NCLEx / med-surg

Cancer - Nursing Priorities

CANCER C-Comfort A-Altered Body Image N-Nutrition C-Chemotherapy E-Evaluate response to meds R-Respite for caretakers These are the top nursing priorities for a patient with CANCER

An 82-year-old client has returned to have a left knee replacement a year after having their right knee replaced. While inserting an IV the client states "I don't think I was awake last time, I think they put my IV in after I was asleep." Having an understanding of general anesthesia which of the following is the best response for the nurse to give the client? "Did they have issues placing your IV last time?" "That isn't possible at all, they would never administer anesthesia without an IV" "Anesthesia can make you forget, that is completely normal" "I think I better look in the chart from your last visit, maybe there was an issue I should know about"

"Did they have issues placing your IV last time?" General anesthesia can cause amnesia in clients, especially the elderly. ✅"Anesthesia can make you forget, that is completely normal" General anesthesia can cause amnesia in clients, especially the elderly. "That isn't possible at all, they would never administer anesthesia without an IV" Although this is true it is not the best response to your client regarding anesthesia and amnesia. "I think I better look in the chart from your last visit, maybe there was an issue I should know about" The client is displaying the results of amnesia from general anesthesia 02.02 General Anesthesia

A nurse is providing teaching about lifestyle changes to a client who had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? "I should eat foods high in saturated fat." "Before taking my medication, I will count my radial pulse rate." "I will exercise once per week for an hour at the health club." "I will stop taking my medication when my blood pressure is within a normal range."

"I should eat foods high in saturated fat." The client should consume foods low in saturated fat to decrease further atherosclerotic plaque development in her arteries. ✅"Before taking my medication, I will count my radial pulse rate." A beta blocker will induce bradycardia. The client should take her pulse rate for 1 min before self-administration. "I will exercise once per week for an hour at the health club." The client should exercise at least three to five times per week for a minimum of 30 min each. "I will stop taking my medication when my blood pressure is within a normal range." The client should not discontinue the prescribed medication because adherence to a medical regimen when taking medication will help to prevent complications following a myocardial infarction. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

While preparing your client for surgery the client tells you how afraid they are to feel pain while under anesthesia. Based on your knowledge of general anesthesia which of the following is the most appropriate response to the client? "I understand your concern but pain is not an issue with general anesthesia. If you would like I could request the anesthesia team come and speak with you again" "I see you signed your consent form, typically we request that if the client has any concerns regarding anesthesia or surgery, they speak with the surgeon before signing the consent form" "I understand your concern, there is always a component of pain with surgery but with anesthesia you will not feel what is happening. It is possible you might have pain when you wake up" "You will definitely feel pain with surgery but the anesthesia will make sure you are unconscious during the entire process. You also will have a muscle relaxant and you will not be breathing on your own"

"I understand your concern but pain is not an issue with general anesthesia. If you would like I could request the anesthesia team come and speak with you again" This is not an appropriate response to give your client and does not provide them support. ✅"I understand your concern, there is always a component of pain with surgery but with anesthesia you will not feel what is happening. It is possible you might have pain when you wake up" You are giving your client correct information regarding their comment while providing support. "I see you signed your consent form, typically we request that if the client has any concerns regarding anesthesia or surgery, they speak with the surgeon before signing the consent form" This is not an appropriate response to give your client who has concerns. "You will definitely feel pain with surgery but the anesthesia will make sure you are unconscious during the entire process. You also will have a muscle relaxant and you will not be breathing on your own" While this is technically correct, you will cause more anxiety than comfort with this response. 02.02 General Anesthesia

A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? "I will use a soft toothbrush or foam swab for oral care." "I will use lemon and glycerine swabs after meals." "I will remove my dentures except while eating." "I will rinse my mouth frequently with hydrogen peroxide solution."

"I will use a soft toothbrush or foam swab for oral care." The nurse should instruct the client to provide oral care with a soft toothbrush or foam swab to prevent additional trauma or bleeding to oral tissues. ✅"I will use lemon and glycerine swabs after meals." The nurse should identify that this client statement indicates a need for further teaching. The nurse should instruct the client who has stomatitis to avoid the use of lemon-glycerine swabs because they cause drying and irritation of the mucous membranes. "I will remove my dentures except while eating." The nurse should instruct the client to remove dentures unless needed for eating due to potential irritation of the dentures on the oral cavity . "I will rinse my mouth frequently with hydrogen peroxide solution." The nurse should instruct the client to rinse the mouth out with a hydrogen peroxide, warm saline, or baking soda solution every 2 to 3 hr to promote comfort and healing. RN Learning System Medical-Surgical: Final Quiz

A nurse is providing teaching to a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include? "It is necessary to take this medication for the rest of your life to prevent recurrence." "Your provider will monitor your thyroid function while you are taking this medication." "You should take this medication on an empty stomach." "It is recommended to take this medication with an antacid."

"It is necessary to take this medication for the rest of your life to prevent recurrence." The nurse should instruct the client that therapy usually lasts 6 months to 2 years depending on the type of TB. The nurse should emphasize the need for adherence during the course of treatment for medication effectiveness. "Your provider will monitor your thyroid function while you are taking this medication." The nurse should inform the client that the provider will monitor his liver function while taking isoniazid due to the risk for hepatotoxicity. ✅"You should take this medication on an empty stomach." The nurse should instruct the client to take isoniazid on an empty stomach to improve absorption of the medication. To ensure the stomach is empty, the client should take the medication either 1 hr before or 2 hr after a meal. "It is recommended to take this medication with an antacid." The nurse should instruct the client to avoid antacids while taking this medication because antacids decrease absorption of isoniazid. RN Learning System Medical-Surgical: Final Quiz

The nurse is about to bring the client into the operating room for surgery and knows all of the following are important to tell the client regarding possible infection, except which of the following? "There are many items that we keep sterile for your surgery so please be sure not to touch anything" "Most of our instruments are sterile during your procedure" "Once you are asleep a drape will be placed over you" "You will see staff members who will be gowned and masked"

"There are many items that we keep sterile for your surgery so please be sure not to touch anything" This is a true response regarding infection in surgery. ✅"Most of our instruments are sterile during your procedure" This is false, all instruments should be sterile during surgery. "You will see staff members who will be gowned and masked" This is important to tell the surgical client. "Once you are asleep a drape will be placed over you" This is a true statement regarding surgery and the prevention of infection. 02.07 Sterile Field

Which of the following statements by a client undergoing treatment for lung cancer represents an understanding of the plan of care? "Worsening shortness of breath is an inevitable result" "We will only switch to palliative care if I exhaust my treatment options" "I should keep seeing my primary care doctor even while I am seeing my oncologist" "There is no point to stopping smoking now. It won't make much of a difference in my life expectancy"

"There is no point to stopping smoking now. It won't make much of a difference in my life expectancy" Smoking cessation can help to slow disease progression and increase the client's tolerance for treatment options. ✅"I should keep seeing my primary care doctor even while I am seeing my oncologist" Clients should continue to seek care from their primary care providers, as they will likely have multiple diagnoses and oncology treatment may affect other treatments. It is important that clients collaborate with both provider teams to ensure uninterrupted care. "We will only switch to palliative care if I exhaust my treatment options" Oncology clients in all phases of treatment benefit from palliative care interventions for pain management, air hunger, and appetite challenges. "Worsening shortness of breath is an inevitable result" This suggests that if a client has worsening shortness of breath they should consider this an expected finding and may decrease their likelihood of seeking medical care. Worsening shortness of breath should be addressed immediately and may alter the plan of care.

A client is concerned that they won't breathe during their surgery. Which of the following is the most appropriate response from the perioperative nurse? "While under anesthesia the anesthesia team will make sure you are breathing with a special tube" "You will be sleeping so you really don't need to worry about that" "What type of anesthesia are you scheduled to have?" "You are right, general anesthesia will stop your breathing"

"You will be sleeping so you really don't need to worry about that" This is an inappropriate response for your client. ✅"While under anesthesia the anesthesia team will make sure you are breathing with a special tube" You are providing accurate information to your client and providing them support. "What type of anesthesia are you scheduled to have?" As the preoperative nurse, you should already be aware of the anesthesia your client is scheduled to have and that is not something the client will always know. "You are right, general anesthesia will stop your breathing" This is an inappropriate response to give your client. 02.01 Intubation in the OR

A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching? "Your provider will prescribe one single antiretroviral medication at a time." "You should take antiretroviral medications on a routine schedule." "You should increase your intake of raw fruits and vegetables while taking antiretroviral medications." "Your provider will prescribe antiretroviral therapy to kill the HIV virus."

"Your provider will prescribe one single antiretroviral medication at a time." The nurse should inform the client that the provider will prescribe multiple antiretroviral medications at a time. This approach, called highly active antiretroviral therapy (HAART), improves the effectiveness of treatment. A prescription for one single antiretroviral medication at a time promotes medication resistance. ✅"You should take antiretroviral medications on a routine schedule." The nurse should inform the client of the need to take antiretroviral therapy exactly as prescribed and to avoid delaying or skipping any doses, which can result in medication resistance. "You should increase your intake of raw fruits and vegetables while taking antiretroviral medications." The nurse should inform the client of the need to avoid raw fruits and vegetables to reduce the risk of infection due to immunosuppression. "Your provider will prescribe antiretroviral therapy to kill the HIV virus." The nurse should inform the client that antiretroviral therapy does not kill the HIV virus, but instead inhibits viral replication. RN Learning System Medical-Surgical: Final Quiz

1. A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? (select all that apply.) A. Potassium 3.9 meq/L B. sodium 145 meq/L C. Creatinine 2.8 mg/dL d. Blood glucose 235 mg/dL e. WBC17,850/mm3

. A. The potassium level is within the expected reference range. B. The sodium level is within the expected reference range. ✅C. CORRECT: report an elevated creatinine level, which can indicate impaired renal function. ✅d. CORRECT: report an elevated blood glucose, which needs treatment prior to surgery. ✅e. CORRECT: report an elevated WBC count, which indicates a need for antibiotic therapy before surgery. NCLEX® Connection: Reduction of Risk Potential, Laboratory Values CHAPTER 95 PreOPerATiVe NUrsiNG CAre NURSING CARE OF PERIOPERATIVE CLIENTS

The nurse is helping a medical student prepare for their first time scrubbed in a surgery. Which of the following should the nurse teach the medical student in terms of the sterile gown and maintaining a sterile field? Select all that apply "Your arms are sterile up to 2 inches above the elbow" "Only touch items and areas that you know are sterile" "You are sterile from the level of the operative field to your neckline" "As long as you have a mask on you can touch your face" "Your back is never sterile"

02.07 Sterile Field

1. A nurse is reviewing the plan of care for a client who has leukemia and has developed thrombocytopenia. Which of the following actions should the nurse take first? A. instruct the client to take rest periods throughout the day. B. encourage the client to reposition in bed every 2 hr. C. Check temperature every 4 hr. d. Monitor platelet counts.

1. a. offer the client rest periods throughout the day to prevent fatigue. However, another action is the priority. B. encourage the client to reposition in bed every 2 hr to prevent skin breakdown. However, another action is the priority. C. Check the client's temperature every 4 hr to monitor for indicators of infection. However, another action is the priority. D. CORRECT: The greatest risk to the client who has thrombocytopenia is injury due to bleeding. The priority action for the nurse to take is to monitor the client's platelet level to ensure it does not reach critical level. The nurse should institute bleeding precautions. NCLEX® Connection: Safety and Infection Control, Standard Precautions/Transmission‐Based Precautions/Surgical Asepsis CHAPTER 92 CANCERS DISORDER

4. A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? A. Monitor blood creatinine levels. B. Provide airway support. C. Turn the client to the right side. d. Administer a diuretic.

4. A. Monitor ABGs, CBC, and electrolytes for a client who has a systemic toxic reaction to a regional block. B. CORRECT: A systemic toxic reaction results in CNs depression. in this event, it is important to support the client's airway with maintaining patency and administering supplemental oxygen. C. Turning the client to the right side will not help with a systemic toxic reaction to a regional block. d. Hypertension is an early finding of systemic toxicity, but it can progress to hypotension. Administering a diuretic could worsen the condition; a barbiturate medication is required. NCLEX® Connection: Physiological Adaptation, Medical Emergencies CHAPTER 94 ANESTHESIA AND MODERATE SEDATION

4. A nurse is providing teaching about colon cancer to a group of females 45 to 65 years of age. Which of the following statements should the nurse include in the teaching? A. "Colonoscopies for individuals with no family history of cancer should begin at age 40." B. "A sigmoidoscopy is recommended every 5 years beginning at age 60." C. "Fecal occult blood tests should be done annually beginning at age 50." d. "An Mri provides a definitive diagnosis of colon cancer."

4. a. a colonoscopy is recommended every 10 years beginning at age 50 for a client who has no family history of cancer. B. a sigmoidoscopy is recommended every 5 years beginning at age 50. C. CORRECT: Fecal occult blood tests should be done annually by clients ages starting at age 50 years. D. a biopsy performed during an endoscopic procedure confirms this diagnosis. NCLEX® Connection: Health Promotion and Maintenance, Aging Process CHAPTER 92 CANCERS DISORDER

5. A nurse is caring for a client who has multiple types of skin lesions. Which of the following skin lesions are indicative of a malignant melanoma? (select all that apply.) A. diffuse vesicles B. Uniformly colored papule C. Area with asymmetric borders d. rough, scaly patch e. irregularcoloredmole

5. a. Diffuse vesicles are consistent with an allergic reaction. B. a uniformly colored papule is consistent with a birthmark or skin injury. C. CORRECT: a lesion with asymmetric borders is considered suspicious for a melanoma. D. a rough, scaly patch is consistent with skin irritation due to friction. e. CORRECT: a lack of uniformity of pigmentation of a mole is considered suspicious for a melanoma. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 92 CANCERS DISORDER

There are four clients waiting in the surgical holding area and after the nurse reviews each of their charts which of the following would the nurse be most concerned about? 12-year-old client with no known medical history having a wart removed under moderate sedation 80-year-old diabetic having a total knee replacement under general anesthesia 40-year-old male patient having a vasectomy with local anesthesia 25-year-old with muscular dystrophy having a frenulectomy under general anesthesia

80-year-old diabetic having a total knee replacement under general anesthesia Although this client will be under general anesthesia, the client that is most concerning is the one at an increased risk for malignant hyperthermia. 12-year-old client with no known medical history having a wart removed under moderate sedation This client will be having moderate sedation, not general anesthesia, which has more risks and the client with a risk for malignant hyperthermia is the most concerning. ✅25-year-old with muscular dystrophy having a frenulectomy under general anesthesia Clients with certain muscular dystrophies have an increased incidence of malignant hyperthermia cancel 40-year-old male patient having a vasectomy with local anesthesia This client will be having local anesthesia, not general anesthesia, and is not concerning. 02.05 Malignant Hyperthermia

5. A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? A. decrease the client's fluid intake. B. Apply pressure to the puncture site. C. Place the head of the bed flat. d. instruct the client to lie prone.

A . increase fluid intake to keep the client well‐hydrated and to help replace cerebrospinal fluid. B. Applying pressure to the puncture site will not relieve the headache from cerebrospinal fluid leakage. ✅C. CORRECT: Placing the head of the bed flat will decrease the intensity of the headache. d. instructing the client to lie prone could worsen or not improve the client's headache pain. NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures CHAPTER 94 ANESTHESIA AND MODERATE SEDATION

You are the circulating nurse and receiving a client from the emergency room for surgery. During report from the emergency room nurse you are told that the client is American Society of Anesthesiologists (ASA) physical status classification VI. Which of the following clients would best describes the client you are going to take care of? A 30-year-old client with no co-morbidities and is coming to the OR for a stat cesarean section A 23-year-old who presented to the emergency room with severe abdominal pain is now coming to the OR for an appendectomy A 60-year-old brought into the emergency room after a motorcycle accident, the client is coming to the OR for organ procurement An 80-year-old with advanced colon cancer who needs to have a colon resection

A 30-year-old client with no co-morbidities and is coming to the OR for a stat cesarean section This client does not have an ASA status classification of VI. ✅A 60-year-old brought into the emergency room after a motorcycle accident, the client is coming to the OR for organ procurement As this client has an ASA status classification of VI. ASA VI are classified as brain dead. An 80-year-old with advanced colon cancer who needs to have a colon resection This client does not have an ASA status classification of VI. A 23-year-old who presented to the emergency room with severe abdominal pain is now coming to the OR for an appendectomy This client does not have an ASA status classification of VI. 02.02 General Anesthesia

The perioperative nurse is reviewing the operating room schedule for the day. Which of the following clients is the most likely candidate for an orchiectomy? A 6-year-old male A 7-year-old female A 75-year-old female A 30-year-old male

A 7-year-old female An orchiectomy is the surgical removal of a testicle, so it is not done for females. ✅A 30-year-old male An orchiectomy is the surgical removal of a testicle, and is done for a client with a testicular tumor. This is most common in males ages 15-40. cancel A 75-year-old female This is a common age for breast cancer. An orchiectomy is the removal of a testicle, so it would not be done for females. A 6-year-old male The most likely client to have an orchiectomy is a male between 15-40 years old, because this is the group that is at highest risk for testicular cancer.

5. A nurse is providing discharge teaching to a client who had diabetic ketoacidosis. Which of the following information should the nurse include about preventing dKA? (select all that apply.) A. drink 2 L fluids daily. B. Monitor blood glucose every 4 hr when ill. C. Administer insulin as prescribed when ill. d. Notify the provider when blood glucose is 200 mg/dL. e. report ketones in the urine after 24 hr of illness.

A CORRECT: drinking 2 L fluids daily can prevent dehydration if the client develops diabetic ketoacidosis. B. CORRECT: Blood glucose tends to increase during illness.Blood glucose should be monitored every 4 hr. C. CORRECT: illness often causes blood glucose to increase.regular doses of insulin should be administered. d. Notify the provider when blood glucose remains greater than 250 mg/dL despite treatment. e. CORRECT: The provider should be notified if there are ketones in the urine after 24 hr of illness. NCLEX® Connection: Physiological Adaptation, Illness Management CHAPTER 83 COMPLICATIONS OF DIABETES MELLITUS

A nurse is preparing to care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse assess first? A client who has benign prostatic hyperplasia (BPH) and reports dysuria A client who has ulcerative colitis and reports diarrhea A client who has emphysema and reports dyspnea A client who has esophageal cancer and reports painful swallowing

A client who has benign prostatic hyperplasia (BPH) and reports dysuria The nurse should assess the client who has BPH and reports dysuria; however, this is an expected finding for BPH. There is another client that the nurse should assess first. A client who has ulcerative colitis and reports diarrhea The nurse should assess the client who has ulcerative colitis and reports diarrhea; however, this is an expected finding for ulcerative colitis. There is another client that the nurse should assess first. ✅A client who has emphysema and reports dyspnea The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the client who has emphysema and reports dyspnea, or shortness of breath, is the first client that the nurse should assess. A client who has esophageal cancer and reports painful swallowing The nurse should assess the client who has esophageal cancer and reports painful swallowing; however, this is an expected finding for esophageal cancer. There is another client that the nurse should assess first. RN Learning System Medical-Surgical: Final Quiz

The nurse is aware of the various postoperative complications that should be reported by the client. In discharge teaching the nurse should include all except which of the following signs to report? Pain that needs prescription medication A fever greater than 101 degree F Inability to void Persistent nausea and vomiting

A fever greater than 101 degree F This should be reported by the client postoperatively. ✅Pain that needs prescription medication As a surgical client will experience some pain or discomfort postoperatively and as long as the pain is relieved with medication that is good, but should be reported when the pain cannot be relieved. Persistent nausea and vomiting This should be reported by the client postoperatively. Inability to void This should be reported by the client postoperatively. 03.04 Discharge (DC) Teaching After Surgery

A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "i will wear gloves while changing the pet litter box." B. "i will rinse raw fruits with water before eating them." C. "i will wear a mask when around family members who are ill." d. "i will cook vegetables before eating them."

A. A client who has Aids should avoid changing the litter box to prevent acquiring toxoplasmosis. B. A client who has Aids should avoid consuming raw fruits due to the presence of bacteria that can cause opportunistic infections. C. due to compromised immune response, a client who has Aids should avoid contact with family members who are ill. d. CORRECT: A client who has Aids should cook vegetables before eating to kill bacteria that cause opportunistic infections. NCLEX® Connection: Physiological Adaptation, Illness Management CHAPTER 86 HIV/AIDS

A nurse is teaching a client who has sLe about self‐care. Which of the following statements by the client indicates an understanding of the teaching? A. "i should limit my time to 10 minutes in the tanning bed." B. "i will apply powder to any skin rash." C. "i should use a mild hair shampoo." d. "i will inspect my skin once a month for rashes."

A. A client who has sLe should avoid the use of tanning beds, as well as prolonged sun exposure. B. A client who has sLe should apply steroid‐based creams to skin rashes, not a powder. C. CORRECT: A client who has sLe should use a mild hair shampoo that does not irritate the scalp. d. A client who has sLe should inspect their skin daily for any open areas or rashes. NCLEX® Connection: Physiological Adaptation, Illness Management CHAPTER 87 LUPUS ERYTHEMATOSUS, GOUT, AND FIBROMYALGIA

3. A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? (select all that apply.) A. Urinalysis B. erythrocyte sedimentation rate (esr) C. BUN d. Antinuclear antibody (ANA) titer e. WBC count

A. A urinalysis is not a laboratory test used to diagnose RA. This test can used for detecting kidney failure. B. CORRECT: esr is a laboratory test used to diagnose RA. This laboratory test will show an elevated result in clients who have RA. C. A BUN is not a laboratory test used to diagnose RA. This test can be used for detecting kidney failure. d. CORRECT: ANA titer is a laboratory test used to diagnose RA. This laboratory test will show a positive result in clients who have RA. e. CORRECT: WBC count is a laboratory test used to diagnose RA. This laboratory test will show a decreased result in clients who have RA NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests CHAPTER 88 RHEUMATOID ARTHRITIS

A nurse is preparing to document administration of a meningococcal vaccine to a client. Which of the following information should the nurse include in the documentation? (select all that apply.) A. Age of client receiving the vaccine B. Name of vaccine manufacturer C. Vaccine expiration date d. date of administration e. serial number of the vaccine

A. Age of the person receiving an immunization is not included. B. CORRECT: document the name of the vaccine manufacturer. C. CORRECT: document the expiration date of the vaccine. d. CORRECT: document the date the vaccine was administered. e. document the lot number, not the serial number, of the vaccine. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions CHAPTER 85 IMMUNIZATIONS

A nurse is preparing to administer a varicella immunization to a client. Which of the following questions by the nurse is appropriate? A. "Are you allergic to eggs?" B. "Are you allergic to baker's yeast?" C. "Are you pregnant?" d. "do you have a history of Guillain‐Barré syndrome?"

A. Allergy to eggs should be reviewed if the client is to receive an influenza immunization. B. Allergy to yeast should be reviewed if the client is to receive HPV immunization. C. CORRECT: Ask whether the client is pregnant because the varicella immunization is contraindicated during pregnancy. d. Guillain‐Barré syndrome is not a contraindication for varicella immunization. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions CHAPTER 85 IMMUNIZATIONS

3. A nurse is reviewing laboratory reports of a client who has HHs. Which of the following findings should the nurse expect? A. Blood pH 7.2 B. Blood osmolarity 350 mOsm/L C. Blood potassium 3.8 mg/dL d. Blood creatinine 0.8 mg/dL

A. Blood pH of 7.2 is an indication of diabetic ketoacidosis and is not an expected finding for HHs. B. CORRECT: A client who has HHs would have a blood osmolarity greater than 320 mOsm/L. C. Potassium 3.8 meq/L is within the expected reference range. A client who has HHs would initially have a decreased blood potassium due to diuresis. d. Creatinine 0.8 mg/dL is within the expected reference range. A client who has HHs would have a blood creatinine of greater than 1.5 mg/dL, secondary to dehydration. NCLEX® Connection: Reduction of Risk Potential, Laboratory Values CHAPTER 83 COMPLICATIONS OF DIABETES MELLITUS

A nurse is teaching a client who is scheduled for a shave biopsy for suspected cancer. Which of the following client statements indicates understanding of the procedure? A. "A test of my bone marrow will be performed." B. "A lymph node will be removed." C. "A needle will be inserted into the mass." d. "A small skin sample will be obtained."

A. Bone marrow aspiration is a type of needle biopsy. B. sentinel node biopsy involves excision of a lymph node. C. Needle biopsy involves aspiration of a tumor for fluid and tissue sampling. d. CORRECT: A shave biopsy is a sampling of the outer skin layer using a scalpel or razor blade. NCLEX® Connection: Physiological Adaptation, Illness Management CHAPTER 90 CANCER SCREENING AND DIAGNOSTIC PROCEDURE

A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (sLe). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (select all that apply.) A. Positive ANA titer B. increased hemoglobin C. 2+ urine protein d. increased serum C3 and C4 e. elevatedBUN

A. CORRECT: A positive antinuclear antibody (ANA) titer is an expected finding in a client who has SLE. The ANA test identifies the presence of antibodies produced against the client's own dNA. B. Pancytopenia, rather than an elevated hemoglobin, is an expected finding in a client who has sLe. C. CORRECT: increased urine protein is an expected finding due to kidney injury as a result of SLE. d. The client who has sLe is expected to have a decreased level of serum C3 and C4. e. CORRECT: elevated BUN is an expected finding due to kidney injury in a client who has SLE. NCLEX® Connection: Reduction of Risk Potential, Laboratory Values CHAPTER 87 LUPUS ERYTHEMATOSUS, GOUT, AND FIBROMYALGIA

A nurse is caring for a client who has lung cancer and is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (select all that apply.) A. Behavioral changes B. Client report of headache C. Urine output 40 mL/hr d. Client report of nausea e. increasedurinespecificgravity

A. CORRECT: Behavioral changes indicate cerebral edema due to SIADH. This finding should be reported to the provider. B. CORRECT: A client report of headache indicates cerebral edema due to siAdH. This finding should be reported to the provider. C. Urine output of 40 mL/hr is a finding consistent with suspected siAdH and does not need to be reported to the provider. d. CORRECT: A client report of nausea can indicate cerebral edema due to SIADH and should be reported to the provider. e. An increased urine specific gravity is a finding consistent with SIADH and does not need to be reported to the provider. NCLEX® Connection: Physiological Adaptation, Illness Management CHAPTER 89 GENERAL PRINCIPLES OF CANCER

A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. The client reports having a cough along with nausea and diarrhea. Their temperature is 38.1° C (100.6° F) orally. The client is concerned about the possibility of having HiV. Which of the following actions should the nurse take? (select all that apply.) A. Perform a physical assessment. B. determine when manifestations began. C. Teach the client about HiV transmission. d. draw blood for HiV testing. e. Obtain a sexual history.

