Medsurg Resp & immune

The nurse is planning care to address ineffective airway clearance for a patient with lung cancer. Which interventions should the nurse include in the patient's plan of care? Select all that apply. 1) Increase fluid intake to 3000 mL per day 2) Turn, cough, and deep breathe every two hours 3) Chest percussion every eight hours 4) Smoking cessation education 5) Administer pneumococcal vaccine

ANS: 1, 2, 3 An adequate fluid intake is needed. Patients with pneumonia should increase their fluid intake in order to decrease the viscosity of respiratory secretions. Turning, coughing, deep breathing, and chest percussion can help clear secretions.

The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to determine whether the patient is experiencing influenza? Select all that apply. 1) "Have you had a flu shot this year?" 2) "Is your cough productive?" 3) "Have you been exposed to anyone with the flu?" 4) "Are you having any trouble urinating?" 5) "Do you have dizziness?"

ANS: 1, 2, 3 Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis.

The nurse is caring for a patient who develops a fever and productive cough after having an appendectomy. Which prescriptions should the nurse expect from the health-care provider for this health problem? Select all that apply. 1) Sputum cultures 2) Antibiotics 3) Chest physiotherapy 4) Bronchial washing for culture 5) Isolation precautions

ANS: 1, 2, 3 The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions.

The school nurse is planning a teaching session with the parents of students to reduce the spread of the influenza virus throughout the school. What should the nurse include when teaching the parents of a diverse population about infection-control techniques? Select all that apply. 1) "Cover your cough" education 2) Appropriate hand hygiene 3) Safe food preparation and storage 4) Sanitizing high-touch items to kill pathogens 5) Withholding immunizations for children with compromised immune systems

ANS: 1, 2, 4 Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as "cover your cough" education all control the growth and spread of microorganisms.

Which assessment data would cause the nurse to suspect that an infant requires further testing for cystic fibrosis? Select all that apply. 1) Rectal prolapse 2) Constipation 3) Steatorrheic stools 4) Meconium ileus 5) Diarrhea

ANS: 1, 3 Steatorrhea and rectal prolapse might be signs of cystic fibrosis in an older infant or child.

The nurse is planning care for a young adolescent patient diagnosed with asthma. Which evidence-based ageappropriate interventions will the nurse include in the plan of care? Select all that apply. 1) Referring to a peer-led support group 2) Teaching the parents how to administer maintenance medication prior to teaching the patient 3) Assessing peer-support when planning care 4) Collaborating with teachers for support in the school setting 5) Telling the patient to avoid medication while at school

ANS: 1, 3, 4 Age-appropriate, evidence-based interventions for a young adolescent patient diagnosed with asthma include referral to a peer-led support group, assessing peer-support of the patient, and collaborating with teachers to ensure the patient has the necessary support in the school setting.

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the patient's history support the current diagnosis? Select all that apply. 1) Working in an industrial environment 2) Working in an office setting with air conditioning 3) History of asthma 4) Current cigarette smoking 5) Playing golf several times a week

ANS: 1, 3, 4 Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking.

Which systems should the nurse anticipate will be affected when planning care for a patient diagnosed with cystic fibrosis? Select all that apply. 1) Respiratory 2) Neurological 3) Reproductive 4) Cardiovascular 5) Gastrointestinal

ANS: 1, 3, 5 Cystic fibrosis is a multisystem disease that produces increased amounts of thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other organs that are affected include the liver, salivary glands, and testes.

The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the disease when educating the patient? Select all that apply. 1) Fatigue 2) Low-grade morning fever 3) Productive cough that later turns to a dry, hacking cough 4) Weight loss 5) Night sweats

ANS: 1, 4, 5 Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention.

