Med surge test 2
A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"
A
A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Elevate the arm above the level of the heart. b. Order a fan to help cool the client if feverish. c. Place cool, wet cloths on top of the wound. d. Take the client's temperature every 4 hours.
A
A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best? a. Assess the client frequently for worsening of his or her condition. b. Delegate comfort measures to unlicensed assistive personnel. c. Ensure the client is placed on Contact Precautions. d. Restrict visitors to the immediate family only.
A
A client has been admitted with suspected Clostridium difficile infection. Which medication does the nurse plan to administer as a priority? A. Metronidazole (Flagyl) B. Acetaminophen (Tylenol) C. Tetracycline (Sumycin) D. Doxycycline (Vibramycin)
A
A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity
A
A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.
A
A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions? A. Airborne B. Standard C. Contact D. Droplet
A
A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? a. Consult with the provider about obtaining stool cultures. b. Delegate frequent perianal care to unlicensed assistive personnel. c. Place the client on NPO status until the diarrhea resolves. d. Request a prescription for an anti-diarrheal medication.
A
A client newly diagnosed with acute leukemia asks why he is at such extreme risk for infection when his white blood cell count is so high. What is the nurse's best response? A. "Even though you have many white blood cells, they are too immature to fight infection." B. "For now, your risk is low; however, when the chemotherapy begins, your risk for infection will be high." C. "These white blood cells are cancerous and live longer than normal white blood cells, so they are too old to fight infection." D. "It is not the white blood cells that provide protection; it is the red blood cells, which are very low in your blood right now."
A
A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate? a. Ensure that the radiology department is aware of the isolation precautions. b. Plan to travel with the client to ensure appropriate precautions are used. c. No special precautions are needed when this client leaves the unit. d. Notify the physician that the client cannot leave the room for the CT scan.
A
A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.
A
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? a. Prepare to administer vancomycin (Vancocin). b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output.
A
A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4° F (39.1° C) b. Client with Bruton's agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
A
A nurse is reviewing a patient's most recent blood count and notes that the patient has a hemoglobin of 9.6 gm/dL and a hematocrit of 33%. The nurse will notify the provider and will expect initial treatment to include: a.determining the cause of the anemia. b.giving intravenous iron dextran. c.giving oral carbonyl iron [Feosol]. d.teaching about dietary iron.
A
A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? a. Auditing staff members' hand hygiene practices b. Ensuring clients are placed in appropriate isolation c. Establishing a policy to remove urinary catheters quickly d. Teaching staff members about infection control methods
A
A patient is receiving oral iron for iron deficiency anemia. Which antibiotic drug, taken concurrently with iron, would most concern the nurse? a.Tetracycline b.Cephalosporin c.Metronidazole [Flagyl] d.Penicillin
A
A patient who has recently immigrated to the United States from an impoverished country appears malnourished. The patient's folic acid levels are low, and the vitamin B12 levels are normal. The nurse expects this patient's treatment to include: a.a diet high in folic acid. b.intramuscular folic acid. c.oral folic acid and vitamin B12. d.oral folic acid supplements.
A
A patient with renal failure is undergoing chronic hemodialysis. The patient's hemoglobin is 10.6 gm/dL. The provider orders sodium-ferric gluconate complex (SFGC [Ferrlecit]). What will the nurse expect to do? a.Administer the drug intravenously with erythropoietin. b.Give a test dose before each administration of the drug. c.Have epinephrine on hand to treat anaphylaxis if needed. d.Infuse the drug rapidly to achieve maximum effects quickly.
A
A patient with vitamin B12 deficiency is admitted with symptoms of hypoxia, anemia, numbness of hands and feet, and oral stomatitis. The nurse expects the prescriber to order which of the following therapies? a.IM cyanocobalamin and folic acid b.IM cyanocobalamin and antibiotics c.PO cyanocobalamin and folic acid d.PO cyanocobalamin and blood transfusions
A
A student nurse asks why brushing clients' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best? a. "It mechanically removes biofilm on teeth." b. "It's easier to clean all surfaces with a brush." c. "Oral care is important to all our clients." d. "Toothbrushes last longer than oral swabs."
