MedSurg2 Final Exam Practice Questions

Place the chest tube in sterile water. If the client is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, place the end of the chest tube in sterile water. Reattaching the chest tube to the drainage system is a source for infection. Do not clamp the chest tube during transport.

A nurse is transporting a client with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse?

Sedation Antihistamines are the major class of medications prescribed for the symptomatic relief of allergic rhinitis. The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines.

A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines?

Primary infection The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection, or stage 1. Initially, there is a period during which those who are HIV positive test negative on the HIV antibody blood test, although they are infected and highly infectious, because their viral loads are very high.

A patient had unprotected sex with an HIV-infected person and arrives in the clinic requesting HIV testing. Results determine a negative HIV antibody test and an increased viral load. What stage does the nurse determine the patient is in?

Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Jabs the autoinjector into the outer thigh at a 90-degree angle To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injecting end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.

After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action?

Reed-Sternberg cells.

The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?

Chest tube drainage, 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse must notify the primary provider if drainage is ≥150 mL/hr.

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?

10:00 AM Mild and moderate reactions begin within 2 hours of exposure.

The nurse tells the client that if exposure to an allergen occurs around 8:00 AM, then the client should expect a mild or moderate reaction by what time?

Intradermal

The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?

a delayed-type hypersensitivity that is mediated by T cells Contact dermatitis is a delayed-type hypersensitivity response that can occur 24 to 72 hours after exposure to an allergen.

The parents of a child with contact dermatitis are asking questions about the reaction within the immune system. What description regarding contact dermatitis as a type IV hypersensitivity reaction is accurate?

He is likely to have lesions on his skin, mouth, or GI tract. The lesions of KS can be found on the skin and in the oral cavity, gastrointestinal tract, and the lungs. More than 50% of people with skin lesions also have gastrointestinal lesions. It is linked with a herpes virus and can often be painless, especially in early stages. Men who have sex with men are at a higher risk of developing KS.

A 48-year-old man who has been HIV positive for 6 years has just learned that he has been diagnosed with Kaposi sarcoma (KS). Which fact most accurately conveys an aspect of his diagnosis?

"Although AIDS is an immune deficiency, your child's condition is different from AIDS." Primary immune deficiencies should be not be confused with AIDS. They are not the same condition. In addition, a primary immune disorder does not increase the child's risk for developing AIDS later in life. Primary immune deficiency diseases are serious, but they are rarely fatal and can be controlled. Testing will reveal the evidence of a primary immune disease, not AIDS. AIDS is classified as a secondary immunodeficiency.

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?

aluminum hydroxide The nurse should assess the client for possible use of antacids such as aluminum hydroxide. Clients should take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.

A client being treated for iron deficiency anemia with ferrous sulfate continues to be anemic despite treatment. The nurse should assess the client for use of which medication?

The lung has fully expanded. Cessation of fluid fluctuation in the tubing can mean one of several things: the lung has fully expanded and negative intrapleural pressure has been reestablished; the chest tube is occluded; or the chest tube is not in the pleural space.

A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. How should the nurse interpret this finding?

Apply a dressing over the wound and tape it on three sides The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

A client has a sucking stab wound to the chest. Which action should the nurse take first?

Oxygen toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

Only use the nasal spray for 3 to 4 days once every 12 hours Adrenergic agents, which are vasoconstrictors of mucosal vessels, are used topically in nasal (oxymetazoline [Afrin]) and ophthalmic (brimonidine [Alphagan P]) formulations in addition to the oral route (pseudoephedrine [Sudafed]). The topical route (drops and sprays) causes fewer side effects than oral administration; however, the use of drops and sprays should be limited to a few days to avoid rebound congestion.

A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"?

Monitor the client's vital signs. Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding To prevent aspiration, the client should not receive food or fluids until the gag reflex returns. Although a small amount of blood in the sputum is expected if a biopsy was performed, frank bleeding indicates hemorrhage and should be reported to the physician immediately. Vital signs should be monitored after the procedure, because a vasovagal response may cause bradycardia, laryngospasm can affect respirations, and fever may develop within 24 hours of the procedure. To reduce the risk of aspiration, the client should be placed in a semi-Fowler's or side-lying position after the procedure until the gag reflex returns. The client does not lose the voice after a bronchoscopy, so voice should not be used as a gauge for resuming food and fluid intake.

