Foundations Exam 2

The fastest growing & most common infections in health care today.

Methicillin-Resistant Staphylococcus aureus (MRSA)

Can give IV vancomycin, oral linezolid, IV ceftraoline fosamil for ___

Methicillin-resistant Staphylococcus aureus

The nurse is caring for a patient with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection. Which prescribed drug would the nurse expect to administer to treat the infection? Vancomycin Linezolid Penicillin Minocycline

Minocycline

Patients with low CD4+ T-cell counts are at risk for which condition that is caused by organisms that are present as part of the body's microbiome & usually kept in check by normal immunity? Primary infections Secondary infections Opportunistic infections Acquired immune deficiency syndrome (AIDS)-defining conditions

Opportunistic infections

VTE or DVT can lead to a ___

PE

The nurse is caring for four patients diagnosed with infectious disorders. Which patient's infection requires dedicated use of equipment during nursing care? Patient A: Mycobacterium tuberculosis Patient B: Neisseria meningitidis Patient C: Varicella-zoster virus Patient D: Respiratory syncytial virus Patient A Patient B Patient C Patient D

Patient D

Which features are associated with basal cell carcinoma? Small papule with dry, rough, adherent yellow scales Pearly papule with a central crater & rolled waxy borders Firm nodular lesions topped with a crust with a central area of ulceration Irregularly shaped, pigmented papule with variegated colors with red tones

Pearly papule with a central crater & rolled waxy borders

A client with a large, irregularly shaped mole on the upper chest expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? Refer to a dermatologic health care provider. Ask if there are any other lesions that are bothersome. Perform a head-to-toe skin assessment and document the findings. Teach about the importance of avoiding excessive sun exposure and tanning beds.

Perform a head-to-toe skin assessment and document the findings.

Which clinical manifestation will warrant priority assessment when the patient presents to the emergency department? Pitting edema Poor skin turgor Red bony prominences Localized redness of the surgical site

Pitting edema

A client is diagnosed with C. difficile infection. What nursing action is the priority for the client? Provide meticulous skin care. Place the client on Contact Precautions. Give the client an antipyretic medication. Encourage the client to drink extra fluids.

Place the client on Contact Precautions.

Malignant hyperthermia symptoms: the cluster of ___ end-tidal carbon dioxide level, ___ oxygen saturation, & ___

elevated, decreased, tachycardia

eschar- ___ tissue that appears like a layer of black, gray, or brown collagen; may appear dry & leathery

eschar

Common signs & symptoms of infection include ___ & ___.

fever, lymphadenopathy

Wound healing ___ intention- edges brought together with skin lined up in correct anatomical position

first

Macular- ___ rash

flat

The true indicator of intestinal activity is the passage of ___

flatus or stool

___-thickness wounds- damage extends into lower layers of dermis, underlying subcutaneous tissue

full

___ tissue- may be pale pink to beefy red; healthy tissue is moist & slightly spongy

granulation

Carbuncles- collection of infected ___ follicles

hair

Folliculitis- inflammation of the ___ follicles (can be caused by bacteria, viruses, or fungi, or can be noninfectious)

hair

Avoid community-acquired MRSA by performing frequent ___ & avoiding ___.

hand hygiene, large crowds

What teaching will the nurse provide when educating about carbon monoxide prevention? "Carbon monoxide is only dangerous if accompanied by fire." "Black smoke can be seen when carbon monoxide is in the air." "Your skin will turn a blue color if you have carbon monoxide poisoning." "Put carbon monoxide detectors in your home, because this is an odorless gas."

"Put carbon monoxide detectors in your home, because this is an odorless gas."

How will the nurse describe a shave biopsy to a client? "A scalpel will be used to remove a deep sample of skin." "A small plug of tissue will be removed with a circular cutting instrument." "A deep specimen of skin will be taken, and the area will be sutured closed." "A razor blade will be gently moved across the skin's surface to obtain a sample."

"A razor blade will be gently moved across the skin's surface to obtain a sample."

Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 × 109/L) to 400 cells/mm3 (0.2 × 109/L) indicates to the nurse that more teaching is needed? "Now my viral load is also probably lower." "I am so relieved that my drug therapy is working." "Although I am still HIV positive, at least I no longer have AIDS." "This change means I am less likely to develop an opportunistic infection."

"Although I am still HIV positive, at least I no longer have AIDS."

What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed this drug? "Do you have glaucoma or any other problem with your eyes?" "Do you take medications for a seizure disorder?" "Are you allergic to sulfa drugs?" "Are you a diabetic?"

"Are you allergic to sulfa drugs?"

Which dietary change does the nurse suggest for the client who has esophageal candidiasis? "Avoid drinking alcoholic beverages." "Eat soft, cool food such as pudding and smoothies." "Limit your intake of fluid to no more than 1 L daily." "Increase your intake of cooked leafy green vegetables."

"Eat soft, cool food such as pudding and smoothies."

Which nonpharmacologic intervention will the nurse suggest to help reduce pain & promote comfort in a patient being treated with analgesics? Select all that apply. One, some, or all responses may be correct. "Elevate & cushion the painful areas." "Massage the calves to promote relaxation." "Apply ice to reduce & prevent swelling." "Try to control or remove noxious stimuli." "Refrain from splinting the wound when you are first able to get out of bed."

"Elevate & cushion the painful areas." "Apply ice to reduce & prevent swelling." "Try to control or remove noxious stimuli."

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? -"When I eat shrimp, my tongue swells and I have trouble breathing." -"I'm feeling more anxious about my surgery than I thought I would be." -"I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." -"My sister had anesthesia a few months ago and she said she didn't like the way she felt."

