Medical-Surg Nursing

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? A)Asking the client to say "one, two, three" while the nurse auscultates the lungs B)Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax C)Instructing the client to take a deep breath and hold it while the diaphragm is percussed D)Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply

B-While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.B-

A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea? A)Diffuse skin rash B)Painless chancre C)Burning on urination D)Dry, hacking cough

C

The nurse is caring for a group of clients at a public health clinic. Which sexually transmitted disease would the nurse focus the client education on curative goals? A)HIV B)Genital herpes C)Chlamydia D)HPV

C

Which is a deformity of the chest that occurs as a result of overinflation of the lungs? A)Pigeon chest B)Funnel chest C)Barrel chest D)Kyphoscoliosis

C-A barrel chest occurs as a result of overinflation of the lungs. The anteroposterior diameter of the thorax increases. Funnel chest occurs when a depression occurs in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum, resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? A)Absent breath sounds B)Egophony C)Crackles at lung bases D)Bronchial breath sounds

C-A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia

A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do? A)Assess the client's vital signs. B)Perform an electrocardiogram (ECG). C)Administer epinephrine. D)Intubate the client.

C-Anaphylaxis is a rapid and profound type I hypersensitivity response. A massive release of histamine causes vasodilation; increased capillary permeability; angioneurotic edema (acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs); hypotension; and bronchoconstriction. A nurse must administer 0.2 mg of epinephrine subcutaneously to a client experiencing a severe allergic reaction. It is outside of the nurse's practice to intubate a client. Performing an ECG and assessing the vital signs delays the treatment of the client and can have negative outcomes.

You are the clinic nurse doing assessments on your clients before they have outpatient diagnostic testing done. What would you document when assessing the client's pulse? A)Rate, rhythm, and volume B)Pressure, rate, and rhythm C)rate, quality, and rhythm D)Quality, volume, and rate

C-Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse quality and volume are not assessed in this instance.

You work on a long-term care unit. In the last two weeks more than half the clients on your unit have been diagnosed with gastroenteritis. What is the most likely reason? A)The visitors brought the disease into the unit. B)The clients are in too small an area, so they pass around diseases. C)The infection is being transmitted by healthcare personnel. D)The clients don't wash their hands after going to the bathroom.

C-Healthcare personnel are in frequent and direct contact with many clients who harbor various microorganisms; the risk for transmitting pathogenic microorganisms between clients is high.

The nurse is completing the admission assessment on a client with renal failure. The client states, "I was diagnosed with impetigo yesterday." Which is the appropriate nursing intervention? A)Educate the client about wearing a mask outside of the assigned room. B)Obtain the name of the antiviral medication used to treat the impetigo. C)Initiate contact isolation protocol. D)Transfer the client to a negative-pressure room.

C-Impetigo is a bacterial infection transmitted via contact. Therefore, the nurse should initiate contact isolation protocol. The client would not be taking an antiviral medication for impetigo, would not need a negative-pressure room, and would not wear a mask when outside the room.

Which organism is responsible for impetigo? A)Clostridium difficile B)Histoplasma capsulatum C)Staphylococcus aureus D)Bacillus anthracis

C-S. aureus and Streptococcus pyogenes are the organisms responsible for impetigo. H. capsulatum is responsible for histoplasmosis. B. anthracis is responsible for anthrax. C. difficile is responsible for some diarrheal diseases.

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body? A)right atrium B)left atrium C)left ventricle D)right ventricle

C-The left ventricle pumps blood to all the cells and tissues of the body. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs to be oxygenated. The right atrium receives deoxygenated blood from the venous system.

The term for the volume of air inhaled and exhaled with each breath is A)expiratory reserve volume. B) vital capacity. C) tidal volume. D) residual volume.

C-Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.

A patient's lung volumes and capacities were assessed to help determine the cause of a respiratory problem. Which of the following findings are indicative of chronic obstructive pulmonary disease (COPD)? A)Functional residual capacity of 2,300 mL B)Residual volume of 1,200 mL C)Vital capacity of 3,000 mL D)Expiratory reserve volume of 1,100 mL

C-Vital capacity is reduced in COPD because of air trapping. The other choices are all normal findings. Refer to Table 8-2 in the text.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? A)Pleural friction rub B)Crackles C)Wheezes D)Rhonchi

C-Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma.