A
A woman whose hemoglobin S levels are less than 1% has a brother with sickle cell disease (SCD) and both parents have been diagnosed as carriers for the disorder. She asks what her risks are of having a child with sickle cell disease. What is the nurse's best response? A. "Because you do not have the trait, you cannot have a child with SCD regardless of your partner's sickle cell status." B. "Because both your parents have the trait, it is possible for you to have a child with SCD if your partner actually has the disease." C. "Because your brother actually has SCD, the risk for your children having SCD is 50% with each pregnancy." D. "Because you are a woman, your daughters will each have a 50% risk for having the disease, and all of your sons will be carriers of the trait."
A
The 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A. Elevated mononuclear leukocyte count B. Decreased leukocyte count C. Decreased neutrophil count D. Elevated erythrocyte sedimentation rate
A
The nurse is assigned to work with a new nursing assistant. Which action by the nursing assistant requires intervention by the registered nurse? A. Using an alcohol-based hand rub after caring for a client with diarrhea B. Washing hands for 20 seconds using warm water and friction C. Cleaning especially carefully under fingernails and around a wedding band D. Using chlorhexidine for handwashing when caring for clients on neutropenic precautions
A
The patient with which of the following is most at risk for folic acid deficiency? a.Alcoholism b.Sprue c.Gastrectomy d.Peptic ulcer disease
A
Which assessment is most important for the nurse to perform for the client receiving one unit of packed red blood cells from an autologous donation? A. Temperature B. Blood pressure C. Oxygen saturation D. IV site for hives
A
Which change in laboratory test results of a client with sickle cell disease who was started on therapy with hydroxyurea 4 weeks ago indicates to the nurse that the therapy is effective? a. Increased HgbF from 2% to 10% b. Decreased HgbA from 3% to 2.5% c. Increased platelets from 250,000/mm3 to 300,000/mm3 d. Decreased white blood cells from 8200/mm3 to 7000/mm3
A
Which information does the nurse include when teaching the client about antibiotic therapy for infection? A. Take all antibiotics as prescribed, unless side effects develop. B. Take antibiotics until symptoms subside, and then stop taking the drugs. C. Take antibiotics when symptoms of infection develop. D. Share antibiotics with family members who develop the same infection.
A
Which laboratory blood test result for a client undergoing hematologic assessment does the nurse report immediately to the prescriber? A. Red blood cell count 1.2 million/mm3 B. Platelets 185,000/mm3 C. Hematocrit 36% D. INR 1.2
A
Which precaution is most important for the nurse to teach a client with autoimmune thrombocytopenic purpura who is receiving corticosteroid therapy to control the disease? A. "Avoid contact sports and any activity that could cause injury." B. "Report any rash to your health care provider immediately." C. "Be sure to drink at least 3 liters of water daily." D. "Take a low-dose aspirin daily with food."
A
Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is true? A. Antibiotics have been given to clients for conditions that do not require antibiotics. B. Microorganisms are more susceptible to antibiotics today than when they were given years ago. C. Additional precautions are taken, along with Standard Precautions, to prevent infection. D. Certain antibiotics are effective for specific infections only.
A
While in the hospital, the client has developed methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? A. The nurse dons a gown to prevent contact with the client or with client-contaminated items. B. Assign the client to a private room with a negative airflow. C. The nurse dons a mask when working within 3 feet of the client. D. Have the client wear a surgical mask when being transported out of the room.
A
client is being treated at home for vancomycin-resistant Enterococcus (VRE). The client and the family are worried about spreading the infection. Which action by the nurse is best? A. Instruct the client to use a separate bathroom. B. Encourage the family to stay 3 feet away from the client. C. Tell the client to cough into tissues and dispose of them immediately. D. Teach the family ways to increase their immune system functioning.
A
he emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients
A
What are the indications for administration of a parenteral iron preparation? (Select all that apply.) a.Blood loss of 750 mL/week b.Celiac disease with anemia c.History of alcoholism d.Intestinal disease impairing absorption e.Megaloblastic anemia
A B D
Which signs and symptoms does the nurse expect to find in clients with any type of anemia? (Select all that apply.) a. Exercise intolerance b. Fatigue c. Glossitis d. Jaundice e. Leukopenia f. Microcytic red blood cells g. Paresthesias of the hands and feet h. Tachycardia
A B H
A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet from the client at all times. c. Order specialized masks/respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care.