Human immunodeficiency virus (HIV) infects and destroys CD4 cells. List the following events in the order in which they occur for a patient who is HIV-positive. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Virus invades helper T cell 2) Viral RNA converts with reverse transcriptase to viral DNA 3) Viral DNA integrates with host cell DNA. 4) Virus remains latent, or actively replicates 5) Virus sheds protein coat

ANS: 13452

A nurse is caring for a patient recovering from a wedge resection of the left lung for a tumor. Which is an appropriate goal for the nursing diagnosis of ineffective airway clearance? 1) Participation in care by the patient 2) Maintain a patent airway 3) Maintain current weight 4) Express feelings and concerns

ANS: 2 All of the outcomes for this patient are viable, but appropriate outcomes for the diagnosis of ineffective airway clearance are maintaining a patent airway and minimizing the accumulation of fluid.

The nurse is caring for an older adult patient who is hospitalized with a second episode of pneumonia in the past 18 months. The patient has expressed frustration to the nurse and states, "I never got sick when I was younger. Why is this happening?" Which response by the nurse is most appropriate? 1) "As you grow older, your immune system just quits working." 2) "As you grow older, there is a decrease in the immune response, which puts you at greater risk for developing an infection." 3) "As you grow older, there in an overall increase in the speed and strength of your immune response." 4) "As you grow older, there is an increase in the number of B cells in the circulation, which hinders the immune response."

ANS: 2 As a person grows older, there is an overall decrease in the speed and strength of the immune response. The immune system does not quit working totally. There is a decrease in the number of B cells in circulation.

A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching? 1) "We'll be sure to use the fireplace often to keep the house warm in the winter." 2) "We will replace the carpet in our child's bedroom with tile." 3) "We'll keep the plants in our child's room dusted." 4) "We're glad the dog can continue to sleep in our child's room."

ANS: 2 Control of dust in the child's bedroom is an important aspect of environmental control for asthma management, and replacing the carpeting in the child's bedroom with tile flooring will reduce dust.

The nurse instructs a patient with asthma on bronchodilator therapy. Which statement indicates patient understanding? 1) "The medication widens the airways because it acts on the parasympathetic nervous system." 2) "The medication widens the airways because it stimulates the fight-or-flight response of the nervous system." 3) "The medication widens the airways because it decreases the production of histamine that narrows the airways." 4) "The medication widens the airways because it decreases the production of mucous that narrows the airways."

ANS: 2 During the fight-or-flight response, beta2-adrenergic receptors of the sympathetic nervous system are stimulated, the bronchiolar smooth muscle relaxes, and bronchodilation occurs.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 480 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

ANS: 2 Herpes zoster virus is a complication that occurs when the patient's CD4+ is between 500 and 350 cells/L.

The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse implement to attain the goal of normal body temperature? 1) Increase the temperature of the room environment to prevent shivering 2) Administer antipyretic medications 3) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance 4) Use ice packs and a tepid bath every two hours

ANS: 2 Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates.

The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being transported to the unit. Which nursing action for infection prevention is the most appropriate in this circumstance? 1) Stock the patient's supply cart at the beginning of each shift 2) Wear a respirator mask and gown when caring for the patient 3) Perform hand hygiene only after leaving the room 4) Test all staff members for TB immediately

ANS: 2 Masks and gowns should be worn when caring for patients who do not reliably cover their mouths when coughing. When a patient has an airborne disease and must go elsewhere in the hospital, the patient must wear a mask.

The nurse is caring for a patient who is admitted to the unit with tuberculosis (TB). The patient is placed in isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most appropriate? 1) Single-door room with positive air flow (air flows out of the room.) 2) Isolation room with an anteroom and negative air flow (air flows into the room.) 3) Isolation room with an anteroom and normal airflow 4) Single-door room with normal airflow

ANS: 2 Patients with airborne infections such as meningococcemia, SARS, or TB are placed in an isolation room with an anteroom and negative pressure airflow. Air flows into the room and is vented in a special manner to prevent the organism from entering the rest of the unit.

The nurse working on a pediatric unit is caring for a patient newly diagnosed with asthma. Which assessment data indicates exhaustion and the need for immediate intervention? 1) Slightly diminished breath sounds 2) Decreased wheezing 3) Increased crackles 4) Increased respiratory rate

ANS: 2 Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow respiration's with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary.