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply.

6 weeks Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels.

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time?

Tracheal ischemia Tracheal bleeding Pressure necrosis Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 20 and 25 mm Hg. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.

A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 mm Hg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply.

Take prescribed albuterol (Ventolin) before performing postural drainage When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (e.g., albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. The client is also to lay in each position for 10 to 15 minutes.

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:

Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Enzyme-linked immunosorbent assay (ELISA) The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. If the ELISA is positive twice then the Western Blot test is run.

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?

"The ELISA test gives some false positives, but the Western blot confirms you don't have HIV." Both the ELISA (or EIA) and Western blot tests search for antibodies in HIV infection. The Western blot is more specific and is used to confirm results from a positive ELISA. If the Western blot is negative, the client does not have HIV.

A client was tested for HIV and received a positive result from the enzyme-linked immunosorbent assay (ELISA) followed by a negative Western blot test. The client asks the nurse what this means. What is the nurse's best response?

Trimethoprim/Sulfamethoxazole To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed.

A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client take for the treatment of this infection?

remove air from the pleural space After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery: one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid.

A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to:

Remove the gray safety-release cap Inject the black tip into the outer thigh Massage the injection area Call the emergency medical response number (911)

A client with a history of anaphylactic reactions to insect stings has just been stung by a wasp. Place the steps in the correct order that the client will follow for self-administration of an EpiPen. Use all options.

84 mm Hg In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

foscarnet The drug foscarnet is used to treat CMV retinitis and is given by controlled IV infusion. Alterations in renal function, fever, nausea, anemia, numbness in the extremities, and diarrhea are the most common adverse effects.

A client with cytomegalovirus (CMV) infection reports difficulty seeing. The physician determines that the client is developing CMV retinitis. What medication does the nurse anticipate the client will receive for this?

"I will dilute the medication and drink it with a straw." Liquid iron supplements should be diluted and taken through a straw to help decrease the likelihood of staining the teeth.Iron causes constipation, not diarrhea.It is normal for the client's stools to become dark during iron therapy.Iron does not cause bleeding gums.

A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which statement indicates the client has adequate knowledge?

Suction the client's artificial airway A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

0.5 An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. Clients with respiratory disorders are given oxygen therapy only to increase the partial pressure of oxygen (PaO2) back to the patient's normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve, arterial hemoglobin at these levels is 80% to 98% saturated with oxygen; higher FiO2 flow values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation. The ideal oxygen source is room air FIO2 0.21.

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting?

shock Complications of respiratory acidosis include shock and cardiac arrest.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

Below 200 cells/μL

A diagnosis of acquired immunodeficiency syndrome (AIDS) is identified when the CD4+ T cell count reaches which level?

February 15 The full benefit of fluticasone (Flonase) should occur no later than 14 days after the first dose. The drug was initiated on February 2. Thirteen days later would be February 15.

A health care provider prescribed fluticasone for a client with a severe case of allergic rhinitis. The client took a first dose on February 2. What is the latest date by which the drug will be fully effective?

Auscultate the lung for adventitious sounds

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Blistering Manifestations associated with allergic contact dermatitis related to latex include blisters, pruritus, erythema, swelling, and crusting or other skin lesions.

A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. What manifestation would the nurse most likely exhibit?

AIDS AIDS, the most common secondary disorder, is perhaps the best-known secondary immunodeficiency disorder. It results from infection with the human immunodeficiency virus (HIV). DAF refers to lysis of erythrocytes due to lack of decay-accelerating factor (DAF) on erythrocytes. CVID is a disorder that encompasses various defects ranging from IgA deficiency (in which only the plasma cells that produce IgA are absent) to severe hypogammaglobulinemia (in which there is a general lack of immunoglobulins in the blood). Severe combined immunodeficiency disease (SCID) is a disorder in which both B and T cells are missing.