-"When I eat shrimp, my tongue swells and I have trouble breathing."

During the discharge process, the nurse educates the caregiver of a patient who has osteomyelitis. Which statement by the caregiver indicated the need for further teaching? "I can apply herbal oil to the hives & rashes." "I should store the medications in the refrigerator." "I should wash all bloody clothes with a disinfectant." "I should dispose of the needles & syringes after each use."

"I can apply herbal oil to the hives & rashes."

Which statement made by the student nurse indicated the need for better understanding by the nurse about immediate postoperative care? "I should auscultate the lung sounds every 8 hours." "I should maintain the oxygen saturation to at least 95%." "I should assess the ability of the patient to raise the head." "I should report when the respiratory rate is below 10 breaths/min."

"I should auscultate the lung sounds every 8 hours."

Which statements by assistive personnel indicate understanding regarding infection control measures needed to care for a client who has possible Clostridium difficile infection? Select all that apply. "I'll wear an isolation gown when providing direct care." "I'll wear gloves when providing direct care." "I'll wear a mask each time I enter the client's room." "I'll use a hand sanitizer when I can't wash my hands." "I'll wear goggles to protect my eyes."

"I'll wear an isolation gown when providing direct care." "I'll wear gloves when providing direct care." "I'll use a hand sanitizer when I can't wash my hands."

The nurse is educating a client newly diagnosed with dandruff. Which teaching will the nurse include? Select all that apply. "It is a cosmetic problem." "An oily scalp contributes to dandruff." "Your scalp is too dry & needs moisture." "Untreated severe dandruff can lead to hair loss." "Diffuse white or gray scales may occur on the scalp surface."

"It is a cosmetic problem." "An oily scalp contributes to dandruff." "Untreated severe dandruff can lead to hair loss." "Diffuse white or gray scales may occur on the scalp surface."

Which client statement regarding treatment of a skin infection requires intervention by the nurse? "I am not going to share my clothes with anyone else." "Because I am over 60, I am going to get the shingles vaccine." "It is important to keep my skin very moist, so I will use lotion." "If I get a fever or chills, I will contact my primary health care provider."

"It is important to keep my skin very moist, so I will use lotion."

When teaching a community group about burn prevention, which education will the nurse include? "Have a smoke detector in one central spot in the home." "If you use home oxygen, turn it down when you are smoking." "Set your water heater temperature below 160°F (71°C.)." "Plan several ways of escape from the home in case the primary exit is blocked."

"Plan several ways of escape from the home in case the primary exit is blocked."

The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane, so he missed all of yesterday's dosages. What action does the nurse recommend? "Take today's dosages as normally prescribed and continue to follow your therapy program." "Don't worry. Unless you miss your drugs for 4 days consecutively, there is not a problem." "Take double doses of the drugs for the next 2 days and do not have sex for at least 4 days." "Go to the nearest emergency department and have an immediate blood test for assessment of viral load."

"Take today's dosages as normally prescribed and continue to follow your therapy program."

While applying compression stockings and pneumatic compression devices, a client questions the purpose of these devices. What is the appropriate nursing response? "These will help to prevent blood clots." "They make your legs feel more comfortable." "These prevent skin breakdown from immobility." "The use of these right after surgery makes it easier to start to ambulate."

"These will help to prevent blood clots."

The surgery for a client scheduled for an 8:00 a.m. procedure is delayed until 11:00 a.m. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? -Administer at 8:00 a.m. as originally prescribed -Adjust the administration time to be given at 10:00 a.m. -Do not administer, as preoperative prophylactic antibiotics are optional -Hold the antibiotic until immediately following surgery, & then administer

-Adjust the administration time to be given at 10:00 a.m.

Medications that increase the risk for surgical complications:

-Antihypertensives -NSAIDS -Anticoagulants -Immunosuppressive drugs -Tricyclic antidepressants

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? -"You cannot have more pain medicine until an hour from now." -"Can you describe the pain you are having, and rate it on a 1-to-10 scale?" -"I can help you begin a pain diary so we can see trends when your pain worsens." -"Let's try some relaxation exercises to help address the discomfort you are feeling."

-"Can you describe the pain you are having, and rate it on a 1-to-10 scale?"

The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. -"Why do you think you're going to get hooked?" -"Don't worry, I won't give you any opioid medications." -"Have you had concerns with drug dependence in the past?" -"Tell me what makes you most fearful about taking opioid medication." -"There are proper ways of taking opioids so you will not become dependent."

-"Have you had concerns with drug dependence in the past?" -"Tell me what makes you most fearful about taking opioid medication." -"There are proper ways of taking opioids so you will not become dependent."

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. -Begin practicing leg exercises prior to surgery -Repeat leg exercises several times daily for each leg -Push the ball of the foot into the bed until the calf & thigh muscles contract -If pain or warmth in the calf is present, discontinue exercises & contact the surgeon -Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch

-Begin practicing leg exercises prior to surgery -Push the ball of the foot into the bed until the calf & thigh muscles contract -If pain or warmth in the calf is present, discontinue exercises & contact the surgeon -Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch

In the early postoperative phase, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? -Blood pressure of 142/90 mm Hg -Headache of 4 on a 1-10 scale -Gradual return of motor function -Increase in back pain when coughing

-Blood pressure of 142/90 mm Hg

Which drug is often administered as an epidural analgesic to manage pain in the postoperative patient? -Ketorolac -Acetaminophen -Bupivacaine -Ibuprofen

-Bupivacaine

Which term describes a splitting open of a wound for a postoperative patient? -Drainage -Intubation -Dehiscence -Evisceration