A C
The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I - Examples include hay fever and anaphylaxis b. Type II - Mediated by action of immunoglobulin M (IgM) c. Type III - Immune complex deposits in blood vessel walls d. Type IV - Examples are poison ivy and transplant rejection e. Type V - Examples include a positive tuberculosis test and sarcoidosis
A C D
A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension
A C D E
A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L
A D E
A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours
ABCD
A client is admitted with infection and a high fever. Which assessments by the nurse take priority? (Select all that apply.) A. Blood pressure B. Mental status C. Pulse quality D. Respiratory effort E. Skin turgor F. Bowel sounds
ABCE
A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective
ABCE
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care.
ABD
The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.) a. Appropriate drug b. Proper route of administration c. Standardized peak levels d. Sufficient dose e. Sufficient length of treatment
ABDE
A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?
Antihistamines do not help poison ivy."
A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate? a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facility's standing policy. d. Place the client on protective isolation precautions.
B
A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management? a. "Infusions will be scheduled every 3 to 4 weeks." b. "Treatment is aimed at treating specific infections." c. "Unfortunately, there is no effective treatment." d. "You will need many immunoglobulin A infusions."
B
A client has been admitted for the second time to treat tuberculosis (TB). Which referral does the nurse initiate as a priority? A. Social worker to see if the client can afford the medications B. Visiting nurses to arrange directly observed therapy on dismissal C. Psychiatric nurse liaison to assess reasons for noncompliance D. Infection control nurse to arrange testing for drug resistance
B
A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best? a. Explain to them that these precautions are mandated by law. b. Inform them that the infection is the issue, not the client. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client.
B
A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3
B
A client has scabies. In addition to Standard Precautions, which information is most important to communicate to visitors and health care providers? A. Do not allow children to visit. B. Wear gloves when entering the room. C. Wear a mask when within 3 feet of the client. D. Keep head covered when providing care.
B
A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.
B
A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.
B
A nurse is caring for a patient after hip replacement surgery. The patient has been receiving iron replacement therapy for 2 days. The nurse notes that the patient's stools appear black. The patient is pale and complains of feeling tired. The patient's heart rate is 98 beats per minute, respirations are 20 breaths per minute, and the blood pressure is 100/50 mm Hg. The nurse will contact the provider to: a.report possible gastrointestinal hemorrhage. b.request a hemoglobin and hematocrit (H&H). c.request an order for a stool guaiac. d.suggest giving a hypertonic fluid bolus
B
A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shift to the left" on the white blood cell count. What action by the nurse is most important? a. Document findings and continue monitoring. b. Notify the provider and request antibiotics. c. Place the client in protective isolation. d. Tell the client this signifies inflammation.
B
A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition? a. Blood urea nitrogen: 12 mg/dL b. Creatinine: 3.2 mg/dL c. Hemoglobin: 8.2 mg/dL d. White blood cell count: 12,000/mm3
B
An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 99.2° F (37.3° C), blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate? A. Perform a Mini-Mental Status Examination. B. Assess the client for other signs of infection. C. Document the findings and continue to monitor. D. Assess the client's pain level and treat if needed.
B
An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."
B
Physiological Integrity How does aspirin interfere with blood clotting? A. Prevents vitamin K synthesis B. Inhibits the activation of platelets C. Increases the rate of platelet destruction D. Prevents fibrin molecules from assembling into long strands
B
The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Cohort the "clients" in the same area of the unit. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.
B
The client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? A. Taking the antibiotic before jogging 2 miles daily B. Taking the antibiotic most days C. Taking the antibiotic as prescribed D. Taking the antibiotic with a full glass of water
B
The nurse is caring for a client with a suspected infection. Which action by the nurse is most appropriate? A. Give antibiotics as soon as possible to prevent sepsis. B. Obtain all required cultures, then administer the antibiotic. C. Wait for culture results to give the most appropriate antibiotic. D. Defer cultures unless the client shows signs of drug resistance.