The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child's urine was orange. Which response by the nurse is accurate? 1) "Encourage your child to drink cranberry juice." 2) "An orange discoloration of urine is expected while your child is on this medication." 3) "Bring your child to the clinic for a urinalysis." 4) "Bring your child to the clinic for a radiograph of the kidneys."

ANS: 2 Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 500 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

ANS: 2 Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L.

A home health nurse is conducting home visits for several patients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which patient would the nurse see first? 1) A patient who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count 2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath 3) A patient with wasting syndrome who needs modifications and education regarding dietary changes 4) A patient who is receiving IV antibiotics daily for toxoplasmosis

ANS: 2 This patient needs to be seen by the nurse; however, based on the ABCs (airway, breathing, and circulation) this patient is not the priority.

The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this diagnosis? 1) Wheezing 2) Hemoptysis 3) Grey sputum 4) Slightly whitish sputum

ANS: 2 Tuberculosis is characterized by hemoptysis, which is the term for coughing up of blood or blood-tinged sputum from the respiratory tract.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a teaching session for this patient regarding this occurrence? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

ANS: 2 Weight loss is generally caused by worsening of the disease or disease progression.

A patient diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which prescription does the nurse question for this patient? 1) Antibiotic therapy 2) Nonsteroidal anti-inflammatory agents 3) Oxygen by nasal cannula at 3-4 liters/minute 4) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents

ANS: 3 The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute. This amount of oxygen is too much for a patient with COPD because the patient's breaths are stimulated by a hypoxic drive and this disease process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure. Oxygen for this patient should be at a lower rate, such as 1-2 liters/minute, with close assessments of the patient's breathing status.

The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement indicates that additional teaching is needed? 1) "I can't get the influenza vaccine due to my allergy to eggs." 2) "I will get the influenza vaccine every year." 3) "I will get the pneumococcal vaccine every fall." 4) "I will get the pneumococcal vaccine as soon as I recover from this pneumonia."

ANS: 3 The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS.

The nurse is caring for a patient in a community clinic who wishes to quit smoking. The patient asks the nurse, "If I quit smoking, will my risk of lung cancer be the same as a nonsmoker?" Which is the best response by the nurse? 1) "No one knows for sure what the risk is for someone who quits smoking." 2) "Your risk of lung cancer will be equal to that of a nonsmoker." 3) "Your risk of lung cancer will decline if you quit, but it will remain higher than a nonsmoker's." 4) "Your risk of lung cancer will never drop because the damage has already been done."

ANS: 3 The risk for someone who quits is known to be dramatically less than for someone who continues to smoke.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is greater than 500 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

ANS: 3 Vaginal candidiasis is a complication that occurs when the patient's CD4+ count is greater than 500 cells/L.

A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus (HIV). The patient states, "I don't plan on giving up sex just because I am HIV positive." Based on this data, which is the priority nursing diagnosis for this patient? 1) Risk for Infection 2) Death Anxiety 3) Deficient Knowledge 4) Social Isolation

ANS: 3 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, "I don't plan on giving up sex just because I am HIV positive." The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners.

An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB). The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most appropriate response by the nurse? 1) "Different medication is used in the second PPD." 2) "The treatment for TB is six months of medication, and we want to make sure the first results of the first PPD were accurate." 3) "The first PPD was not interpreted in the correct time frame of 48-72 hours." 4) "There is an increased risk for a false-negative response for people who work in long-term care facilities. The two-step is recommended to accurately screen for TB."

ANS: 4 PPD testing is done in a two-step process for people who work in long-term care facilities because of the risk of false-negative responses.

The nurse is providing care to a patient newly diagnosed with asthma. When developing the patient's plan of care, which intervention would be most appropriate to promote airway clearance? 1) Provide adequate rest periods 2) Reduce excessive stimuli 3) Assist with activities of daily living 4) Place in Fowler position

ANS: 4 Placing the patient in Fowler position facilitates breathing and lung expansion, promoting airway clearance.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 250 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

ANS: 4 Severe bacterial infection is a complication that occurs when the patient's CD4+ is 350 and 200 cells/L.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of less than 200 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

ANS: 4 Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.