A. CORRECT: Perform a physical assessment to gather data about the client's condition. B. CORRECT: Gather more data to determine whether the manifestations are acute or chronic. C. Teaching the client about HiV transmission is not an appropriate action at this time. d. drawing blood for HiV testing is not an appropriate action at this time. e. CORRECT: Obtain a sexual history to determine how the virus was transmitted. NCLEX® Connection: Physiological Adaptation, Illness Management CHAPTER 86 HIV/AIDS

A nurse is assessing a client for HiV. The nurse should identify that which of the following are risk factors associated with this virus? (select all that apply.) A. Perinatal exposure B. Pregnancy C. Monogamous sex partner d. Older adult woman e. Occupational exposures

A. CORRECT: Perinatal exposure is a risk factor associated with HiV. Women who are pregnant should take precautionary measures to prevent HiV exposure. B. Women who are pregnant should be tested for HiV, but pregnancy is not a risk factor associated with this virus. C. Having a monogamous sex partner is not a risk factor associated with the HiV virus. d. CORRECT: Being an older adult woman is a risk factor associated with the HiV virus due to vaginal dryness and the thinning of the vaginal wall. e. CORRECT: Occupational exposure, such as being a health care worker, is a risk factor associated with the HiV virus. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention CHAPTER 86 HIV/AIDS

A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (select all that apply.) A. Western blot B. indirect immunofluorescence assay C. Cd4+ T‐lymphocyte count d. HIV RNA quantification test e. Cerebrospinal fluid (CsF) analysis

A. CORRECT: Positive results of a Western blot test confirm the presence of HIV infection. B. CORRECT: Positive results of an indirect immunofluorescence assay confirm the presence of HiV infection. C. Cd4+ T‐lymphocyte count assists with classifying the stage of HiV infection. d. HiV rNA quantification tests are used to determine vial level and to monitor treatment. e. A CsF analysis can be used to confirm meningitis. NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests CHAPTER 86 HIV/AIDS

1. A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemic hyperosmolar state (HHs)? (select all that apply.) A. evidence of recent myocardial infarction B. BUN 35 mg/dL C. Takes a calcium channel blocker d. Age 77 years e. daily insulin injections

A. CORRECT: The client who has type 2 diabetes mellitus and had a myocardial infarction is at risk for developing HHs. This is due to the increased hormone production during illness or stress, which can stimulate the liver to produce glucose and decrease the effects of insulin. B. CORRECT: The client who has type 2 diabetes mellitus can be at risk for developing HHs when the BUN is 35 mg/dL because it is an indication of decreased kidney function and inability of the kidney to filter high levels of blood glucose into the urine. C. CORRECT: A calcium channel blocker is one of several medications that increase the risk for HHs in a client who has type 2 diabetes mellitus. d. CORRECT: The older adult client is at risk for developing type 2 diabetes mellitus and can be unaware of associated manifestations, increasing the risk for HHs. e. Taking insulin does not increase the risk for HHs. When a client is experiencing hyperglycemia, insulin prevents the client from developing dKA. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 83 COMPLICATIONS OF DIABETES MELLITUS

A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (select all that apply.) A. Advise the client to keep a food diary. B. encourage the client to brush teeth before and after meals. C. Assess the laboratory report of ferritin. d. eat nutrient‐dense foods last at meal time. e. encourage the client to limit drinking fluids during meals.

A. CORRECT: The use of a food diary assists in monitoring changes in eating habits that occur in malnutrition due to cancer. B. CORRECT: Oral hygiene before and after meals promotes increased salivation and improves taste perception. C. CORRECT: Ferritin is an indicator of the protein intake of a client who has malnutrition due to cancer. d. instruct the client to eat nutrient‐dense foods first to increase adequate nutritional intake to treat malnutrition. e. CORRECT: encourage the client to limit drinking fluids with meals because fluids can cause early satiety and decrease adequate intake of food, causing malnutrition, when the client has cancer. some fluids are needed to treat dry mouth and thickened saliva. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration CHAPTER 89 GENERAL PRINCIPLES OF CANCER

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (select all that apply.) A. diuretic use B. Obesity C. deep sleep deprivation d. depression e. Cardiovascular disease

A. CORRECT: The use of diuretics is a risk factor for gout. B. CORRECT: Obesity is a risk factor for gout. C. deep sleep deprivation is a manifestation of fibromyalgia and is not a risk factor for gout. d. depression is a manifestation of SLE and is not a risk factor for gout. e. CORRECT: Cardiovascular disease is a risk factor for gout. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 87 LUPUS ERYTHEMATOSUS, GOUT, AND FIBROMYALGIA

5. A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? A. Assess bowel sounds. B. Administer antiemetic medication. C. restart prescribed iV fluids. d. insert a prescribed nasogastric tube.

A. CORRECT: Using the nursing process, the first step is to assess the client. This enables the nurse to check for peristalsis and will guide further interventions. B. Administering an antiemetic medication can alleviate nausea and vomiting, but it is not the first nursing action. C. restarting prescribed iV fluids will prevent dehydration, but it is not the first nursing action. d. inserting a prescribed nasogastric tube can alleviate nausea and vomiting, but it is not the first nursing action. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration CHAPTER 96 POSTOPERATIVE NURSING CARE

3. A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A. Compare and contrast the peripheral pulses. B. Apply a warm blanket. C. Assess dressings. d. Place the client in a lateral position.

A. Comparing and contrasting peripheral pulses is important to ensure adequate circulation, but it is not the first nursing action. B. Applying warm blankets to prevent hypothermia is important, but it is not the first nursing action. C. Assessing dressings for drainage is important to monitor the amount of drainage present, but it is not the first nursing action. ✅d. CORRECT: The greatest risk to the client who is unresponsive or unconscious is injury from aspiration. Turning the client to the side will help keep the airway clear of secretions NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures NURSING CARE OF PERIOPERATIVE CLIENTS CHAPTER 96 POSTOPERATIVE NURSING CARE

A nurse is teaching a client who is scheduled for nuclear imaging for suspected cancer. Which of the following statements should the nurse give? A. "The presence of a liver enzyme will be identified." B. "you will be given an injection of a radioactive substance." C. "An endoscope will be inserted through your mouth." d. "The tumor will be aspirated."

A. Liver function tests involve the identification of altered liver enzymes, which can be present in a client who has cancer. They are not nuclear imaging tests. B. CORRECT: Nuclear imaging involves the administration of an oral or iV radioactive tracer to identify cancerous tissue. C. endoscopy permits visualization inside the body. it is not a form of nuclear imaging. d. A needle biopsy is performed to aspirate fluid and tissue samples for cancer cells. it is not a form of nuclear imaging. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 90 CANCER SCREENING AND DIAGNOSTIC PROCEDURE

A nurse is reviewing strategies to promote comfort with a client who received an immunization. Which of the following information should the nurse include? (select all that apply.) A. Massage the injection site. B. Apply a cool compress to the injection site. C. Take acetaminophen or ibuprofen. d. Use the affected extremity. e. Apply an antimicrobial ointment to the injection site.

A. Massaging the injection site for any extended period of time can increase localized discomfort. B. CORRECT: Applying a cool compress to the injection site can relieve discomfort from the localized reaction. C. CORRECT: Taking an antipyretic can relieve a low‐grade fever and localized discomfort at the injection site. d. CORRECT: Mobilizing the affected extremity will help relieve discomfort due to a localized reaction. e. Applying an antimicrobial ointment at the injection site is not indicated. NCLEX® Connection: Pharmacological and Parenteral Therapies, Parenteral/Intravenous Therapies CHAPTER 85 IMMUNIZATIONS

4. A nurse is caring for a client who has a prescription for gabapentin for neuropathic pain. The nurse should monitor the client for which of the following adverse effects of this medication? A. Constipation B. Urinary retention C. insomnia d. dizziness

A. Monitor a client who is taking an opioid analgesic for constipation. However, constipation is not an adverse effect of gabapentin. B. Monitor a client who is taking an opioid analgesic for urinary retention. However, urinary retention is not an adverse effect of gabapentin. C. Monitor the client for sedation, rather than insomnia. ✅d. CORRECT: Monitor the client for dizziness. instruct the client to avoid driving until medication effects are known . NCLEX® Connection: Reduction of Risk Potential, Potential for Alterations in Body Systems CHAPTER 93 PAIN MANAGEMENT FOR CLIENTS WHO HAVE CANCER

A nurse administered midazolam iV bolus to a client before a procedure. The client's blood pressure is 86/40 mm Hg, and the heart rate is 134/min. Which of the following iV medications should the nurse administer? A. Naloxone B. Morphine C. Flumazenil d. Atropine

A. Naloxone reverses respiratory depression resulting from an opioid medication. B. Morphine relieves pain and can cause hypotension and respiratory depression. C. CORRECT: Midazolam is a benzodiazepine. Administer flumazenil to reverse its effects. d. Atropine sulfate treats bradycardia. NCLEX® Connection: Physiological Adaptation, Unexpected Response to Therapies CHAPTER 94 ANESTHESIA AND MODERATE SEDATION

A nurse is caring for a client who has a WBC count of 20,000/mm3. The nurse should conclude that the client has which of the following? A. Neutropenia B. Leukocytosis C. Left shift d. Leukopenia

A. Neutropenia is a neutrophil count less than 2,000/mm3. B. CORRECT: Leukocytosis is a WBC count greater than 10,000/mm3, which can indicate inflammation or infection. C. A left shift is an increase in immature neutrophils (bands or stabs) that occurs with acute infection. d. Leukopenia is a total WBC count of less than 4,000/mm3, which can indicate overwhelming infection or drug toxicity. NCLEX® Connection: Reduction of Risk Potential, Laboratory Values CHAPTER 84 IMMUNE AND INFECTIOUS DISORDERS DIAGNOSTIC PROCEDURES

A nurse is reviewing the laboratory findings of a client who has measles. The nurse should expect to find an increase in which of the following types of WBCs? A. Neutrophils B. Basophils C. Lymphocytes d. eosinophils

A. Neutrophils increase with an acute bacterial infection. Measles is a viral infection. B. Basophils increase with leukemia. C. CORRECT: Lymphocytes increase with viral infections (measles, mumps, mononucleosis). d. eosinophils increase with allergic reactions, leukemia, eczema, and parasitic infections. NCLEX® Connection: Reduction of Risk Potential, Laboratory Values CHAPTER 84 IMMUNE AND INFECTIOUS DISORDERS DIAGNOSTIC PROCEDURES

A nurse is collecting information from a client in a provider's office. Which of the following findings should the nurse identify as an indication of possible cancer? (select all that apply.) A. Temperature 102° F (38.9° C) for more than 48 hr B. sore that does not heal C. difficulty swallowing d. Unusual discharge e. Weight gain 4 lb (1.8 kg) in 2 weeks

A. Presence of a fever for an extended period is not a finding of possible cancer. Unexplained night sweats can indicate a need to have a cancer screening. B. CORRECT: A sore that does not heal is a finding of possible cancer. C. CORRECT: difficulty swallowing is a finding of possible cancer. d. CORRECT: The presence of unusual discharge is a finding of possible cancer. e. CORRECT: Weight gain or loss can indicate possible cancer. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention CHAPTER 90 CANCER SCREENING AND DIAGNOSTIC PROCEDURE

A nurse is providing teaching for a client who has stage 2 HiV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "i will choose a diet high in fat to help gain weight." B. "i will be sure to eat three large meals daily." C. "i will drink up to 1 liter of liquid each day." d. "i will add high‐protein foods to my diet."

A. The client should be taught to avoid high‐fat foods to gain weight because fat intolerance—causing flatus, bloating, and diarrhea—is common in clients who have HiV/Aids. B. The client should be taught that small frequent meals (such as six meals daily) are better tolerated than three large meals. C. The client should be taught to drink 2 to 3 L of liquids daily to maintain nutrition status. d. CORRECT: The client should be taught to add high‐protein, high‐calorie foods to the diet daily as the best way to gain weight and maintain health. NCLEX® Connection: Physiological Adaptation, Illness Management CHAPTER 86 HIV/AIDS

A nurse is teaching a client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of the teaching? A. "i will need to have a mammogram every 2 years beginning at age 45." B. "i should have a colonoscopy every 15 years beginning at age 60." C. "i will need to have an annual breast examination every year after 40." d. "i should have a fecal occult test done every 3 years."

A. The client should begin annual mammograms beginning at age 40. B. The client should begin to have a colonoscopy at age 50 and then every 10 years thereafter. C. CORRECT: instruct the client that after the age of 40, they should have annual clinic breast exams. d. The client should have a fecal occult test done every year. The client can have the stool dNA test every 3 years in place of fecal occult blood testing. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention CHAPTER 89 GENERAL PRINCIPLES OF CANCER

5. A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A. encourage the client to void after preoperative medication administration. B. Administer antibiotics 2 hr prior to surgical incision. C. remove hair using a manual razor. d. remove nail polish on fingers and toes

A. The client should void before administration of medication for relaxation or sedation to prevent the risk for falls. B. Administer antibiotics within 1 hr prior to the surgical incision as a prophylactic measure to prevent infection. C. remove hair at the surgical site with electric clippers or use a chemical depilatory to prevent traumatizing the skin and increasing the risk for infection. ✅d. CORRECT: ensure the nail beds are visible for color and circulation by removing nail polish before surgery. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures NURSING CARE OF PERIOPERATIVE CLIENTS

A nurse in a clinic is caring for a client who is to receive an immunization. The client asks about contraindications to immunizations. Which of the following responses should the nurse make? A. "The use of insulin is a contraindication." B. "An anaphylactic reaction is a contraindication for administration of any type of immunization." C. "The common cold is a contraindication for receiving an immunization." d. "your provider will weigh the risks if you have experienced any adverse effects."

A. The client who takes insulin is able to receive immunizations unless other contraindications are present. B. The client who has experienced an anaphylactic reaction can receive other immunizations that contain different substances. C. The client who has a common cold can receive an immunization because the client is not immunosuppressed. d. CORRECT: The client who has experienced adverse effects should inform the provider, who can weigh the risks of an immunization. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions CHAPTER 85 IMMUNIZATIONS

3. A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (select all that apply.) A. explain to the client the purpose of having the procedure. B. inform the client of risks to having the procedure. C. ensure the client understands information about the procedure. d. Witness the client signing the informed consent form. e. determine if the client is capable of understanding the reason for the procedure.

A. The provider should explain the purpose of the procedure. B. The provider should inform the client of risks to having the procedure. ✅C. CORRECT: ensure the client understands the information about the procedure. ✅d. CORRECT: Witness the client sign the informed consent. ✅e. CORRECT: determine if the client is capable of understanding the reason for the procedure. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures NURSING CARE OF PERIOPERATIVE CLIENTS

A nurse is preparing to administer an iM injection of immune globulin to a client who has been exposed to hepatitis A. Which of the following statements by the nurse is appropriate? A. "This medication offers permanent immunity to hepatitis A." B. "This medication involves three injections over several months." C. "This medication provides you with an immune response more quickly than your body can produce it." d. "This medication contains an attenuated virus to help your body create antibodies."

A. This medication produces passive‐artificial immunity that lasts only several weeks or months. B. This medication produces passive‐artificial immunity and is given one time after exposure to hepatitis A. C. CORRECT: This medication produces passive‐artificial immunity and contains antibodies to help protect against hepatitis A for several weeks or months. d. This medication contains antibodies, not an attenuated virus. NCLEX® Connection: Pharmacological and Parenteral Therapies, Parenteral/Intravenous Therapies CHAPTER 85 IMMUNIZATIONS

A nurse is preparing to administer a scratch test to a client who has possible food and environmental allergies. Which of the following actions should the nurse perform prior to the procedure? (select all that apply.) A. Cleanse the client's skin with povidone‐iodine. B. Ask the client about previous reactions to allergens. C. Ask the client about medications taken over the past several days. d. inform the client to expect itching at one site. e. Obtain emergency resuscitation equipment.

A. Use soap and water to cleanse the skin. Povidone‐iodine could interfere with an allergen and elicit a response. B. CORRECT: Ask the client about any previous reactions to allergens, which could indicate an increased risk of an anaphylactic reaction. C. CORRECT: Ask the client about medications taken over the past several days. Antihistamines and corticosteroids can suppress reactions. d. CORRECT: Histamine will be applied at a control site, so the client will probably have itching at this site. e. CORRECT: emergency equipment should be available, even if the client denies previous anaphylactic reactions. NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests CHAPTER 84 IMMUNE AND INFECTIOUS DISORDERS DIAGNOSTIC PROCEDURES

2. A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (select all that apply.) A. Weight gain B. Fruity odor of breath C. Abdominal pain d. Kussmaul respirations e. Metabolicacidosis

A. Weight loss occurs when the cells are unable to use glucose because of insulin deficiency and places the body in a catabolic state, and fluid loss from dehydration decreases body weight. B. CORRECT: Fruity odor of breath is a manifestation of elevated ketone levels that lead to metabolic acidosis. C. CORRECT: Abdominal pain is a Gi manifestation of increased ketones and acidosis. d. CORRECT: Kussmaul respirations are an attempt to excrete carbon dioxide and acid when in metabolic acidosis. e. CORRECT: Metabolic acidosis is caused by glucose, protein, and fat breakdown, which produces ketones. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 83 COMPLICATIONS OF DIABETES MELLITUS

A nurse is assessing a client who has a new diagnosis of sLe. Which of the following findings should the nurse expect? A. Weight gain B. Petechiae on thighs C. systolic murmur d. Alopecia

A. Weight loss, rather than weight gain, is an expected finding in a client who has a new diagnosis of SLE. B. A butterfly rash on the face is a finding in a client who has lupus. C. A cardiac friction rub is an expected finding of sLe. d. CORRECT: Alopecia (hair loss) is an expected finding in a client who has SLE. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 87 LUPUS ERYTHEMATOSUS, GOUT, AND FIBROMYALGIA

A nurse is caring for a client who has sLe and is experiencing an episode of raynaud's phenomenon. Which of the following findings should the nurse anticipate? A. swelling of joints of the fingers B. Pallor of toes with cold exposure C. Feet that become reddened with ambulation d. Client report of intense feeling of heat in the fingers

A. swelling, pain, and joint tenderness are findings in a client who has sLe and is not specific to an episode of raynaud's phenomenon. B. CORRECT: Pallor of the extremities occurs in raynaud's phenomenon in a client who has sLe and has been exposed to cold or stress. C. The extremities becoming red, white, and blue when exposed to cold or stress is characteristic of an episode of raynaud's phenomenon in a client who has sLe. d. A client report of intense pain in the hands and feet is characteristic of an episode of raynaud's phenomenon in a client who has sLe. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 87 LUPUS ERYTHEMATOSUS, GOUT, AND FIBROMYALGIA

4. A nurse is reviewing the medical record for a client who is to begin therapy for dKA. Which of the following prescriptions should the nurse expect? A. Administer an iV infusion of regular insulin at 0.3 unit/kg/hr. B. Administer a slow iV infusion of 3% sodium chloride. C. rapidly administer an iV infusion of 0.9% sodium chloride. d. Add glucose to the iV infusion when blood glucose is 350 mg/dL.

A.expect to administer an iV infusion of regular insulin at 0.1 unit/kg/hr to gradually lower blood glucose to prevent cerebral edema B. expect to administer a 3% sodium chloride solution to a client who has hyponatremia. C. CORRECT: expect to rapidly administer an iV infusion of 0.9% sodium chloride, an isotonic fluid, as prescribed to maintain blood perfusion to vital organs. The initial infusion for a client who has an elevated sodium would be 0.45% sodium chloride. d. Add glucose to the iV infusion when the blood glucose is 250 mg/dL, not 350 mg/dL, to prevent hypoglycemia and minimize cerebral edema. NCLEX® Connection: Pharmacological and Parenteral Therapies, Parenteral/Intravenous Therapies

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ANS C * ✅BUN 7 mg/dL A client with kidney problems will have an increased BUN rather than a low-to-normal BUN. * BUN 42 mg/dL This is a high blood urea nitrogen level, which is expected in the client with chronic kidney failure. * Creatinine 2.1 mg/dL This is a high creatinine level, which is expected in the client with chronic kidney failure. * K 6.1 mEq/L This electrolyte would build up in the blood with chronic filtering problems, and since normal potassium is 3.5-5 mEq/L, this is an expected lab value.

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

ANS: Answers: A, C, D, E Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed linens and clothing should be washing in hot water to remove lice and eggs; that lice can live on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can infest any body part that has hair. These parasites do not die off without treatment. Cognitive Level: Application Client Needs Category: Physiological Integrity Nursing Process Step: Implementation  Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

​How do plasma cells provide immune protection? A. They actively secrete immunoglobulins against specific antigens. B. They interact with virgin B lymphocytes upon first exposure to an antigen, enhancing B-lymphocyte sensitization. C. They regulate the function of natural killer cells, preventing unnecessary damage or death to normal health body cells. D. They are responsible for balancing helper cell activity with regulator T cell activity, ensuring that an immunologic response can be mounted whenever the body is invaded by pathologic microorganisms but limiting the response when the body receives antigens as drugs or food.

Answer: A Rationale: Plasma cells are the immediate result of cell division by a sensitized B-cell in response to initial recognition of a specific antigen, such as a virus. The plasma cell secretes immunoglobulins (antibodies) directed against the invading virus. Although this response does not always prevent the person from becoming ill as a result of the exposure, it does limit the duration of illness and sets up more long-lasting adaptive immunity. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 16 - Concepts of Inflammation and Immunity

The primary healthcare provider has prescribed 1 liter of D5NS to infuse at a rate of 125 ml/hour. The nurse begins the infusion at 0700 (7am). When will the nurse anticipate completion of the infusion? A. 1300 hours (1pm) B. 1500 hours (3pm) C. 1900 hours (7pm) D. 2100 hours (9pm)

Answer: B Rationale: The nurse will anticipate completion of the infusion at 1500 hours (or 3 pm). To calculate this the nurse will take the total volume of 1000 mls and divide by the rate 125 ml/hr which equals 8. Thus, the infusion will be complete in 8 hours. If the nurse begins the infusion at 0700, in 8 hours it will be 1500 hours (or 3 pm). 1000 ml __________ = 8 hours 125 ml/hr Cognitive Level: Analysis Integrative Process: Nursing Process Chapter 15 - Concepts of Infusion Therapy

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L? A. Asking about the use of sugar substitutes. B. Determining what drugs are taken daily C. Measuring the client's response to Chvostek testing D. Asking about a history of kidney disease

Answer: B Rationale: The serum potassium level is low and the client has hypokalemia. Misuse or overuse of diuretics, especially high ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia among older adults or clients with eating disorders. Sugar substitutes do not change serum potassium levels. A positive Chvostek sign or test occurs with hypocalcemia but not with hypokalemia. Kidney disease is associated with hyperkalemia. Cognitive level:​Applying or higher Client Needs Category:​Physiological Integrity Nursing Process Step: Assessment Chapter 13 - Concepts of Fluid and Electrolyte Balance

What is the priority nursing action when a nurse observes an adult drowning in a lake? A. Stabilize the spine with a board B. Consider personal swimming abilities C. Safely remove student from the water D. Initiate airway clearance and deliver rescue breaths

Answer: B Rationale: Immediate emergency care focuses on a safe rescue of the victim. Potential rescuers must consider their own swimming abilities and limitations and any natural or human-made hazards before attempting to save the victim; failure to do so could place additional lives in jeopardy. Therefore, the nurse will first consider his or her own personal swimming abilities. Once the student has been rescued, spine stabilization, and airway clearance can be initiated. Cognitive Level: Analysis Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control Nursing Process Step: Implementation Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

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

Answer: B​​ Rationale: Esophageal candidiasis not only makes food "taste funny" but it is painful and irritating. Eating soft food and liquids is less likely to irritate the esophagus further. Cooler and cold food can reduce discomfort by numbing sensations somewhat. Cognitive Level: Applying or higher Client needs category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? A. Notify the health care provider B. Place the client on oxygen C. Sit the client upright in bed D. Assess the client's lung sounds

Answer: C Rationale: Because the client is short of breath, the priority action that can be done immediately is to sit the client upright in bed. Assessing the lung sounds can occur after sitting the client upright. Use of oxygen and contacting the healthcare provider will follow the priority action. The rate of infusion is likely too fast for an older adult client which has created fluid build-up. The nurse will anticipate fine crackles in the lung bases and decrease in the IV flow rate and notify the health care provider. Cognitive Level: Analyzing Integrated Process: Nursing Process Chapter 15 - Concepts of Infusion Therapy

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

Answer: C Rationale: The nurse will intervene if the lesion's borders have expanded and are shaped differently, as this indicates a change in status that must be addressed. Lesions that are of the same light pink color in both photographs do not require intervention at this time. Lesions that have almost disappeared in this time frame do not require intervention at this time. Lesions that have well-approximated margins and size that has not changed do not require intervention at this time. Cognitive Level: Application Client Needs Category: Physiological Integrity Nursing Process Step: Implementation Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

A client asks the nurse why his colorectal cancer is being tested for genetic mutations even though no one else in the family has ever had cancer. What is the nurse's best response? A. "Colorectal cancer is rare and most cases are caused by a genetic mutation." B. "The results of this testing will indicate what caused your cancer so you can avoid further exposure." C. "Many tumors have one or more genetic differences that can help determine the most effective treatment options." D. "Genetic testing of tumor cells can help determine the stage of your cancer and whether it has spread to other organs."

Answer: C Rationale: Genetic testing of tumor cells (not the client with cancer) can indicate genetic mutations that would increase the susceptibility of the tumor to being killed off or having its growth controlled by targeted therapy. It does not indicate cause, stage, or degree of metastasis. Colorectal cancer is very common. Although some colorectal cancers are caused by a genetic mutation, these cancers "run in families." Cognitive Level: Applying or higher Client needs category: ​Psychosocial Integrity Nursing Process Step: ​Intervention Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

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

Answer: C Rationale: HIV particles are made within the infected CD4+ T-cell, using the host cell's protein synthesis processes. The new virus particle is made as one long inactive protein strand. The strand is clipped by the enzyme HIV protease into smaller active pieces. Protease inhibitors block the enzyme from creating active viral pieces that can leave the cell and infect other cells. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

​Which new onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm? A. Increased bruising B. Increased daily output of slightly foamy urine C. Failure to see letters in the middle of a word D. Sensation of nausea within an hour of taking the drug

Answer: C Rationale: Hydoxychloroquine can be toxic to retinal cells, especially near the macula. This would result in decreased or lost central vision such as would be seen as "missing" letters in the center of a word being read. Bruising is an expected side effect of the drug because is decreases clotting. Although foamy urine is an early indicator of protein in the urine and would need to be addressed, it is not as pressing a problem as the decreased central vision, which is irreversible and an indication that the drug must be stopped immediately. Nausea, although unpleasant, does not have a high risk for causing harm. Cognitive Level: Applying or Higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluation Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate? A. Discontinue the SPC. B. Relocate the SPC for infection control. C. Assess the SPC for redness, swelling, or pain. D. Change the occlusive dressing covering the SPC.

Answer: C Rationale: It is important for the nurse to assess the SPC for signs of infection or infiltration which include redness, swelling, and pain. The nurse would not discontinue the SPC as there is no indication in the stem that the client has concluded IV therapy. It is no longer common practice to relocate SPCs based on a 48-hour time frame. If the site assessed is free from signs of infection or infiltration, relocating the site is not warranted. Changing the dressing should only be done when relocating an IV or when the dressing is visible soiled. Cognitive Level: Apply Integrative Process: Nursing Process Chapter 15 - Concepts of Infusion Therapy

How do macrophages contribute to the neutrophilia that occurs in response to an acute bacterial infection? A. When invasion occurs, macrophages mature into neutrophils, increasing their circulating numbers. B. Macrophages have only an indirect role in neutrophilia by secreting substances that reduce bone marrow production of erythrocytes and platelets. C. At the onset of invasion, macrophages secrete a colony-stimulating factor to induce the bone marrow to increase production and release of neutrophils. D. Inflammatory damage to macrophages allows release of proteolytic enzymes that enhance liver production of all white blood cell types, including mature segmented neutrophils.

Answer: C Rationale: Macrophages in the area where acute infection initially occurs have two functions. One is to try an eliminate the infectious agent by phagocytosis. The other is to secrete the growth factor granulocyte-colony stimulating factor (G-CSF) to stimulate the bone marrow to greatly increase the rate of neutrophil production and maturation in order to help provide more defenses against the infectious agent, a process known as neutrophilia. Cognitive Level: Understanding Client Needs Category: Physiological integrity Nursing Process Step: N/A Chapter 16 - Concepts of Inflammation and Immunity

The white blood cell count with differential of a client undergoing preadmission testing before surgery indicates a total count of 5,000 cells per cubic millimeter (mm3) of blood. Which of the follow differential counts or percentages does the nurse report to the surgeon to prevent harm? A. Eosinophils 300/mm3 B. Monocytes 600/mm3 C. Segmented neutrophils 2000/mm3 D. Lymphocytes 2100/mm3

Answer: C Rationale: The total white blood cell count is in the normal range. However, the normal segmented neutrophil population in peripheral blood should be at least 55%. A segmented neutrophil count of 2000 in 5,000 white blood cells represents only 40% of the total and indicates a significant decrease. Depending on the nature of the surgery, it may be postponed until the cause of the low neutrophil count is identified and possibly corrected. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment Chapter 16 - Concepts of Inflammation and Immunity

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? A. Contact the primary health care provider. B. Document findings in the electronic health record. C. Change the IV site to a new location. D. Stop the infusion of the drug.