A hospitalized client with terminal heart failure is nearing the end of life. The nurse observes which of the following breathing patterns?

Cheyne-Stokes breathing is characterized by a regular cycle where the rate and depth of breathing increase, then decrease until apnea occurs. The duration of apnea varies but progresses in length. This breathing pattern is associated with heart failure, damage to the respiratory center in the brain, or both

Patients who have had pelvic inflammatory disease (PID) are prone to which of the following complications? A)Bacteremia B)Thrombophlebitis C)Inguinal lymphadenopathy D)Ectopic pregnancy

D

The nurse auscultates the PMI (point of maximal impulse) at which anatomic location? A)5 cm to the left of the lower end of the sternum B)2.5 cm to the left of the xiphoid process C)3 cm to the right of the sternum D)left midclavicular line, fifth intercostal space

D

The nurse observes a nursing assistant leave the room of client diagnosed with Clostridium difficile infection without washing hands. Which is the priority action by the nurse? A)Teach the nursing assistant about the chain of infection. B)Report the nursing assistant to the nurse manager. C)Provide written documentation about the incident. D)Have the nursing assistant wash hands with soap and water.

D-Although all actions listed are appropriate, the priority nursing action is to ensure that the nursing assistant washes their hands with soap and water. Allowing nursing assistants to continue with their job without washing their hands could lead to the nursing assistant infecting other clients with whom they come in contact. The potential for health care-associated acquisition is increased because the spore is relatively resistant to disinfectants and can be spread via the hands of healthcare providers.

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide? A)Passive immunity B)Naturally acquired active immunity C)Forced immunity D)Artificially acquired active immunity

D-Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid. Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection . Not all invading microorganisms produce a response that gives lifelong immunity. There is not a type of immunity called forced immunity.

A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected? A)Review the urinalysis report for hematuria B)Assess for hepatosplenomegaly by measuring abdominal girth C)Assess joint mobility using passive range of motion. D)Assess for ataxia using the finger-to-nose test and heel-to-shin test

D-Ataxia should be assessed when suspecting immune dysfunction in the neurosensory system. Joint movement, a urinalysis results positive for hematuria , and measuring abdominal girth are not used to assess for issues with the neurosensory system in relation to immune dysfunction.

The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following? A)Atrioventricular tendons B)Semilunar tendineae C)Papillary tendons D) Chordae tendineae

D-Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Options B, C, and D are distractors for the question.

You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response? A) "Anytime there is a chronic disease process it is hard for the person to breathe." B)"Having a chronic respiratory disease scars the lung and affects the effort it takes to breathe." C)"In this particular case your family member is just overly tired and having problems breathing." D)"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

D-Conditions that may alter bronchial diameter and affect airway resistance include contraction of bronchial smooth muscle (e.g., asthma); thickening of bronchial mucosa (e.g., chronic bronchitis); airway obstruction by mucus, a tumor, or a foreign body; and loss of lung elasticity (e.g., emphysema). Option A is incorrect, not all chronic diseases make it hard to breathe. Option B is incorrect; not all chronic respiratory diseases caused scarring in the lung. Option C is incorrect; this response negates the families question and belittles their concern.

A nurse would anticipate instituting contact precautions for a client with which of the following? A)Mumps B)Measles C)Varicella D)Clostridium difficile infection

D-Contact precautions would be appropriate for a client with an infection due to Clostridium difficile. Airborne precautions are appropriate for clients with measles or varicella. Droplet precautions are appropriate for clients with mumps.

Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure? A)Avoid atropines as they dry the secretions. B)Practice holding the breath for short periods. C)Avoid sedatives or narcotics as they depress the vagus nerve. D)Abstain from food for at least 6 hours before the procedure.