Which assessment finding supports the nurse's suspicion that a patient is experiencing chronic obstructive pulmonary disease (COPD)? 1) Dysrhythmias 2) Cyanotic nail beds 3) Clubbing of the fingers 4) Cough in the morning producing clear sputum

ANS: 4 The earliest-presenting symptom of COPD is coughing in the morning with clear sputum unless the patient develops an infection, in which case the sputum would become yellow or green in color.

The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this patient? 1) Herpes zoster 2) Sickle cell disease 3) Sick sinus syndrome 4) Tuberculosis

ANS: 4 The homeless patient who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this patient for TB.

Which patient should the nurse offer the opportunity for human immunodeficiency virus (HIV) testing during an annual physical examination? 1) A 66-year-old male patient 2) A 75-year-old female patient 3) An 8-year-old school-age child 4) An 18-year-old young adult patient

ANS: 4 The nurse offers HIV testing to all patients between the ages of 15 years and 65 years of age.

The nurse is planning care for the patient diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minute, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this patient? 1) Ineffective Coping 2) Ineffective Airway Clearance 3) Anxiety 4) Ineffective Breathing Pattern

ANS: 4 The patient's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the patient at this time.

The nurse is reviewing diagnostic and laboratory studies performed for an older adult patient with influenza. Which result should the nurse recognize as being consistent with influenza? 1) Increased BUN 2) Decreased sodium level 3) Fluid-filled lungs on chest x-ray 4) Decreased white blood cell count

ANS: 4 The white blood cell count of a patient with influenza will typically be decreased.

A nurse is caring for an older adult patient admitted to the hospital with pneumonia. The patient asks the nurse what can be done to decrease the risk for developing pneumonia in the future. Which response by the nurse is inappropriate? 1) "You should avoid alcohol." 2) "You can start by not smoking." 3) "You can get the pneumonia vaccination, which may help to decrease your risk in the future." 4) "You should drink a yogurt drink once a day that is supplemented with L. casei immunitas cultures."

ANS: 4 There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function.

The nurse is planning care for a patient diagnosed with influenza. Which intervention should the nurse include when planning this patient's care? 1) Placing a ventilator in the room 2) Notifying other departments of the diagnosis 3) Placing the patient in a negative air flow room 4) Placing droplet and contact precaution signs on the patient room door

ANS: 4 To prevent the spread of influenza, the patient is placed in a private room with signs for droplet and contact precautions. It is appropriate for the health-care workers to use appropriate PPE for these transmission-based precautions.

The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the patient makes which statement? 1) "Multiple drugs are necessary to develop immunity to tuberculosis." 2) "Multiple drugs are necessary because I became infected from an immigrant." 3) "Multiple drugs will be required as long as I am contagious." 4) "Multiple drugs are necessary because of the risk of resistance."

ANS: 4 Tuberculosis bacilli are likely to develop resistance to one drug, so multiple drugs must be used.

Place the progression of human immunodeficiency virus (HIV) in sequential order. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) AIDS 2) Death 3) Seroconversion 4) Viral transmission 5) Acute viral infection 6) Asymptomatic chronic infection

ANS: 435612

The nurse is providing care for a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which intervention is inappropriate to control the patient's breathing pattern? 1) Instruct in pursed-lip breathing 2) Teach visualization and meditation 3) Deep breathing and coughing every hour 4) Instruct in abdominal breathing

ANS: 3 Deep breathing and coughing should be done every two hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.

The student nurse is questioning the instructor about the different types of chemotherapeutic agents used to treat cancer. Which statement by the instructor best explains why lung cancers are less sensitive to antineoplastic agents than other types of cancers? 1) "Lung cancer cells have a low growth fraction, so they are less sensitive to antineoplastic agents." 2) "Lung cancer cells grow in a high-oxygen environment, so they are not very sensitive to antineoplastic agents." 3) "Lung cancer cells have been growing for a long time before detection, so they are less sensitive to antineoplastic agents." 4) "Lung cancer cells have a very erratic cell cycle, so they are not very sensitive to antineoplastic agents."