Answer: D Rationale: The nurse needs to stop the infusion of the drug first because the IV site is likely infiltrated. Then documentation, notifying the primary health care provider, and starting a new IV can occur. Cognitive Level: Analyzing Integrated Process: Nursing Process Chapter 15 - Concepts of Infusion Therapy

Which change would the nurse expect to see in the white blood cell differential of a client who has a prolonged, severe intestinal helminth infestation? A. Band neutrophils outnumber segmented neutrophils. B. Macrophage count is low. C. Monocyte count is high. D. Eosinophil count is high.

Answer: D Rationale: Eosinophils are the most effective immune system cell type that attacks parasitic infections, especially helminths (worms). The numbers of eosinophils greatly increase during such an infestation. A is incorrect because this change is associated with an ongoing bacterial infection. B is incorrect because macrophages are not present in circulating blood. C is incorrect because a high monocyte count indicates mononucleosis, not a helminth infestation. Cognitive Level: Applying or higher Client Needs Category: Safe and effective care environment Nursing Process Step: Assessment Chapter 16 - Concepts of Inflammation and Immunity

Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately? A. The oxygen flow rate is set at 12 L/minute. B. The exhalation ports are open during exhalation. C. The exhalation ports are closed during inhalation. D. The reservoir bag is not inflated during inhalation.

Answer: D Rationale: The nonrebreather mask has a one-way valve between the mask and the reservoir and has two flaps over the exhalation ports. The flaps should be closed during inhalation to prevent room air from entering and diluting the oxygen concentration. During exhalation, air leaves through these exhalation ports. The client can only draw needed air with oxygen from the reservoir bag, which must be inflated during inhalation. The flow rate of 12 L/min is sufficient to keep the bag inflated during inhalation. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation Chapter 25/Chapter 28 - Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy

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

Answer: D​​ Rationale: Tipranavir is a protease inhibitor. St. John's Wort changes the activity of metabolizing enzymes resulting in more rapid elimination of all the protease inhibitors and reducing their effectiveness. Cognitive Level: Applying or higher​​​ Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

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

Answers: A, B, C, D, E Rationales: Cellulitis is an inflammation and infection of the skin and underlying tissues. Therefore, all of these signs and symptoms occur as part of the inflammatory response. 2.​A client is diagnosed with C. difficile infection. What nursing action is the priority for the client? A.​Provide meticulous skin care. B.​Place the client on contact precautions. C.​Give the client an antipyretic medication. D.​Encourage the client to drink extra fluids. Answer: B Rationale: While all of these interventions are important, the priority nursing action is to make sure that the infection is not spread to other clients. Contact precautions with good handwashing is the best method for preventing this potential spread. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

​A nursing assistant in a nursing home reports to nurse that an 87-year-old nursing home client has a 6 inch reddened wound with pus draining from on his shin where he scratched it open yesterday. After directly assessing the client's wound, what are the most relevant priority actions for the nurse to take? Select all that apply. A. Take a photo of the wound to show the primary health care provider when rounds are made 2 days from now B. Assess the client for signs and symptoms of systemic infection, including temperature elevation C. Notify the primary health care provider now and request a prescription for antibiotic therapy D. Ask the primary health care provider to prescribe a tetanus booster vaccination E. Immediately obtain a specimen for culture and sensitivity testing F. Cleanse the wound and apply a dry dressing to it

Answers: A, B, C, F Rationale: Taking a real-time photo is helpful to establish a good record regardless of when physical rounds are made. Although the client may not have a fever or other obvious signs and symptoms of systemic infection because of his age, it is still a priority nursing action. This client is older. With pus present the wound is obviously infected. At 87, this client could develop systemic infection and sepsis very quickly. Antibiotics should be started today and not be delayed until usual rounds are made in 2 days. The infection came from scratching the skin in a nursing home. The client's usual flora are most like the causative organism or organisms, not tetanus. Thus, there is no need for either a tetanus booster or obtaining a specimen for culture and sensitivity. With an open, draining wound, cleansing and dressing are always appropriate. Whether or not the dressing is should be sterile depends on agency policy and the client's health status. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation Chapter 16 - Concepts of Inflammation and Immunity

Which cells, products, or actions are involved in long-lasting immunity resulting from exposure to a specific antigen? Select all that apply. A. Antibody attenuation B. Interleukin 10 (IL-10) C. Memory B-cells D. Monocyte maturation E. Neutrophilia F. Phagocytosis

Answers: C, D Rationale: Memory B-cells are the ones that secrete huge numbers of antibodies whenever the host experiences a subsequent exposure to the same antigen (especially a microorganism) that initially sensitized the B-cells. Monocytes mature into macrophages, which are essential in antigen presenting and processing for the naive B-cell to become sensitized to the antigen. If this initial sensitization does not take place, no long-lasting immunity develops as a result of the exposure. Antibody attenuation is the laboratory modifying of an infectious organism before administering it as a vaccination to prevent the host from becoming ill as a result of the vaccination. Attenuation is not a part of the mechanism for developing long-lasting immunity. Interleukin 10 has immunosuppressive effects, not immune stimulating effects. Neutrophils do not have a direct role in the development of long-lasting immunity, only innate-native immunity. Phagocytosis is not a direct action for long-lasting immunity. Although macrophages are a part of antigen presentation for B-cell sensitization, the presentation does not occur through phagocytosis. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 16 - Concepts of Inflammation and Immunity

A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? Apply a broad-spectrum sunscreen 5 min before sun exposure. Wear a sun visor instead of a hat when outside in the sun. Avoid exposure to the midday sun. Use a tanning booth instead of sunbathing outdoors.

Apply a broad-spectrum sunscreen 5 min before sun exposure. The nurse should instruct clients to apply a broad-spectrum sunscreen 15 min prior to sun exposure. Wear a sun visor instead of a hat when outside in the sun. The nurse should instruct clients to wear a wide-brimmed hat because it provides better protection from the sun than a sun visor. ✅Avoid exposure to the midday sun. The nurse should instruct clients to avoid skin exposure to the sun, especially during the midday hours of 1000 to 1600 because sun rays are the strongest at that time. Use a tanning booth instead of sunbathing outdoors. The nurse should instruct clients to avoid sunbathing, as well as tanning booths, sunlamps, and tanning pills. RN Learning System Medical-Surgical: Dermatological Practice Quiz

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? Bradycardia with S-T segment depression Relief of chest pain with deep inspiration Dyspnea with hiccups Chest pain that increases when sitting upright

Bradycardia with S-T segment depression Pericarditis is usually seen on an ECG as an ST-T spiking. This elevation represents ischemic changes caused by the inflammation around the heart. The client who has pericarditis will have tachycardia because of decreased cardiac output and oxygen perfusion. Relief of chest pain with deep inspiration Chest pain associated with pericarditis will increase with deep inspiration due to increased pressure on the pericardial sac. ✅Dyspnea with hiccups The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade. Chest pain that increases when sitting upright Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which of the following traits places a client at risk for developing malignant melanoma? Brown eyes Light skin Black hair Dark skin

Brown eyes Brown eyes do not place a client at risk for developing malignant melanoma. ✅Light skin Light skin and less pigmentation place a client at risk for developing malignant melanoma. Black hair Black hair does not place a client at risk for developing malignant melanoma. Clients who have red or blonde hair are at risk for developing malignant melanoma. Dark skin Dark skin does not place a client at risk for developing malignant melanoma. RN Learning System Medical-Surgical: Dermatological Practice Quiz

Cancer - Early Warning Signs

CAUTION UP C-Change in bowel or bladder A-A lesion that does not heal U-Unusual bleeding or discharge T-Thickening or lump in breast or elsewhere I-Indigestion or difficulty swallowing O-Obvious changes in wart or mole N-Nagging cough or persistent hoarseness U-Unexplained weight loss P-Pernicious Anemia

1. A nurse is caring for a client who has blood glucose 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. recheck blood glucose in 15 min. B. Provide a carbohydrate and protein food. C. Provide 15 g of simple carbohydrates. d. report findings to the provider.

CHAPTER 82 DIABETES MELLITUS MANAGEMENT

2. A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take? A. Check blood glucose immediately after breakfast. B. Administer insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. d. Clarify the prescription because insulin should not be administered at this time.

CHAPTER 82 DIABETES MELLITUS MANAGEMENT

3. A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose 278 mg/dL. Which of the following actions should the nurse take? A. draw up the regular insulin and then the glargine insulin in the same syringe. B. draw up the glargine insulin then the regular insulin in the same syringe. C. draw up and administer regular and glargine insulin in separate syringes. d. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin

CHAPTER 82 DIABETES MELLITUS MANAGEMENT

4. A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (select all that apply.) A. eat at regular intervals. B. decrease intake of saturated fats. C. increase daily fiber intake. d. Limit saturated fat intake to 15% of daily caloric intake. e. include omega‐3 fatty acids in the diet.

CHAPTER 82 DIABETES MELLITUS MANAGEMENT

5. A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (select all that apply.) A. remove calluses using over‐the‐counter remedies. B. Apply lotion between toes. C. Test water temperature with the fingers before bathing. d. Trim toenails straight across. e. Wear closed‐toe shoes.

CHAPTER 82 DIABETES MELLITUS MANAGEMENT

6. A nurse is reviewing testicular self‐examination with a client. Which of the following client statements indicates understanding? A. "it is best to examine the testicles before bathing." B. "it is not necessary to report small lumps, unless they are painful." C. "i will examine one testicle at a time." d. "i will use my palms to feel for abnormalities."

CHAPTER 92 CANCERS DISORDER

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? Cadaver skin Pig skin Amniotic membranes Beef collagen

Cadaver skin Homographs are obtained from cadaver skin. ✅Pig skin Heterografts are obtained from an animal, usually a pig. Amniotic membranes Human amniotic membranes are used to treat burns; however, they are not heterograft dressings. Beef collagen Artificial skin made from beef collagen is used to treat burns; however, it is not a heterograft dressing. RN Learning System Medical-Surgical: Dermatological Practice Quiz

10 of 25 Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? Serum chloride level is 100 mEq/L (mmol/L) Blood urea nitrogen (BUN) is elevated Arterial blood pH is 7.37 Hematocrit is 29% (0.29 volume fraction)

Chapter 13 - Concepts of Fluid and Electrolyte Balance

14 of 25 Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? Teaching the client which foods to avoid Administering sodium polystyrene sulfonate orally Collaborating with the registered dietitian nutritionist to provide a potssium-restricted diet Initiating continuous cardiac monitoring

Chapter 13 - Concepts of Fluid and Electrolyte Balance

15 of 25 What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? Urge the client to drink more water. Notify the primary health care provider. Assess the client's deep tendon reflexes. Document the finding as the only action.

Chapter 13 - Concepts of Fluid and Electrolyte Balance

20 of 25 Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? Shortened QT-interval Absent P wave Prominent U wave Inverted T waves

Chapter 13 - Concepts of Fluid and Electrolyte Balance

21 of 25 Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.) Select all that apply. Tops of the forearms Skin of the shins Skin of the forehead Skin over the abdomen Skin over the sternum Back of the hand

Chapter 13 - Concepts of Fluid and Electrolyte Balance

22 of 25 Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.) Select all that apply. Testing skin turgor Asking about any abdominal pain Assessing cognition Checking deep tendon reflexes Monitoring urine output Checking for the presence of fever

Chapter 13 - Concepts of Fluid and Electrolyte Balance

23 of 25 In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) Select all that apply. Red meat Cereal Citrus fruit Salt substitutes Eggs Bread

Chapter 13 - Concepts of Fluid and Electrolyte Balance

24 of 25 Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) Select all that apply. Keeping the client NPO during drug treatment Pushing the drug as a bolus slowly over 5 minutes Using an IV controller to deliver the drug Checking IV access for blood return after the infusion Initiating the IV in a hand vein for rapid access Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

Chapter 13 - Concepts of Fluid and Electrolyte Balance

25 of 25 Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) Select all that apply. Management of hypertension with an angiotensin converting enzyme inhibitor Presence of chronic kidney disease Vegan diet Excessive use of salt substitute Daily therapy with a potassium-sparing diuretics Past history of hepatitis A

Chapter 13 - Concepts of Fluid and Electrolyte Balance

6 of 25 Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful? Pulse pressure has decreased. Client reports feeling hungry. Hematocrit is 58% (0.58 volume fraction). Hourly urine output is greater than 15 mL.

Chapter 13 - Concepts of Fluid and Electrolyte Balance

8 of 25 Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload? Checking for presence of dependent edema Assessing blood pressure Measuring intake and output Elevating the head of the bed

Chapter 13 - Concepts of Fluid and Electrolyte Balance

What is the nurse's best first action when a client's hand goes into flexion contractures during blood pressure measurement with an external cuff? Deflating the blood pressure cuff and giving the client oxygen Documenting the finding as the only action Initiating the Rapid Response Team Placing the client in the high-Fowler position and increasing the IV flow rate

Chapter 13 - Concepts of Fluid and Electrolyte Balance

15 of 16 Which conditions could cause a client to develop acidosis? (Select all that apply.) Select all that apply. Ventilator at too low a tidal volume Sepsis Severe diarrhea Hypovolemic shock Prolonged nasogastric suctioning Hyperventilation

Chapter 14 - Concepts of Acid-Base Balance

16 of 16 For which signs and symptoms will the nurse assess in a client who has acute respiratory acidosis with a PaCO2 level of 88 mm Hg? (Select all that apply.) Select all that apply. Hyperactive deep tendon reflexes Acute confusion Lethargy Hypotension pH 7.49 Tall T-waves

Chapter 14 - Concepts of Acid-Base Balance

4 of 13 A client who was treated last month for a severe respiratory infection reports many of the same symptoms today. Which factor in the client's use of antibiotic therapy most likely caused the client's relapse? Taking the antibiotic most days Taking the antibiotic as prescribed Taking the antibiotic before jogging 2 miles daily Taking the antibiotic with a full glass of water

Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? Cholesterol level 195 mg/dL Elevated HDL levels Elevated LDL levels Triglyceride level 135 mg

Cholesterol level 195 mg/dL The nurse should identify that total cholesterol levels less than 200 mg/dL are recommended to help reduce the incidence of developing atherosclerosis. Elevated HDL levels The nurse should expect a decreased HDL level in a client who is at risk for atherosclerosis. Elevated HDLs have a protective effect against the development of atherosclerosis. The client's desirable HDL level is 40 mg/dL or greater. ✅Elevated LDL levels The nurse should identify that an elevated LDL level increases a client's risk for artherosclerosis. The client's desirable LDL level is below 100 mg/dL. Triglyceride level 135 mg The nurse should identify that triglyceride levels less than 150 mg/dL for male clients and 135 mg/dL for female clients are recommended to help reduce the incidence of atherosclerosis. RN Learning System Medical-Surgical: Final Quiz

The nurse working in the PACU knows that which of the following can be expected to learn from the anesthesia provider during the hand-off report? Select all that apply Dressing type Client special requests ASA classification of client Location of drains Fluids administered

Client special requests The anesthesia provider will not typically communicate this type of information during the hand-off report. The handoff from anesthesia will include fluids and medication that they gave during the procedure as well as their ASA classification ✅ASA classification of client This is information that the anesthesia provider will communicate to the PACU RN during the hand-off report. Location of drains The anesthesia provider will not typically communicate this type of information during hand-off report. The handoff from anesthesia will include fluids and medication that they gave during the procedure as well as their ASA classification. ✅Fluids administered This is information that the anesthesia provider will communicate to the PACU RN during the hand-off report. Dressing type The anesthesia provider will not typically communicate this type of information during the hand-off report. The handoff from anesthesia will include fluids and medication that they gave during the procedure as well as their ASA classification 03.01 Post-Anesthesia Recovery

The circulating nurse in the operating room has a client scheduled for a c-section. Based on knowledge of surgical incisions, which of the following types of incisions does the nurse expect to see? Oblique incision Paramedian incision Collar incision Transverse incision

Collar incision This is not an incision for a c-section. This is for a thyroidectomy. Oblique incision This is not a typical incision for a c-section. This is sometimes used for bariatric surgery. Paramedian incision This is not a typical incision for a c-section. This is used in laparotomies. ✅Transverse incision Transverse suprapubic incision is common for a c-section. 03.03 Surgical Incisions & Drain Sites

1.​How does a mutation is a suppressor gene, such as BRCA1, increase the risk for cancer development? A.​Converting a proto-oncogene into an oncogene B.​Removing the control over proto-oncogene expression C.​Reducing the amount of cylins produced by the oncogenes D.​Inhibiting the recognition of abnormal cells through immunosurveillance Correct Answer: B

Correct Answer: B Rationale: Suppressor genes make products that control proto-oncogenes and prevent them from being over expressed, which would increase cell division. Thus when suppressor genes are mutated cellular regulation is lost and the increased cell division can result in cancer development. Conversion of a proto-oncogene to an oncogene requires a mutation in the proto-oncogene, not the suppressor gene. Health suppressor genes do control the amount of cyclins produced by either oncogenes or proto-oncogenes, so a mutated suppressor gene would lose this function. Suppressor genes do not interfere with the immunosurveillance performed by certain immune system cells to detect the presence of abnormal cells. Cognitive Level: Understanding Client needs category: ​Physiological Integrity Nursing Process Step: ​N/A Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

​A client's cancer is staged as T1, N2, M1 by the TNM classification system. How does the nurse interpret this report? A.​The client has two tumors that are nonresponsive to treatment. B.​The client has leukemia confined to the bone marrow. C.​The client has a 2 cm tumor with one regional lymph node involved and no distant metastasis. D.​The client has a small primary tumor extension into 3 lymph nodes and one site of distant metastasis.

Correct Answer:​D Rationale: T = primary tumor. A T1 indicates a primary tumor is detectable but still relatively small. N = regional lymph nodes. An N2 indicates regional lymph nodes are involved. M = distant metastasis. M1 indicates there is evidence of distant metastasis in at least one site. Cognitive level:​​Applying or higher Client Needs Category:​​Physiological integrity Nursing Process Step:​​Assessment Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

An older client reports all of the following changes since his last checkup. Which changes alerts the nurse to the possibility of prostate cancer? Select all that apply. A. Bloody urine B. Constipation intermittent with diarrhea C. Erectile dysfunction D. Night sweats and fever E. Persistent pain in the lower back and legs F. Reduced urine stream

Correct Answers: D, E, F Rationale: Bloody urine is most associated with bladder cancer. Constipation/diarrhea and erectile dysfunction are not common signs or symptoms of prostate cancer. Reduced urine stream is associated with both prostate cancer and benign prostatic hyperplasia and is considered a red flag for prostate cancer when associated with other prostate cancer symptoms. Persistent pain in the lower back and legs, as well as night sweats and fever are associated with late stage prostate cancer. Cognitive Level: Applying or higher Client needs category: ​​Physiological Integrity Nursing Process Step: ​​Assessment Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

Physiological Integrity Which specific cancer types have a higher rate of occurrence among the Hispanic/Latino population of the U.S. compared with the nonHispanic white population? Select all that apply. A. Breast B. Colorectal C. Gall bladder D. Liver E. Lung F. Prostate G. Stomach

Correct Answers: ​C, D, G Rationale: The most common cancers in the United States among nonHispanic whites are breast, colorectal, lung, and prostate cancers. These occur at lower rates among Hispanic/Latino adults living in the U.S. However, the infection-associated cancers (gall bladder, liver, stomach) occur in this population at a higher rate. Cognitive Level: Understanding Client needs category:​​Physiological Integrity Nursing Process Step: ​​N/A Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? Cover the insertion site with a hydrocolloid dressing after removal. Provide pain medication immediately after removal. Instruct the client to perform the Valsalva maneuver during removal. Delegate removal of the chest tube to a licensed practical nurse (LPN).

Cover the insertion site with a hydrocolloid dressing after removal. The nurse should cover the insertion site with an occlusive dressing to prevent air entry into the pleural space. Provide pain medication immediately after removal. The nurse should provide the client with pain medication prior to the procedure to promote comfort during the removal of the chest tube. ✅Instruct the client to perform the Valsalva maneuver during removal. The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space. Delegate removal of the chest tube to a licensed practical nurse (LPN). The nurse should expect a provider or specially trained RN to remove the client's chest tube. The nurse should not delegate this procedure to an LPN, as it is beyond the LPN's scope of practice. RN Learning System Medical-Surgical: Final Quiz

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? Decreased capillary refill Dyspnea Orthopnea Dependent edema

Decreased capillary refill Decreased capillary refill occurs in clients who have decreased cardiac output resulting from left-sided heart failure. Dyspnea When the left side of the heart fails, blood return from the lungs via the pulmonary vein is slowed, causing fluid buildup in the lungs that results in shortness of breath. Orthopnea Dizziness occurs in clients who have decreased cardiac output resulting from left-sided heart failure. ✅Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to development of dependent edema. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

The circulating nurse is orienting a new nurse who asks what a "time-out" is. The circulating nurse explains that the "time out" is a nursing priority that decreases the risk of which of the following? Anesthesia reaction Wrong-site surgery Perioperative hypothermia Deep vein thrombosis

Deep vein thrombosis The "time out" is not utilized for this risk. The time out is done to decrease the risk of wrong-site surgery and ensure everyone is in agreement. ✅Wrong-site surgery The "time out" is utilized to decrease the risk of wrong-site/wrong surgery/wrong person. cancel Perioperative hypothermia The "time out" is not utilized for this risk. The time out is done to decrease the risk of wrong-site surgery and ensure everyone is in agreement. Anesthesia reaction The "time out" is not utilized for this risk. The time out is done to decrease the risk of wrong-site surgery and ensure everyone is in agreement. 02.10 Intraoperative Nursing Priorities

Question 8 of 10 The nurse is preparing a 40-year-old client for surgery when they explain they are concerned about blood clots. Based on the nurse's knowledge of postoperative complications which of the following statements is true? Select all that apply Deep vein thrombosis is typically painless in postoperative clients Shortness of breath and chest can be an indication of a pulmonary embolism Facilities should follow DVT protocols to prevent this complication Blood clots are only a concern with a family history Sequential compression devices are used to prevent deep vein thrombosis

Deep vein thrombosis is typically painless in postoperative clients Deep vein thrombosis typically causes pain because blood flow is blocked and not occurring as it should, which causes pain. ✅Facilities should follow DVT protocols to prevent this complication This is a true statement regarding blood clots. DVT protocols help to ensure nurses are doing best practices to prevent a DVT and proper treatment if one is suspected. ✅Shortness of breath and chest can be an indication of a pulmonary embolism This is a true statement regarding blood clots. When a blood clot is released into circulation and gets to the lung it is known as a pulmonary embolus. This will cause shortness of breath and chest pain. Blood clots are only a concern with a family history This is a false statement regarding blood clots. Blood clots are a risk for anyone having surgery. ✅Sequential compression devices are used to prevent deep vein thrombosis This is a true statement regarding blood clots. The sequential compression device will help keep the blood pumping and moving.

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? Document the client's food allergies on the medical record. Ask the client to identify the specific food allergies. Monitor the client for indications of anaphylaxis. Have epinephrine available for administration.

Document the client's food allergies on the medical record. The nurse should document the client's food allergies on the medical record to communicate the information to other members of the health care team; however, there is another action that the nurse should perform first. ✅Ask the client to identify the specific food allergies. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, he must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the client's allergies and identify the specific allergens so that the nurse can ensure that the specific foods are not offered to the client during meals. Monitor the client for indications of anaphylaxis. The nurse should monitor the client for indications of anaphylaxis due to allergen exposure; however, there is another action that the nurse should perform first. Have epinephrine available for administration. The nurse should have epinephrine available for administration to treat the manifestations of an allergic reaction; however, there is another action that the nurse should perform first. RN Learning System Medical-Surgical: Final Quiz

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? Ecchymosis of the thigh Serous drainage at the pin site Chest petechiae Muscle spasms in the left leg

Ecchymosis of the thigh The nurse should identify ecchymosis of the thigh as an expected finding for a client who has a fractured left femur. Serous drainage at the pin site The nurse should identify that serous drainage is expected at the pin site for a client who is in skeletal traction. The nurse should monitor for purulent drainage that can indicate an infection at the site. ✅Chest petechiae The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones, such as the femur, are at increased risk for fat emboli. Fat emboli typically occur 12 to 48 hr after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress into acute respiratory failure. Muscle spasms in the left leg The nurse should identify muscle spasms in the left leg as an expected finding for a client who has a fractured left femur. RN Learning System Medical-Surgical: Final Quiz

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse take? Elevate the residual limb on a soft pillow. Assist the client to a prone position every 4 hr. Reapply a bandage to the residual limb every 12 hr. Apply dressings to the site in a proximal-to-distal direction.

Elevate the residual limb on a soft pillow. The nurse should avoid elevation of the residual limb 72 hr following an amputation because this position increases the client's risk for flexion contractures. ✅Assist the client to a prone position every 4 hr. The nurse should assist the client to a prone position for 20 to 30 min every 3 to 4 hr following an amputation because it reduces the risk of flexion contractures. Reapply a bandage to the residual limb every 12 hr. The nurse should reapply a bandage to the residual limb every 4 to 6 hr to assist in preparation for a prosthetic limb. Apply dressings to the site in a proximal-to-distal direction. MY ANSWER The nurse should apply bandages to the residual limb in a distal-to-proximal direction to prevent restriction of blood flow. RN Learning System Medical-Surgical: Final Quiz

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? First-degree frostbite Second-degree frostbite Third-degree frostbite Fourth-degree frostbite

First-degree frostbite When a client has first-degree frostbite, the skin of the affected area is reddened and looks waxy. Second-degree frostbite When a client has second-degree frostbite, the skin of the affected area has large, fluid-filled blisters. ✅Third-degree frostbite When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled and the skin does not blanch. Fourth-degree frostbite When a client has fourth-degree frostbite, the skin of the affected area is frozen. Blisters do not appear. The client's muscles and bones are affected. RN Learning System Medical-Surgical: Dermatological Practice Quiz

The client is scheduled for laparoscopic surgery and the surgeon wants to place the client in reverse trendelenburg. The nurse knows that which of the following positioning devices are useful to prevent shearing in this position? Foot roll Stirrups Beanbag Footboard

Foot roll This device is not used to prevent shearing. ✅Footboard This device is helpful in preventing shearing when the client is in reverse trendelenburg. Shearing is done when the client is not positioned correctly causing pulling and injury. Beanbag Even though this device is useful in preventing shearing it is most helpful in the trendelenburg position. Stirrups This device is not used to prevent shearing. 02.08 Intraoperative Positioning

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? Hypokalemia Lead poisoning Hypercalcemia Iron toxicity

Hypokalemia The client who has received several blood transfusions is at risk for hyperkalemia. Stored blood releases increased amounts of potassium due to red blood cell hemolysis. Lead poisoning The client who has received numerous blood transfusions is not at risk for lead poisoning because lead is not found in blood. Hypercalcemia The client who has received several blood transfusions is at risk for hypocalcemia. The citrate in the transfused blood bonds with calcium, causing calcium to be excreted. ✅Iron toxicity The client who has received several blood transfusions is at risk for development of hemosiderosis, which is excess storage of iron in the body. The excessive iron can come from overuse of supplements or from receiving frequent blood transfusions, as in sickle cell anemia. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? Increased cardiac output Increased pulmonary congestion Decreased left atria pressure Decreased pulmonary artery pressure

Increased cardiac output Cardiac output is decreased in a client who has heart failure related to mitral stenosis because the left ventricle is receiving insufficient blood volume to pump into the systemic circulation. ✅Increased pulmonary congestion Pulmonary congestion occurs due to right-sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in pulmonary artery pressure, and hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right-sided heart failure. Decreased left atria pressure As the mitral valve opening narrows, blood flow from the atria to the ventricle falls causing a back-up, and increased pressure, in the left atria. Decreased pulmonary artery pressure Pulmonary artery pressure is increased as a result of back-up pressure from the narrowing, or stenosis, of the mitral valve that affects the flow of blood from the left atrium to the left ventricle. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? Infective endocarditis Pericarditis Ventricular dysrhythmias Pulmonary emboli

Infective endocarditis Infective endocarditis occurs when bacteria invades the endothelial surface of the heart. Infective endocarditis is usually seen in clients who have prosthetic heart valves or pacemakers. Pericarditis Pericarditis can occur 10 days to 2 months following a myocardial infarction. Pericarditis is an inflammation of the pericardial sac that surrounds the heart and is usually a result of infection, connective tissue disorders, or trauma. ✅Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system. Pulmonary emboli Pulmonary emboli occur if the client develops heart failure following a myocardial infarction. Pulmonary emboli are found more commonly with valvular disorders, atrial fibrillation, or from a deep-vein thrombosis. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postprocedure plan of care? Instruct the client on a long-term cardiac conditioning program. Administer scheduled doses of acetaminophen. Check for peak laboratory markers of myocardial damage. Monitor for bleeding.