-Dehiscence

The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data will the nurse communicate immediately to the surgeon & anesthesia provider? Select all that apply. -Blood pressure 130/72 mm Hg -Serum potassium 3.5 mEq/L -Diffuse rash on upper torso -Took 650 mg of aspirin yesterday -Has not had food or water since 9:00 p.m. last night

-Diffuse rash on upper torso -Took 650 mg of aspirin yesterday

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. -Left arm prosthesis -Skin turgor <3 seconds -Blood pressure 160/100 mm Hg -Presence of chest rigidity -Has been NPO since midnight -Expressed concern about surgery payment

-Left arm prosthesis -Blood pressure 160/100 mm Hg -Presence of chest rigidity

Which condition can contribute to impaired wound healing after surgery? Select all that apply. -Obesity -Diabetes -Dysrhythmias -Weak immune system -Electrolyte imbalances

-Obesity -Diabetes -Weak immune system

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? -Perform thorough auscultation of the lungs -Assess response to pinprick stimulation from feet to mid-chest level -Determine level of consciousness and response to environmental stimuli -Compare blood pressure findings from preoperative assessment to the present

-Perform thorough auscultation of the lungs

Which cardiovascular complication can arise after a surgery? Select all that apply. -Sepsis -Atelectasis -Dysrhythmias -Joint contractures -Electrolyte imbalances

-Sepsis -Dysrhythmias

Which topic is included in preoperative patient teaching? Select all that apply. -Splinting -Incisional Care -Pain Management -Incentive Spirometry -Lower Extremity Exercises

-Splinting -Pain Management -Incentive Spirometry -Lower Extremity Exercises

Which laboratory &/or diagnostic test is routinely carried out before any surgery is performed? Select all that apply. -Urinalysis -Electrolyte levels -Hemoglobin level -MRI examination -Blood type & screen

-Urinalysis -Electrolyte levels -Hemoglobin level -Blood type & screen

Transmission of infection requires 3 factors:

1) reservoir 2) susceptible host with a portal of entry 3) route & method of transmission

Postop: Less than ___ breaths/min may indicate anesthetic or opioid analgesic induced respiratory depression

10

Wound healing: proliferative phase- lasts ___-___ weeks

2-4

Postop: Report BP changes that are ___% higher or lower than values obtained before surgery

25

Wound healing: maturation phase- begins as early as ___ weeks & may continue for a year or longer

3

The first phase of wound healing lasts how long? 3-5 days 5-7 days 2-4 weeks 3 weeks or longer

3-5 days

When caring for four clients, which client does the nurse identify at highest risk for infection? 20-year-old with stomach pain 31-year-old with chronic kidney disease 44-year-old using a 10-day steroid taper 62-year-old with history of prostate hyperplasia

31-year-old with chronic kidney disease

ABCDEs of skin cancer:

A: Asymmetry B: Border irregularity C: Color variation D: Diameter greater than 1/4 in or 6 mm E: Evolving or changing in any feature

A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient's pregnancy? Abacavir Darunavir Tipranavir Raltegravir

Abacavir

The nurse recommends which method of sexual contact to reduce the risk for human immune deficiency virus (HIV) transmission? Select all that apply. One, some, or all responses may be correct. Oral sex Abstinence Monogamy Condom use Heterosexual sex

Abstinence Monogamy Condom use

According to the Centers for Disease Control & Prevention (CDC), in the United States & Canada, which population has the highest rates of new human immune deficiency virus (HIV) infections? Women Men who have sex with men African-American & Hispanic adults Adults who have used injection drugs

African-American & Hispanic adults

The nurse is conducting a handwashing refresher session. For which situation will the nurse remind all staff that cleansing hands with an alcohol-based hand rub is appropriate? After using the bathroom To cleanse visibly soiled hands After handing oral medications to a client After caring for a client with Clostridium difficile

After handing oral medications to a client

By which mode is the Mycobacterium tuberculosis infection transmitted? Vehicle Droplet Airborne Vector

Airborne

Administration of which drug may cause toxic dermal epidermal necrolysis (TEN)? Select all that apply. Allopurinol Carbamazepine Lamotrigine Phenobarbital Phenytoin

Allopurinol Carbamazepine Lamotrigine Phenobarbital Phenytoin

Which activities can the nurse postpone or eliminate for the client who has extreme fatigue today? Select all that apply. Administering prescribed drug therapy Ambulating in the hall Culturing suspected infectious drainage Performing pulmonary hygiene Performing oral care Providing a complete bed bath Teaching about nutrition therapy

Ambulating in the hall Providing a complete bed bath Teaching about nutrition therapy

Which sexual act carries the highest risk for the transmission of human immune deficiency virus (HIV)? Kissing Oral sex Anal sex Vaginal sex

Anal sex

Which factor increases the risk for developing a multidrug-resistant organism (MDRO)? Select all that apply. Antibiotics prescribed for conditions that did not need them Cohorting of patients having infections with the same pathogen Higher doses of antibiotics prescribed than required Formation of biofilm coating on medical devices Antibiotics prescribed for shorter periods than necessary

Antibiotics prescribed for conditions that did not need them Higher doses of antibiotics prescribed than required Formation of biofilm coating on medical devices

___ & ___ are the most common types of drugs used when infection is accompanied by fever.

Antimicrobials, antipyretics

A patient with vancomycin-resistant enterococcus (VRE) infection is placed on Contact Precautions. Which intervention would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. Wear a mask while in the room Apply gloves before entering the room Assign the patient to a private room Use of gown to prevent contact with body fluids Use Transmission-Based Precautions during transport outside of the room

Apply gloves before entering the room Assign the patient to a private room Use of gown to prevent contact with body fluids Use Transmission-Based Precautions during transport outside of the room

Which intervention will the nurse delegate to assistive personnel (AP) for a client who has poor personal hygiene? Select all that apply. Obtain a social history. Assist the client with bathing. Help the client with brushing of teeth. Tell the client that he or she smells bad. Consult social services to assess the client's living conditions. Teach client and family members how to help with personal hygiene. Notify the health care provider of suspected drug or alcohol addiction. Assess for cognitive function or physical limitations that can interfere with grooming.