D-For at least 6 hours before bronchoscopy, the client must abstain from food or drink to decrease the risk of aspiration. Risk is increased because the client receives local anesthesia, which suppresses the reflexes to swallow, cough, and gag. The client receives medications before the procedure. Typically, atropine is given to dry secretions and a sedative or narcotic is given to depress the vagus nerve. The client may need to hold his or her breath for short periods during lung scans and for bronchoscopy.

The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position? A)Supine B)Lateral recumbent C)Prone D)Sitting on the edge of the bed

D-If possible, it is best to place the client upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the client could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which data is necessary to collect if the client is experiencing chest pain? A)blood pressure in the left arm B)sound of the apical pulses C)pulse rate in upper extremities D)description of the pain

D-If the client is experiencing chest pain, a history of its location, frequency, and duration is necessary. A description of the pain is also needed, including if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the client and measures vital signs. The nurse may measure blood pressure in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities.

A college student comes to the campus health care center complaining of headache, malaise, and a sore throat that has worsened over the past 10 days. The nurse measures a temperature of 102.6° F (39.2° C) and finds an enlarged spleen and liver and exudative tonsillitis. Laboratory tests reveal a leukocyte count of 20,000/mm3, antibodies to Epstein-Barr virus, and abnormal liver function tests. These findings suggest: A)infectious mononucleosis. B)poliomyelitis. C)herpangina. D)mumps.

D-The client's clinical manifestations and laboratory test results suggest infectious mononucleosis. Mumps, a viral disease, usually causes an earache and fever from parotid gland involvement. Poliomyelitis is an acute communicable disease that has been largely eradicated by the polio vaccine. Although its symptoms resemble those of mononucleosis, it typically has a central nervous system component, causing back, neck, and arm pain or paralysis. Herpangina is an acute viral infection that causes seizures, vomiting, stomach pain, and grayish papulovesicles on the soft palate.

A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client? A) Advise the client to use prescribed analgesics B)Gently rub the swollen area to accelerate blood flow C)Apply ice packs to reduce the swelling D)Assure the client that this is a normal reaction

D-The nurse should assure the client that this is a normal reaction. When disease-specific antigens are injected, the injection area swells as a result of the client developing antibodies against the antigen that is introduced. The nurse should also keep in mind that the client is not necessarily actively infectious if the test result is positive. Rubbing the area gently or even applying ice packs may only aggravate the swelling. The swollen area should be left open to heal by itself. The nurse should await the physician's instructions before advising the client to use any prescribed analgesics.

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? A) "Contact your primary care provider if you develop a temperature above 102°F." B)"You can take a tub bath or a shower when you get home." C)"If any discharge occurs at the puncture site, call 911 immediately." D)"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."

D-The nurse should instruct the client to follow these guidelines: For the next 24 hours, do not bend at the waist, strain, or lift heavy objects if the artery of the groin was used; contact the primary provider if swelling, new bruising or pain from the procedure puncture site, or a temperature of 101°F or more occur. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The client should not drive to the hospital.

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections? A) "Encourage your family to adopt a healthy diet and exercise regimen." B)"Encourage your family to stop smoking." C) "Make sure your family has regular checkups." D)"Make sure your family has all their childhood immunizations."

D-To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular checkups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections either.

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about? A) Raised temperature in the affected limb B)Excessive capillary refill C)Flushed feeling in the client D)Absent distal pulses

D-When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling

When a hospitalized client is in contact precautions, which action is necessary? A) Masks should be worn when caring for the client. B)The client should be in a room with negative air pressure. C)The client's door should be closed. D)The client should be placed in a private room when possible.

D-When possible, the client requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed and doors do not need to be closed.

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? A)Hematoma B)Absent distal pulses C)Urge to cough D)Difficulty in breathing

Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.