Instruct the client on a long-term cardiac conditioning program. The nurse should provide teaching about cardiac rehabilitation prior to the client's discharge from the hospital. Administer scheduled doses of acetaminophen. The nurse should plan to administer scheduled doses of aspirin postprocedure. This maintains the patency of the client's coronary arteries following the PTCA by preventing platelet aggregation and thrombus formation around the newly placed stent. Check for peak laboratory markers of myocardial damage. The nurse should monitor for peak laboratory markers of myocardial damage following a myocardial infarcation and reperfusion with thrombolytic therapy. ✅Monitor for bleeding. Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client remains on bed rest until hemostasis is assured. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? Kussmaul respirations Diaphoresis Decreased skin turgor Ketonuria

Kussmaul respirations A nurse should expect a client who has a blood glucose level below 70 mg/dL to exhibit manifestations of hypoglycemia. The nurse should expect Kussmaul respirations in a client who has hyperglycemia. ✅Diaphoresis A nurse should expect a client who has a blood glucose level below 70 mg/dL to exhibit manifestations of hypoglycemia. Expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion. Decreased skin turgor A nurse should expect a client who has a blood glucose level below 70 mg/dL to exhibit manifestations of hypoglycemia. The nurse should expect dehydration and decreased skin turgor in a client who has hyperglycemia. Ketonuria A nurse should expect a client who has a blood glucose level below 70 mg/dL to exhibit manifestations of hypoglycemia. The nurse should expect ketonuria in a client who has hyperglycemia. RN Learning System Medical-Surgical: Final Quiz

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? P waves occurring at 0.16 seconds before each QRS complex Atrial rate of 300/min with QRS complex of 80/min Ventricular rate of 82/min with an atrial rate of 80/min An irregular ventricular rate of 125/min with a wide QRS pattern

P waves occurring at 0.16 seconds before each QRS complex The nurse should interpret this finding as a normal sinus rhythm. ✅Atrial rate of 300/min with QRS complex of 80/min The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting. Ventricular rate of 82/min with an atrial rate of 80/min The nurse should interpret this finding as ventricular ectopy, such as premature ventricular contractions. An irregular ventricular rate of 125/min with a wide QRS pattern The nurse should interpret this finding as ventricular tachycardia. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? Partial-thickness burn Stage III pressure ulcer Surgical incision Dehisced sternal wound

Partial-thickness burn A partial-thickness burn heals by spontaneous re-epithelialization. Since it involves the uppermost layers of the dermis, scarring can be minimal or extensive depending on the depth of the burn. Stage III pressure ulcer A stage III pressure ulcer will heal by secondary intention. ✅Surgical incision With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention. Dehisced sternal wound A dehisced sternal wound can either close by secondary or tertiary intention. RN Learning System Medical-Surgical: Dermatological Practice Quiz

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? Pitting edema Areas of reddish-brown pigmentation Dry, pale skin with minimal body hair Sunburned appearance with desquamation

Pitting edema The client who has venous insufficiency can display pitting edema because the valves of the veins are damaged from venous hypertension from sitting or standing in place for too long. This also can be a manifestation of congestive heart failure due to coronary artery disease. Areas of reddish-brown pigmentation The client who has venous insufficiency can display areas of reddish-brown pigmentation because the valves of the veins are damaged from venous hypertension from sitting or standing in place for too long. ✅Dry, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses . Sunburned appearance with desquamation Desquamation, which is the loss of bits of outer skin by peeling or shedding, is associated with sunburn, Kawasaki's disease, and various other skin lesions. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which of the following nutrients promotes wound healing? Vitamin B1 Calcium Vitamin C Potassium

Vitamin B1 Vitamin B1 promotes functioning of the nervous system; however, it does not specifically promote wound healing. Calcium Calcium aids in blood clotting and muscle contraction; however, it does not specifically promote wound healing. ✅Vitamin C A diet high in protein and vitamin C is recommended because these nutrients promote wound healing. Potassium Potassium is necessary for muscle activity and fluid balance; however, it does not specifically promote wound healing. RN Learning System Medical-Surgical: Dermatological Practice Quiz

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? Remain NPO 6 to 8 hr prior to the EEG. Take a sedative the night prior to the EEG. Thoroughly shampoo hair prior to the EEG. Sleep for at least 8 hr the night prior to the test.

Remain NPO 6 to 8 hr prior to the EEG. The nurse should instruct the client to eat regularly scheduled meals prior to the EEG because a low blood glucose level resulting from NPO status can alter EEG results. Take a sedative the night prior to the EEG. The nurse should inform the client that a sedative is not administered the night before a standard EEG because a sedative depresses CNS functioning and can alter EEG results. ✅Thoroughly shampoo hair prior to the EEG. The nurse should instruct the client to thoroughly wash her hair prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG. Sleep for at least 8 hr the night prior to the test. The nurse should instruct the client to be sleep-deprived prior to the EEG to increase the likelihood of recording seizure activity. The nurse should instruct the client to awaken at 0200 to 0300 on the morning of the EEG. RN Learning System Medical-Surgical: Final Quiz

The nurse brings the client into the operating room to prepare for surgery. The anesthesia team starts to give the client anesthesia and the nurse knows that which of the following is the nursing priority? Select all that apply. Assist the anesthesia team with intubation of the client Inform the healthcare provider that the client is ready for surgery Provide emotional support to the client during induction and intubation Update the family of the start of the procedure Assist the scrub tech with initial counts

Update the family of the start of the procedure Although this could eventually be an appropriate action this is not the nursing priority in this situation. ✅Assist the anesthesia team with intubation of the client It is critical to assist the anesthesia team during intubation. ✅Provide emotional support to the client during induction and intubation It is critical to support the client during induction and intubation. The client is not awake during intubation but with the start of the medication to induce sleep the client needs support. Inform the healthcare provider that the client is ready for surgery This is not a nursing priority. Assist the scrub tech with initial counts This is not a nursing priority. 02.01 Intubation in the OR

The circulating nurse in the operating room is assigned a client that is scheduled to have a thyroidectomy. Based on the nurse's knowledge of surgical incisions, which of the following types of incisions would be expected to see in the client? Inframammary incision Collar incision Supraclavicular Wilde's incision

Wilde's incision This is an incision for mastoiditis. ✅Collar incision This is a type of incision for a thyroidectomy. Inframammary incision This is a typical incision for a breast procedure. Supraclavicular This is not a typical incision for a thyroidectomy. 03.03 Surgical Incisions & Drain Sites

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? Zoster vaccine Acyclovir Amoxicillin Infliximab

Zoster vaccine The nurse should anticipate a prescription for the zoster vaccine for an older adult client to prevent herpes zoster. ✅Acyclovir The nurse should anticipate a prescription for acyclovir, an antiviral medication, because it inhibits replication of the virus that causes herpes zoster. Amoxicillin The nurse should anticipate a prescription for amoxicillin for a client who has a bacterial infection. Infliximab The nurse should anticipate a prescription for infliximab for a client who has Crohn's disease. RN Learning System Medical-Surgical: Dermatological Practice Quiz

3. A nurse is caring for a client 24 hr following a liver lobectomy for hepatocellular carcinoma. Which of the following laboratory reports should the nurse monitor? A. Urine specific gravity B. Blood glucose C. serum amylase d. d‐dimer

a. alterations in urine specific gravity following a liver lobectomy are not expected. B. CORRECT: Blood glucose should be monitored during the first 24 to 48 hr following a liver lobectomy due to decreased gluconeogenesis and stress to the liver from surgery. C. alterations in serum amylase following a liver lobectomy are not expected. D. alterations in the D‐dimer following a liver lobectomy are not expected. NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems CHAPTER 92 CANCERS DISORDER

A post anesthesia care unit (PACU) nurse knows that confusion and agitation can be common after anesthesia postoperatively. The nurse know that which of the following can contribute to these issues? Select all that apply. Hypertension Pain Hypoxemia Anxiety Anesthesia

✅ Pain This can cause confusion and agitation after surgery. The client might not be fully awake and feeling pain can cause the client to be confused as to where this is coming from and unsure what is happening. ✅ Hypoxemia This can cause confusion and agitation after surgery. If a client's oxygen level is low then they are not going to be thinking correctly. ✅ Anxiety This can cause confusion and agitation after surgery. Anxiety can lead to poor concentration and cause frustration. ✅ Anesthesia This can cause confusion and agitation after surgery. Anesthesia is still in the system so this would make the client not be fully "awake". Hypertension This is not a typical reason for confusion and agitation after surgery. 03.02 Postoperative (Postop) Complications

A nurse in a clinic is talking with a client scheduled for a sentinel lymph node biopsy. Which of the following information should the nurse include? A. dye is used during the procedure. B. The lymph nodes closest to the tumor are removed during the biopsy. C. A small amount of chemotherapy is used to test the lymph node response. d. A 2 mm plug of tissue is removed during the biopsy.

✅ A CORRECT: The client will receive a dye or colloid as a tracer to help identify lymph nodes during a sentinel lymph node biopsy. B. The lymph nodes close to the tumor might be removed in a later procedure if the sentinel lymph node is positive for cancer. C. Chemotherapy is not administered during a sentinel lymph node biopsy. d. A punch biopsy involves removing a 2 to 6 mm plug of tissue. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention CHAPTER 90 CANCER SCREENING AND DIAGNOSTIC PROCEDURE

1. A nurse is reviewing the medical records of several clients in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (select all that apply.) A. A client who has a WBC of 22,500/uL B. A client who uses an insulin pump C. A client who takes warfarin daily d. A client who has heart failure e. A client who has a BMi of 26

✅ A. CORRECT: An increased WBC indicates an underlying infection and places the client at risk for postoperative complications. ✅B. CORRECT: An insulin pump indicates the client has diabetes mellitus and places the client at risk of postoperative complications (delayed wound healing). ✅C. CORRECT: A client who takes warfarin daily is at risk for bleeding and postoperative complications (hemorrhage). ✅d. CORRECT: A client who has a history of heart failure is at risk for complications (fluid overload, dysrhythmias). e. BMi 26 is within the expected reference range and does not place the client at risk for postoperative complications. NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures NURSING CARE OF PERIOPERATIVE CLIENTS CHAPTER 96 POSTOPERATIVE NURSING CARE

16 of 18 Which client assessment findings indicate to the nurse that leukemia may be present? (Select all that apply.) Select all that apply. Multiple bruises Night sweats Severe epistaxis Fever Frequent colds Fatigue

✅ Multiple bruises ✅Night sweats Severe epistaxis ✅Fever ✅Frequent colds ✅Fatigue All of the answers can be linked to leukemia, especially when they occur together. (Other issues can account for any one of them when they occur singly). Leukemia is a blood and bone marrow cancer. Prolonged bleeding (bruises and epistaxis) can be caused by immature white cells crowding the client's platelets. Night sweats are often caused by fevers that are common with leukemia. Fatigue can be caused by the presence of persistent infection or by the cancer itself as it grows. Decreased ability to fight infection (frequent colds) is caused by the lack of mature white blood cells, as leukemic cells cannot function properly. Fever is associated with an increased rate of metabolism among the leukemic cells and the presence of any infection. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

18 of 20 The nurse is documenting peripheral venous catheter insertion for a client. What will the nurse include in the note? (Select all that apply.) Select all that apply. Vein used for insertion Client's response to the insertion Date and time inserted Client's name and hospital number Type of dressing applied Type and size of device

✅ Vein used for insertion ✅Client's response to the insertion ✅Date and time inserted ✅Type of dressing applied ✅Type and size of device The client's ability to adapt to interventions, such as IV insertion, should be noted when the intervention is performed. The date and time of the insertion are important data. IV sites need to be routinely monitored and changed at prescribed intervals per facility policy. It is important to note the device used (often the brand name is given), as well as all specifics such as needle or cannula length, gauge, and material (Teflon). It is necessary to describe the dressing applied, and the vein used should be noted. The client's name and hospital number should be on the medical record, but the nurse makes certain that the information is recorded in the correct medical record. Chapter 15 - Concepts of Infusion Therapy

4 of 14 The client who wants to use Truvada for preexposure prophylaxis (PreP) asks the nurse why testing is needed for HIV status before starting this drug. How does the nurse respond? "Although this drug can help prevent HIV infection, it is not enough by itself to control "the disease if you are HIV positive." "The side effects of this drug are worse if you have a detectable HIV viral load." "If you take this drug and are HIV positive, your risk for co-infection with the hepatitis B virus is increased." Some people have a genetic mutation that increases the risk for life-threatening reactions "while taking this drug if they are also HIV positive."

✅"Although this drug can help prevent HIV infection, it is not enough by itself to control "the disease if you are HIV positive." The drug can help prevent HIV infection, but alone does not adequately suppress viral replication. In addition, taking it when HIV positive often leads to drug resistance. None of the other statements are true Chapter 17 - Concepts of Care for Patients With HIV Disease

12 of 18 Which statement by a client who has systemic lupus erythematosus (SLE) indicates to the nurse that more education about the disorder and its management is needed? "My friend and I are going to start walking 2 miles daily." "Taking my temperature every day can help me recognize when a flair is starting." "If I still have a lot of pain after taking an NSAID, I can also take acetaminophen." "At the first sign of a flare, I will begin taking my medication again."

✅"At the first sign of a flare, I will begin taking my medication again." The client's statement suggests that he or she believes that daily medication is not needed and would be required only during a flare. However, daily drug therapy is essential to slow the progression of the disease and organ damage. Low-impact exercise such as walking is highly recommended to maintain mobility and promote cardiovascular health. Fevers are often associated with a flare. There is no contraindication to taking both NSAIDs and acetaminophen. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

6 of 18 In teaching a client about primary prevention of skin cancer, which instruction does the nurse include? "Examine your skin quarterly for lesions." "Avoid sun exposure between 11 a.m. and 3 p.m." "If you feel, you must tan, use a tanning bed." "Report skin changes only if a lesion gets larger."

✅"Avoid sun exposure between 11 a.m. and 3 p.m." The nurse teaches the client that the sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time. Skin should be examined at least monthly. Skin changes of any kind should be reported. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

12 of 18 An 85-year-old client tells the nurse that she does not perform breast self-exam because there is no history of breast cancer in her family. What is the nurse's best response? "Because your breasts are no longer as dense as they were when you were younger, your risk for breast cancer is now decreased." "Breast cancer can be found more frequently in families; however, the risk for general, nonfamilial breast cancer increases with age." "You are correct. Breast cancer is an inherited type of malignancy and your family history indicates a low risk for you." "Examining your breasts once per year when you have your mammogram is sufficient screening for someone with your history."

✅"Breast cancer can be found more frequently in families; however, the risk for general, nonfamilial breast cancer increases with age." The risks for all types of sporadic (noninherited, nonfamilial) cancers increase with age. An 85-year-old woman is two to three times more likely to have breast cancer than is a 30-year-old woman. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

While at a routine clinic appointment, the nurse notes a client with lung cancer is breathing heavily, wearing dirty clothes, and looking disheveled. The client has lost 15 pounds since the last visit. Which of the following statements by the nurse therapeutically assesses the client's functional capacity? Select all that apply. "Can you tell me how you are doing at home managing your daily activities?" "Tell me more about your support system at home" "I am going to contact the social worker since you can't afford to purchase food" "I am going to arrange for someone to come to your home to wash your clothes" "Have you noticed that you are more short of breath than usual lately?"

✅"Can you tell me how you are doing at home managing your daily activities?" This allows the client to speak to their functional capacity and ability to complete their activities of daily living. This question allows the nurse to assess how the client's cancer and treatment regimen is affecting the client's ability to meet his/her own needs. ✅"Have you noticed that you are more short of breath than usual lately?" Both the disease process and treatment regimen in lung cancer can negatively impact the client's respiratory status and is a common reason that the client struggles to complete ADLs. ✅"Tell me more about your support system at home" This is an open-ended question that will allow the nurse to assess the client's resources and support network. "I am going to contact the social worker since you can't afford to purchase food" This statement is based on the assumption that the client has lost weight because they don't have the resources to food, which may be true, but it is also likely that the client has lost weight due to lack of appetite, nausea, or vomiting as a result of their treatment plan. "I am going to arrange for someone to come to your home to wash your clothes" This statement is based on the assumption that the client is no longer able to do laundry independently. The nurse should begin by asking open-ended questions to determine the reason why the client is dressed in dirty clothing.

A nurse is orienting a new perioperative nurse in the operating room. After bringing the client into the OR the surgeon instructs the new nurse to shave the surgical site and the nurse asks you where they can find a razor. Which of the following is the best response? Select all that apply. "Clipping has shown to decrease irritation that shaving can cause" "Even though the surgeon is saying to shave, we only clip clients" "Confirm with the surgeon that shaving is what is needed and not clipping" "We keep razors in the central supply area" "Shaving increases the risk of surgical site infection"

✅"Clipping has shown to decrease irritation that shaving can cause" This is an appropriate response to the new RN. ✅"Even though the surgeon is saying to shave, we only clip clients" This is an appropriate response to the new RN. Shaving can increase the risk of infection. ✅"Shaving increases the risk of surgical site infection" This is an appropriate response to the new RN. This can cause cuts and a way for infection to enter. "We keep razors in the central supply area" Razors should not be utilized on the surgical client. "Confirm with the surgeon that shaving is what is needed and not clipping" Shaving is never an appropriate action for the surgical client. 02.06 Surgical Prep

9 of 17 What is the nurse's best next question after observing that a 60-year-old client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter? "What are your hobbies?" No questions are needed regarding this normal finding. "Do you have any chronic breathing problems?" "How often do you perform aerobic exercise?"

✅"Do you have any chronic breathing problems?" The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a "barrel" chest. Most commonly, a barrel chest occurs as a result of a long-term chronic airflow limitation problem such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at high altitudes for many years. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

3 of 16 Which client arterial blood pH value indicates to the nurse the lowest concentration of free hydrogen ions? 7.45 7.42 7.36 7.29

✅7.45 The concentration of hydrogen ions is inversely (negatively) related to the pH. Thus the lower the pH, the higher the concentration of hydrogen ions and the higher the pH, the lower the concentration of free hydrogen ions. The pH of 7.29 represents the greatest concentration of free hydrogen ions in this list and the pH of 7.45 represents the lowest concentration of free hydrogen ions. Chapter 14 - Concepts of Acid-Base Balance

1 of 13 The nurse is assessing a young adult client who missed multiple work days this winter due to having pneumonia or other respiratory infection four times. What question would be most appropriate for the nurse to ask as part of the health interview? "Have you received your pneumonia vaccines?" "Do you have any environmental concerns at work?" "Did you have the flu before developing pneumonia?" "Do you travel out of the country a lot?"

✅"Do you have any environmental concerns at work?" The client may be exposed to inanimate substances in the work environment, such as mold, toxic metals, or asbestos. This particulate matter exposure can cause respiratory infections and allergies. Traveling can also predispose a client to infections, but this factor is less likely to be a major risk factor. Pneumonia vaccines are usually given for clients who are over 65 years of age. Having influenza can lead to pneumonia is the client has a depressed immune system or does not take care of him- or herself. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

The elementary school nurse is teaching children how to prevent injuries from cold exposure in the winter. Which student statement demonstrates that the teaching has been effective? "Dressing in layers is important." "I will drink lots of water when I exercise." "Wearing cotton socks to stay warm is very important." "Taking frequent breaks will help me rest."

✅"Dressing in layers is important." Teaching has been effective when the student states that "Dressing in layers is important." Layering is very helpful in preventing cold injuries. The inner layer of clothing will provide insulation and the outer layers will help protect from wind and moisture. Lightweight and synthetic fabrics are preferable. Drinking lots of water and taking frequent breaks are associated with prevention of heat-related injuries. Cotton socks are not an appropriate choice as they will prevent evaporation of any moisture and can lead to hypothermia. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

10 of 14 Which statement made by the nurse during an admission assessment for a client who is HIV positive demonstrates a nonjudgmental approach in discussing sexual practices and behaviors? "You must tell me all of your partners' names, so I can let them know about possibly being infected." "I hope you use condoms to protect your partners." "Have you had sex with men or women or both?" "You don't participate in anal intercourse, do you?"

✅"Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate. "I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. By stating the question about anal intercourse as a negative is very judgmental. Chapter 17 - Concepts of Care for Patients With HIV Disease

A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the following responses should the nurse make? "Adults receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox." "Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant." "A client who has herpes zoster is not contagious if blisters are present on the skin." "Herpes zoster is not contagious to people who have had chickenpox."

✅"Herpes zoster is not contagious to people who have had chickenpox." The nurse should inform the AP that varicella zoster is the causative agent of both chickenpox and herpes zoster. This virus is contagious to people who have not had chickenpox or have not received vaccination for varicella. "Adults receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox." The nurse should inform the AP that adults do not develop a natural immunity to chickenpox. This immunity is acquired through the development of chickenpox or by receiving vaccination for varicella. "Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant." The nurse should inform the AP that herpes zoster is not contagious to people who have received vaccination for varicella. The measles, mumps, and rubella (MMR) vaccine does not provide protection against herpes zoster. "A client who has herpes zoster is not contagious if blisters are present on the skin." The nurse should inform the AP that herpes zoster is most contagious while fluid-filled blisters are present on the skin. RN Learning System Medical-Surgical: Final Quiz

18 of 18 Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? (Select all that apply.) Select all that apply. "Stress can cause my flare-ups." "I am glad that this drug therapy will cure my condition." "A tanning bed will supply the ultraviolet light I need." "I can never be cured." "Medicine can prevent the growth of new skin cells."

✅"I am glad that this drug therapy will cure my condition." ✅"A tanning bed will supply the ultraviolet light I need." Use of commercial tanning beds is specifically not recommended for clients. Psoriasis is a lifelong disorder and cannot be cured. These statements indicate that the client requires further teaching. Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

You are the preoperative nurse and you are getting your client ready for their procedure and realize the client does not understand that they are receiving local anesthesia when they say which of the following? "I'm glad I won't feel anything" "You will talk to me during the procedure, right?" "I am so happy I will be asleep during this procedure" "Will the surgeon talk to me during the procedure?"

✅"I am so happy I will be asleep during this procedure" The client will not be "asleep" during the procedure. "You will talk to me during the procedure, right?" The client understands that they are awake and alert during local anesthesia. "I'm glad I won't feel anything" The client understands that they won't feel anything with local anesthesia. "Will the surgeon talk to me during the procedure?" The client understands that they are awake and alert during local anesthesia. 02.03 Local Anesthesia

The triage nurse has a suggestion for improving response in the next mass casualty event. Which option does the nurse use to introduce this idea? Administrative review Hospital suggestion box Supervisor Communicate to colleagues

✅Administrative review The triage nurse uses the administrative review process to present suggestions to improve responses in the next mass casualty event. The goal of the administrative review is to discern what went right and what went wrong during activation and implementation of the emergency preparedness plan. In this way, changes can be made. The hospital suggestion box, the supervisor, and communicating to colleagues are not effective ways to implement change in this situation. Chapter 12- Concepts of Disaster Preparedness

13 of 18 What response by the nurse would be most therapeutic when a client who has systemic lupus erythematosus (SLE) says, "My face has changed so much. I feel really ugly"? "I know what you mean, I feel that way sometimes too." "I bet that was hard to say. Thank you for trusting me with your feelings." "Don't worry, treatment will make everything better." "You look great. It's what is inside that counts."

✅"I bet that was hard to say. Thank you for trusting me with your feelings." "I bet that was hard to say. Thank you for trusting me with your feelings" is an empathetic response in a hard conversation. It acknowledges the client's bravery for sharing and encourages further therapeutic communication. "You look great. It's what is inside that counts" is dismissive of the client's feelings. "Don't worry we will make everything better" is considered false reassurance, this can discount the client's feelings. "I know what you mean, I feel that way sometimes too" is focused on the nurse at a time when the focus should be on the client. All three responses hinder a continued conversation and therapeutic communication. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

2 of 20 The nurse is teaching a client who is being discharged about care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? "The PICC line can stay in for months." "I have less chance of getting an infection because the line is not in my hand." "I can continue my 20-mile (32-km) running schedule as I have in the past." "I can still go about my normal activities of daily living."

✅"I can continue my 20-mile (32-km) running schedule as I have in the past." The statement by the client stating that his or her normal running schedule can continue indicates a need for further education. Excessive physical activity can dislodge the PICC or lead to catheter occlusion and should be avoided. Clients with PICCs should be able to perform normal activities of daily living. PICCs have lower complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months). Chapter 15 - Concepts of Infusion Therapy

4 of 13 The home health nurse is doing an intake assessment on a client who had a recent punch biopsy of a basal cell carcinoma on the left cheek. Which client statement requires further nursing teaching? "I expect to have a large scar as a result of this procedure." "Every morning, I check my cheek for signs of infection." "No harsh chemicals should be used on my skin." "I have been cleaning my face with soap and water."

✅"I expect to have a large scar as a result of this procedure." The client's comment about expecting a large scar after a skin punch biopsy indicates a need for client teaching. Punch and shave biopsies cause little or no scarring. The nurse should further assess the client for knowledge about the association between sun exposure and skin cancers and for use of sunscreens. The client should check the biopsy site daily for signs of infection. Cleaning the face with soap and water helps to prevent infection. Harsh chemicals should not be used. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

16 of 18 A client with a bacterial skin infection is being taught home care for treatment of this infection. Which statement by the client indicates a need for further teaching? "I should cover the lesions if necessary to limit exposure to other people." "I may stop using the topical antibiotic when the lesions disappear." "I will remove crusts with soap and water before applying the medication." "I should contact my provider if I develop a fever or if the lesions spread.

✅"I may stop using the topical antibiotic when the lesions disappear." The statement by the client that, "I may stop using the topical antibiotic when the lesions disappear," indicates the need for further teaching. The antibiotic should be used for the time prescribed and not just until the lesions seem to be resolved. Clients should be taught to remove crusts before applying the medication to improve absorption. If signs of systemic disease occur, the client should contact the provider since oral antibiotics may be necessary. Covering the lesions will help prevent spread to others. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

8 of 13 The nurse is instructing a client about skin and sun protection. Which statement by the client indicates a need for further nursing teaching? "I use a tanning bed to avoid the sun's harmful rays." "My sunglasses are UVA and UVB protected." "I am better protected from the sun because I am dark skinned." "Sunscreen should be applied liberally."

✅"I use a tanning bed to avoid the sun's harmful rays." The client who reports using a tanning needs further teaching. Tanning beds are just as damaging to the skin as the sun's rays. Individuals with dark skin are better protected from the sun than people with light skin. Regular use of sunscreen helps protect skin from the sun. Sunglasses with UVA- and UVB-protected lenses help shield the eyes from the sun's harmful rays. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? "I will need to take methotrexate even if I'm in remission." "I'm thankful that this type of lupus only affects the skin." "Each day I should apply a sunblock with a sun protection factor of 15." "A mild fever is common with SLE and usually does not require medical intervention."