Assist the client with bathing. Help the client with brushing of teeth.

Which action will the nurse take for a patient postsurgery who is experiencing postoperative nausea & vomiting (PONV)? Ask the patient to try not to get out of bed Assist the patient to a side-lying position Place the patient in the supine position Ask the patient to use the call light as needed

Assist the patient to a side-lying position

Which intervention will the nurse include in the plan of care to assist with early recovery for a patient who underwent abdominal surgery? Assist the patient to turn every 2 hours & take deep breaths Allow the patient to get out of bed only on the 3rd day after surgery Provide pain medication 30 minutes after a walk Ask the patient to avoid coughing to prevent harm to incisions

Assist the patient to turn every 2 hours & take deep breaths

When assessing a client's skin, which lesion finding requires further nursing intervention? Select all that apply. Asymmetry Color variation Diameter of 4 mm Irregularity of borders Growth in the last 2 months

Asymmetry Color variation Irregularity of borders Growth in the last 2 months

Which respiratory condition is a potential complication associated with surgery? Select all that apply. One, some, or all responses may be correct. Asthma Atelectasis Pneumonia Laryngeal edema Chronic obstructive pulmonary disorder (COPD)

Atelectasis Pneumonia Laryngeal edema

___- Hallmark in adults is lichenification with scaling and excoriation.

Atopic dermatitis

A client who has been hiking in the woods comes to the ED with urticaria. After administering an antihistamine as prescribed, what teaching does the nurse provide? Avoid outdoor activity Use a sauna to relieve pain Apply tea bags to the lesions Consume 1-2 alcoholic beverages

Avoid outdoor activity

A nurse is caring for a patient with tinea pedis infection. Which instruction would the nurse provide to prevent further infection? Select all that apply. Avoid public showers Apply a topical antibiotic Keep feet clean & dry Refrain from sharing shoes Wash items from garage sales

Avoid public showers Keep feet clean & dry Refrain from sharing shoes

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? Activating the viral enzyme "integrase" within the infected host's cells Binding of the virus to the CD4+ receptor and either of the two co-receptors Clipping the newly generated viral proteins into smaller functional pieces Fusing of the newly created viral particle with the infected cell's membrane

Binding of the virus to the CD4+ receptor and either of the two co-receptors

Which assessment will the nurse perform first in conducting a postoperative assessment of a patient? Breathing pattern Level of consciousness Oxygen saturation Surgical site

Breathing pattern

Which assessment data regarding a lesion found on a 39-year-old client who uses a tanning bed requires nursing intervention? Select all that apply. Symmetrical and light pink Brownish-purple with irregular borders Changed in shape since last appointment 8 mm wide and described as itching often Regular border with fixed size and elevation

Brownish-purple with irregular borders Changed in shape since last appointment Regular border with fixed size and elevation

Which action will the nurse take first upon discovering that a patient's abdominal incision is eviscerating after the patient coughed? Call for help & ask to notify the surgeon immediately Place the patient in the supine position with hips & knees bent Assess for symptoms of shock, & document vital signs Cover the wound with dressings moistened with warm saline

Call for help & ask to notify the surgeon immediately

Which is an effective way of assessing for inflammation of the skin in a dark-skinned patient? Check for areas that are taut & shiny Palpate with the fingertips for increased warmth Palpate with the back of the hand for a "woody" feeling Check for areas that appear lighter than normal skin tone

Check for areas that are taut & shiny

Upon removing a dressing from a wound, the nurse notices a strong odor. What is the appropriate nursing action? No action is necessary at this time Notify the health care provider of the possible wound infection Clean the wound & reassess for presence of infection Culture the wound & anticipate an order for antibiotics

Clean the wound & reassess for presence of infection

Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors? Activating the viral enzyme "integrase" within the infected host's cells Binding of the virus to the CD4+ receptor and either of the two co-receptors Clipping the newly generated viral proteins into smaller functional pieces Fusing of the newly created viral particle with the infected cell's membrane

Clipping the newly generated viral proteins into smaller functional pieces

When caring for a client with MRSA, which precaution will the nurse institute? Droplet Contact Airborne Neutropenic

Contact

A patient who is on mechanical ventilation has developed methicillin-resistant Staphylococcus aureus (MRSA) infection. Which type of precautions would the nurse implement? Contact precautions Droplet precautions Airborne precautions Standard precautions only

Contact precautions

The nurse is caring for a patient diagnosed with vancomycin-resistant enterococcus (VRE) infection. Which type of precautions would the nurse use when providing patient care? Standard precautions Contact precautions Airborne precautions Droplet precautions

Contact precautions

Which age-related change increases the risk for infection in older adults? Select all that apply. One, some, or all responses may be correct. Increased vascularity Decreased cough reflex Decreased antibody production Slowed gastric motility Decreased auditory ability

Decreased cough reflex Decreased antibody production Slowed gastric motility

Which factor increases the risk of infection in older adults? Select all that apply. One, some, or all responses may be correct. Decreased subcutaneous tissue Increased gastric acid production Decreased antibody production Decreased cough & gag reflexes Increased vascularity of the skin Decreased intestinal motility