B
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client
B
The nurse is taking a medication history on a newly admitted patient. The patient reports taking folic acid and vitamin B12. The nurse notifies the provider because of the concern that folic acid can: a.cause fetal malformation. b.mask the signs of vitamin B12 deficiency. c.negatively affect potassium levels. d.worsen megaloblastic anemia.
B
The nurse is told that a client with measles is being admitted. Which action by the nurse is best? A. Implement Contact Precautions. B. Check negative airflow monitors. C. Ensure that hand sanitizer is readily available. D. Place the client in a room with another measles client.
B
The nurse reviews laboratory results for a client and notes that the erythrocyte sedimentation rate (ESR) is 32 mm/hr. What action by the nurse is best? A. Document the findings and call the health care provider. B. Assess the client for any manifestations of infection or inflammation. C. Review the client's chart to see what medications have been given. D. Call the physician and request blood cultures and a chest x-ray.
B
The nurse works in a long-term care facility. Which resident does the nurse assess most carefully for manifestations of infection? A. Resident who has long-standing dementia B. Resident with incontinence C. Resident who eats a lot of sweets and little protein D. Resident whose family won't allow an influenza vaccination
B
Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized? a. Assessing skin and mucous membranes b. Consistently using appropriate hand hygiene c. Monitoring daily white blood cell counts d. Teaching visitors not to visit if they are ill
B
Which client does the nurse consider to be at increased risk for infection? A. Young adult who wears contact lenses B. Adult with type 1 diabetes mellitus C. Adult with known hypersensitivity to latex D. Adolescent using analgesics for migraine headaches
B
Which precaution is most important for the nurse to teach a client with leukemia to prevent an infection by autocontamination? A. Take antibiotics exactly as prescribed. B. Perform mouth care three times daily. C. Avoid the use of pepper and raw foods. D. Report any burning on urination immediately.
B
Which statement about handwashing, in accordance with recommendations by the Centers for Disease Control and Prevention (CDC), is true? A. If gloves are worn between treatments for clients sharing a room, handwashing is not necessary until the nurse has finished assessing the second client. B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. C. Handwashing does not need to be done after resetting a client's IV pump. D. If the hands are not visibly soiled, washing the hands is not necessary.
B
client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first? a. Obtain cultures of the lesions. b. Place the client on Airborne Precautions. c. Prepare to administer antibiotics. d. Provide comfort measures for the rash.
B
he nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action by the nurse is most important? A. Check the IV for patency. B. Assess the client for allergies. C. Double check the "five rights." D. Teach the client about the drug.
B
.A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3
B C
A client with an infection has a fever. What actions by the nurse help increase the client's comfort (Select all that apply.) A. Administer antipyretics around the clock. B. Change the client's gown and linens when damp. C. Offer cool fluids to the client frequently. D. Place ice bags in the armpits and groin. E. Provide a fan to help cool the client
B C
A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.) a. Administer antipyretics around the clock. b. Change the client's gown and linens when damp. c. Offer cool fluids to the client frequently. d. Place ice bags in the armpits and groin. e. Provide a fan to help cool the client.
B C
A client in the family practice clinic reports a 2-week history of an "allergy to something." The nurse obtains the following assessment and laboratory data: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2° F (37.9° C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimaton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics
B C D E
A client in the family practice clinic reports a 2-week history of an "allergy to something." The nurse obtains the following assessment and laboratory data: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2° F (37.9° C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimaton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics
B C D E
Which actions aid in the prevention and early detection of infection in the client at risk? Select all that apply. A. Inspect the skin for coolness and pallor. B. Promote sufficient nutritional intake. C. Encourage fluid intake, as appropriate. D. Monitor the red blood cell (RBC) count. E. Obtain cultures as needed.
B E
The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.) a. Colonization b. Host c. Mode of transmission d. Portal of entry e. Reservoir
BCDE
A client comes to the emergency department with a fever, diarrhea, and general malaise. Which information obtained during assessment does the nurse communicate immediately to the health care provider? A. Blood pressure of 110/90 mm Hg B. Allergy to aspirin C. The client having just returned from a 14-day trip to Asia D. A blood transfusion 12 years ago
C
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.