You are caring for a client who is receiving morphine for pain relief. After the latest dose, you notice that the client's respiratory rate has declined to 10 breaths per minute. Which of the following nursing diagnoses would be most appropriate for this client? 1) Ineffective Airway Clearance (respiratory depression) related to overdose of morphine 2) Ineffective Breathing Pattern (hypoventilation) related to overdose of morphine 3) Impaired Gas Exchange related to respiratory depression secondary to overdose of morphine 4) Impaired Spontaneous Ventilation related to hypoventilation secondary to overdose of morphine

2

A patient recently diagnosed with pericarditis asks the nurse to explain what area of the heart is involved. How does the nurse best describe the pericardium to the client? A)Thin fibrous sac that encases the heart. B)Inner lining of the heart and valves. C)Exterior layer of the heart. D)Heart's muscle fibers.

A

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. A)On the cheeks below the eyes B)Between the eyes and behind the nose C)Above the eyebrows D)Behind the ethmoid sinuses

A) To palpate the maxillary sinuses, the nurse should apply gentle pressure in the cheek area below the eyes, adjacent to the nose.

A client the nurse is caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for two weeks. The client's family asks you how the client got this infection. What would be the nurse's best response? A) "People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital." B)"People in hospitals sometimes exhibit signs of infections they had before being admitted." C)"Sometimes people in hospitals get exposed to microorganisms that their visitors bring in." D)"People in hospitals are surrounded by infectious agents, so they can get infections they didn't have before being admitted."

A)Hospitalized clients are more susceptible to infections than well people because they are exposed to pathogens in the health care environment, may have incisions or invasive equipment (e.g., intravenous lines) that compromise skin integrity, or may be immunosuppressed from poor nutrition, their disease process, or its treatment. Although all answers are correct, the most complete answer is A.

The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (Select all that apply.) A)Previous history of lung disease in the patient or family B)Previous history of smoking C)Financial ability to pay the bill D)Occupational and environmental influences E)Social support

A, B, D Risk factors associated with respiratory disease include smoking, exposure to allergens and environmental pollutants, and exposure to certain recreational and occupational hazards. Financial ability and social support are not pertinent to a chronic cough.

The nurse is performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph nodes on the left. What should the nurse document? (Select all that apply.) A)Consistency B)Temperature C)Reports of tenderness D)Size E)Location

A,C,D, E are correct-The anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement; if palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Joints are assessed for tenderness, swelling, increased warmth, and limited range of motion.

The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action? A)Ensure the client remains moderately sedated to decrease anxiety. B)Instruct the client that bed rest must be maintained for 2 hours. C)Assess the client for a cough reflex. D)Offer the client ice chips.

A-After the procedure, the client must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the client demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The client is sedated during the procedure, not afterward. The client is not required to maintain bed rest following the procedure.

A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment? A)Bilateral lower lobes B)Right lower lobe C)Posterior bronchioles D)Anterior bronchial tree

A-Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation. Fluid overload should be monitored for accumluation in the lungs. Dependent areas must be assessed for breath sounds. The bases of the lungs are considered dependent areas. Fluid in the lungs will usually produce the adventitious sounds of crackles, most frequently auscultated in the bilateral bases of the lungs.

Which of the following cell types are involved in humoral immunity? A)B lymphocytes B)Helper T lymphocyte C) Memory T lymphocyte D)Suppressor T lymphocyte

A-B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.

Bradypnea is associated with which condition? A)Increased intracranial pressure B)Pulmonary edema C)Metabolic acidosis D)Pneumonia

A-Bradypnea is associated with increased intracranial pressure, brain injury, and drug overdose. Tachypnea is commonly seen in clients with pneumonia, pulmonary edema, and metabolic acidosis.

The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking? A)Angiotensin converting enzyme (ACE) inhibitors B)Aspirin C)Bronchodilators D)Cardiac glycosides

A-Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.

After a routine physical exam, a female client is devastated to receive a diagnosis of the sexually transmitted infection, gonorrhea. What would contribute to the client's ignorance of this condition? A) being asymptomatic B)knowing the signs and symptoms of STIs C)being sexually inactive D)All options are correct.

A-Many women who have gonorrhea are asymptomatic, a factor that contributes to the spread of the disease. Knowing the signs and symptoms of STIs will not help with an asymptomatic disease. Being sexually inactive currently will not prevent having been infected with a disease in the past.