Decreased subcutaneous tissue Decreased antibody production Decreased cough & gag reflexes Decreased intestinal motility

The nurse takes a history for a client admitted to the hospital. Which factors in the nursing history indicate that the client is at risk for infection? Select all that apply. Diabetes mellitus type 2 for 20 years 52-pack year history of cigarette smoking Admitted from a long-term care facility Has a history of multiple urinary tract infections Is 84 years of age

Diabetes mellitus type 2 for 20 years 52-pack year history of cigarette smoking Admitted from a long-term care facility Has a history of multiple urinary tract infections Is 84 years of age

An older adult client with a long history of congestive heart failure is being treated for a pressure injury over the coccyx that is 4 cm wide & 5 cm long, with eschar present. What technique does the nurse anticipate will be used to remove the necrotic tissue? Surgical removal Biological dressing Continuous dry gauze dressing Dressings along with a topical enzyme preparation

Dressings along with a topical enzyme preparation

Which finding would the nurse expect during the assessment of a patient with actinic keratosis? Select all that apply. Pearly papule Irregular shape Dry rough growth Indurated margins Redness around growth

Dry rough growth Redness around growth

Which condition is indicated by the presence of a pulse deficit when assessing the vital signs of a postoperative patient? Dyspnea Dysrhythmia Hypothermia Deep vein thrombosis

Dysrhythmia

Which intervention would the nurse implement for a patient with a high fever? Select all that apply. Encourage fluid intake Apply ice packs to the patient's body Encourage use of a fan to circulate cool air Sponge the patient's body with iced water Apply cool compresses to the skin & pulse points

Encourage fluid intake Apply ice packs to the patient's body Apply cool compresses to the skin & pulse points

Which is an immunologic manifestation of acquired immune deficiency syndrome (AIDS)? Fatigue Nocardiosis Night sweats Nausea & vomiting

Fatigue

Which clinical manifestation presents with adrenal insufficiency associated with acquired immune deficiency syndrome (AIDS)? Select all that apply. One, some, or all responses may be correct. Fatigue Nausea Diarrhea Weight gain High blood pressure Electrolyte disturbances

Fatigue Nausea Electrolyte disturbances

A client who was bitten by a spider develops cellulitis of the left lower arm. What assessment findings will the nurse expect when caring for this client? Select all that apply. Fever Pain Redness around the spider bite Warmth in the affected arm Swelling of the affected arm

Fever Pain Redness around the spider bite Warmth in the affected arm Swelling of the affected arm

The nurse educated a patient who is immunocompromised about preventing infection & identifies that which occurrence warrants immediate notification of the health care provider (HCP)? Foul-smelling or cloudy urine Missing a dose of prescribed drugs An intermittent cough without sputum Temperature greater than 99 F (37.2 C)

Foul-smelling or cloudy urine

Which drug inhibits biosynthesis or reproduction of the infectious agent? Penicillin G Ceftriaxone Gentamicin Actinomycin

Gentamicin

A patient recently diagnosed with Clostridium difficile infection is admitted to the hospital. Which personal protective equipment (PPE) would the nurse wear when completing a physical assessment of the patient? Select all that apply. Gown Goggles Gloves Shoe cover N95 respirator

Gown Gloves Shoe cover

Which process is required for restoring skin integrity? Select all that apply. Maturation Granulation Inflammation Re-epithelialization Wound contraction

Granulation Re-epithelialization Wound contraction

Which is a probable cause for excessive hair growth on the face & chest in a female patient? Hirsutism Petechiae Ecchymosis Chronic paronychia

Hirsutism

Which assessment would be part of the focused assessment of a patient's surgical incision site when the patient is transferred from the postanesthesia care unit (PACU) to the medical-surgical care unit? Is the neck in proper alignment? Does the patient respond to verbal stimuli? How much drainage is present in the drainage container? What type of solution is being infused & with what additives?

How much drainage is present in the drainage container?

Stage ___ pressure ulcer: nonblanchable erythema of intact skin

I

Stage ___ pressure ulcer: partial-thickness loss with exposed dermis (dermis exposed)

II

Stage ___ pressure ulcer: full-thickness skin loss (adipose visible)

III

Stage ___ pressure ulcer: full-thickness loss of skin & tissue (exposed fascia, muscle, tendon, ligament, cartilage, or bone)

IV

The nurse is performing a physical examination of a patient who has streptococcal pharyngitis infection. Which precaution would the nurse take? Select all that apply. One, some, or all responses may be correct. If possible, place the patient in a private room. Maintain a distance of at least 1 to 2 feet from other patients. Perform handwashing before leaving the patient's room. Wear a specifically fitted N95 respirator when entering the patient's room. Place a surgical mask on the patient when the patient travels to the radiology department.

If possible, place the patient in a private room. Perform handwashing before leaving the patient's room. Place a surgical mask on the patient when the patient travels to the radiology department.

Which issue would contribute to a chronic non healing wound for an older-adult patient? Perspiration Emotional stress Inadequate nutrition Increased temperature

Inadequate nutrition

A patient who is receiving antipyretic therapy has a blood pressure of 80/50 mm Hg & is diaphoretic, with recurring fever. Which action would the nurse take? Increase the patient's fluid intake. Elevate the head of the patient's bed. Administer an antihypertensive medication. Administer a corticosteroid.

Increase the patient's fluid intake.