C
A client is being treated with acetaminophen (Tylenol). Which assessment finding is most likely to occur after a dose of the medication? A. A febrile seizure B. Nausea and vomiting C. Episodes of sweating D. Syncope
C
A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.
C
A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. "I need to take extra vitamin C while on INH." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."
C
A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.
C
A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a client's bed linens. What action by the UAP requires intervention by the nurse? a. Not using gloves while combing the client's hair b. Rinsing the client's commode pan after use c. Shaking dirty linens and placing them on the floor d. Wearing gloves when providing perianal care
C
A patient is diagnosed with moderate vitamin B12 deficiency. The nurse reviews the laboratory work and notes that the plasma B12 is low; also, a Schilling test reveals B12 malabsorption. The provider orders oral cyanocobalamin 500 mcg per day. The nurse will contact the provider to: a.discuss IM dosing. b.request an order for folic acid. c.suggest an increased dose. d.suggest platelet transfusion therapy
C
A patient with chronic renal failure who is on dialysis receives an ESA. The nurse caring for this patient during dialysis notes that the patient's hemoglobin is 10.9 gm/dL, up from the 10.2 gm/dL recorded 2 weeks ago. The patient's blood pressure is 120/80 mm Hg. The nurse will contact the provider to suggest: a.adding an antihypertensive drug. b.discontinuing the ESA. c.giving heparin. d.increasing the dose of the ESA.
C
After an infection control in-service, which statement by the nurse demonstrates an accurate understanding of the mode of transmission of influenza? A. "I will not develop the infection unless I have physical contact with the client." B. "I should wear an N95 respirator to provide care for the client with influenza." C. "I should try to stay at least 3 feet away from the client, if at all possible." D. "The infection is spread through droplets suspended in the air and inhaled."
C
Six weeks after hematopoietic stem cell transplantation for leukemia, the client's white blood cell (WBC) count is 8200/mm3. What is the nurse's best action in view of this laboratory result? A. Notify the health care provider immediately. B. Assess the client for other symptoms of infection. C. Document the laboratory report as the only action. D. Remind the client to avoid crowds and people who are ill.
C
The nurse manager for a long-term care facility is in charge of implementing a plan to decrease the spread of infection within the facility. Which part of the plan is most appropriate to delegate to nursing assistants working at the facility? A. Evaluating each other's handwashing technique B. Deciding which brand of handwashing soap to use C. Reinforcing the need for handwashing after caring for clients D. Determining which clients are most likely to infect other residents C. Reinforcing the need for handwashing after caring for clients
C
Which client is at greatest risk for developing an infection? A. 54-year-old man with hypertension B. 17-year-old woman with a fractured tibia in a cast C. 65-year-old woman who had coronary bypass surgery 4 days ago D. 71-year-old man in a nursing home
C
Which of these nurses would be assigned to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A. An experienced LPN/LVN who has worked on the medical unit for 10 years B. An RN with experience in the operating room who transferred a month ago to the medical unit C. A float RN with 7 years of experience on the inpatient oncology unit D. An RN who has worked mostly on the same-day surgery unit since graduating a year ago
C
Which statement about the transmission of hepatitis C is true? A. Feces are a likely body fluid by which to transmit the disease. B. Airborne Precautions are used for the prevention of hepatitis C. C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D. No precautions are necessary with the use of nail clippers or scissors.
C
While sponging a client who has a high fever, the nurse observes the client shivering. Which is the nurse's priority action? A. Administering oral acetaminophen B. Placing a heated blanket on the client C. Stopping sponging the client D. Warming up the water and continuing sponging
C
A nurse works in an allergy clinic. What task performed by the nurse takes priority?
Checking emergency equipment each morning
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?
Correctly identifying the client prior to a blood transfusion
A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?