ANS: 1 Growth fraction is a ratio of the number of replicating cells to the number of resting cells. Antineoplastic drugs are much more toxic to tissues and tumors with high growth fractions. Breast and lung cancers have low growth fractions.

The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is in antiretroviral therapy. The patient reports nausea, fever, severe diarrhea, and anorexia. Which prescribed medication does the nurse anticipate in order to relieve the anorexia and to stimulate the patient's appetite? 1) Dronabinol (Marinol) 2) Abacavir (Ziagen) 3) Ciprofloxacin (Cipro) 4) Zidovudine (Retrovir, AZT)

ANS: 1 Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase patient appetite and promote weight gain.

The nurse is caring for a patient who is newly diagnosed with human immunodeficiency virus (HIV). The patient asks the nurse if there are ways to protect the patient's life partner from getting the HIV virus. After educating the patient, which statement indicates the need for further education? 1) "I know to use an oil-based lubricant to prevent spread of the disease to my partner." 2) "I can still kiss and hug my partner to show affection." 3) "I will not share my razor with my partner." 4) "I know I have to practice safer sex with my partner by using a latex condom."

ANS: 1 The nurse should educate the patient on methods that will decrease the risk of transmitting the HIV. The patient statement regarding the use of an oil-based lubricant requires further education. The patient should use only water-based lubricants, not oil based, such as petroleum jelly, which can result in condom damage.

Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care? 1) Washing the injury under running water 2) Squeezing the site to remove the patient's blood 3) Taking two or three drugs for 28 days 4) Consenting to a human immunodeficiency virus (HIV) test

ANS: 1 The priority nursing action in this situation is to wash the injury under running water.

The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this patient? 1) Ineffective Therapeutic Regimen Management 2) Deficient Knowledge 3) Ineffective Breathing Pattern 4) Risk for Injury

ANS: 1 The treatment regimen for tuberculosis requires that the patient take many medications, maintain nutrition, and be aware of potential side effects. Due to increased age and normal forgetfulness, this patient is at risk for ineffective treatment in the home.

An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, for which potential risk should the nurse include when planning care for this patient? 1) Pneumothorax 2) Pneumonia 3) Renal failure 4) Septicemia

ANS: 1 This patient was foreign-born, a risk factor for tuberculosis (TB), and has the classic symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this child is at risk for pneumothorax.

The nurse is providing care to a pediatric patient who is HIV-positive. The patient's mother is describing the child's current condition and activities to the nurse. Which parental statement indicates that the child may require further intervention? 1) "My child seems somewhat isolated and doesn't have any real friends." 2) "My child has a good appetite and eats regular meals." 3) "My child hasn't shown any sign of infection." 4) "My child attends school and doing well in class."

ANS: 1 This statement indicates that the patient is not adequately coping with the current situation and requires further assessment and/or intervention by the nurse.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is less than 200 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

ANS: 1 Toxoplasmosis is a complication that occurs when the patient's CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS).

The nurse is providing care to an infant in the emergency department (ED). Initial assessment indicates that the infant is experiencing an asthma attack. The infant is unresponsive to medication and a chest x-ray reveals a foreign body partially obstructing the airway. While placing an oxygen mask on the infant, the nurse notes a total obstruction of the airway. Which nursing action is appropriate? 1) Attempt to clear the obstruction by delivering back blows and chest thrusts. 2) Attempt to clear the obstruction by delivering back blows. 3) Attempt to clear the obstruction by delivering back blows and abdominal thrusts. 4) Attempt to clear the obstruction by delivering abdominal thrusts.

ANS: 1 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction include back blows and chest thrusts in an infant; therefore, the appropriate action for the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in older children.

A patient asks why asthma medication is needed even though the patient's last attack was several months ago. Which response by the nurse is appropriate? 1) "The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack." 2) "The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him." 3) "The medication is still needed to decrease inflammation in your airways and help prevent an attack." 4) "The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it."