✅"I will need to take methotrexate even if I'm in remission." The nurse should inform the client that SLE is an autoimmune disorder characterized by exacerbations and remissions. It affects the skin as well as joints, organs, and any structure in the body that contains connective tissue. Methotrexate is an immunosuppressive medication given during remission to help prevent exacerbation. The medication is also given when exacerbations occur to reduce the severity of manifestations. "I'm thankful that this type of lupus only affects the skin." The nurse should inform the client that discoid lupus erythematosus only affects the skin; however, SLE affects the skin as well as joints, organs, and any structure in the body that contains connective tissue. "Each day I should apply a sunblock with a sun protection factor of 15." The nurse should inform the client of the need to protect the skin from sun exposure to reduce the incidence of exacerbations. The nurse should recommend that the client use a sunblock with a sun protection factor of at least 30. "A mild fever is common with SLE and usually does not require medical intervention." The nurse should inform the client that an elevated temperature is an indication of an exacerbation. The client should report this finding to the provider immediately. RN Learning System Medical-Surgical: Final Quiz

6 of 18 Which client statement about the use and care of an epinephrine autoinjector for a peanut allergy indicates to the nurse that more teaching is needed? "If I inject myself, I will still go immediately to the emergency department." "When needed, I can inject the drug right through my clothing." "My wife and I will both practice putting the device together." "If I keep the injector in the refrigerator, the drug will not expire as quickly."

✅"If I keep the injector in the refrigerator, the drug will not expire as quickly." Although it is true that the drug may not deteriorate as quickly if refrigerated, the client needs to have the drug with him or her at all times to use as soon as symptoms of anaphylaxis occur in order to prevent death. All other statements for the use and care of an epinephrine autoinjector are correct Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

12 of 18 Which statement by a client with psoriasis indicates that teaching by the nurse has been effective? "Lesions must be covered to prevent spread to my family." "If I plan to get pregnant while taking tazarotene, I'll talk with my provider." "I should be in the sunlight as much as possible for UV rays." "Psoriasis can be cured with steroids."

✅"If I plan to get pregnant while taking tazarotene, I'll talk with my provider." The client taking tazarotene who acknowledges the need to talk with the provider if planning a pregnancy has demonstrates that teaching has been effective. This drug is teratogenic, even if used topically. Therefore, this client should speak with the provider to consider other therapies, and practice strict contraceptive measures. Although ultraviolet irradiation has been shown to be beneficial in controlling psoriatic lesions, treatment should be completed under the supervision of a dermatologist; the client should be taught to avoid being in the sun for health promotion purposes. Psoriasis is not contagious, but it cannot be cured. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

Which of the following statements by a client who smokes and is at high risk for lung cancer represents an understanding of primary prevention measures? "I will start using smokeless tobacco to reduce my risk of developing lung cancer" "I'll let my doctor know right away if I start coughing up more sputum than normal" "I will follow up with my doctor about getting a spiral CT done" "If I stop smoking, I will decrease my chance of getting lung cancer"

✅"If I stop smoking, I will decrease my chance of getting lung cancer" This is the only statement by the client that represents primary prevention of lung cancer. The risk of developing lung cancer decreases almost immediately after the client stops smoking, and returns to that of an average adult after 10 years after cessation. "I will follow up with my doctor about getting a spiral CT done" This is an example of secondary prevention, which means we are aiming to detect the disease in its early stages to increase the likelihood of survival. "I'll let my doctor know right away if I start coughing up more sputum than normal" This is an example of secondary prevention, which means we are aiming to detect the disease in its early stages to increase the likelihood of survival. "I will start using smokeless tobacco to reduce my risk of developing lung cancer" This is not an appropriate response by the client, as smokeless tobacco use would greatly increase the risk of oral and head and neck cancers.

The nurse is reviewing discharge instructions with a client to prepare them to go home after an outpatient hernia repair that was under general anesthesia. The client signs the discharge papers and the nurse gets a wheelchair to take the client out of the hospital. The client starts searching for the car keys and states "I wish my spouse could be here to take me home". Which of the following is best response by the nurse to the client? "Let me check with your surgeon to see if you are cleared to drive" "It is not safe for you to drive after having anesthesia" "I think I saw your car keys in your client belongings bag, let me help you find them" "Are you sure you feel ok to drive?"

✅"It is not safe for you to drive after having anesthesia" Clients who receive anesthesia are not permitted to drive for at least 24 hours after anesthesia. "I think I saw your car keys in your client belongings bag, let me help you find them" The nurse should not let the client drive after general anesthesia. An alternative means of transporting the client home should be arranged. "Are you sure you feel ok to drive?" Even if the client feels well enough to drive, the nurse must help the client make alternative plans for transportation home because driving is contraindicated for at least 24 hours following general anesthesia. "Let me check with your surgeon to see if you are cleared to drive" Although surgeons often give clients restrictions regarding driving after surgery the primary issue is the risk of driving after anesthesia. 02.02 General Anesthesia

The preoperative nurse is asked by the client when they will be able to leave. The nurse knows that which of the following is the best response to give the client? "It varies between patients, there is certain criteria for you to meet in the recovery area that indicates it is safe for you to go home " "You will have to ask your surgeon that question, I'm not sure how extensive your surgery is going to be or how much anesthesia you will require" "We are really busy, we like clients to be out of the recovery area within 30 minutes so hopefully you will wake up easily after anesthesia" "It all depends on how well your surgery goes and how well you do when you wake from anesthesia"

✅"It varies between patients, there is certain criteria for you to meet in the recovery area that indicates it is safe for you to go home " It is an appropriate response to give your client that relates to general anesthesia and surgery. "We are really busy, we like clients to be out of the recovery area within 30 minutes so hopefully you will wake up easily after anesthesia" This is an inappropriate response to give your client. "You will have to ask your surgeon that question, I'm not sure how extensive your surgery is going to be or how much anesthesia you will require" Although this may be true, you should give them more specific information. "It all depends on how well your surgery goes and how well you do when you wake from anesthesia" Although this may be true, you should give them more specific information. 02.02 General Anesthesia

7 of 18 A client has been diagnosed with tinea corporis (ringworm). To avoid spreading the infection, what does the nurse suggest? "No special precautions are necessary as this is not contagious." "Keep the site covered with a bandage." "Use hand sanitizer instead of soap and water to clean your hands." "Isolate yourself from everyone until healed."

✅"Keep the site covered with a bandage." Keeping the site covered with a bandage prevents spread of the infection. The client should always wash with soap and water. Hand sanitizer is an alternate if soap and water are not available. Total isolation is not needed, yet precautions to avoid transmission of the infection are necessary. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? "May I go with my family to the visitor's lounge?" "I'll see my friends when I get home." "My dad is coming to visit. Can you fix my hair for me?" "I told my cousins I'm in protective isolation."

✅"May I go with my family to the visitor's lounge?" This statement demonstrates a positive self-image. The client is asking to visit with her family in a public setting. "I'll see my friends when I get home." This statement indicates that the client does not feel comfortable being seen by her peer group. Since interaction with the peer group is important to an adolescent, the client's statement shows that she has not accepted the alterations in her face and hands. "My dad is coming to visit. Can you fix my hair for me?" Asking for assistance with her appearance indicates the client has not yet accepted or adapted to her changed body image. Encouraging the client's participation in self-care activities is one suggested nursing intervention because the independence fosters self-worth and self-image. "I told my cousins I'm in protective isolation." This statement indicates that the client does not feel comfortable being seen by her extended family. This statement demonstrates an attempt to escape from interpersonal contact and indicates that the client has not accepted the alterations in her face and hands. RN Learning System Medical-Surgical: Dermatological Practice Quiz

17 of 20 The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? "It hurts when you are inserting the line." "My hand tingles when you poke me." "My IV lines never last very long." "I hate having IVs started."

✅"My hand tingles when you poke me." The client's statement about a tingling feeling indicates possible nerve puncture and is of greatest concern to the nurse. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site. Statements such as, "I hate having IVs started," "It hurts when you are inserting the line," and "My IVs never last very long," are addressed with teaching about the importance of proper protection of the site. Chapter 15 - Concepts of Infusion Therapy

The preoperative nurse is preparing a client for a thyroidectomy. Which of the following comments makes the nurse concerned about malignant hyperthermia? "I ate a banana this morning" "My mom had heat stroke when she had surgery" "I have never had surgery before, I am nervous" "Will I have a tube in my throat?"

✅"My mom had heat stroke when she had surgery" This is an indication of malignant hyperthermia. "I have never had surgery before, I am nervous" This comment is not directly related to malignant hyperthermia. "I ate a banana this morning" Although this is a major concern it is not related to malignant hyperthermia. "Will I have a tube in my throat?" This would not be concerning. A family member having heatstroke in surgery is a sign of malignant hyperthermia 02.05 Malignant Hyperthermia

1 of 18 A nurse is giving a group presentation on cancer prevention and factors that cause cancer. Which statement by a client indicates understanding the education provided? "Nearly 1/3 of cancers in the United States are related to tobacco use." "Red meat helps to prevent cancer development." "If I eat a healthy diet and exercise I will not develop cancer." "Most cancer is hereditary."

✅"Nearly 1/3 of cancers in the United States are related to tobacco use." Tobacco can be linked directly to the development of about 30% of all cancers in North America. Hereditary cancer occurs in a small percentage of the population. Increased red meat intake appears to increase risk of cancer development. A healthy diet and exercise can be helpful in self-care and overall health, but are not a guarantee that cancer will not develop Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

10 of 18 What is the nurse's best response to a client newly diagnosed with systemic lupus erythematosus (SLE) who asks why nicotine use, especially cigarette smoking or vaping, should be avoided? "Nicotine reduces blood flow to your organs and increases the risk for permanent damage." "Using nicotine in any form reduces the effectiveness of drug therapy for lupus." "Nicotine promotes muscle cell loss, increases joint inflammation, and reduces functional mobility." "Smoking or vaping increases your risk for lung cancer development."

✅"Nicotine reduces blood flow to your organs and increases the risk for permanent damage." Nicotine in any form constricts blood vessels and reduces perfusion. Perfusion is already reduced by the vasculitis that is part of the disease. Thus, use of nicotine greatly increases the risk for necrosis of many tissues and organs. Although smoking or vaping do increase the risk for lung cancer, their effects on blood vessels are a greater issue for the client with SLE. Nicotine neither reduces the effectiveness of drug therapy nor promotes muscle cell loss. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? "Move between the bed and the wheelchair once every 2 hours." "Make sure that your caregiver massages your skin daily." "Use a rubber ring when sitting at the bedside." "Shift your weight in the wheelchair every 15

✅"Shift your weight in the wheelchair every 15 minutes." This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure. "Move between the bed and the wheelchair once every 2 hours." The nurse should instruct wheelchair-bound clients at risk for pressure ulcer formation to change position at least once every hour. "Make sure that your caregiver massages your skin daily." The nurse should instruct the client and his caregiver to avoid massaging the skin, especially over bony prominences, because it can further traumatize fragile tissues. "Use a rubber ring when sitting at the bedside." The nurse should instruct the client and his caregiver to avoid using a rubber ring for sitting because it reduces circulation to the client's skin. RN Learning System Medical-Surgical: Dermatological Practice Quiz

9 of 18 A 74-year-old client recovering from lung cancer surgery tells the nurse, "I don't understand why I have lung cancer. I have never even touched a cigarette." Which factor may explain the cause? A history of cardiac disease Advancing age A history of military service A diagnosis of diabetes

✅Advancing age Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases and therefore risk for overgrowth of cancer cells increases. Diabetes is not known to cause lung cancer. A history of cardiac disease does not predispose a person to lung cancer, nor does a history of military service. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

3 of 13 The nurse is caring for a client who has methicillin-resistant staphylococcus aureus (MRSA) infection and is starting oral delafloxacin therapy. What health teaching would the nurse include about this drug? "Take the drug every day until you feel you better or until your fever does away." "Take the drug at least 2 hours before or 6 hours after any antacids or minerals." "Take the drug every other day as prescribed unless you feel nauseated." "If you forget a dose of the drug, wait until the next day to take the next dose."

✅"Take the drug at least 2 hours before or 6 hours after any antacids or minerals." Delafloxacin interacts with metals such as magnesium and iron. Therefore, the drug must not be given when drugs containing metals are in the stomach. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

A high school athlete recently suffered heat exhaustion. The school nurse is instructing the student on how to prevent a recurrence of this situation. Which student statement demonstrates that the nurse's teaching has been effective? "Taking frequent rests is important when in a hot environment." "I will limit my fluids to drinking 'sports' drinks after exercise." "Wearing dark-colored clothing will deflect the sun away from me." "I should try to exercise between noon and 3 p.m.."

✅"Taking frequent rests is important when in a hot environment." The student demonstrates that teaching about heat exhaustion is effective when articulating the importance of frequent rest periods when in a hot environment. Frequent rest periods will decrease the risk of heat exhaustion. Exercising during times of peak sun exposure (midday) increases the risk of heat exhaustion. Fluids, particularly water, have to be consumed throughout the exercise period and not be limited to a certain type. Light-colored clothing, not dark, reflects the sun away from the individual. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

The nurse is caring for a client who was recently diagnosed with testicular cancer. The client appears anxious and asks the nurse questions about his condition. Which of the following statements by the nurse is correct? "You should consider sperm banking, because once treatment begins for this type of cancer your chances of becoming infertile increase to 95%." "Testicular cancer is known to spread to other areas, even when caught early. You will need to prepare for chemotherapy right away." "Testicular cancer is highly treatable, and has a high survival rate." "You will want to think carefully about having children, because the risk of birth defects increases after treatment for this cancer."

✅"Testicular cancer is highly treatable, and has a high survival rate." This type of cancer has a high rate of survival, even with metastases present. If caught early, treatment may only consist of an orchiectomy, and often just one dose of chemotherapy. However, the treatment for this condition may impact fertility, so the client must be educated on sperm banking and risk of infertility in order to make informed decisions prior to beginning cancer treatment. "Testicular cancer is known to spread to other areas, even when caught early. You will need to prepare for chemotherapy right away." When caught early, it is common for a client with this condition to be cured with surgery alone. "You should consider sperm banking, because once treatment begins for this type of cancer your chances of becoming infertile increase to 95%." Around 50% of clients are infertile following treatment for testicular cancer. "You will want to think carefully about having children, because the risk of birth defects increases after treatment for this cancer." There is no increased risk of birth defects in fertile clients following treatment for this condition.

The clinic nurse is discussing recommended screenings with a 55-year-old male client. The client mentions that his father had prostate cancer and asks what he can do to minimize the risk of getting this type of cancer. Which response by the nurse is correct? "Diet has been strongly linked to prostate cancer, so it is important for you to avoid consumption of too much red meat, and increase consumption of vegetables." "The biggest risk factors are age and family history, so there is not much you can do to minimize the chance of getting prostate cancer." "There is nothing you can do to minimize your risk for prostate cancer, so early detection will be important for you. Plan for routine screenings starting at age 65." "Since you have a family history of the disease, you will need to be screened for the PSA antigen as soon as you experience urinary changes."

✅"The biggest risk factors are age and family history, so there is not much you can do to minimize the chance of getting prostate cancer." The only modifiable risk factor for prostate cancer is diet, but the link is unclear. Routine screenings starting between 50-60 years of age is best, as this will provide early detection and treatment for this type of cancer. "There is nothing you can do to minimize your risk for prostate cancer, so early detection will be important for you. Plan for routine screenings starting at age 65." There is very little a client can do to minimize the risk for prostate cancer, because most risk factors are non-modifiable. However, routine screenings beginning at age 50 will detect cancer early, which means the client will have early treatment and an increased life expectancy. "Diet has been strongly linked to prostate cancer, so it is important for you to avoid consumption of too much red meat, and increase consumption of vegetables." The link between diet and prostate cancer is unclear. In general, consuming a diet high in vegetables and low in red meat is healthy, but there is weak evidence that this affects a person's risk for prostate cancer. "Since you have a family history of the disease, you will need to be screened for the PSA antigen as soon as you experience urinary changes." A client should not wait for urinary changes to occur in order to be screened for a prostate-specific antigen level. This will need to be done on a routine basis starting around age 50 for a client at risk for prostate cancer.

1 of 18 What is the nurse's best response to a client who had a severe allergic reaction to shrimp states, "I have had shrimp once before and did not have a reaction. Why is this happening now?" "Allergies are tricky, and many reasons for responses are not known." "It is most likely that you didn't eat enough shrimp the first time to cause a reaction." "The first time your body recognized the shrimp as an allergen, and the second time it reacted to it." "This means you may be allergic to something else and not to shrimp."

✅"The first time your body recognized the shrimp as an allergen, and the second time it reacted to it." Type I reactions have two parts. During the first exposure, the client makes antigen-specific IgE, and becomes sensitized to the allergen. When the sensitized client is re-exposed to the allergen, a more severe reaction occurs. To point out the amount of shrimp eaten is not helpful and could make the client believe that eating only a small amount of shrimp would not cause a reaction. The same is true for option C. Stating that allergies "are tricky" does not help to inform or educate the client about what he or she should do to prevent harm. This response may make the client afraid of everything in his or her environment. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

9 of 14 Which statement made to the nurse by an assistive personnel (AP) assigned to care for an HIV-positive client indicates a breach of confidentiality and requires further education by the nurse? "The client's spouse told me she got HIV from a blood transfusion." "The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client." "I told family members they need to wash their hands when they enter and leave the room." "Yes, I understand the reasons why I have don't need to wear gloves when I feed the client."

✅"The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse. Instruction on handwashing to family members or other visitors is not a breach of confidentiality. Understanding the reasons for when and when not to wear gloves when performing direct client care is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality. Chapter 17 - Concepts of Care for Patients With HIV Disease

The client is sitting in the preoperative department as they are being prepared for surgery. They ask the nurse "why did I have to shower with that special soap last night?" Which of the following is the best response by the nurse? "The surgeon requests this because it helps with the surgery" "It's hospital policy that all surgical clients bathe with this soap before surgery" "This helps to decrease any bacteria on your skin" "We need to make sure you are clean before surgery"

✅"This helps to decrease any bacteria on your skin" This is the purpose of preoperative bathing. "The surgeon requests this because it helps with the surgery" This is not the most appropriate response to give the client. It is used to decrease bacteria and decrease infection. "We need to make sure you are clean before surgery" This is not the reason for preoperative bathing. It is used to decrease bacteria and decrease infection. "It's hospital policy that all surgical clients bathe with this soap before surgery" Although this may be true it is not the most appropriate response to give the client. It is used to decrease bacteria and decrease infection. 02.06 Surgical Prep

5 of 14 Which point is most important for the nurse to include when teaching assistive personnel (AP) about protecting themselves from HIV exposure when caring for HIV-positive clients? "Always wear a mask when entering an HIV-positive client's room." "Talk to the employee health nurse about starting preexposure prophylaxis." "Wear gloves when in contact with clients' mucous membranes or nonintact skin." "Wear full protective gear when providing any care to HIV-positive clients."

✅"Wear gloves when in contact with clients' mucous membranes or nonintact skin." Standard Precautions are all that is needed when caring for any client, including those who have HIV. Masks and full protective gear are not needed. Preexposure prophylaxis is not used for potential occupational exposure. Chapter 17 - Concepts of Care for Patients With HIV Disease

A client who lost a home to a hurricane several years ago tells the nurse, "I get very nervous during a thunderstorm and want to hide under the bed." What is the appropriate nursing response? "It's just a thunderstorm. You would have warning if a hurricane was approaching." "That is posttraumatic stress disorder (PTSD). A counselor can help you." "I understand. That is normal and is nothing to worry about." "What helps you when you begin feeling this way?"

✅"What helps you when you begin feeling this way?" The appropriate nursing response to a client who reports being nervous during a storm is to ask what helps when the client begins to feel this way. This statement helps to acknowledge the client's statement and further evaluates whether the thought is causing maladaptive behavior to the situation. Weather-related concerns, particularly stemming from past experience, are not necessarily an indication of maladaptive behavior. Minimizing the client's concerns is not therapeutic. Telling the client he or she has PTSD is out of scope, and not appropriate. Chapter 12- Concepts of Disaster Preparedness

10 of 16 What is the nurse's best response to a 38-year-old client with a large wound who does not want to receive a tetanus toxoid vaccination because he had a tetanus shot just 1 year ago? "Tetanus is a more serious disease and a "booster" is required every year to ensure adequate immunity and protection against it." "You may not need this vaccination now, I will check with your health care provider." "You need this vaccination because the strain of tetanus changes every year." "Because antibody production slows down as you age, it is better to take this vaccination as a booster to the one you had a year ago."

✅"You may not need this vaccination now, I will check with your health care provider." When people have been "boosting" their tetanus antibodies on a regularly scheduled basis, they should have sufficient circulating antibodies to mount a defense against exposure to tetanus. If this client's medical records substantiate that he did indeed receive a tetanus toxoid booster 1 year ago, he does not need another one now. Chapter 16 - Concepts of Inflammation and Immunity

The nurse is teaching a class of park ranger trainees about prioritizing care for clients who have received snakebites. Which ranger's statement demonstrates a need for further teaching? "EMS should be called to transport the client." "Do not allow the victim to ingest any alcohol or caffeine." "The extremity should be kept below the level of the heart." "You should place a tourniquet above the site of the bite."

✅"You should place a tourniquet above the site of the bite." The ranger trainee's statement about placing a tourniquet above the bite indicates a need for further teaching. Placing a tourniquet above the bite could worsen local tissue necrosis by retaining venom in the tissues. Nursing teaching will include avoidance of incising or sucking the wound, and avoidance of use of a tourniquet. Alcohol or stimulants such as caffeinated beverages must not be offered because they may speed up the absorption of venom. Affected extremities are kept below the level of the heart. EMS should be called to transport the client Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

Which client will the nurse consider to be at greatest risk for dehydration?? A 75-year-old woman with chronic back pain A 25-year-old woman taking oral contraceptives A 75-year-old man who has a vitamin deficiency A 25-year-old man who has frequent esophageal reflux

✅A 75-year-old woman with chronic back pain Women at any age have a higher risk for dehydration because women have more body fat than men, and fat cells contain practically no water. Men have a higher percentage of total body water at any age because they have more muscle mass than women and muscle cells contain a high concentration of water. The risk for dehydration increases with age. As adults age, their total body water volume decreases because both older men and older women loss muscle mass with aging. Chapter 13 - Concepts of Fluid and Electrolyte Balance

The preoperative nurse is preparing the client for surgery and the client asks you what will happen during surgery with local anesthesia. Which of the following is the best response by the nurse? "When you enter the operating room you will be given medication to make you go to sleep. The nurse anesthetist will place a breathing tube into your trachea to make sure you are ventilated" "You will be hooked up to monitors when you enter the operating room, given sedative and pain medications while the monitor nurse makes sure you are stable" "You will be hooked up to monitors when you enter the operating room by the monitoring nurse. The nurse will watch your vital signs and make sure you are comfortable during the procedure" "You will be given sedative and pain medications to make sure you do not know what is going on so the surgeon can operate"

✅"You will be hooked up to monitors when you enter the operating room by the monitoring nurse. The nurse will watch your vital signs and make sure you are comfortable during the procedure" This is an accurate description of a local anesthesia procedure. "When you enter the operating room you will be given medication to make you go to sleep. The nurse anesthetist will place a breathing tube into your trachea to make sure you are ventilated" This is not an accurate description of local anesthesia. Local anesthesia will not cause the client to go to sleep. "You will be given sedative and pain medications to make sure you do not know what is going on so the surgeon can operate" This is not an accurate description of local anesthesia. Local anesthesia will not cause the client to be unaware. "You will be hooked up to monitors when you enter the operating room, given sedative and pain medications while the monitor nurse makes sure you are stable" This is not an accurate description of local anesthesia. Local anesthesia will not sedate the client. 02.03 Local Anesthesia

13 of 13 The nurse is educating a client who is to undergo a Wood Lamp examination. What teaching will the nurse provide? (Select all that apply.) Select all that apply. "You will be in a darkened room while the provider uses the lamp." "Take ibuprofen before the examination to minimize pain." "Certain kinds of skin infections can be visualized." "This examination requires a small injection of lidocaine." "An antibiotic ointment needs to be applied after the exam."

✅"You will be in a darkened room while the provider uses the lamp." ✅"Certain kinds of skin infections can be visualized." Certain skin infections can be seen using a Wood Lamp, which produces a specific color, such as blue-green or red, that can be used to identify infection. Hypopigmented skin is more prominent when it is viewed under black light, making evaluation of pigment changes in lighter skin easier. This examination is carried out in a darkened room and does not cause discomfort. Lidocaine, ibuprofen, and an antibiotic ointment are not needed. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

12 of 16 What is the most important precaution for the nurse to teach a client who has few natural killer cells and the natural killer cells are not very active? "You will need to avoid people with viral infections because it is harder now for you to develop antibodies." "You will need to have yearly checkups because your risk for cancer development is greater now." "You will be at an increased risk for developing allergies, so it will be necessary for you to avoid common allergens." "You will no longer develop a fever when you have an infection, so you must learn to identify other symptoms of infection."

✅"You will need to have yearly checkups because your risk for cancer development is greater now." Natural killer cells provide protection against development of cancer by recognizing unhealthy or cancer cells as non-self and taking action to destroy them. Chapter 16 - Concepts of Inflammation and Immunity////Chapter 17 Principles of Inflammation and Immunity

The nurse is caring for a client who will undergo surgery for a right-sided colectomy due to colon cancer. The client asks about what changes to expect after surgery. Which is the accurate response? "You'll have a colostomy bag for 3-6 weeks following surgery, so I will help you learn how to care for the site and equipment starting prior to surgery." "You will need to make sure you are getting enough nutrients because absorption time is shortened due to the lack of bowel." "There is an increased risk for constipation following a right-sided colectomy, so you will need to take laxatives during the recovery period." "Short-gut syndrome is one of the expected changes following a colectomy. Your GI tract will be expelling contents more rapidly than normal, so you will be on parenteral nutrition to promote bowel rest."

✅"You will need to make sure you are getting enough nutrients because absorption time is shortened due to the lack of bowel." The right-sided colon, or ascending colon, is a place where last-minute nutrients and fluids are absorbed before the stool is eliminated from the body. The client will have changes in nutrient and water absorption following a right-sided colectomy. "There is an increased risk for constipation following a right-sided colectomy, so you will need to take laxatives during the recovery period." Diarrhea is common, but constipation is not. "You'll have a colostomy bag for 3-6 weeks following surgery, so I will help you learn how to care for the site and equipment starting prior to surgery." The client may have a colostomy placed during surgery, but the majority of clients undergoing a right-sided colectomy do not need a colostomy. "Short-gut syndrome is one of the expected changes following a colectomy. Your GI tract will be expelling contents more rapidly than normal, so you will be on parenteral nutrition to promote bowel rest." Short-gut syndrome is a risk, but is not expected following a colectomy. If short-gut syndrome is noted, then TPN is a potential treatment for this condition.

10 of 18 A 40-year-old man who has a mother who was diagnosed with breast cancer at age 45, a father who was diagnosed with smoking-related lung cancer at age 55, a 33-year-old sister with breast cancer, and a 38-year-old sister with ovarian cancer, asks if he should be concerned for his cancer risk. What is the nurse's best response? "You have two first-degree relatives and two second-degree relatives with cancer, which increases your general risk for cancer." "Your risk for breast cancer is increased; however, your risk for lung cancer is not affected by this history." "Your risk for cancer is affected by your parents' cancer development; your sisters' cancers have no bearing on your risk." "Your risk is not affected by this family history because most of the cancers arose in female sex-associated tissues."

✅"Your risk for breast cancer is increased; however, your risk for lung cancer is not affected by this history." This man has four first-degree relatives with cancer, three of whom have cancers that are associated with a genetic risk. The fact that the sisters and mother were diagnosed at relatively young ages increases the likelihood of a genetic predisposition. The genetic association with these cancers also increases the risk for male members of the family. Lung cancer has not been found to have a genetic association Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

A nurse is reviewing the medical record of a client who had surgery to stage ovarian cancer. The nurse reviews the following diagnostic notation on the pathology report: T2‐N3‐MX. Which of the following findings should the nurse identify as a supporting diagnosis? A. The tumor is moderate in size. B. No lymph nodes contain cancer cells. C. The tumor is receptive to current medication therapy. d. The cancer has metastasized to other areas in the body.