A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?

Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

using the minimal-leak technique with cuff pressure less than 25 cm H2O

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7." Pursed-lip breathing is a technique used to prolong exhalation by propping the airways open and promoting the removal of trapped air and carbon dioxide.

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.

Milk Eggs Shrimp

A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply.

early fall Ragweed has a seasonal occurrence in early fall. Tree pollen and mold spore levels rise in the spring. Rose and grass pollen is prevalent in the summer.

A nurse is teaching a client who is allergic to ragweed. What season does the nurse advise the client to expect an increase in symptoms?

Dyspnea, bronchospasm, and/or laryngeal edema Severe systemic, anaphylactic reactions have an abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?

2:00 PM Rebound reactions can occur from 4 to 10 hours after an initial allergic reaction. Therefore the patient needs to be assessed from 2:00 PM to 8:00 PM.

A patient received epinephrine in response to an anaphylactic reaction at 10:00 AM. The nurse knows to observe the patient for a "rebound" reaction that may occur as early as:

"The full benefit of the medication may take up to 2 weeks to be achieved." Patients must be aware that full benefit of corticosteroid nasal sprays may not be achieved for several days to 2 weeks.

A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?

Angiotensin-converting enzyme (ACE) inhibitor

A patient was seen in the clinic for hypertension and received a prescription for a new antihypertensive medication. The patient arrived in the emergency department a few hours after taking the medication with severe angioedema. What medication prescribed may be responsible for the reaction?

Active substance abuse Depression Lack of social support

A patient with HIV has been on antiretroviral therapy (ART) for 6 months. The patient comes to the clinic with home medications and the nurse observes that there are too many pills in the container. What does the nurse know about the factors associated with nonadherence to ART? (Select all that apply.)

Serum IgE level Normally, serum IgE levels are below 1.0 mg/mL. The patient's level is significantly elevated suggesting allergic reaction.

A patient with a history of allergies comes to the clinic for an evaluation. The following laboratory test findings are recorded in a patient's medical record: Total serum IgE levels: 2.8 mg/mL White blood cell count: 5,100/cu mm Eosinophil count: 4% Erythrocyte sedimentation rate: 20 mm/h The nurse identifies which result as suggesting an allergic reaction?

Rh-hemolytic disease A type II hypersensitivity, or cytotoxic, reaction, which involves binding either the IgG or IgM antibody to a cell-bound antigen, may lead to eventual cell and tissue damage. The reaction is the result of mistaken identity when the system identifies a normal constituent of the body as foreign and activates the complement cascade. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia.

An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred?

"It's discouraging to know that my breast milk can pass on HIV to my baby." Transmission from mother to infant is the most common way that children become infected with HIV. HIV may be transmitted from infected women to their offspring in utero, during labor and delivery, or through breast-feeding. Ninety percent of infected children acquired the virus from their mother. The risk of transmission of HIV from mother to infant is approximately 25%, with estimates ranging from 15% to 45% depending on what country they live in.

As part of her prenatal education, a 29-year-old woman who is pregnant with her first child is receiving teaching from her primary care provider. Which statement by the woman reflects an accurate understanding of HIV transmission?

Anaphylactic (type 1) The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases.

At an office birthday party, one of the executives ate a piece of cake that he was unaware had been made with peanut oil. He begins wheezing, with an inspiratory stridor and air hunger. The occupational health nurse is called to the office. The nurse recognizes he is suffering from which type of hypersensitivity?

Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation

For a client with an endotracheal (ET) tube, which nursing action is the most important?

Lymphocyte

HIV is harbored within which type of cell?

biopsy

Kaposi sarcoma (KS) is diagnosed through

The female condom The female condom, the first barrier method controlled by women, is the only proven, effective method to prevent the transmission of HIV and sexually transmitted infections (STI).

Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives?