The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmias. Which of the following assessment considerations is essential when caring for this age-group? A)Digoxin level B)Activity level C)Dyspnea D)Cardiac output

A-The action of Digoxin slows and strengthens the heart rate. Assessment of the pulse rate is essential prior to administration in all clients. Due to decreased perfusion common in geriatric clients, toxicity may occur more often. The nurse must monitor Digoxin levels in the body. Monitoring symptoms reflecting cardiac output, activity level, and dyspnea are also important assessment considerations for all clients.

The nurse teaches the parent of a child with chickenpox that the child is no longer contagious to others when A)the vesicles and pustules have crusted. B)the rash is changing into vesicles, and pustules appear. C)the fever disappears. D)the first rash appears.

A-When the lesions have crusted, the client is no longer contagious to others. The child remains contagious when the rash is present, if fever occurs as the rash is progressing, and when the rash is changing into vesicles and pustules.

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response? A)"It is a muted response to something in the environment." B)"It is a hyperimmune response to something in the environment that is usually harmless." C)"It means you are very sensitive to something inside of yourself." D)"It is a harmless reaction to something in the environment."

B

What types of cells are the primary participants in immune response? Select all that apply. A)monocytes B)T-cell lymphocytes C)leukocytes D)B-cell lymphocytes

B and D)B-cell and T-cell lymphocytes are the primary participants in the immune response.

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? A)Use standard precautions, which require gloves for suctioning. B)Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. C)Take no special precautions for this client. D)Put on gloves, a mask, and eye protection.

B) Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis.

During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply. A)fomites B)susceptible host C)infectious agent D)portal of entry E)virulence

B,C,D are correct-The six components involved in the transmission of microorganisms are described as the chain of infection. All components in the chain of infection must be present to transmit an infectious disease from one human or animal to a susceptible host: an infectious agent, an appropriate reservoir, exit route, means of transmission, portal of entry, and susceptible host.

The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition? A)Pulmonary embolism B)Heart failure C)Pericarditis D)Myocardial infarction

B-An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system? A)Burning upon urination B)Ataxia C)Hematuria D)Urinary frequency

B-Ataxia should be assessed when immune dysfunction in the neurosensory system is suspected. Hematuria, discharge, and frequency of and burning upon urination are associated with the genitourinary system.

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response? A)The invading antigens link together (agglutination). B)T-cell lymphocytes survey proteins in the body and attack the invading antigens. C) Toxins of invading antigens are neutralized. D)The invading antigens precipitate.

B-During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their toxins through agglutination or by causing them to precipitate.

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? A) Inflammation B)Iodine allergy C)Bleeding D)Dysrhythmias

B-During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.

In which group is it most important for the client to understand the importance of an annual Papanicolaou test? A)Clients with a long history of hormonal contraceptive use B)Clients infected with the human papillomavirus (HPV) C)Clients with a pregnancy before age 20 D)Clients with a history of recurrent candidiasis

B-HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and use of hormonal contraceptives don't increase the risk of cervical cancer.

The infection control nurse collects data that indicates an increase in the number of clients in the hospital with multidrug-resistant infections. What priority education should healthcare providers receive? A)Using contact precautions on all clients in the hospital B)Hand hygiene C)Administering antibiotics to all clients prophylactically D)Emptying trash cans immediately in client's rooms

B-Infections with multidrug-resistant microorganisms are very difficult to destroy with current pharmacologic agents, increasing the need to be vigilant about performing hand hygiene measures. It is unnecessary to use contact precautions, administer antibiotics prophylactically, or empty trash cans immediately for the preventions of multidrug-resistant infections.

The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following? A)Serum, which depletes the body's store of glucagon B)Serum, which depletes the body's store of immunoglobulins C)Plasma, which depletes the body's store of calcitonin D)PLasma, which

B-Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. Loss of serum or plasma does not deplete the body of catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas).