✅. A. CORRECT: A T2 designation describes the size and extent of the ovarian tumor using the tumor‐node‐metastasis (TNM) staging system. A T1 tumor is smallest in size, and a T4 tumor is largest. B. A N3 designation indicates that three adjacent lymph nodes show evidence of spread of cancer using the TNM staging system. C. The TNM diagnostic notation of the staging system is not used to indicate the response of a tumor to a medication therapy regimen used for treatment. d. The MX designation indicates there is no evidence of distant metastasis to other areas of the body using the TNM staging system. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 89 GENERAL PRINCIPLES OF CANCER

2. A nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (select all that apply.) A. Urine output less than 25 mL/hr B. Hematocrit 53% C. BUN 24 mg/dL d. Tenting of skin over the sternum e. Apical pulse rate 62/min

✅. A. CORRECT: Urine output less than 25 mL/hr is a manifestation of hypovolemia and requires intervention by iV fluid therapy. ✅B. CORRECT: Hematocrit 53% indicates concentrated blood volume and is a manifestation of hypovolemia, requiring intervention by iV fluid therapy. ✅C. CORRECT: BUN 24 mg/dL indicates decreased kidney function and can be a manifestation of hypovolemia, requiring intervention with iV fluid therapy. ✅d. CORRECT: Tenting of skin indicates decreased or absent skin turgor due to dehydration, requiring intervention with iV fluid therapy. e. An apical pulse rate of 62/min is not a manifestation of hypovolemia. NCLEX® Connection: Physiological Adaptation, Medical Emergencies NURSING CARE OF PERIOPERATIVE CLIENTS CHAPTER 96 POSTOPERATIVE NURSING CARE

3. A nurse is caring for a client who has cancer and has a prescription for transcutaneous electrical nerve stimulation (TeNs) for pain management. Which of the following actions should the nurse take? A. remove hair before applying the electrodes from the TeNs unit on the skin. B. Apply alcohol to the client's skin before attaching the electrodes from the TENS unit. C. Attach the electrodes from the TeNs unit over painful incisions or skin damage. d. Avoid other pain medications when using the TeNs unit.

✅. A. CORRECT: remove the client's hair before applying the electrodes from the TeNs unit to the skin. B. The skin should be clean and intact before applying the electrodes, but the skin does not have to be cleansed with alcohol . C. Apply the electrodes over intact skin that is over or near the site of pain, but not over incisions or areas of damage. d. Administer pain medication while the client is using the TeNs unit. NCLEX® Connection: Basic Care and Comfort, Non‐Pharmacological Comfort Interventions CHAPTER 93 PAIN MANAGEMENT FOR CLIENTS WHO HAVE CANCER

2. A nurse is reviewing the medical record of a client who has suspected ovarian cancer. Which of the following findings should the nurse identify as a risk factor for ovarian cancer? (select all that apply.) A. Previous treatment for endometriosis B. Family history of colon cancer C. First pregnancy at age 24 d. report of first period at age 14 e. Use of oral contraceptives for 10 years

✅. a. CORRECT: endometriosis is a risk factor for ovarian cancer. B. CORRECT: a family history of breast, ovarian, or colon cancer is a risk factor for ovarian cancer. C. a first pregnancy after 30 years of age or nulliparity is a risk factor for ovarian cancer. D. early menarche is a risk factor for ovarian cancer. e. Birth control pills offer protection against ovarian cancer. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention CHAPTER 92 CANCERS DISORDER

The client is a 37-year-old man with a diagnosis of pneumonia. He reports that he has felt more tired than usual for several days but only noticed a breathless sensation this morning. He has had a chronic cough for years and noted that it is worse today. During the nurse's admission assessment, he reports that he is a 2-pack per day smoker but recently converted to an e-cigarette in an effort to quit smoking because he believes it is a healthier alternative. He lives with his wife, a former smoker. He tells you this is a healthier alternative. Other client information the nurse collects includes: ⏺Client History: • Has high a high blood cholesterol level and hypertension • Takes lisinopril 20 mg orally each morning • Takes atorvastatin 20 mg orally each evening • Lives with his wife, a former smoker, in an affluent suburban neighborhood • Is an attorney in a large law firm • Plays golf twice weekly • Has two school-aged children • Last "flu shot" was 10 years ago ⏺Current Assessment: • Oral temperature = 102.6 degrees F (39.2 degrees C) • Apical pulse = 120 BPM; respiratory rate = 28 breaths/minute • Blood pressure = 138/84 • Oxygen saturation by pulse oxymetry = 90% • Productive cough ⏺Laboratory findings: • Hemoglobin (Hgb) = 18 g/dL • Hematocrit (Hct) = 45% • WBC = 13,000/mm3 • Total cholesterol = 198 mg/dL • Low density liproprotein = 102 mg/dL 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to help the nurse determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.)

✅1 The most immediate concern to the nurse about this client is the low oxygen saturation, which indicated poor gas exchange. Although his history does not indicate any other respiratory problems or a previous oxygen saturation, 90% is low for a 37-year-old adult. This information coupled with his subjective report of breathlessness indicates some degree of respiratory distress and potential for respiratory failure. ✅2. The temperature elevation, elevated white blood cell count, and productive cough are consistent with pneumonia as a cause of poor gas exchange. The fact that he is a smoker now using e-cigarettes instead of tobacco can compound his decreased gas exchange. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

The client is a 66-year-old homeless Viet Nam veteran admitted through the emergency department this morning for a compound fracture of the left femur with hemorrhaging sustained when he was hit by a motorcycle. He usually sleeps outdoors in warmer weather and uses a variety of shelters now that it is winter. Surgery is planned for later today. The bleeding is now under control and he has received three units of packed red blood cells. The nurse performing the nursing unit admission assessment records vital signs of: Temperature 101.6 degrees Fahrenheit (38.7 degrees Celsius), heart rate 102, respiratory rate 22, blood pressure 110/84, oxygen saturation 92%. The nurse notes the client is quite dirty and gaunt appearing. He says he is 6 feet (1.83 m) tall and his admitting weight is 129 lbs (58.5 kg). He reports being homeless for 5 years after losing his job as a welder when he was found using IV drugs while at work. He tells the nurse that the shelter is noisy, and he is always tired because he doesn't sleep well. During the assessment, he coughs frequently (without covering his mouth) and produces thick greenish sputum with bloody streaks that he spits into his hand. 1.​What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) •​Compound fracture with open wound •​Low-grade fever •​Lower-than-normal oxygen saturation •​Productive cough •​Receive three units of packed red blood cells earlier •​Poor hygiene •​Homeless or staying in a crowded shelter •​Weight less than expected for height •​Fatigue 2.​What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) •​Lower-than normal oxygen saturation •​Low-grade fever •​Productive cough (mucoid with streaks of blood) •​Open leg wound •​Other signs and symptoms of active tuberculosis (poor nutrition, fatigue) •​Risk factors for active tuberculosis (homeless or living in crowded conditions, poor hygiene, IV drug user) 3.​Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4.​What activities would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5.​Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6.​What client assessment would indicate the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged patient condition.)

✅1. •​Compound fracture with open wound •​Low-grade fever •​Lower-than-normal oxygen saturation •​Productive cough •​Receive three units of packed red blood cells earlier •​Poor hygiene •​Homeless or staying in a crowded shelter •​Weight less than expected for height •​Fatigue ✅2. •​Lower-than normal oxygen saturation •​Low-grade fever •​Productive cough (mucoid with streaks of blood) •​Open leg wound •​Other signs and symptoms of active tuberculosis (poor nutrition, fatigue) •​Risk factors for active tuberculosis (homeless or living in crowded conditions, poor hygiene, IV drug user) ✅3. •​The low-grade fever could be caused by beginning infection in the open leg wound, especially given his poor hygiene, a transfusion reaction, or a respiratory infection. •​A transfusion reaction would be the most serious and should be addressed first. The Client's level of consciousness and reasonable vital signs are not consistent with either a blood infection or an incompatibility reaction. •​A beginning wound infection may still be possible but will be explored more during the surgery and is not the priority problem at this time. •​The most likely issue is a respiratory infection given the nature of the productive cough. Although all respiratory infections are serious, he has many of the symptoms of and risk factors for active tuberculosis, which is a communicable disorder. ✅4. •​The most important short-term outcome for this client is to determine the cause of his respiratory symptoms. •​The nurse needs to ensure the client does not come into contact with other patients or visitors at this time. •​The nurse needs to avoid performing any activities with this client that could induce more coughing (e.g., forcing him to talk, making him laugh, etc) ✅5. •​Until a diagnosis is made, the nurse must treat this client as if he has active tuberculosis and immediately implement Airborne Precautions. •​The nurse needs to provide the client with paper tissues and a paper bag. He or she needs to instruct the client to cough and spit into the tissue and then place the tissue in the bag. •​The nurse needs to instruct the client to keep talking to a minimum and avoid laughing or singing. •​The nurse should notify the surgeon of the possibility of TB and request TB testing as soon as possible. •​With surgery planned for today, it is likely a chest x-ray has already been taken. The nurse should call the radiology department for a reading on the x-ray to determine if it indicates TB or pneumonia. If it has not yet been evaluated, the nurse needs to request a STAT reading. ✅6. ​The client's respiratory condition is not likely to change quickly. Rather, behavioral changes are used to determine whether the action to reduce the risk for spread of an infectious disease is working, such as observing the client comply with using tissues when coughing and spitting Chapter 28 ///Chapter 31 -Concepts of Care for Patients With Infectious Respiratory Problems

A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long term care facility after having an ischemic stroke. The client's partner reports that before the stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult with significant left-sided weakness who requires assistance dressing, eating, and transferring between the wheelchair to the bed. While assisting the client with change clothes, the nurse notes a large reddened area on the left hip that doesn't change color when it is pressed on. 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) . 4. What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5. Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. What client assessment would indicate that the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.) .

✅1. It is important to note that the client has a large reddened area on the left hip that doesn't blanch. This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the client is frail and has significant unilateral weakness that may impact his or her ability to turn and reposition, which can contribute to pressure injury formation or exacerbation. The weakness is not completely new, as the client needed help before the stroke with ADLs, so the nurse can anticipate that even at baseline, assistance in positioning and with skin care will be needed. Notation of urinary incontinence is also important. If the client has urine continually making contact with the skin, there is a higher risk for skin breakdown. ✅2. A Stage 1 pressure injury is most consistent with the relevant information collected. ✅3. The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition, as this type of injury can progress quickly without prompt, thorough intervention to prevent loss of skin integrity ✅4. The actions that would achieve the desired outcome of preserving skin integrity include using a skin bundle to provide care; continuous assessment and reassessment of the client's skin; keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as needed); implementing pressure-reducing devices; and turning and repositioning the client at least every two hours and more frequently as needed. Harmful actions include ignoring the reddened area on the left hip, as this will allow the injury to progress. ✅5. All actions listed in #4 should be implemented right away. These independent actions are usually all incorporated in an evidence-based skin bundle. ✅6. Resolution of the reddened area on the left hip would indicate that the nurse's actions were effective Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

A 38-year-old mildly obese woman is brought to the emergency department by her older sister with a severe asthma attack. The client has audible wheezes on inhalation and exhalation. Her admitting vital signs are blood pressure 172/100, pulse rate 114, respiratory rate 24, temperature 100 degrees Fahrenheit (38 degrees Celsius); oxygen saturation 78%. When the nurse asks her if she took any asthma medications today, she nods yes but is too breathless to speak. Her lips and nailbeds are cyanotic, and she has an anxious expression on her face. The nurse notes that the client has a brace around her right knee and a swollen right wrist. Her sister tells the nurse that the client called her about 30 minutes ago and asked to be taken to the hospital because several doses of her reliever inhaler within an hour was not helping her asthma attack, that in fact is was worsening, and that her husband refused to drive her. The sister goes on to say that the husband does not believe that asthma attacks are real and considers them only a way to get more attention even though the client has had asthma since childhood and has been taking prescribed asthma medications for years. The sister has all of the client's prescribed medications in her purse, which include an albuterol inhaler, a salmeterol inhaler, and a fluticasone inhaler. When asked about the client's obvious injuries, the sister reports that the client fell while walking the dog a week ago and has been taking both acetaminophen and an NSAID daily since then. 1. 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What activities would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5. Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. What client assessment would indicate the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged patient condition.)

✅1. • Oxygen saturation 78% • Blood pressure and pulse rate are elevated (indicating stress, dyspnea, effects of short-acting beta agonist [SABA]) • Audible wheezes on inhalation as well as exhalation despite repeated use of reliever drug (possible incorrect inhaler use or increasing attack) • Client is too breathless with labored breathing to speak (although respiratory rate is only marginally elevated, the cycle is lengthened by a prolonged exhalation) • Lips and nailbeds are cyanotic (major indication of inadequate gas exchange) • Client has a chronic knee issue and may be in pain, which could add to anxiety • Client has been taking acetaminophen and NSAIDs for a while (NSAIDs can trigger an asthma attack by suppressing some inflammatory mediators but increasing the concentration of others) ✅2. • Asthma severity has increased despite use of SABA reliever inhaler • Poor gas exchange • Client may have a poor understanding of prescribed asthma management plan ✅3. • Client's increasing severity of asthma attack increases the risk for moving into status asthmaticus or losing airway patency ✅4. The desired outcomes for this client are a return to adequate gas exchange, and eventually to develop a correct understanding of the asthma management plan, and physical safety. At this time, the highest priority is adequate gas exchange. • Client's respiratory effectiveness needs to be continuously monitored • Client's gas exchange needs to be improved by ensuring airway adequacy Prevention of another serious asthma attack by teaching the client how to correctly use her prescribed drugs must wait until the critical event has resolved. In addition, although the client is anxious and may be in pain, she should not receive any medication that would reduce her cognition, depress her respiratory drive, or make her sleepy because she needs to focus her efforts on the work of breathing. ✅5. • Start oxygen therapy • Help client to an upright position • Immediately establish an IV and initiating intravenous therapy with both bronchodilators and a corticosteroid to improve airway patency, as prescribed • Ensure intubation or tracheotomy equipment is at bedside and ready to use if needed • Continually monitor oxygen saturation and vital signs ✅6. • Client's oxygen saturation at 90% or higher • Lips and nailbeds no longer cyanotic • Wheezing on inhalation is reduced or absent • Client can speak a few words between breaths • Blood pressure and heart rate are decreased (closer to client's normal levels) • Anxious expression is absent When client is breathing comfortably, she can be assessed for correct understanding of controller and reliever inhaler use. If instruction is needed, it can begin at that time. Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

The client is a 28-year-old social worker and former opioid addict who was a passenger in a car crash about an hour ago in which he was restrained but a heavy object came through the windshield and hit him in the face. He is bleeding heavily from facial trauma and has lost several front teeth. His face and neck have extensive bruising and lacerations. He is alert and aware of his surroundings and can talk. He is concerned about his girlfriend who was driving the car when it was hit by a vehicle that swerved into her lane while trying to avoid a deer. He rates his pain as an 8 on a 0 to 10 scale. His admitting vital signs are: HR = 110 bpm RR = 30 BP = 108/50 Oxygen saturation = 91% 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What activities would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5. Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6.​ What client assessment would indicate the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged patient condition.)

✅1. •​Facial trauma with heavy facial bleeding and tooth loss •​Alert and aware of his surroundings •​Is able to talk •​Pain level is high •​Psychosocial concern for welfare of girlfriend •​Oxygen saturation of 91% •​Elevated HR and RR •​BP slightly low with narrow pulse pressure •​Car crash-related injuries but was restrained ✅2. •​Pain is significant •​Low oxygen saturation •​Heavy bleeding •​Anxiety for his own and his girlfriend's condition •​HR, RR, and blood pressure slightly abnormal ✅3. •​In danger of poor gas exchange and losing his airway from blood aspiration and/or trauma-induced swelling •​Hemorrhage •​Client is anxious •​Client is in severe pain and has a history of opioid use disorder •​Client may have sustained a cervical spine injury ✅4. The desired outcomes are to reduce anxiety, maintain a patent airway and gas exchange, manage pain, and prevent hypovolemic shock. At this time the highest priority is to maintain a patient airway and gas exchange. •​Client's gas exchange needs to be improved by ensuring airway patency •​Client's respiratory effectiveness needs to be monitored continuously to know whether laryngeal damage and swelling may contribute to airway obstruction The second priority is preventing further injury if a cervical spinal injury is present. This risk is lower because the client was restrained in the car but he was hit in the face and neck. The third priority is preventing hypovolemic shock Although the Client's pain is significant, management is complicated by a previous opioid use disorder, which could be reactivated by the use of opioids to manage pain at this time. Opioids should be avoided at this time. The client's anxiety for his girlfriend should be addressed as soon as possible although not at the expense of airway and bleeding management. ✅5. •​Check to see whether there is bleeding in the mouth, nose or throat that could lead to aspiration. If present and unable to be cleared, an artificial airway may need to be placed. •​Continuously monitor oxygen saturation. •​Apply oxygen. •​Assess for stridor, drooling, or increased respiratory effort •​Keep the client's head and neck stabilized and aligned in a neutral in-line position. •​Obtain IV access •​Monitor heart rate and blood pressure for indications of shock (rising HR, decreasing systolic BP with narrowing pulse pressure) •​Assess for source of bleeding. •​Apply pressure to obvious external bleeding sites. •​Request prescription for typing and cross-matching for possible transfusion of blood products. •​Ask assistive personnel to determine where the girlfriend is located and her condition. Tell the client that this information is being gathered and he will be told as soon as information is known. •​Collaborate with emergency department health care providers and possibly anesthesia to determine what type of medication for pain could be safely administered to this client without either increasing bleeding risk or potentially reactivating the opioid use disorder. ✅6. • Oxygen saturation increases to 95% or higher •​Stridor is absent •​Overt bleeding slows or stops •​Heart rate is below 100 and strong and regular •​Blood pressure shows increasing systolic and wider pulse pressure •​Client states pain is reduced below 8 •​Client's anxiety consistent with condition of girlfriend Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

A 75-year old woman fell in her yard and injured her leg on a leaf rake two days ago. The prongs of the rake caused a large laceration on her right calf. Her husband took her to the local Urgent Care Center where her wound was cleaned and dressed. She was placed on an oral antibiotic and told to follow up with her primary health care provider (PHCP). This morning she noticed increased redness, swelling, and a "red streak" above her wound. Her husband called her PHCP who arranged for a direct admission to the local hospital. On admission to the hospital, the nurse collects this information based on admission assessment: ⏺Client History •​Has had diabetes mellitus Type II and hypertension for over 10 years •​Takes amlodipine 5 mg orally each morning •​Takes metformin 500 mg twice a day •​Lives at home with her husband •​Is able to perform ADLs independently •​Does not drive •​Has two daughters who live several hours away ⏺Current Assessment •​Reports affected leg pain is 8/10 •​Oral temperature = 102.6 degrees F (39.2 degrees C) •​Apical pulse = 100 BPM; respiratory rate = 22 breaths/minute •​Blood pressure = 88/54 •​Laboratory findings: o​Hemoglobin (Hgb) = 13 g/dL o​Hematocrit (Hct) = 40% o​WBC = 14,000/mm3 o​Erythrocyte sedimentation rate (ESR) = 46 mm/hr o​Fasting blood glucose = 289 mg/dL 1.​What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to help you determine what is most important.) 2.​What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3.​Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4.​What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided, are irrelevant, or are potentially harmful? (Hint: Determine the desired outcomes first to help you decide which actions are appropriate and those that should be avoided.) 5.​Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6.​What client assessment would indicate that your actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.) Assessment findings that would indicate effectiveness of nursing actions include:

✅1. •​Older adult (over 65 years of age) •​Affected leg is swollen, reddened, and has a red streak •​Increased body temperature (normal range is 98-98.6 degrees F [37 degrees C]) •​Tachycardia (greater than 90 bpm) with hypotension (systolic pressure less than 100 and diastolic pressure less than 60) •​Increased WBCs (normal is 5,000 - 10,000/mm3) •​Fasting blood glucose = 289 mg/dL (normal for older adult is 82-115 md/dL) •​Has diabetes mellitus ✅2. •​Affected leg phlebitis (venous inflammation) •​Fever •​Hyperglycemia •​Dehydration •​Risk for impaired perfusion in affected leg ✅3. ■​The client has signs and symptoms of a systemic infection as a result of impaired tissue integrity (leg wound). ■​The client's fever caused her to become dehydrated as evidenced by tachycardia and hypotension. ■​Hypotension and advanced age increases the client's risk for falls. ■​Dehydration can lead to acute confusion in older adults and organ damage if not treated. ■​The wound may be slow in healing because the client is older and has diabetes. ■​The leg swelling can contribute to impaired perfusion (blood flow) to the affected leg and foot. ✅4. Actions that are appropriate include: ■​Treat infection with antibiotic therapy. ■​Manage fever with fluids, antipyretics, and rest. ■​Administer IV fluids and increase oral fluid intake. ■​Manage client's pain. ■​Monitor vital signs frequently, including finger stick blood sugars (FSBS). ■​Manage diabetes to get blood glucose within normal range. ■​Monitor wound and affected leg for signs and symptoms of decreased blood flow (frequent circulation checks); report changes to the primary health care provider. ■​Provide wound care to the affected leg as prescribed; consult with the wound care team to plan the best approach for wound healing. ■​Implement fall precautions. ■​Monitor urinary output to ensure at least 30 mL/hr (Dehydration may cause decreased output.) Actions that should be avoided, are irrelevant, or are potentially harmful include: ■​Elevate the affected leg (This action should be avoided and could be harmful because elevation can prevent adequate blood flow to the affected leg and foot.) ■​Teach the client that she may get out of bed often to prevent complications of decreased mobility.(The staff should assist the client when she gets out of bed to prevent dizziness due to hypotension. Dizziness may cause her to fall.) ■​Administer IV solutions that contain glucose (The client is a diabetic and her current FBS is elevated indicating hyperglycemia. Additional glucose would cause her blood sugar to continue to increase.) ■​Massage the affected leg to promote comfort (Due to phlebitis in the affected leg, the client is at risk for possible venous thrombosis, Massage could dislodge a clot and cause a pulmonary embolus, a life-threatening complication.) ✅5. ■​The first priority is to place the client on fall precautions and teach the client not to get out of bed without assistance. This is an independent nursing action that promotes client safety. ■​The next priority intervention is to contact the primary health care provider to obtain prescriptions for: •​Continued drug therapy as previously prescribed (amlodipine and metformin) •​IV antibiotic therapy •​IV fluids •​PRN antipyretic, such as acetaminophen •​Additional drug therapy to manage hyperglycemia (e.g., sliding scale insulin) ■​In addition, collaborate with the wound care specialist to plan and implement wound management. Assess neurovascular status ("circ check"), vital signs, and FSBS frequently as per agency protocol or primary health care provider preference. ✅6. ■​Decreased body temperature to within normal parameters ■​Increased blood pressure to within normal parameters ■​Decreased pulse to within normal parameters ■​No indication of impaired blood flow to the affected leg or foot ■​Blood glucose within normal parameters ■​No indication of venous thrombosis or pulmonary embolus ■​No falls Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

A 45-year-old client is an inpatient with type I diabetes who has just started receiving the antibiotic ceftriaxone intravenously for a facial abscess that is close to her right eye. Her other health problems include moderate hypertension well controlled with lisinopril and osteoarthritis of the left knee for which she takes meloxicam daily. She has documented allergies to peanuts, other tree nuts, and penicillin. She is married, with two children, and is a full-time third grade teacher. She puts on her call light to report that she feels dizzy and is having shortness of breath. When the nurse reached the bed-side, the following observations are noted: • oxygen saturation by pulse oximetry is 86% • all the food on the lunch tray has been eaten • there is normal saline hanging and 125 mL of the 250 mL total of the ceftriaxone remains in the piggy-back bag • she received her premeal insulin dose 45 minutes ago • vital sign assessment reveals a respiratory rate of 34, heart rate of 110, and BP of 94/50 • can talk but is having a hard time finding words 1.​What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2.​What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3.​Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4.​What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5.​Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6.​What client assessment would indicate that the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

✅1. •​Reports shortness of breath •​Reports dizziness •​Oxygen saturation of 84% •​Rapid heart and respiratory rates •​Has type 1 diabetes •​Received insulin 45 minutes ago •​Has known drug allergy •​Is receiving a drug intravenously •​Has long-standing hypertension ✅2. •​Hypoxia with poor gas exchange and shortness of breath •​Lower than normal blood pressure •​Cognition is decreasing ✅3. •​Changes in vital signs could be due to anaphylaxis or serious hypoglycemia •​Anaphylaxis is more likely because she has a known penicillin allergy and is receiving ceftriaxone (which is chemically very similar to penicillin and most people with a penicillin allergy are also allergic to the cephalosporins) •​Serious hypoglycemia is less likely even though she received insulin 45 minutes ago because she has eaten her lunch ✅4. •​The priority outcomes are to stop anaphylaxis (and shock) and restore gas exchange •​Testing of the client's blood glucose level is not critical at this time and the nurse should not take the time needed to perform this action •​Client needs appropriate drug therapy immediately •​Client needs oxygen therapy •​Client needs IV fluids to support perfusion ✅5. •​Stop the infusion of ceftriaxone and clear the main IV line •​Administer 0.3 ml of epinephrine (1:1000 solution) IM or subcutaneously now •​Have a coworker call the Rapid Response Team •​Apply oxygen •​Increase flow rate of normal saline •​If no improvement in oxygen saturation or BP in 5 minutes, repeat the epinephrine dose ✅6. •​Client's oxygen saturation is 90% or higher •​Client's blood pressure remains the same or is higher •​Client remains conscious and is more alert •​Client reports less or no shortness of breath Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

The nurse is working in the emergency department (ED) when a client arrives with a friend, reporting being bitten on the left foot by a snake 15 minutes prior to arrival. Fishing while barefoot in a marshy area of nearby water, the client describes a sensation of being bitten and then seeing the snake appear to swim away. The client cannot describe characteristics of the snake except that is was estimated to be 18 to 24 inches long, and brown or black in color. Nursing assessment reveals two puncture wounds over the left 5th metatarsal with surrounding swelling and mild redness. The client reports mild pain of 3 on a scale of 0-10 at the puncture sites, and the sensation of muscle twitching in the lower extremities. There has been no vomiting, but the client reports an onset of nausea and weakness soon after being bitten. Vital signs include BP 98/60, T 99.9°F, P 100 beats per minute, and R 20 breaths per minute. The client reports no pre-hospital care was given other than to be transported by the friend to the ED. 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) Relevant information includes: a. Timing of the snake bite (15 minutes earlier) b. Presence and location of puncture wounds c. Presence of swelling and mild redness d. Degree of pain felt e. Sensation of muscle twitching f. Onset of nausea and vomiting g. Increased temperature h. Hypotension, coupled with fast pulse rate and breaths taken per minute. 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What interventions would most likely achieve the desired outcomes for this client? Which interventions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5. Which interventions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. What client assessment would indicate that the nurse's interventions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

✅1. All of these pieces of assessment data help the nurse to assess the anticipated severity of envenomation. ✅2. Moderate envenomation via snake bite is the client condition that is consistent with the most relevant information. See Table 11-1 in Chapter 11. ✅3. It is important to note that as a nurse, you are not making a medical diagnosis. You are using critical thinking proactively to anticipate cause and effect, which will lead to effective clinical judgment. In this case, the explanation for the symptoms is what the client reported - a snakebite with moderate envenomation. As such, this is a matter of urgency that the nurse recognizes. ✅4. The nurse recognizes that the client reported receiving no pre-hospital care. Therefore, all interventions to treat the client are going to take place immediately in the ED. A matter of key importance is to contact the regional poison control center for specific advice on antivenom dosing and medical management. This will guide the most important intervention of antivenom treatment. Harmful actions include delaying care, neglecting to seek information about antivenom treatment, and neglecting to monitor for clotting abnormalities or DIC (see #5 below). ✅5.While the regional poison control center is being contacted regarding advice on antivenom dosing and medical management, supplemental oxygen should be applied, two large bore IV's should be inserted, and normal saline or Ringer's lactate infused (based upon the healthcare provider's prescription). Heart function and blood pressure must be monitored. The client should be also be monitored closely for clotting abnormalities or DIC. A coagulation panel, CBC, CK, type and cross, and urinalysis should be obtained, and an ECG done. ✅6. Non-progression of systemic effects (e.g., subcutaneous ecchymosis; severe symptoms including manifestations of coagulopathy) would indicate that the nurse's interventions were effective. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

The patient is a 50-year-old nursing home resident with a severe seizure disorder as a result of a traumatic brain injury. Because of confusion regarding his prescription renewal, he has not received his antiepilepsy drugs for the past 3 days. He has just had a grand mal seizure lasting 2 minutes. 1.​What type(s) of acid base imbalance will be present immediately following the seizure? 2.​If arterial blood gases were drawn immediately after the seizure, which if any, values would you expect to be within the normal range and why? 3.​Which if any intervention could help him restore acid-base balance faster? Explain your answer. 4.​What acid-base regulatory mechanism would be active during the seizure and why?