Circulatory hypoxia Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Pneumocystis pneumonia Pneumocystic pneumonia (PCP) is one of the first and most common opportunistic infections associated with AIDS. It may be present despite the absence of crackles. If untreated, PCP progresses to cause significant pulmonary impairment and respiratory failure.

The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurrence) in persons with AIDS?

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?

Assist with chest physiotherapy every 2 to 4 hours The nurse should include interventions such as assisting with and/or performing chest physiotherapy every 2 to 4 hours to prevent stasis of secretions, assist the client to attain the semi- or high Fowler's position to facilitate breathing and airway clearance, allow for frequent rest periods to prevent excessive fatigue, and maintain a fluid intake of at least 3 liters per day unless contraindicated.

The nurse identifies a nursing diagnosis of ineffective airway clearance related to Pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care?

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

5 to 10 minutes

The nurse is caring for a client experiencing an anaphylactic reaction. The nurse prepares for the maximum intensity of histamine response to occur within which time frame?

returning to the nursing unit with two chest tubes The nurse should plan for the client to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.

The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client

Routinely deflating the cuff Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?

Cytotoxic Cytotoxic hypersensitivity occurs when the body mistakenly identifies a part of the body as foreign, as in myasthenia gravis, where the body mistakenly identifies normal nerve endings as foreign.

The nurse is caring for a client with myasthenia gravis. The nurse generates a plan of care for the client based on which type of hypersensitivity reaction?

Rhinitis medicamentosa Rhinitis medicamentosa is a rebound reaction from overuse of sympathomimetic nose drops or sprays that worsen the congestion, causing the client to use more of the medication, thereby leading to more nasal congestion.

The nurse is completing the intake assessment of a client new to the allergy clinic. The client states that he was taking nose drops six times a day to relieve his nasal congestion. The nasal congestion increased, causing him to increase his usage of the nasal spray to eight times a day. But again the congestion worsened. The nurse communicates to the health care provider that the client experienced

The client has converted from HIV infection to AIDS AIDS is the end stage of HIV infection. Certain events establish the conversion of HIV infection to AIDS: a markedly decreased T4 cell count from a normal level of 800 to 200/mm3 and the development of certain cancers and opportunistic infections.

The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse?

blood breast milk semen vaginal secretions

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply.c

plant pollen Plant pollen (from trees, grass, and other plants) causes the most common form of allergic rhinitis, which is known as hay fever.

The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response?

intranasal cromolyn sodium

The nurse is teaching a client with allergic rhinitis about medications. What medication is a mast cell stabilizer used in the treatment of allergic rhinitis?

IgE-mediated hypersensitivity A type I, IgE-mediated hypersensitivity can cause severe reaction symptoms such as laryngeal edema and bronchospasm.

The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema?

fexofenadine Fexofenadine, an antihistamine, is used to treat allergic rhinitis.

The nurse is working with a client with allergic rhinitis. What medication does the nurse anticipate will be prescribed to treat the allergic rhinitis?

intradermal testing The diagnosis of anaphylaxis risk is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended.

The nurse is working with a client with allergies. What will the nurse use to confirm allergies and decrease the risk of anaphylaxis?

Chronic diarrhea Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of AIDS can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.

The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is:

Assess pulse and blood pressure The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:

The patient is hypoxic from suctioning Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

lack of symptoms Chronic viruses have a period of latency, or dormancy, where the virus is not replicating and the client will not have symptoms. Specific to HIV, the three phases experienced are primary infection phase, chronic asymptomatic or latency phase, and overt AIDS phase. Mononucleosis-like symptoms and high viral loads are seen in the primary infection phase, whereas the AIDS phase is characterized with opportunistic infections.

What is a characteristic indicator that an individual is in the latent phase of a chronic viral infection such as human immunodeficiency or herpes zoster viruses?

Poor helper T-cell function HIV infects a limited number of cell types in the body, including a subset of lymphocytes called CD4+T lymphocytes (also known as T-helper cells or CD4+T cells). The CD4+T cells are necessary for normal immune function. Among other functions, the CD4+T cell recognizes foreign antigens and helps activate antibody-producing B lymphocytes. The phagocytic function of monocytes and macrophages is also influenced by CD4+T cells.