ANS: 3 Effective treatment of asthma includes long-term treatment to prevent attacks and decrease inflammation, as well as short-term treatment when an attack occurs.

A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement when providing direct care? 1) Droplet 2) Reverse 3) Standard 4) Contact

ANS: 3 Health-care workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the health-care professionals treat all patients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids.

The nurse is reviewing discharge instructions with a patient who is newly diagnosed with asthma. Which patient statement indicates a need for further teaching? 1) "I need to rinse my mouth after every use of my inhaler." 2) "I need to take my Singulair at least one hour before I eat." 3) "I can resume my ephedra when I return home." 4) "Because I am on theophylline, I will need to have therapeutic blood levels drawn."

ANS: 3 Herbal preparations that include atropa belladonna (the natural form of atropine) or ephedra (also called ma huang), an herb that contains ephedrine, should not be used, as they can interact with prescribed medications, indicating a need for further teaching.

The nurse is providing care to a patient admitted after experiencing an acute asthma attack. Which assessment findings indicate the need for immediate intervention by the nurse? 1) Retractions and fatigue 2) Tachycardia and tachypnea 3) Inaudible breath sounds 4) Diffuse wheezing and the use of accessory muscles when inhaling

ANS: 3 Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air movement into and out of the lungs is taking place. Therefore, this set of symptoms represents the most urgent need, which is immediate intervention by the nurse to open up the lungs with drug management to prevent total respiratory failure.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient reports night sweats. Which is the most likely reason for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

ANS: 3 Night sweats are caused by a mycobacterial infection.

An older adult patient diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate? 1) Ineffective Airway Clearance 2) Impaired Tissue Perfusion 3) Ineffective Breathing Pattern 4) Activity Intolerance

ANS: 3 Not enough information is provided to determine whether the patient has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.

The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does the nurse anticipate for this patient? 1) Night sweats 2) Swollen lymph nodes 3) Cough 4) Hemoptysis

ANS: 3 Presenting symptoms of tuberculosis in the older adult are often vague and include coughing, weight loss, diminished appetite, and periodic fevers.

A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease. Which nursing intervention is most appropriate for this patient? 1) Administer the medication with meals to reduce gastrointestinal side effects 2) Record a baseline visual examination before initiating therapy 3) Administer the medication on an empty stomach 4) Administer the medication by deep intramuscular injection into a large muscle mass

ANS: 3 Rifampin is an oral antituberculosis medication that should be administered on an empty stomach.

The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient's diagnosis? 1) Cough reflex 2) Filtration of air 3) Alveolar macrophages 4) Mucociliary clearance system

ANS: 3 Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria and often fail as a result of cigarette smoking.

A male Hispanic patient has had a lung biopsy. The results indicate a poor prognosis for the patient. The family is at the patient's bedside and begins to moan and cry loudly. The health-care provider has told the nurse that he needs to have the consent form signed for surgery. The patient has asked the nurse to allow the family private time. What should the nurse do at this time? 1) Ask the family to come back later 2) Have the doctor get the consent with the family present 3) Provide the patient and family privacy 4) Take the patient to another room

ANS: 3 As the patient advocate, the nurse would allow this family to bond according to their customs.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 300 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

ANS: 3 Stage 2 is documented for a patient with a CD4+ count of 200-499 cells/L.

Which immunization should the nurse encourage for a patient who is diagnosed with Stage 2 human immunodeficiency virus? 1) Measles, mumps, and rubella (MMR) vaccine 2) Oral polio vaccine (OPV) 3) Influenza vaccine 4) Varicella vaccine

ANS: 3 The influenza vaccine is not a live virus vaccine and is recommended annually, early in the flu season, for patients with HIV.

The nurse is providing care to a patient diagnosed with chronic obstruction pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this patient? 1) Tachycardia 2) Cough 3) Barrel chest 4) Wheezing

ANS: 3 Barrel chest occurs because the lungs are chronically overinflated with air, so the rib cage stays partially expanded.