Which can be the underlying pathophysiology of erythema rashes on the skin? Elevated serum carotene level Increased blood flow to the skin Decreased peripheral circulation Impaired blood flow to the skin

Increased blood flow to the skin

Which factor may hamper the natural wound healing process? Select all that apply. One, some, or all responses may be correct. Infection Constipation Cool environments Unrelieved pressure Mechanical obstacles

Infection Unrelieved pressure Mechanical obstacles

Which external manifestation in a skin lesion indicated a likelihood of cancer? Select all that apply. One, some, or all responses may be correct. Bleeding into the skin from an injured lesion Shiny, taut skin around the suspected area Irregular borders Asymmetry in shape Diameter of greater than 6 mm

Irregular borders Asymmetry in shape Diameter of greater than 6 mm

Which measure would the nurse implement to prevent skin damage from scratching & secondary infection for a patient with pruritus? Avoid mittens or splints at night Keep the fingernails trimmed short Maintain a warm sleeping environment Apply an astringent to the skin after bathing

Keep the fingernails trimmed short

Which intervention will the nurse include in the plan of care for a patient who reports itching? Keep the patient's room warm Keep the patient's fingernails trimmed & filed Advise the patient to take a shower on a daily basis Advise the patient to drink iced tea at bedtime to promote sleep

Keep the patient's fingernails trimmed & filed

Which issue may cause a systemic altered inflammatory response? Leukemia Heart failure Hypovolemia Lymphedema

Leukemia

Which is correct nursing documentation for a skin lesion that is flat, red, & approximately 0.6 cm in diameter? Cyst Nodule Macule Vesicle

Macule

Which factor places patients at increased risk for infection? Select all that apply. Malnutrition Phagocytosis Chemotherapy Adolescence Antibiotic therapy Corticosteroid therapy

Malnutrition Chemotherapy Antibiotic therapy Corticosteroid therapy

Droplet precautions have been put into place for a patient with an active infection. Which condition would the nurse suspect the patient to have? Meningitis Tuberculosis Measles Chickenpox

Meningitis

Which drug can be prescribed for epidural administration in a postoperative patient requiring pain management? Select all that apply. One, some, or all responses may be correct. Morphine Ketorolac Fentanyl Butorphanol Bupivacaine

Morphine Fentanyl Bupivacaine

Which item is a host factor that influences the development of infection? Select all that apply. Natural immunity Nutrition Phagocytosis Inanimate reservoir Carrier Pathogenicity

Natural immunity Nutrition Phagocytosis

___ injuries are the main means of occupation-related HIV infection for health care workers

Needlestick & "sharps"

When preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? Select all that apply. Nits can be removed with a fine-tooth comb. Parasites eventually die off without treatment. Wash bed linens in hot water to remove lice and eggs. Lice can live on clothing items and any surface that is covered by fabric. Lice can infest any place on the body with hair, including eyelashes and axillae.

Nits can be removed with a fine-tooth comb. Wash bed linens in hot water to remove lice and eggs. Lice can live on clothing items and any surface that is covered by fabric. Lice can infest any place on the body with hair, including eyelashes and axillae.

The nurse is examining the scalp of students in a classroom for Pediculosis capitis infestation. Which finding would indicate a positive infection? Select all that apply. Nits near hair follicle Excoriated red areas Matted, crusted spots Visible lice on the scalp Unpleasant smell to hair

Nits near hair follicle Excoriated red areas Matted, crusted spots Visible lice on the scalp Unpleasant smell to hair

A patient sitting in the waiting area has a wound that is draining profusely. Which action would the nurse take? Select all that apply. One, some, or all responses may be correct. Place the patient in an examination room. Perform hand hygiene before putting on gloves. Apply gloves & wear a gown before touching the patient. Transfer the patient to an Airborne Infection Precautions room. Wear a fit-tested N95 respirator provided by the health care facility.

Place the patient in an examination room. Perform hand hygiene before putting on gloves. Apply gloves & wear a gown before touching the patient.

The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which assessment finding requires immediate nursing intervention? Increased itching Temperature of 100°F Presence of new plaques on leg Expression of impaired self-image

Presence of new plaques on leg

Which class of drugs for human immune deficiency virus (HIV) infection prevents new virus particles from splitting into functional pieces? Fusion inhibitors Protease inhibitors Integrase inhibitors Nucleoside reverse transcriptase inhibitors (NRTIs)

Protease inhibitors

Which treatment would the nurse include in the plan of care for a patient with small pustules & inflammation of the hair follicles who was diagnosed with folliculitis? Select all that apply. Provide proper hygiene Apply warm compresses Initiate Contact Precautions Give IV vancomycin Schedule incision & drainage

Provide proper hygiene

Which recommendation will the nurse provide to the caregiver of an older patient with pruritus about preventing disruption of skin integrity? Select all that apply. Provide therapeutic baths Trim patient's fingernails regularly Encourage a warm shower before bedtime Assist the patient to put on mittens or gloves Provide a warm environment to promote sleep

Provide therapeutic baths Trim patient's fingernails regularly Assist the patient to put on mittens or gloves

To advocate for safe transition in care, for which process will the nurse advocate? Select all that apply. Providing patient history and current assessment information Communicating updates and changes in condition Verbally verifying that the receiving nurse understands the report Using a standardized hand-off communication tool Encouraging the receiving nurse to interrupt to ask questions during report

Providing patient history and current assessment information Communicating updates and changes in condition Verbally verifying that the receiving nurse understands the report Using a standardized hand-off communication tool

___ lesions are scaled with underlying dermal inflammation from an abnormality in the growth of epidermal cells. Cannot be cured.