What is the main effect of HIV infection?

Penicillin Penicillin is the most common pharmacological cause of anaphylaxis and accounts for about 75% of fatal anaphylactic reactions in the United States each year.

What is the most common cause of anaphylaxis?

Vaginal and anal intercourse The most common method of transmission of HIV is from vaginal and anal sexual intercourse. Only 25% of newly diagnosed HIV infections are in those individuals who share needles. Transmission from mother to infant is the most common way children are affected but not the most common overall. Occupation exposure and blood transfusion are the least common of the choices provided

What is the most common mode of transmission of HIV?

Use a sterile catheter each time the client is suctioned.

What should the nurse do when suctioning a client who has a tracheostomy tube 3 days following insertion?

type II (cytolytic, cytotoxic) hypersensitivity reaction ABO (blood type) incompatibility, such as from an incompatible blood transfusion, is a type II hypersensitivity reaction.

When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching and there is a rise in the client's temperature. The nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction with a blood transfusion?

Dorsal aspect of the hand

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likely expect to find irritation at which area?

"If I am pregnant, I should take half the dose." Antihistamines are contraindicated during the third trimester of pregnancy, in nursing mothers and newborns, in children and elderly people, and in patients whose conditions may be aggravated by muscarinic blockade (e.g., asthma, urinary retention, open-angle glaucoma, hypertension, prostatic hyperplasia).

When evaluating a client's knowledge about use of antihistamines, what statement indicates further education is required?

HIV-1 is more prevalent than HIV-2 subtypes Two HIV subtypes have been identified: HIV-1 and HIV-2. HIV-1 mutates easily and frequently, producing multiple substrains that are identified by letters from A through O. HIV-2 is less transmittable, and the interval between initial infection with HIV-2 and development of AIDS is longer. HIV-1 is more prevalent in the United States and in the rest of the world. Western Africa is the primary site of infection with HIV-2.

When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic?

Histamine

Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?

Past substance abuse

Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?

client with AIDS, fever, diarrhea, and significant involuntary weight loss A client diagnosed with wasting syndrome (an AIDS-defining illness) would have chronic fever, diarrhea, and a significant involuntary weight loss (usually more than 10%) without an opportunistic infection.

Which client would be diagnosed with wasting syndrome?

Increase in compliance A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing, decreased lung compliance, and a plugged airway tube cause an increase in peak airway pressure.

Which finding would indicate a decrease in pressure with mechanical ventilation?

Leukotrienes Leukotrienes are a group of chemical mediators that initiate the inflammatory response.

Which group of mediators initiates the inflammatory response?

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.

Which is a potential complication of a low pressure in the endotracheal tube cuff?

Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen.

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

activated partial thromboplastin time (APTT) APTT is used to measure the clotting status when the client is receiving heparin.The INR and PT are used to measure clotting status in a client receiving warfarin.

Which laboratory test should be monitored closely by the nurse while the client is receiving heparin therapy?

Nonrebreathing mask

Which oxygen administration device has the advantage of providing a high oxygen concentration?

They are localized to the area of exposure, usually the back of the hands

Which statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex?

K-Y jelly K-Y jelly is water-based and will provide lubrication while not damaging the condom. The oils in skin lotion and petroleum jelly, and baby oil, will cause a latex condom to break.

Which substance may be used to lubricate a condom?

Hapten

Which term refers to an incomplete antigen?

Complete protein antigen

While interviewing a client with an allergic disorder, the client tells the nurse about an allergy to animal dander. The nurse knows that animal dander is what type of substance?

15% to 40% Eosinophils, which are granular leukocytes, normally make up 0% to 3% of the total number of WBCs. A level between 5% and 15% is nonspecific but does suggest allergic reaction. Higher percentages of eosinophils are considered to represent moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and may be found in patients with allergic disorders.

While monitoring the patient's eosinophil level, the nurse suspects a definite allergic disorder when seeing an eosinophil value of what percentage of the total leukocyte count?