✅1. Severe acute respiratory acidosis will be present. He has not been breathing during the seizure, which will make his PaO2 quite low with no gas exchange. During those 2 minutes of the seizure all of his metabolism was occurring under anaerobic conditions, which would greatly increase his PaCO2 levels. The heavily contracting skeletal muscles of seizure activity would generate even more CO2. The low PaO2 and high PaCO2 would result in a huge increase in hydrogen ions, resulting in a low pH. ✅2. The only normal arterial blood gas value would be the bicarbonate (HCO3−) level. Although increasing the bicarbonate could help offset the acidosis and restore pH balance, the mechanisms for increasing bicarbonate are slow to start and have no effect in a sudden condition leading to an acute respiratory acidosis. ✅3. The only route to restoring acid-base balance in this situation is breathing more rapidly and deeply to blow off the high levels of carbon dioxide. Supplying him with oxygen to help reduce the generation of more carbon dioxide and ensuring that he does not have another seizure could help restore acid-base balance. ✅4. There are three major acid-base mechanisms: chemical buffers in the blood and cells, respiratory rate and depth changes, and kidney control actions. Only the chemical buffers are immediately available during a grand mal seizure because breathing does not occur, and the kidney actions require hours to days to initiate control actions. Chapter 14 - Concepts of Acid-Base Balance

Clinical Judgment Challenge 12-1: Safety The nurse is serving on a DMAT team that has been dispatched to help a community after a category 4 hurricane came ashore in a rural, underserved area. The nurse has been notified that so far, ten people have been declared dead on the scene, and over 200 have been identified as injured. The first individual the nurse encounters is a 21-year old female that is quickly triaged with a green tag, as she has only experienced a few abrasions from brushing her legs against a downed tree. Her blood pressure is 150/90 and her pulse rate is 94 beats per minute. She breathlessly tells the nurse that she cannot find her 69-year old grandmother, and she is quickly becoming panicked. 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What interventions would most likely achieve the desired outcomes for this client? Which interventions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5. Which interventions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. What client assessment would indicate that the nurse's interventions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

✅1. The fact that the client does not have apparent life-threatening injury is relevant (thus, the application of a green tag), as is the fact that she is frantically expressing fear of not being able to locate her loved one. ✅2. Given that the individual has experienced a natural disaster, these signs may be indicative of an anxiety or panic reaction. ✅3. It is reasonable to assume that the client is very fearful of what may have happened to her loved one. She may be experiencing the beginning of a shock reaction in response to the disaster that has occurred. Although the client is not in physiological danger, she has a significant psychosocial need at this moment in time. ✅4. The triage nurse recognizes that pairing the client with a responder who is assisting with location of people would be an appropriate intervention. The nurse needs to continue triaging others, so he or she cannot stop to stay exclusively with this client; that action should be avoided, as it would place other clients at risk of not being appropriately triaged in a timely fashion. The desired outcome is to have this client delivered to another caregiver who is assigned to the role of helping to locate loved ones. This intervention allows the triage nurse to continue triaging victims and places this client into the care of someone who can supervise her and more immediately address her needs. ✅5. The triage nurse recognizes that pairing the client with a responder who is assisting with location of people is an appropriate intervention that must take place as the priority. The nurse needs to continue triaging others, so he or she cannot stop to stay exclusively with this client; that action would place other clients at risk of not being appropriately triaged in a timely fashion. The priority intervention is to safely deliver this client to another caregiver who is assigned to the role of helping to locate loved ones, and then continue triaging other victims. This intervention allows the triage nurse to continue triaging those in need and places this client into the care of someone who can supervise her and more immediately address her needs. ✅6. Although the triage nurse will not remain with the client after safely delivering her, the nurse to whom the client is entrusted can evaluate that interventions were effective by seeing a decrease in the client's verbalized panic, and a reduction to normal parameters of blood pressure, pulse rate, and respirations if they were initially elevated Chapter 12- Concepts of Disaster Preparedness

Clinical Judgment Challenge 13-1. You observe that a 78-year-old patient has been admitted through the emergency department twice in the past 6 weeks and four times in the past 12 months for severe dehydration. He appears to be in the early stage of Alzheimers disease and has a history of heart failure for which he is taking furosemide 40 mg orally once daily and the combination of valsartin/sacubitril (103 mg/97 mg) twice daily. He lives with his 74-year-old wife in a modest neighborhood on a fixed income. For the previous dehydration episodes, the patient has been discharged to home in the care of his wife with a referral to his primary health care provider. 1.​What described factors could be contributing to this patient's fluid imbalance? Explain your choices. 2.​Is this case an appropriate patient problem to initiate a systems thinking collaboration for change? Why or why not? 3.​What is the most important step to take to help this patient avoid future episodes of dehydration? 4.​Where and how would you initially gather information to start a systematic approach to change this patient's future risk?

✅1. This situation describes several immediate factors that could contribute to recurring risk for and actual dehydration. The patient is older, which increases dehydration risk because of a lower total body water content resulting from age-related muscle mass loss and an overall decreased sensitivity to the sensation of thirst. At this point we do not know whether he has any age-related mobility problems that would impair his self-care for fluid intake. He is thought to be in the early stages of Alzheimer's disease and may not remember to drink sufficient fluids. The two prescribed drugs do cause diuresis and can contribute to dehydration. Because he has been diagnosed with heart failure, he may have been told to avoid excessive fluid intake. ✅2. Absolutely this care is an appropriate patient problem for a systems thinking collaboration for intervention. First this is a serious and common problem that could be avoided. Severe dehydration can lead to death. For this patient, the fact that the problem is recurrent warrants investigation. ✅3. After the current episode of dehydration has resolved, the most important step is to determine what specific actions or conditions lead to it and to explore what the patient and his wife understand about adequate fluid intake. ✅4. Interview the patient and his wife (together and separately) to discover what they know and what they believe about dehydration in their own words. Ask them to relate a typical day's activity, meals, and fluid intake. If intake does not appear adequate, ask them if there is any reason the patient does not drink more. Find out who is responsible for the patient's daily medications and exactly how these are taken or administered. Examine the patient's previous health record to determine whether any teaching about prevention of dehydration has been performed and documented. Contact the primary health care provider to determine whether information from this patient's previous episodes of dehydration and course of management were communicated adequately. This is also a good time to assess what the primary health care provider's role in prevention of dehydration has been. Chapter 13 - Concepts of Fluid and Electrolyte Balance

The client is a 31-year-old female certified emergency medical technician (EMT) who passed out on the job and was brought to the emergency department with shortness of breath and a pulse oxymetry reading of 88%. She is found to have pneumonia by auscultation and chest x-ray. Her vital signs are temperature 101 degrees F (38.3 C), pulse 126, respiratory rate of 32, and blood pressure of 102/60. She is now alert and able to answer questions. On being told that she has pneumonia, she sighs and say that this is the third time in the past year she has had pneumonia. The admitting nurse documents the following history and physical assessment data: • Most recent episode of pneumonia (community acquired, 10 weeks ago) was treated with amoxicillin • Has a productive cough that kept her awake last night • Was once homeless and an injection drug user who also misused alcohol • Is not on speaking terms with her parents • Was admitted five years ago with an opioid overdose • Admitted to an inpatient rehabilitation center after the overdose and has been clean and sober ever since • Other hospitalizations include surgery for appendicitis 15 years ago and emergency treatment for a fractured wrist 2 years ago • Has worked as an EMT for 3 years • Is married with no children • Uses oral contraceptives as her preferred method of birth control • Married the EMT who transported her during the overdose episode • Other current daily drugs include a multiple vitamin and NSAIDs for perceived job-related muscle pain • Admitting white blood cell count = 3,400/mm3 1.What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to help the nurse determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What interventions would most likely achieve the desired outcomes for this client? Which interventions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to help the nurse decide which interventions are appropriate and those that should be avoided.) 5. Which interventions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. What client assessment would indicate that the nurse's interventions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

✅1. • Has a low oxygen saturation • Fever is present • Has productive cough severe enough to keep her awake • Lost consciousness earlier • Diagnosis pneumonia • Previous injection drug user and alcohol misuser • Is married • Uses oral contraceptives for birth control • Admitting white blood cell count = 3,400/mm3 ✅2. The priority problems relate to reduced Gas Exchange and potential for reduced Immunity. The low oxygen saturation, tachypnea, tachycardia, cough, reduced level of consciousness, and fever support the clinical diagnosis of pneumonia. However, the low white blood cell count is not consistent of an infection in a client of this age. The fact that this count is low and that she has had multiple episodes of a pneumonia diagnosis within a year both point to a possible problem with reduced immunity. ✅3. Pneumonia can lead to sepsis, which is a possibility for this client, especially in view of the low WBC count (left shift with severe or prolonged infection). Her blood pressure is low normal; however, it is not known at this time what her usual blood pressure is. Another possibility is that she has reduced immunity as a result of undiagnosed and untreated HIV disease. Even if this is the case, the priority problem that must be addressed first is the reduced gas exchange. ✅4.The priority desired outcome at this time is to improve the client's gas exchange. The two most important interventions to achieve an outcome of improved gas exchange is oxygen therapy and institution of appropriate antibiotic therapy. Forcing the client to talk more at this time should be limited to prevent reducing the gas exchange further. Thus questions regarding other risks or indications of HIV disease should be avoided at this time to prevent potential harm of further reducing gas exchange and stimulating more coughing. ✅5. The most important immediate interventions are to apply oxygen (given the degree of hypoxia present, this can be done without a prescription) and prepare for intravenous antibiotic therapy to help improve gas exchange and prevent or treat sepsis. Oxygen should be applied first, and an immediate prescription for antibiotic therapy obtained and implemented. Placing the client in an upright position also may help improve gas exchange. The client's condition must be monitored often and carefully to determine the effectiveness of interventions and whether or not changes are needed. ✅6. Areas to monitor and evaluate to determine therapy effectiveness include oxygen saturation by pulse oximetry, heart rate, respiratory effort and rate, and other indicators of oxygenation such as capillary refill, and the presence or absence of cyanosis. Increased oxygen saturation, decreased heart rate and respiratory rate, reduced fever, and absence of peripheral or central cyanosis indicate improvement. Lower oxygen saturation, increased heart and respiratory rate, rising fever, slowing capillary refill, and increased cyanosis indicate ineffective interventions. Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

The home health care nurse is assessing a 59-year old African American client who has a history of chronic obstructive pulmonary disease. Assessment reveals moist, pink and pale oral mucous membranes without petechiae; pink and pale nail beds, hand palms, and feet soles; and symmetrical warmth in all extremities. Vital signs include BP 130/80, P 80 beats per minute, R 20 breaths per minute, and T 98.0°F. The client reports cutting the lawn earlier in the day and feeling "a bit tired but otherwise fine". 1.​What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2.​What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.)

✅1.​The most important information in this client situation is the correlation between the pale oral mucous membrane and pale nail beds. Although these are not dire findings, they are in keeping with impaired oxygenation as would be expected in a client with a history of COPD. The nurse will continue to perform a full assessment, yet the other findings in this client situation indicate that the client is in no distress and likely operating at baseline. ✅2.​As noted in #1 above, the condition of impaired oxygenation due to COPD is consistent with the most relevant information noted in the assessment. The nurse has not observed assessment data that indicates that the client has cyanosis, jaundice, or inflammation. The nurse must recognize normal findings, as well as abnormal ones, when assessing a client. In this client situation, the findings are expected based on the client's history of COPD, and they are also in keeping with the client's report of "feeling fine" other than being a bit tired. There is no other data indicating that an exacerbation of COPD should be anticipated, nor that other priority problems are present at this time  Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

5 of 17 How will the nurse document the pack-year smoking history for a client who reports smoking 3 packs of cigarettes per day for 25 years and then smoking 2 packs per day for the past 20 years? 45-pack-year 90-pack-year 115-pack-year 80-pack-year

✅115-pack-year Smoking history is documented in pack-years (number of packs per day smoked multiplied by the number of years the client has smoked). 3 packs/day × 25 years = 75-pack-year, plus 2 packs/day × 20 years = 40-pack-year. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

The charge nurse on a pediatric ward is making assignments for the shift. One of the clients admitted to the ward is a five-year-old with severe neutropenia and a fever. Which of the following clients would be most appropriate to assign with this client? Four-year-old admitted with respiratory distress Three-year-old with Cellulitis 15-year-old with an uncomplicated appendectomy Two-week-old with suspected meningitis

✅15-year-old with an uncomplicated appendectomy This client is unlikely to have any infectious disease that could compromise the health of the child with neutropenia. Two-week-old with suspected meningitis There is a risk that the nurse could expose the child with neutropenia to meningitis. Three-year-old with Cellulitis There is a risk that the nurse could expose the child with neutropenia to the bacterial infection that is causing the cellulitis. Four-year-old admitted with respiratory distress There is a risk that the nurse could expose the child with neutropenia to whatever virus or bacteria may be causing the respiratory distress

5 of 16 Which number will the nurse calculate as the absolute neutrophil count (ANC) for a client whose differential includes: total WBCs 5300/mm3 (5.3 × 109/L ); segs 2800/mm3 (2.8 × 109/L); bands 200/mm3 (0.20 × 109/L); monos 250/mm3 (0.25 × 109/L); lymphs 2000/mm3 (2.0 × 109/L); eosins 25/mm3 (0.025 × 109/L); basos 25 (0.025 × 109/L)? 2800/mm3 (2.8 × 109/L) 3200/mm3 (3.2 × 109/L) 3000/mm3 (3.0 × 109/L) 2300/mm3 (2.3 × 109/L)

✅3000/mm3 (3.0 × 109/L) The absolute neutrophil count is calculated by adding the mature neutrophil count (segs) with the slightly less mature band neutrophil count (which will mature within a matter of hours into segs). Monos, lymphs, eosins, and basos are not neutrophils. Chapter 16 - Concepts of Inflammation and Immunity

Based on the nurse's understanding of local anesthesia which of the following clients would give concern for the procedure? Select all that apply. 34-year-old client with an allergy to lidocaine 45-year-old client with an allergy to penicillin 76-year-old client with an allergy to cephalexin 88-year-old client with an allergy to bupivacaine 10-year-old client with an allergy to amoxicillin

✅34-year-old client with an allergy to lidocaine A common local medication is lidocaine and this is the same drug class. 45-year-old client with an allergy to penicillin This client allergy is not a concern. ✅88-year-old client with an allergy to bupivacaine A common local medication is lidocaine and this is the same drug class. 76-year-old client with an allergy to cephalexin This client allergy is not a concern. cancel 10-year-old client with an allergy to amoxicillin This client allergy is not a concern. 02.03 Local Anesthesia

Which of the following is an acronym or mnemonic associated with postoperative fever? 5 W's HAART The 5 Ts The 3 Ds MOPS FAT BAT Mnemonic

✅5 W's The 5 W's is a mnemonic used to organize the most common causes of postoperative fever, as well as help determine the etiology based on postoperative day.

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy? 3000 6300 9300 7000

✅6300 kg = 2.2 lb. 1 kg of water = 1 L (1000 mL) of water. 14 lb divided by 2.2 = 6300 g (6300 mL). Chapter 13 - Concepts of Fluid and Electrolyte Balance

A nurse is educating a group of women on breast cancer prevention. When should the nurse teach the clients is the best time to perform a monthly self breast exam (SBE)? The day menses has begun The day menses is completed 7-10 days after menses 2 days before menses

✅7-10 days after menses Completing an SBE 7-10 days after menses is appropriate, as any edema from menses has most likely subsided by this time. Also, the impact breast edema has monthly can fluctuate, therefore doing this after the edema has subsided makes it much easier to compare month to month. It also provides consistency in hormonal timing. The day menses is completed Clients are likely to experience breast swelling or tenderness during their menstrual cycle and may not be able to accurately detect any abnormalities in breast tissue. The day menses has begun Clients are likely to experience breast swelling or tenderness during their menstrual cycle and may not be able to accurately detect any abnormalities in breast tissue until the swelling has decreased. 2 days before menses Even before menses have begun, clients may begin to have some swelling of the breast tissue. It is best to perform an SBE after the swelling has most likely subsided (7-10 days later).

5 of 16 Which client arterial blood pH value will the nurse interpret as normal? 7.37 7.27 7.47 7.5

✅7.37 The normal range for arterial blood pH is 7.35 to 7.45. A value of 7.27 indicates acidosis. Values of 7.47 and 7.5 indicate alkalosis. Chapter 14 - Concepts of Acid-Base Balance

14 of 17 The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 40 year old admitted 3 hours ago for a scheduled thoracentesis in 30 minutes. A 55 year old with bronchogenic lung cancer who returned from bronchoscopy 4 hours ago. A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. A 68 year old with pleural effusion who has decreased breath sounds at the right base.

✅A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen saturation level less than 91% indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation. The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed. There is no evidence the client who had a bronchoscopy 3 hours ago is unstable and therefore does not require attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

8 of 18 Which client with persistent joint and muscle pain will the nurse consider as most likely to have a systemic lupus erythematosus (SLE) diagnosis? A 33-year-old African-American man whose father died from a myocardial infarction. A 33-year-old white woman whose sister has Grave disease. A 33-year-old African-American woman whose mother has psoriasis. A 33-year-old man whose identical twin brother has acute myelogenous leukemia.

✅A 33-year-old African-American woman whose mother has psoriasis. SLE is an autoimmune disorder that is much more common in women than in men and has a genetic predisposition related to tissue type. A client with SLE is very likely to have another close relative who also has an autoimmune disorder, such as psoriasis (myocardial infarction, type 2 diabetes mellitus, and thrombotic stroke are not autoimmune disorders). In addition, the incidence of SLE is about eight times greater for African-American women than for white women. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

3 of 18 For which hypersensitivity situation will the nurse prepare a client for management with plasmapheresis? A 35 year old with drug-induced hemolytic anemia A 30 year old with poison ivy lesions on 60% of the body A 25 year old with penicillin-induced anaphylaxis A 40 year old with angioedema and tongue swelling

✅A 35 year old with drug-induced hemolytic anemia Drug-induced hemolytic anemia is a type II hypersensitivity reaction in which the body makes autoantibodies directed against red blood cells that have foreign proteins from the drug attached to them. In this type of reaction, the autoantibody binds to red blood cells, forming immune complexes that destroy red blood cells along with the attached protein. Management starts with discontinuing the offending drug and, performing plasmapheresis (filtration of the plasma to remove specific substances) to remove the formed autoantibodies. Plasmapheresis is not beneficial with other types of hypersensitivity reactions. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

12 of 16 Which client will the nurse observe frequently for indications of hyperkalemia? A 72 year old receiving total parenteral nutrition A 65 year old taking furosemide for chronic heart failure A 38 year old being managed for diabetic ketoacidosis A 30 year old who has anxiety-induced hyperventilation

✅A 38 year old being managed for diabetic ketoacidosis Hyperkalemia occurs as compensation for any type of acidosis, including diabetic ketoacidosis, by having cells take up excess hydrogen ions (from the acidosis) in exchange for releasing intracellular potassium to maintain electroneutrality in both fluid compartments. The client receiving TPN is at risk for metabolic alkalosis due to an increase in base components. Hyperventilation leads to respiratory alkalosis, which causes hypokalemia. Furosemide increases potassium loss, leading to hypokalemia. Chapter 14 - Concepts of Acid-Base Balance

After receiving the change-of-shift report, which client does the nurse assess first? A 67 year old with nausea and vomiting who reports abdominal cramps. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

✅A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia and may require immediate action. All other clients listed have less urgent problems and do not require immediate assessment. Chapter 13 - Concepts of Fluid and Electrolyte Balance

6 of 13 Which client is at greatest risk for developing an infection? A 65-year-old woman who had heart surgery 4 days ago A 54-year-old man with hypertension A 21-year-old woman with a fractured tibia in a cast A 71-year-old man in a nursing home

✅A 65-year-old woman who had heart surgery 4 days ago Older clients such as the 65-year-old woman with compromised skin (surgical incision) are at the highest risk for infection. No coexisting conditions are present for the client with hypertension to be at risk for infection. The 71-year-old client in a nursing home is not at highest risk because no coexisting conditions make this client most vulnerable to infection. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? A 26 year old with hyperparathyroidism A 70 year old who has alcoholism and malnutrition A 40 year old taking tetracycline for an infection A 35 year old athlete taking NSAIDs for joint pain

✅A 70 year old who has alcoholism and malnutrition Calcium is absorbed from the gastrointestinal tract under the influence of vitamin D. When a client is malnourished, not only is the dietary intake of calcium usually low, but the client is also vitamin deficient. Hyperparthyroidism would increase serum calcium levels. Neither NSAIDs nor tetracycline increase the risk for hypocalcemia. Chapter 13 - Concepts of Fluid and Electrolyte Balance

Which client does the nurse identify at greatest risk for heat exhaustion? A 34-year-old police officer A 42-year-old swimming instructor A 24-year-old construction worker A 78-year-old gardener

✅A 78-year-old gardener Older adults are particularly at risk for heat-related illnesses because of decreased body fluid volume. Heat exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse as a result of the body overheating. Older adults may also be at risk due to medications they are taking that lead to electrolyte imbalances for treatment of medical comorbidities. The 24-year-old construction worker is at risk due to being outdoors, but is not the one at highest risk. Most outdoor workers have a "thirst" response and will keep hydrated as needed. The police officer is a young adult who must be in acceptable state of fitness to hold this job. The swimming instructor may be at risk due to being outdoors, but has the ability to cool off rapidly by getting into the water Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

The charge nurse is making assignments for the next shift. Which of the following clients can be assigned to the same nurse as the client with a neutrophil count of 490? Select all that apply. A client with a broken hip A client with HIV A client with pneumonia A client with glaucoma A client with MRSA

✅A client with a broken hip A client with a neutrophil count of 490 is immunocompromised, and should be placed on neutropenic precautions. The nurse caring for this client cannot care for clients with transmittable diseases at the same time. ✅A client with glaucoma This client is appropriate because glaucoma is not a transmittable disease. A client with MRSA Since a neutropenic client has little to no immunity, they cannot risk exposure to bacteria or viruses. A client with HIV This client is contagious and cannot be exposed to a client with neutropenia. A client with pneumonia This client is contagious and cannot be exposed to a client with neutropenia.

The charge nurse is making assignments for the next shift. Which of the following clients can be assigned to the same nurse as the client with a neutrophil count of 490? Select all that apply. A client with pneumonia A client with MRSA A client with HIV A client with glaucoma A client with a broken hip

✅A client with a broken hip A client with a neutrophil count of 490 is immunocompromised, and should be placed on neutropenic precautions. The nurse caring for this client cannot care for clients with transmittable diseases at the same time. ✅A client with glaucoma This client is appropriate because glaucoma is not a transmittable disease. A client with MRSA Since a neutropenic client has little to no immunity, they cannot risk exposure to bacteria or viruses. A client with HIV This client is contagious and cannot be exposed to a client with neutropenia. A client with pneumonia This client is contagious and cannot be exposed to a client with neutropenia.

Clients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which client is most appropriate for the nurse to assign to an LPN/LVN? A client with heat exhaustion, receiving an IV of normal saline, with a temperature of 98.6° C (37° C) A client reporting right forearm swelling secondary to a "bug bite" with capillary refill in the right hand of greater than 3 seconds A client stung by an unknown insect who reports shortness of breath A client who was hiking and is now confused, and has crackles throughout all lung fields

✅A client with heat exhaustion, receiving an IV of normal saline, with a temperature of 98.6° C (37° C) It is appropriate to assign an LPN/LVN to care for the stable client with heat exhaustion who is already receiving appropriate treatment. The data from the other three clients all support the need for ongoing assessment and intervention by an RN. The client who presents with vascular instability and compromise needs quick intervention. The client who is confused and has the potential to deteriorate rapidly and the client with the unknown insect bite also need assessment by the RN. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

The nurse received report on 4 clients and has decided that the client who needs methotrexate should be seen first. Which of the following clients needs methotrexate? A client with asthma A client with rheumatoid arthritis A client with seizures A client with a bowel obstruction

✅A client with rheumatoid arthritis Methotrexate is an anti-rheumatic used to treat psoriasis or rheumatoid arthritis. A client with asthma Methotrexate is not indicated in the treatment of asthma. A client with seizures Methotrexate is not indicated in the treatment of seizures. A client with a bowel obstruction Methotrexate is not indicated in the treatment of bowel obstructions.

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? (Select all that apply.) Gown Gloves Mask Hair cover Goggles

✅A gown is correct. The nurse should follow standard precautions when caring for a client who has AIDS. Because the bed linens might be soiled, the nurse should don a gown in addition to other necessary PPE. ✅Gloves are correct. The nurse should follow standard precautions when caring for a client who has AIDS. Because the nurse's hands will come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other necessary PPE. A mask is incorrect. The nurse should practice standard precautions in the care of the client who has AIDS. AIDS is not transmitted by droplet or inhalation, so a mask is not necessary when changing the client's bed linens. A hair cover is incorrect. The nurse should practice standard precautions in the care of the client who has AIDS. A hair cover is not necessary when changing the client's bed linens. Goggles are incorrect. The nurse should practice standard precautions in the care of the client who has AIDS. Goggles are not necessary since splashing of bodily fluids is unlikely when changing the client's bed linens. RN Learning System Medical-Surgical: Final Quiz

5 of 13 When the nurse is assessing the skin of an older adult client, which finding must be reported to the health care provider (HCP)? Cherry hemangiomas are scattered on the back. The skin on the extremities is paper-thin. A multicolored lesion is present on the thigh. Liver spots are present on both hands.

✅A multicolored lesion is present on the thigh. The multicolored lesion on the client's thigh must be reported to the health care provider. Color variation within a lesion is associated with skin cancer; the health care provider should be informed so that the lesion can be further assessed. Liver spots, cherry hemangiomas, and loss of skin elasticity are findings that are associated with aging and are normal for an older adult. They will be documented, but are not reportable to the health care provider Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer? Lumps that are mobile and tender upon palpation prior to a menstrual period Multiple round masses that are tender and found in both breasts Bilaterally darkened areolas

✅A nontender, hard lump that is palpated in one breast The nurse should identify that cancerous tumors are typically hard, fixed, irregular in shape, and nontender to palpation. The nurse should instruct the client to notify the provider promptly if she palpates a hard, nontender lump. Lumps that are mobile and tender upon palpation prior to a menstrual period The nurse should identify moveable lumps that increase in tenderness during the menstrual period as an indication of fibrocystic breast tissue. Multiple round masses that are tender and found in both breasts The nurse should identify that multiple masses of regular shape in both breasts are characteristic of fibrocystic breast disease. Bilaterally darkened areolas The nurse should identify that bilaterally darkened areolas are an expected finding in dark-skinned women and an expected change during pregnancy in light-skinned women. RN Learning System Medical-Surgical: Final Quiz

A client who has to start chemotherapy for a new diagnosis of cancer becomes very anxious and upset about the thought of the new treatment. Which type of referral could the nurse make in this situation? Select all that apply. A referral to a cancer support group A referral to a doctor of homeopathy A referral to have a diagnostic test done A referral to an integrative health care provider A referral for a new oncologist

✅A referral to an integrative health care provider Referrals that would be helpful for the client with anxiety are focused on relaxation, support, and stress reduction. Natural homeopathic remedies do not address the client's anxiety, nor does switching oncologists or more diagnostic tests. ✅A referral to a cancer support group A nurse has the capability of making some types of referrals, particularly those that are for supportive care for the client. The nurse cannot write orders or prescribe, but can make a referral for such services as complementary therapies, use of assistive devices, or information about support groups and community resources. A referral to have a diagnostic test done A nurse has the capability of making some types of referrals, particularly those that are for supportive care for the client. The nurse cannot write orders or prescribe, but can make a referral for such services as complementary therapies, use of assistive devices, or information about support groups and community resources. A referral for a new oncologist A nurse has the capability of making some types of referrals, particularly those that are for supportive care for the client. The nurse cannot write orders or prescribe, but can make a referral for such services as complementary therapies, use of assistive devices, or information about support groups and community resources. A referral to a doctor of homeopathy Natural homeopathic remedies do not address the client's anxiety

A nurse is planning care for a client who is scheduled for genetic testing for suspected cancer. Which of the following interventions should the nurse include in the plan of care? A. determine the need for informed consent. B. send testing results to the client's insurance agency. C. Verify the prescription for a tumor marker assay. d. ensure the client is placed in a recovery position after testing.

