is dehydrated after a long run and has a pulse rate of 103 and a blood pressure of 102/56?

Offer oral fluids at frequent intervals

Which would the nurse instruct the client with iron deficiency anemia to drink with daily ferrous sulfate supplements?

Orange juice

A female client with Hodgkin disease is to begin chemotherapy and is concerned that sterility may result because of treatment. On which information would the nurse base the response?

Ova can be harvested and frozen for future use.

Which action is important when administering blood?

Obtain baseline vital signs before beginning blood administration

Which fluid therapy will the nurse prepare to infuse when a client with hypovolemic shock has a hematocrit value of 25%?

Packed red blood cells