A nurse is performing an admission assessment on a patient with symptoms that indicate human immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting HIV? 1) "Has your partner been experiencing these symptoms?" 2) "When was your first sexual experience?" 3) "Have you had any fever, diarrhea, or chills over the last 48 hours?" 4) "Have you ever experimented with intravenous drugs?"

ANS: 4 One risk factor for contracting HIV is the use of intravenous recreational drugs. This question is appropriate to determine the patient's risk for HIV.

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). A nursing diagnosis for this patient is Imbalanced Nutrition: Less than Body Requirements. Which intervention is appropriate for this nursing diagnosis? 1) Encourage a diet high in protein and fats 2) Keep snacks to a minimum 3) Encourage carbohydrate-rich foods to provide needed calories for energy 4) Suggest the patient eat three meals per day to maintain energy needs

ANS: 1 A diet high in protein and fats without excess carbohydrates is recommended to minimize carbon dioxide production during metabolism. Frequent small meals help maintain intake and reduce fatigue associated with eating.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient presents with a fever without other notable symptoms. Which is the most likely cause of this data? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

ANS: 1 A fever is caused by infection.

The nurse is assessing a patient who is diagnosed with human immunodeficiency virus (HIV) who presents with a rash. Which assessment question is most appropriate? 1) "Are you taking Bactrim?" 2) "Have you recently used a new soap?" 3) "What have you eaten in the last few days?" 4) "Did you have unprotected sex within the last week?"

ANS: 1 A new onset rash for a patient diagnosed with HIV is often a delayed reaction to a prophylactic antibiotic, such as Bactrim. This question is the most appropriate.

The nurse is instructing a patient who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this patient's teaching? 1) Take no more than the prescribed number of doses each day. 2) Rinse the mouth after taking this medication. 3) Take on an empty stomach. 4) Take with meals or a full glass of water.

ANS: 1 Appropriate teaching for a patient prescribed ipratropium bromide (Atrovent) includes only taking the prescribed number of doses each day to prevent a drug overdose.

The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a patient with pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the nurse include in this patient's plan of care? 1) Perform chest percussion every four hours and prn 2) Administer the pneumococcal vaccine prior to discharge 3) Limit fluid intake to 1,000 mL per day 4) Provide the patient with smoking cessation education

ANS: 1 Chest percussion can help clear secretions.

During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which diagnosis presents with this assessment finding? 1) Pneumonia 2) Cystic fibrosis 3) Bronchospasm 4) Interstitial edema

ANS: 1 Coarse crackles are often auscultated for patients diagnosed with pneumonia.

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which observation would indicate that care provided to this patient has been effective? 1) Patient conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading. 2) Patient needs assistance with morning care and meals due to shortness of breath. 3) Patient states family members are discussing admission to a nursing home for continuing care. 4) Patient leaves hospital unit to smoke outside four times a day.

ANS: 1 Evidence that care provided to a patient with COPD was successful would be the patient conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the patient's ability to maintain adequate oxygenation and perform activities of daily living.

The nurse is discharging a pediatric patient who was recently diagnosed with acquired immunodeficiency syndrome (AIDS). When discussing appropriate health promotion activities for this child, which immunization is contraindicated? 1) Varicella vaccine 2) Haemophilus influenzae type B (HIB conjugate vaccine) 3) Hepatitis B vaccine (hep B) 4) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

ANS: 1 A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease.

The nurse is reviewing the laboratory values of a patient who is newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which values should be reported to the patient's health-care provider? Select all that apply. 1) CD4 cell count 1,100/mm3 2) T4 cell count 150 3) CD4 lymphocytes 12% 4) Viral load 11,500 copies/mL 5) WBC 6,500

ANS: 2, 3, 4 The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3 . All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range.

The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse? 1) "The doctor prefers this test." 2) "To rule out the possibility that your problems are caused by pneumonia." 3) "It is more specific in diagnosing your condition." 4) "Why are you concerned about this test?"

ANS: 3 Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors in the lung parenchyma and pleura. It also is done before needle biopsy to localize the tumor. In addition, CT scanning can detect distant tumor metastasis and evaluate tumor response to treatment.