The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin? A)Assess for clubbing of the fingers. B)Report any incident of bloody urine, stools, or both. C)Assess for hypokalemia. D)Administer calcium supplements.

B-The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both. Clients taking enoxaparin will not need to take calcium supplements or have potassium imbalances related to the medication. The clubbing of fingers may occur with chronic pulmonary diseases.

Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue? A)pericardium B)endocardium C)epicardium D)myocardium

B-The inner layer, the endocardium, is composed of a thin, smooth layer of endothelial cells. Folds of endocardium form the heart valves. The middle layer, the myocardium, consists of muscle tissue and is the force behind the heart's pumping action. The pericardium is a saclike structure that surrounds and supports the heart. The outer layer, the epicardium, is composed of fibrous and loose connective tissue.

A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event? A)genetics B)eustachian tubes C)oropharynx D)epiglottis

B-The nasopharynx contains the adenoids and openings of the eustachian tubes. The eustachian tubes connect the pharynx to the middle ear and are the means by which upper respiratory infections spread to the middle ear. The client's infection is not caused by genetics. The oropharynx contains the tongue. The epiglottis closes during swallowing and relaxes during respiration.

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? A)The AV node B)The sinoatrial node C)The Purkinje fibers D)The ventricles

B-The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body (Weber & Kelley, 2010).

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? A)Controlled breathing B)Use of accessory muscles C)Diaphragmatic breathing D)Pursed-lip breathing

B-The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse? A)"They really do not have a function and should be removed." B)"These tissues filter bacteria from tissue fluid." C)"The tissue removes blood and bacteria." D)"The tissue acts as an emergency reservoir of blood."

B-Tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral cavity, they can become infected and locally inflamed. The spleen acts as an emergency reservoir of blood and removes blood and bacteria, not the tonsils

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: A)helps people who cannot breathe on their own. B)is breathing air in and out of the lungs. C)is when the body changes oxygen into CO2. D)provides a blood supply to the lungs.

B-Ventilation is the actual movement of air in and out of the respiratory tract. Diffusion is the exchange of oxygen and CO2 through the alveolar-capillary membrane. Pulmonary perfusion refers to the provision of blood supply to the lungs. A mechanical ventilator assists patients who are unable to breathe on their own.

The nurse is meeting with the mother of an 11-year-old girl to provide decision making support and education regarding human papillomavirus (HPV) vaccination. The mother states, "I am confused about why my 11 year old needs to be protected from a sexually transmitted infection. She is so young and not sexually active. Why does she need the vaccination now?" What is the nurse's best response? A)"You're daughter is at risk for ectopic pregnancy and even infertility without this vaccination. If you chose not to vaccinate, you are choosing to put your daughter at risk." B)"The vaccination helps to prevent cervical cancer in adult women. It works better if she has it before she becomes sexually active. Let's talk about some of the concerns you have about the vaccination" C)"HPV vaccination is very common and most parents are choosing to protect their children. Although your child is not sexually active now, she will be soon and this will protect her from sexually transmitted infections." D)"Although HPV infections are not very common, it is important to take precaution with vaccination. If you prefer, you can wait until your daughter is older than 15 years, because she would require fewer doses of the vaccine."

B-When counseling clients regarding the HPV vaccination, it is important to use supportive communication to help reduce the client's anxiety and help them make the best decision for his or her health. The nurse should provide facts about the benefits of vaccination along with the potential long term consequences of abstaining from vaccination. The nurse should be careful when stating the child will be "protected from sexually transmitted infections." The HPV vaccination only protect against infections caused by HPV and the primary purpose of the vaccination is to prevent the development of certain cancers related to the infection. Telling the mother her daughter is at risk for ectopic pregnancy and infertility is ineffective because the nurse has not yet discussed the possible consequences of a HPV infections. The nurse is not communicating in a manner that would reduced the mother's anxiety. The response may be perceived as accusatory and judgemental. By telling the mother if she waits to vaccinate her daughter until she is 15 years old, the nurse is providing incorrect information. Children between the ages of 9 and 14 require fewer doses of the vaccination that children 15 and older up to 26 years of age.