Creatinine: 3.2 mg/dL
A client and his family are waiting for the results of clinical tests to determine whether the client has an infection. They are becoming anxious. What is the most important assessment that the nurse should make of the client and family members? A. Understanding of insurance reimbursement for testing B. Use of appropriate coping mechanisms for anxiety C. Understanding of the infectious disease process D. Understanding of the diagnostic procedures
D
A client is admitted with possible sepsis. Which action should the nurse perform first? a. Administer antibiotics. b. Give an antipyretic. c. Place the client in isolation. d. Obtain specified cultures.
D
A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy
D
A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the client's oxygen during activity. d. Pace activities, allowing for adequate rest.
D
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly
D
A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications.
D
A hospital unit is participating in a bioterrorism drill. A "client" is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the "client"? a. Airborne Precautions b. Contact Precautions c. Droplet Precautions d. Standard Precautions
D
A patient is admitted to the hospital. The patient's initial laboratory results reveal megaloblastic anemia. The patient complains of tingling of the hands and appears confused. The nurse suspects what in this patient? a.Celiac disease b.Folic acid deficiency c.Iron deficiency anemia d.Vitamin B12 deficiency
D
A patient was given a 30-day supply of Feosol and has been taking the drug for 4 weeks for iron deficiency anemia. The patient's initial hemoglobin was 8.9 gm/dL. The nurse notes that the hemoglobin has risen to 9.7 gm/dL. What will the nurse ask the patient about? a.Dietary iron intake b.Gastrointestinal (GI) upset c.Whether stools have been tarry or black d.Whether the prescription needs to be refilled
D
Before discharge, the nurse confirms that the client understands antibiotic therapy for a wound infection by which statement? A. "I should take the antibiotic until my temperature is normal." B. "If my temperature elevates, I should increase my dose of antibiotic." C. "If my drainage is clear, I do not need the antibiotic." D. "I need to take the medication until the prescription is finished."
D
The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? a. Colonization by host bacteria b. Gastrointestinal secretions c. Inflammatory processes d. Skin and mucous membranes
D
Which clinical manifestation reported by a client suggests to the nurse that anemia is a possibility? A. Difficulty sleeping B. Cold hands and feet C. Chronic headaches D. Shortness of breath
D
Which is a common clinical manifestation of infectious disease? A. Dry and pink skin B. Hypothermia C. Decreased respiratory rate D. Decreased level of consciousness
D
Which laboratory value in a client with sickle cell disease does the nurse report immediately to the health care provider? A. Hematocrit 24% B. Hemoglobin S (HbS) 78% C. Platelet count 260,000/mm3 D. White blood cell (WBC) count 20,000/mm3
D
Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A. Carefully washes hands that are visibly soiled B. Wears a mask and gloves when the client's body secretions or body fluids are likely to be handled C. Wears a mask with eye protection and performs proper handwashing D. Wears gloves when contact with body secretions or body fluids is expected
D
Which statement made by a client with folic acid deficiency anemia indicates to the nurse a correct understanding of self-management for this health problem? A. "If my fingers and toes become numb, I will notify my health care provider immediately." B. "I will stop playing contact sports or any activity that increases my risk for injury." C. "My diet now includes more carrots, cauliflower, and apples." D. "I have stopped drinking alcohol completely."
D
With which client will the nurse apply pressure to an injection site for 5 minutes because of an increased risk for bleeding? a. 28-year-old who has had type 1 diabetes for 15 years b. 42-year-old newly diagnosed with type 2 diabetes c. 58-year-old with chronic hypertension and heart failure d. 62-year-old with extensive liver damage from cirrhosis
D
client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. "Are any family members also ill?" b. "Have you traveled recently?" c. "How long have you been ill?" d. "What is your occupation?"
D
Which statements are true regarding Standard Precautions? (Select all that apply.) a. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. c. Remain 3 feet away from any client who has an infection. d. Use personal protective equipment as needed for client care. e. Wear gloves when touching client excretions or secretions.
D E
A client is in the hospital and receiving IV antibiotics. When the nurse answers the client's call light, the client presents an appearance as shown below: What action by the nurse takes priority?
Ensure a patent airway while calling the Rapid Response Team.
A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best?
Ensure the information is relayed to the surgical team.
A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
I dont need to go to the hospital after using it
The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands "HIV+" d. Wearing a mask within 3 feet of the client
a
A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?
nstruct the client not to get up without help.