The nurse is planning care for a pediatric patient diagnosed with human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric patient. Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply. 1) Administering tuberculosis skin tests every six months 2) Teaching proper food-handling techniques to the family 3) Instructing on the importance of consuming ample fresh fruits and vegetables 4) Assessing the health status of all visitors 5) Monitoring hand-washing techniques used by the family

ANS: 2, 4, 5 A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection.

The nurse is assessing several patients at a community clinic. Which patient should not receive an annual influenza vaccination? 1) A 65-year-old woman 2) A 3-year-old with cystic fibrosis 3) A 35-year-old man with a severe allergy to eggs 4) A 25-year-old pregnant woman at 20 weeks' gestation

ANS: 3 A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the vaccine contains eggs and it is not recommended.

An older adult patient is admitted with pneumonia. Which manifestation is unexpected during the nurse's initial assessment? 1) Lethargy 2) Hemoptysis 3) Increased appetite 4) Increased respirations

ANS: 3 A decreased, not increased, appetite is anticipated when providing care to a patient diagnosed with pneumonia.

The nurse makes a home visit to a patient recovering from complications related to influenza. Which patient statement indicates the need for further intervention by the nurse? 1) "I went back to work." 2) "I'm eating healthy foods now." 3) "I continue to wake up coughing at night." 4) "I have not had chills since I left the hospital."

ANS: 3 A patient who continues to be awoken during the night because of coughing may require further intervention by the nurse.

The nurse is teaching a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which patient statement indicates a need for further teaching? 1) "I should inhale by sniffing." 2) "I should avoid aerosol sprays." 3) "I should limit my fluid intake to 1-1.5 quarts daily." 4) "I should get a flu vaccine every year."

ANS: 3 Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about drinking 1-1.5 quarts daily indicates the need for further teaching.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Which patient statement indicates the need for further education regarding HIV management? 1) "I will eat small, frequent meals." 2) "I will use condoms for every sexual encounter." 3) "I will take my medications when others can see me, even if that means taking them late." 4) "I will ask my spouse to clean the cat litter to decrease my risk for developing toxoplasmosis."

ANS: 3 Adherence is essential in managing the progression of the disease. Taking medications as ordered and at the same time each day (plan administration times around activities of daily living) helps maintain therapeutic drug levels and decreases the risk of viral resistance developing.

The nurse is caring for an older adult patient who is very thin and emaciated. The patient reports new onset of shortness of breath. A chest x-ray reveals a spot on the lungs that the physician believes is an inoperable lung cancer. Due to the patient's poor nutritional status, chemotherapy is not an option. The health-care provider also believes that the location of the cancer would make radiation therapy unsuccessful. In advocating for this patient, what should the nurse encourage the health-care team to do? 1) Provide palliative care to keep the patient comfortable without diagnostic testing 2) Perform any procedure necessary to diagnose the patient properly 3) Promote the use of blood tests to diagnose the suspected cancer 4) Determine the patient's and family's wishes regarding diagnostic testing

ANS: 4 An older adult emaciated patient may have few options for treatment of cancer, if confirmed. The best course of treatment may be palliative care, but it is the choice of the patient and family that should direct the plan of care and choices of diagnostic testing.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has shortness of breath when walking, but no problems breathing at rest. Which is the most likely cause for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

ANS: 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.

A patient with the flu is experiencing tachypnea. What intervention is inappropriate to address in the nursing diagnosis of Ineffective Breathing Pattern related to the flu? 1) Maintain adequate hydration 2) Keep the head of the bed elevated 3) Teach the patient coughing, deep breathing, and hydration 4) Prepare the patient for the possibility of a tracheostomy tube.

ANS: 4 Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance.

Friends of a patient hospitalized with asthma would like to bring the patient a gift. Which gift would the nurse recommend for this patient? 1) A basket of flowers 2) A stuffed animal 3) Fruit and candy 4) A book

ANS: 4 Objects void of irritants, such as a book, would be an appropriate gift.