Psoriasis

The nurse explains to a client that the surgeon uses a smaller circular instrument to cut & remove a small plug of tissue for evaluation. Which procedure has the nurse described? Unroofing Punch biopsy Shave biopsy Excisional biopsy

Punch biopsy

Which will the nurse document when the patient presents with a skin lesion 0.9 cm in diameter filled with pus? Ulcer Bullae Pustule Vesicle

Pustule

Which skin condition discovered during the postoperative assessment requires an urgent response? Cool extremities Café au lait spots Clubbing of the nail beds Reddish-blue area on the calf

Reddish-blue area on the calf

Arteriosclerosis contributes to impaired wound healing through which mechanism? Low tissue oxygen tension Reduced local tissue circulation System inhibition of leukocytic response Impaired cellular proliferation & collagen synthesis

Reduced local tissue circulation

Which information would the nurse plan to teach the patient who has an infection? Select all that apply. Relationship of fever to the immune response triggered by the pathogen Potential side effects from antimicrobial prescriptions Need for physical therapy in relation to activity restrictions Risk for feelings of isolation related to Transmission-Based Precautions Cellular level & chemical effects of antimicrobials on the pathogen

Relationship of fever to the immune response triggered by the pathogen Potential side effects from antimicrobial prescriptions Risk for feelings of isolation related to Transmission-Based Precautions

Which intervention will the nurse include in the plan of care for a patient who is brought to the inpatient unit from the postanesthesia care unit (PACU)? Assess vital signs every 8 hours Assess lungs every 6 hours Report 25% variation in blood pressure Examine the foot & leg every hour

Report 25% variation in blood pressure

Which vital sign is the most important for the nurse to monitor in a patient receiving general anesthesia in the postanesthesia care unit? Pulse Blood pressure Respiratory rate Body temperature

Respiratory rate

Plaque psoriasis is commonly found on which area of the body? Select all that apply. Scalp Lower back Knees Facial skin Elbows

Scalp Lower back Knees Elbows

Which risk category is measured by the Braden Scale assessment tool? Select all that apply. Sensory perception Moisture Mobility Nutritional status Pressure distribution

Sensory perception Moisture Mobility Nutritional status

Pressure injuries can cause which complication? Select all that apply. Sepsis Uremia Diabetes Cirrhosis Kidney failure

Sepsis Kidney failure

As the nurse evaluates a laboratory report for a client scheduled for surgery, which finding requires nursing intervention? Hemoglobin 10.4 g/dL Serum potassium 2.5 mEq/L Serum sodium level 145 mEq/L Fasting blood glucose 110 mg/dL

Serum potassium 2.5 mEq/L

Which predisposing condition does the nurse suspect when the client presents with decreased turgor on the forehead & abdomen? Select all that apply. One, some, or all responses may be correct. Trauma Anxiety Inflammation Severe dehydration Sudden weight loss

Severe dehydration Sudden weight loss

Which factor can trigger or exacerbate a psoriasis outbreak? Select all that apply. Smoking Alcohol use Obesity Stress Infection

Smoking Alcohol use Obesity Stress Infection

Which parameter would the nurse monitor for a patient related to the use of general anesthesia in surgery? Color of wound drainage Texture & turgor of the skin Redness & warmth in feet & legs Snores & high-pitched crowing sounds

Snores & high-pitched crowing sounds

Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid? Caffeinated beverages Grapefruit juice Dairy products St. John's wort

St. John's wort

Which information would the nurse teach the patient & the caregiver about the management of fever? Anti-infective agents are not helpful for most types of fevers Sweating is expected after each dose of an antipyretic drug Fans may be used to cool the patient's body & reduce fever Shivering is expected when ice packs are used to cool the body

Sweating is expected after each dose of an antipyretic drug

Which finding for an older-adult patient would be consistent with an infection? Select all that apply. Tachycardia Decreased skin turgor Restlessness Enlargement of lymph nodes Dry mucous membranes Acute confusion

Tachycardia Restlessness Enlargement of lymph nodes Acute confusion

A patient who was treated last month for bronchitis & pneumonia reports many of the same symptoms today. Which factor likely caused the patient's relapse? Taking the antibiotic before jogging each day Taking the antibiotic on most days Taking the antibiotic as prescribed Taking the antibiotic with a full glass of water

Taking the antibiotic on most days

How does gender affect human immune deficiency virus (HIV) transmission? The infection is more easily transmitted from infected men to uninfected women. The infection is more easily transmitted from infected women to uninfected men. Uninfected women only need to use a barrier method of protection with male partners. Uninfected women only need to use a barrier method of protection with female partners.

The infection is more easily transmitted from infected men to uninfected women.

A client shows the nurse two pictures of the same lesion, taken 1 month apart. Which assessment finding requires nursing intervention? The light pink color of the lesion is the same in both photographs. The lesion has almost disappeared by the time of the second photograph. The lesion borders have expanded and are shaped differently in the second picture. The lesion's well-approximated margins and size look no different in either photograph.

The lesion borders have expanded and are shaped differently in the second picture.

___ pressure ulcer: obscured full-thickness skin & tissue loss

Unstageable

A patient with which condition requires immediate attention in the postanesthesia care unit? Bleeding time is 5 minutes Body temperature is 98.6 F Urine output is 20 mL/hr Blood pressure is 110/80 mm Hg

Urine output is 20 mL/hr

Which teaching will the nurse provide to the client who just underwent a skin biopsy and had sutures placed to close the wound? Select all that apply. Use antibiotic ointment as prescribed. Return for suture removal in 2 to 3 days. Report redness to the health care provider. Keep dressing moist so skin does not dry out. Use tap water or saline to remove any crusting.

Use antibiotic ointment as prescribed. Report redness to the health care provider. Use tap water or saline to remove any crusting.

The nurse suspects which diagnosis in a patient with acquired immune deficiency syndrome (AIDS) who presents with headaches, fluid-filled blisters, and a low-grade fever? Cytomegalovirus (CMV) Kaposi sarcoma Herpes simplex virus Varicella-zoster virus

Varicella-zoster virus

Which organism causes infection by spread through direct contact with infectious fluid in vesicles & by airborne particles? Hepatitis A virus Salmonella typhi Varicella-zoster virus Mycobacterium tuberculosis

Varicella-zoster virus

___- Bright red erythematous macules and papules are found. Skin blisters in extreme cases.

drug eruption

How to manage pruritus: keep ___ skin, keep nails ___, ___ may be prescribed

dry, nails, antihistamine

In which situation would the nurse prioritize handwashing instead of using an alcohol-based hand rub (ABHR)? Select all that apply. One, some, or all responses may be correct. After manipulation of IV tubing With visibly soiled hands When an infection is caused by spore-forming organisms Before the administration of eyedrops When gloves are used

With visibly soiled hands When an infection is caused by spore-forming organisms Before the administration of eyedrops

Which abdominal incision assessment finding will the nurse report to the surgeon for a patient on the sixth day after surgery? Yellowish mixed with light red drainage Slight swelling under the sutures Crusting on the incision line Pink coloration on the incision

Yellowish mixed with light red drainage

___ precautions are used for patients who have infections transmitted through the air (Ex. TB)

airborne

Cutaneous anthrax is caused by contact with an infected ___

animal

___ cell carcinoma- genetic predisposition, UV exposure

basal

Sanguineous drainage

bloody

Furuncles- often called "___", inflammation of the ___ follicles

boils, hair

___- leading cause of unintentional death & injury worldwide

burn injury

Wound healing: inflammatory phase- begins at ___ death & lasts ___-___ days

cell, 3-5

National Patient Safety Goals (NPSGs) focus on ___ with & between the surgical team

communication

___ precautions are used for patients who have infections transmitted by direct or contact with items in the patient's environment

contact

___- localized eczematous eruption with well-defined, geometric margins that are consistent with contact with an irritant or allergen

contact dermatitis

Cellulitis- ___ & ___ tissue infection

dermal, subcutaneous

___ precautions are used for patients who have infections transmitted by droplets such as influenza & certain types of meningitis

droplet

Stevens-Johnson Syndrome & Toxic Epidermal Necrolysis is commonly triggered by a ___

drug

HIV is more easily transmitted from infected ___ to uninfected ___

male, female

___- genetic predisposition, UV exposure, chemical carcinogens, precursor lesions

melanomas

___ membrane pressure injury: found on mucous membranes where a medical device is in use; unstageable ulcers

mucosal

___- evolution of lesions from vesicles to weeping papules & plaques

nonspecific eczematour dermatitis (eczema)

Postexposure prophylaxis (PEP) with cART is used for adults who have had an ___ exposure, those who have had a nonoccupational exposure, & those who have suffered sexual assault.

occupational

Serous drainage

pale yellow

___-thickness wounds- damage to epidermis, upper layer of dermis

partial

Postop: assess for a ___ airway

patent

___ is the most common reaction after surgery

postoperative nausea & vomiting (PONV)

___ lesions develop as a direct result of a disease process

primary

___ is the most important safety strategy

prophylaxis

___- a distressing & debilitating condition caused by the stimulation of itch-specific nerve fibers

pruritus

___- scaled lesions with underlying dermal inflammation from epidermal cell growth abnormality

psoriasis

___ is the leading cause of preventable in-hospital death

pulmonary embolism

___ biopsy- most common biopsy technique

punch

___ exudate- creamy yellow pus; greenish-blue pus that stains dressings & has a "fruity" odor; beige pus with a "fishy" odor; brownish pus with a "fecal" odor

purulent

Papular- ___ rash

raised

___ biopsy- accomplished by deep excision with a scalpel followed by closure with sutures

scalpel/excisional

Wound healing ___ intention- required gradual filling in of dead space with connective tissue

second

___ lesions evolve from primary lesions or develop as a consequence of the patient's activities

secondary

undermining- ___ of the skin layers at the wound margins from the underlying granulation tissue

separation

___ exudate- blood-tinged amber fluid consisting of serum & red blood cells

serosanguineous

___ biopsy- removes only the part of skin that rises above the surrounding tissue

shave

Postop: Rapid, shallow respirations may signal ___, ____ problems, ___ metabolic rate, or ___

shock, cardiac, increased, pain

cellulitis- inflammation of the ___ & ___ tissue extending beyond the area of injury

skin, subcutaneous

___ cell carcinoma- chronic skin damage

squamous

Use ___ precautions for a patient with HIV

standard

___ precautions are used with all patients in health care settings, assuming that all body excretions & excretions are potentially infectious

standard

Postop: Listen for snoring & ___

stridor

actinic keratosis- ___-damaged skin

sun

Surgical Care Improvement Project (SCIP) reduces ___ complications

surgical

___ deep-tissue injury- persistent nonblanchable deep red, maroon, or purple discoloration

suspected

Wound healing ___ intention- delayed closure; high risk for infection with resulting scar

third

How to manage urticaria: remove ___ substance, ___

triggering, antihistamine

___- a rash of white or red edematous papules or plaques of various sizes

urticaria (hives)

Current combination antiretroviral therapy (cART) can reduce the ___ of some patients to below detectable levels.

viral load

___- the amount of virus present in blood & other body fluids, effects transmission

viral load

Serosanguineous drainage

yellowish with small amounts of blood