✅A. CORRECT: A signed informed consent form should be obtained prior to the procedure. B. Genetic testing information is confidential. do not send the information unless the client requests it. C. A tumor marker assay is a laboratory test to identify the presence of specific body proteins in blood, body secretions, and tissue. it is not a component of genetic testing. d. Genetic testing involves collection of blood or saliva. recovery positioning is not required following testing. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration CHAPTER 90 CANCER SCREENING AND DIAGNOSTIC PROCEDURE

2. A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (select all that apply.) A. "Take your heart medication with a sip of water before surgery." B. "splint the abdominal incision with a pillow when coughing and deep breathing." C. "Bed rest is recommended for the first 48 hours." d. "Anti‐embolism stockings are applied before surgery." e. "you can eat solid foods up to 4 hours before surgery."

✅A. CORRECT: Teach the client to take certain cardiac and other medications as prescribed with a sip of water before surgery. ✅B. CORRECT: Teach the client how to splint with a pillow to support the incision when coughing and deep breathing postoperatively. C. Teach the client the importance of early ambulation following abdominal surgery to prevent complications. ✅d. CORRECT: inform the client of the application of antiembolism stockings to prevent deep‐vein thrombosis. e. inform the client to stop eating solid food for 6 hr or more before surgery. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures CHAPTER 95 PREOPERATIVE NURSING CARE NURSING CARE OF PERIOPERATIVE CLIENTS

2. A nurse is assisting an anesthesiologist who is delivering nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? A. Assess oxygen saturation. B. Measure blood pressure. C. Palpate pulse rate. d. Check temperature.

✅A. CORRECT: The greatest risk for the client is injury from hypoxia. Therefore, this is the priority finding. B. Measuring blood pressure is important for assessing the client's cardiovascular status. However, another finding is the priority. C. Palpating pulse rate is important for assessing the client's cardiovascular status. However, another finding is the priority. d. Checking temperature at the time of induction is important for identifying hypothermia. However, another finding is the priority. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures CHAPTER 94 ANESTHESIA AND MODERATE SEDATION

4. A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (select all that apply.) A. encourage use of the incentive spirometer q 2 hr. B. instruct the client to splint the incision when coughing and deep breathing. C. reposition the client every 2 hr. d. Administer antibiotic therapy. e. Assistwithearlyambulation.

✅A. CORRECT: Use of the incentive spirometer every 2 hr expands the lungs and prevents atelectasis. B. CORRECT: incisional splinting with a pillow or blanket supports the incision during coughing and deep breathing, which prevents atelectasis. C. CORRECT: repositioning the client every 2 hr will mobilize secretions and allow the client to deep breathe and expand the lungs to prevent atelectasis. d. Antibiotic therapy is used to prophylactically prevent or treat infection and does not prevent atelectasis. e. CORRECT: early ambulation expands the lungs through deep breathing and prevents atelectasis. NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems CHAPTER 96 POSTOPERATIVE NURSING CARE

A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (rA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (select all that apply.) A. recent influenza B. decreased range of motion C. Hypersalivation d. increased blood pressure e. Pain at rest

✅A. CORRECT: exacerbating factors, such as a recent illness like influenza, are indicative in clients who have RA. B. CORRECT: A decrease in range of motion is indicative in clients who have RA. C. Clients who have RA can experience xerostomia, not hypersalivation. d. increased blood pressure is not indicative of RA e. CORRECT: Pain at rest is indicative of RA. NCLEX® Connection: Physiological Adaptation, Pathophysiology CHAPTER 88 RHEUMATOID ARTHRITIS

4. A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39° C (102.2° F) orally. Which of the following actions should the nurse take? A. inform the surgeon of the elevated temperature. B. Transfer the client to the preoperative unit. C. Apply ice packs to the groin. d. encourage the client to increase intake of clear liquids.

✅A. CORRECT: immediately notify the surgeon of the elevated temperature to determine if canceling the surgery is necessary due to an underlying infection. B. Transferring the client to the preoperative unit is not an appropriate nursing action when there is a possible underlying infection. C. Applying ice packs to the client's groin is not an appropriate action for a temperature of 39° C (102.2° F). d. increasing intake of clear liquids is not an appropriate action because the client should be NPO for at least 2 hr before surgery. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures NURSING CARE OF PERIOPERATIVE CLIENTS

A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? A. "you can experience morning stiffness when you get out bed." B. "you can experience abdominal pain." C. "you can experience weight gain." d. "you can experience low blood sugar."

✅A. CORRECT: include in the teaching that the client who has RA can experience stiffness in the joints upon rising. B. The client who has RA can experience pleuritic pain upon inspiration, not abdominal pain. C. The client who has RA can experience weight loss, not weight gain. d. The client who has RA does not experience a low blood sugar. NCLEX® Connection:

2. A nurse is caring for a client who will undergo a neurolytic ablation. The client asks the nurse the reason for this procedure. Which of the following responses should the nurse make? A. "it should provide permanent pain relief." B. "it reduces the adverse effects of your pain medication." C. "it increases your ability to fight infections." d. "it increases cells that stop bleeding."

✅A. CORRECT: inform the client that neurolytic ablation causes permanent destruction of the nerves that transmit pain from a specific area and is a last resort after other methods have been unsuccessful. B. Neurolytic ablation should reduce the need for analgesics. However, it does not reduce the adverse effects of pain medication. C. Neurolytic ablation does not treat myelosuppression (which reduces immunity) or increase the ability to fight infections. d. Neurolytic ablation does not treat thrombocytopenia. The procedure can cause complications, such as disruption of bladder and bowel function, but it does not affect clotting mechanisms. NCLEX® Connection: CHAPTER 93 PAIN MANAGEMENT FOR CLIENTS WHO HAVE CANCER

3. A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? (select all that apply.) A. infuse iced iV fluids. B. Provide 100% oxygen. C. Place a cooling blanket on the client. d. Treat the complication while the surgeon continues surgery. e. AdministeriVdantrolene.

✅A. CORRECT: infusing iced iV fluids should help lower the client's rapidly rising temperature. ✅B. CORRECT: Providing 100% oxygen will help prevent hypoxia due to muscle tremors and rigidity from increased lactic acid. ✅C. CORRECT: Placing a cooling blanket on the client will help lower the rapidly rising temperature. d. Terminating surgery should occur as soon as the surgical team suspects malignant hyperthermia. ✅e. CORRECT: dantrolene iV is a muscle relaxant that treats malignant hyperthermia. NCLEX® Connection: Physiological Adaptation, Medical Emergencie CHAPTER 94 ANESTHESIA AND MODERATE SEDATION

1. A nurse is caring for a client who has chronic cancer pain and has a permanent epidural catheter for administration of a fentanyl/bupivacaine solution. The nurse should monitor the client for which of the following findings? (select all that apply.) A. respiratory depression B. Hypotension C. sedation d. Muscle spasticity e. sensory blockage

✅A. CORRECT: respiratory depression is an adverse effect of epidural analgesics. Other adverse effects include seizures and dura puncture. ✅B. CORRECT: Hypotension is an adverse effect of epidural analgesics that can be corrected by administration of fluids. Other adverse effects include hematoma and infection. ✅C. CORRECT: sedation is an adverse effect of epidural analgesics. Other adverse effects include anaphylaxis and severe headache. d. Muscle weakness, not spasticity, is an adverse effect of epidural analgesics. ✅e. CORRECT: sensory blockage is an adverse effect of epidural analgesics. Other adverse effects include decreases in bowel and bladder control. NCLEX® Connection: Pharmacological and Parenteral Therapies, Pharmacological Pain Management CHAPTER 93 PAIN MANAGEMENT FOR CLIENTS WHO HAVE CANCER

Which is the most common reason a client cannot receive chemotherapy? Mucositis Absolute neutrophil count Nausea and vomiting Fatigue

✅Absolute neutrophil count This is the most common reason a client is not cleared for chemotherapy. The absolute neutrophil count (ANC) must be above 1,000 in order for the provider to allow the client to go ahead with chemotherapy. Nausea and vomiting Nausea and vomiting are a side-effect of chemotherapy, but are not typically a reason that chemotherapy is delayed. The neutrophil count is the most common reason for a client to have to wait for a dose of chemotherapy. Fatigue Excessive fatigue is an expected outcome of chemotherapy treatments. While it is not a reason to forego chemotherapy, it will prompt the nurse to talk to the client about getting enough rest and nutrition. Mucositis Mucositis, or inflammation of the mucous membranes, is a side effect of chemotherapy. This does not lead to a delay in chemotherapy administration, but may require frequent medicated rinses of the oral cavity, increased brushing with a soft toothbrush, and actions to keep the mouth from becoming too dry.

A nurse working on a surgical unit admits a client from the PACU after a hysterectomy. The nurse is concerned that this client is oversedated. Which of the following findings would NOT be consistent with the clinical presentation of oversedation? Sp02 86% PaO2 66 mmHg Accessory muscle use GCS 13

✅Accessory muscle use Accessory muscle use occurs when clients are working much harder to breathe, usually due to obstruction or airway narrowing. It is an increased work of breathing. Oversedation would cause a DECREASED respiratory effort due to CNS depression. PaO2 66 mmHg Oversedation would cause a decreased respiratory effort because of CNS depression, which would lead to hypoxia. Normal PaO2 is 80 and above - this would be a sign of low oxygenation - which could be evidence of oversedation. Sp02 86% Because of the CNS depression, oversedation usually causes a decreased respiratory rate and effort, which would lead to hypoxemia - evidenced here by a low oxygen saturation. This would be a correct sign of oversedation. GCS 13 Although a GCS of 13 seems "high" or close to normal, it can be a sign of oversedation. This client may be not even opening their eyes to voice. Or maybe they'll open their eyes to voice, but they're confused. Or maybe they've got their eyes open, but they're confused and not following commands. All of these things can be signs of oversedation. 03.02 Postoperative (Postop) Complications

Question 2 of 10 A client with chronic pain due to arthritis is diagnosed with a stomach ulcer. Which of the following medications is appropriate for the nurse to give the client for arthritis pain relief? Naprosyn Acetaminophen Ibuprofen Aspirin

✅Acetaminophen Acetaminophen is not an NSAID, and is safe to take long-term for relief of chronic pain. The other medications are NSAIDS and affect gut mucosa to worsen stomach ulcers if taken chronically. Ibuprofen This is a non-steroidal anti-inflammatory drug which, if taken chronically, affects gut mucosa to allow naturally occurring stomach acid to perforate the gut, causing ulcers. Naprosyn This is a non-steroidal anti-inflammatory drug which, if taken chronically, affects gut mucosa to allow naturally occurring stomach acid to perforate the gut, causing ulcers. Aspirin This is a non-steroidal anti-inflammatory drug which, if taken chronically, affects gut mucosa to allow naturally occurring stomach acid to perforate the gut, causing ulcers.

8 of 13 A client is preparing to give a client an antipyretic drug for a temperature of 101° F (38.3° C). What drug would be the most appropriate for the nurse to administer? Acetaminophen Aspirin Doxycycline Ibuprofen

✅Acetaminophen While all of these drugs may reduce fever, acetaminophen is an antipyretic and analgesic agent that has less side/adverse effects than the other drugs. Doxycycline is an antibiotic which may treat infection and thus reduce fever. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

2 of 16 Which acid-base problem does the nurse expect when the ventilator of a client being mechanically ventilated is set at too high a rate of breaths per minute for 6 hours? Acid-deficit alkalosis Acid excess acidosis Base excess alkalosis Base-deficit acidosis

✅Acid-deficit alkalosis A ventilator set at either too high a ventilation rate and/or at too great a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid-deficit respiratory alkalosis. Chapter 14 - Concepts of Acid-Base Balance

A 6-month-old child has just received the 6 month scheduled immunizations. Which type of immunity does this process best describe? Acquired immunity Passive immunity Natural immunity Active artificial immunity

✅Active artificial immunity When a child receives immunizations, he or she is incurring active artificial immunity. There are two forms of active immunity: natural and artificial. Natural immunity develops when a child has a disease and then becomes immune to it. Active artificial immunity is the process of artificially exposing the child to the disease so he or she can develop immunity, such as with vaccines. Natural immunity This term refers to when a child has a disease and the body becomes immune to the disease. Passive immunity This term refers to when a child has a disease and the body becomes immune to the disease. Acquired immunity Passive immunity is short-term, and occurs when an infant breastfeeds and receives the mother's immunity through breastmilk.

On a hot summer day, an older adult is found by a neighbor lying on the floor, agitated and confused. After calling 911, the neighbor places ice bags on the client's groin area and armpits. Upon arrival at the hospital, which action does the emergency department (ED) nurse perform first? Administer high-flow oxygen therapy. Place a cooling blanket on the client. Monitor vital signs. Contact family members for a history.

✅Administer high-flow oxygen therapy. The first action made by the ED nurse is to check the client's airway and give high-flow oxygen therapy. All other actions can be taken after the airway is supported with oxygen Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

Question 5 of 10 The nurse is caring for a client who has just been admitted to the floor following a knee replacement surgery. The client received a total of 100 mcg fentanyl in the PACU, of which 25 mcg were administered just before the trip to the floor. During the initial assessment, the nurse notes the client's respirations are 8, he requires sternal pressure to open his eyes but then falls back asleep again, and his oxygen saturation is 82%. What is the nurse's priority intervention at this time? Administer morphine Administer epinephrine Administer acetylcysteine Administer naloxone

✅Administer naloxone This client received too much fentanyl and is over-sedated. Of the interventions listed, the most appropriate is to administer the opioid-reversal agent naloxone. The nurse will expect this client to immediately become conscious and also experience intense pain because the fentanyl will no longer be circulating in the body. Administer acetylcysteine Acetylcysteine is the antidote for acetaminophen, and is not indicated. Administer epinephrine Epinephrine will not bring the client out of this overdosed state. This client needs naloxone. Administer morphine Morphine is an opioid. It is contraindicated to give another opioid to a client with an opioid overdose. 03.02 Postoperative (Postop) Complications

The nurse is coordinating care for a client who was bitten by a black widow spider. Which nursing action can be delegated to the LPN/LVN? Assessing the client for neurologic changes Administering tetanus toxoid vaccine intramuscularly Providing discharge instructions to the client when the family arrives Monitoring for respiratory compromise in the client

✅Administering tetanus toxoid vaccine intramuscularly Administration of intramuscular medication is within the scope of practice and education level of an LPN/LVN. Physical assessment and ongoing monitoring for complications, as well as client education and planning for discharge, are all actions that require broader education and scope of practice of an RN. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

The post-anesthesia care unit (PACU) nurse caring for a client who just underwent a carpal tunnel procedure. The nurse completed the immediate admission assessment, initial assessment, implementation of interventions, and evaluation. The nurse knows that which of the following is one tool to evaluate the client's readiness for discharge? Glasgow coma score ASA classification system ACE score Aldrete score

✅Aldrete score This is a scoring system used to determine if a client can be discharged from the PACU safely ASA classification system This is not the score used to determine safe discharge. This is a way to evaluate a client's "sickness" or "physical state" before selecting the appropriate anesthetic. Glasgow coma score This is not the score used to determine safe discharge. This is used to describe the level of consciousness in a person. ACE score This is not the score used to determine safe discharge. This is used to describe the level of consciousness in a person. 03.01 Post-Anesthesia Recovery

4 of 16 Which problem does the nurse expect resulted in a client's acid-base imbalance during an illness that causes vomiting for 2 days? Alkalosis from overelimination of hydrogen ions Acidosis from overproduction of of hydrogen ions Alkalosis from overproduction of bicarbonate ions Acidosis from underelimination of bicarbonate ions

✅Alkalosis from overelimination of hydrogen ions Prolonged or excessive vomiting results in alkalosis from overelimination of hydrogen ions when stomach hydrochloric acid is lost in the vomit. Chapter 14 - Concepts of Acid-Base Balance

The perioperative nurse who is monitoring the client during the procedure has a good understanding of signs and symptoms associated with local anesthesia including local anesthesia systemic toxicity. The nurse knows that which of the following are signs of this issue? Select all that apply. Numbness of lips Bradycardia Tachycardia Metallic taste Shivering

✅All are correct check_circle Tachycardia Anesthesia and anesthesia toxicity can cause tachycardia or bradycardia. check_circle Bradycardia Anesthesia and anesthesia toxicity can cause tachycardia or bradycardia. check_circle Metallic taste A metallic taste can occur from anesthesia. check_circle Numbness of lips Anesthesia can cause numbness of lips. check_circle Shivering Local anesthesia can cause shivering. 02.03 Local Anesthesia

12 of 13 The nurse is teaching a group of senior citizens about recommended immunizations. What immunizations would the nurse include? (Select all that apply.) Select all that apply. Herpes zoster vaccine Pneumococcal vaccine polyvalent vaccine Adult Tdap with Td booster every 10 years Annual influenza vaccine Pneumococcal 13-valent conjugate vaccine

✅All of these immunizations are very important for people over 65 years of age to obtain due to the high risk of the diseases that they help prevent. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

A 48-year-old client has been diagnosed with advanced lung cancer. The client complains of pain in the chest wall from the primary tumor. Which of the following adjuvant medications has been shown to be beneficial in the management of this type of cancer pain? Famotidine (Pepcid) Allopurinol (Zyloprim) Amitriptyline (Elavil) Lovastatin (Mevacor)

✅Amitriptyline (Elavil) Many clients with cancer also have pain associated with the condition. Pain may be treated through various means, including the administration of opioid and non-opioid analgesics. Adjuvant medications are also given to support the work of pain medications as well as to treat other symptoms that may exacerbate pain. Adjuvants such as antidepressants (amitriptyline), anticonvulsants, muscle relaxants, and corticosteroids are some examples of drugs that may be given. Lovastatin (Mevacor) This is not used as adjuvant drug therapy for clients with cancer. Allopurinol (Zyloprim) This is not used as adjuvant drug therapy for clients with cancer. Famotidine (Pepcid) This is not used as adjuvant drug therapy for clients with cancer.

8 of 17 What is the nurse's interpretation of a 50-year-old client's respiratory assessment findings when hearing bronchial breath sounds over the left lower lobe and noting decreased fremitus and dullness to percussion in the same area? Obstruction of the larger airways Normal physical exam for a 50 year old An area of increased density Subcutaneous emphysema

✅An area of increased density Peripheral bronchial breath sounds are abnormal and can indicate atelectasis, tumor, or pneumonia. Decreased fremitus and dullness to percussion may indicate pleural effusion, which is more dense than air. Bronchial breath sounds are normally heard only over the large airways in patients of any age, not in the periphery. An obstructed airway would have reduced bronchial breath sounds, and they would not be present in the periphery. Subcutaneous emphysema is a condition in which air is trapped within or beneath the skin. It is felt and heard as a "crackling" in the skin and subcutaneous tissues, not within any part of the respiratory tract. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

The nurse is discussing colon cancer risks with a 40-year-old client. Which of the following are modifiable factors that contribute to an increased risk for colon cancer? Select all that apply. A diet high in alcohol consumption Advanced age An inactive lifestyle Smoking Inflammatory bowel disease

✅An inactive lifestyle Persons who lead an active lifestyle are less likely to get colon cancer than those who lead a sedentary lifestyle. ✅A diet high in alcohol consumption Diet plays an important role in cancer prevention. A client whose diet includes a high consumption of alcohol and red meat has an increased risk for developing colon cancer. ✅Smoking Smoking increases the risk of developing many types of cancer, including colon cancer. Advanced age The risk for colorectal cancers increases with advanced age, but this is not a modifiable risk factor. Inflammatory bowel disease Inflammatory bowel disease (IBD) includes various inflammatory conditions of the bowel, which increase the risk for colorectal cancer. However, a person does not choose to have IBD, so it is not a modifiable risk factor.

1 of 16 What is the relationship between free hydrogen ions and carbon dioxide? An increase in free hydrogen ions always lowers carbon dioxide levels. Carbon dioxide can bind free hydrogen ions to increase the pH. Carbon dioxide can bind free hydrogen ions to decrease the pH. An increase in free hydrogen ions always increases carbon dioxide levels.

✅An increase in free hydrogen ions always increases carbon dioxide levels. In human physiology and homeostasis, free hydrogen ions and carbon dioxide levels are directly related. Any condition that changes the concentration of one always causes a corresponding change in the concentration of the other in the same direction. Carbon dioxide is not a buffer and does not directly bind free hydrogen ions. Chapter 14 - Concepts of Acid-Base Balance

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? One solid color Symmetrical in shape Less than 6 mm in diameter An irregular border

✅An irregular border The nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit border irregularity. The nurse should instruct clients on the use of the ABCDE pneumonic when monitoring for skin lesions: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature. One solid color The nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit color variation. Symmetrical in shape The nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit asymmetry in shape. Less than 6 mm in diameter The nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit a diameter that is greater than 6 mm. RN Learning System Medical-Surgical: Final Quiz

13 of 20 Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. A client receiving blood products after excessive blood loss during surgery. A client admitted for hyperglycemia who has an IV insulin drip and needs frequent glucose checks. A client who has a diltiazem IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min.

✅An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN. The client with a diltiazem IV infusion, the client with an IV insulin drip, and the client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN. Chapter 15 - Concepts of Infusion Therapy

The PACU nurse is providing discharge teaching to a client who just underwent a bunionectomy under general anesthesia. The nurse knows that which of the following information should be provided regarding anesthesia? Select all that apply Do not drive for 7 days after anesthesia A caretaker should be available to the client after anesthesia Anesthesia may cause dizziness Anesthesia may cause drowsiness Do not drink alcohol for 24 hours after anesthesia

✅Anesthesia may cause drowsiness This is a true statement regarding anesthesia postoperatively. Anesthesia can have effects in the postop period that cause drowsiness and dizziness. ✅Anesthesia may cause dizziness This is a true statement regarding anesthesia postoperatively. Anesthesia can have effects in the postop period that cause drowsiness and dizziness. Do not drive for 7 days after anesthesia Driving is typically restricted only 24 hours after anesthesia. ✅Do not drink alcohol for 24 hours after anesthesia This is a true statement regarding anesthesia postoperatively. Because anesthesia can have lasting effects alcohol should be avoided as together it is not a safe combination. ✅A caretaker should be available to the client after anesthesia This a true statement regarding anesthesia postoperatively. Anesthesia can have lasting effects making the client dizzy and tired and unable to drive so having a caretaker to assist them is best. 02.02 General Anesthesia

A client is asking about surgical history and assessed prior to surgery. The intraoperative nurse is aware that a thorough preoperative assessment is critical in decreasing the risk of which of the following? Perioperative hypothermia Retained surgical item Intraoperative infection Anesthesia reactions

✅Anesthesia reactions As a thorough preoperative assessment can decrease this risk. It is important to understand the risk of any anesthesia reaction to decrease the clients' risk during the procedure. Retained surgical item A preoperative assessment does not decrease the risk of a retained surgical item. Intraoperative infection Infection does not occur intraoperatively but postoperatively. Perioperative hypothermia A preoperative assessment does not decrease this risk to the client. 02.10 Intraoperative Nursing Priorities

Which statement made by a client prescribed oxygen therapy at home indicates to the nurse that more instruction is needed? A. "When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank." B. "Using oxygen should help me have more breath and stamina when I eat, bathe, and take care of myself." C. "Even though they contain alcohol, I can still drink a glass of wine or can of beer while using oxygen." D. "If my shortness of breath becomes worse or if I have chest pain, I will contact my primary health care provider immediately."

✅Answer: A Rationale: Oxygen, whether from a liquid reservoir or compressed oxygen tank, enhances combustion and is not to be used around open flames. Thus, the statement that switching to a liquid oxygen reservoir is safer to use while smoking rather than a oxygen from a compressed tank is completely erroneous and dangerous. Clients should contact their health care providers if breathing becomes more difficult or if chest pain occurs. Neither wine nor beer contain enough alcohol to be combustible in the presence of oxygen. Oxygen therapy can improve a client's activity tolerance and stamina. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention Chapter 25/Chapter 28 - Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy

Physiological Integrity What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1 hour time period? A. Plasma volume osmolarity increases; blood pressure increases B. Plasma volume osmolarity decreases; blood pressure increases C. Plasma volume osmolarity increases; blood pressure decreases D. B.​Plasma volume osmolarity decreases; blood pressure decreases

✅Answer: A Rationale: A 3% saline solution is hypertonic to body fluids and would immediately increase the osmolarity of the plasma volume, making it somewhat hypertonic to other body fluids. Not only does the 500 mL increase the plasma volume to raise blood pressure, the increased osmolarity of the plasma would cause the interstitial fluid to move into the plasma volume, contributing to blood pressure increase. Cognitive Level: Understanding Client needs category: Physiological Integrity Nursing Process Step: NA Chapter 13 - Concepts of Fluid and Electrolyte Balance

When answering the call light for a client on bedrest, the nurse finds the client's visitor unconscious on the floor with no discernable pulse and not breathing. The nurse estimates that at least 2 minutes have passed since the client's light first came on. What is the nurse's priority action? A. Initiate CPR with chest compressions. B. Perform an abdominal thrust maneuver. C. Assess the visitor for the presence of a head injury. D. Ask the client what event lead up to the visitor's fall.

✅Answer: A Rationale: Abdominal thrust maneuver is performed on an unconscious patient instead of chest compressions only when a known obstruction is present. If no obstruction has been observed in an unconscious person, chest compressions are started instead of abdominal thrusts because more unconscious adults have cardiac problems rather than airway obstruction. The fact that the visitor has no discernable pulse is an indication of a cardiac dysrhythmia causing the problem. Time is critical to a successful resuscitation outcome. Assessing for a head injury and ask the client to relate events would delay the intervention. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Implementation Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

​How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

✅Answer: A Rationale: Carbon dioxide is a gas that can be eliminated during exhalation, and this action is important for acid-base balance. When any condition causes the blood free hydrogen ion concentration to increase, extra CO2 is produced in the same proportion. This extra CO2 is eliminated during exhalation, helping to bring the hydrogen ion concentration down to normal and raising the pH, indicating that fewer free hydrogen ions are present. Whenever the CO2 level changes, the pH changes to the same degree, in the opposite direction. Cognitive Level: Understanding Client needs category: Physiological Integrity Nursing Process Step: N/A Chapter 14 - Concepts of Acid-Base Balance

Which statement about the genetics of cystic fibrosis is true? A. Recessive disorder affecting chloride transport B. Recessive disorder affecting alpha1-antitrypsin levels C. Dominant disorder inhibiting alveoli formation D. Dominant disorder increasing production of interleukin-5

✅Answer: A Rationale: Cystic fibrosis is caused by a mutation in both alleles of the CFTR gene, which results in the inhibition of chloride transport in epithelial cells, especially of the lungs, allowing thick, stick mucus to plug the airways. Although alpha1-antitrypsin deficiency is inherited in an autosomal pattern, this problem is associated with emphysema, not CF. Alveolar formation are not affected by CF, nor is interleukin-5 production increased. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

While responding to questions in a health history, the client reports that he usually expectorates about 2 ounces of thin, clear, colorless sputum daily, usually on getting up in the morning. What is the nurse's best action related to this finding? A. Document the report as the only action. B. Arrange for the client to have tuberculosis testing. C. Collect a sputum specimen for laboratory analysis. D. Alert the primary health care provider about this funding.

✅Answer: A Rationale: Sputum production is a normal function of the respiratory tract. Most healthy adults produce 2 to 3 ounces (about 90 mL) of sputum daily. Sputum from an adult without respiratory problems is thin, clear, colorless, and has minimal or no odor. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment Chapter 24 /Chapter 27 - Assessment of the Respiratory System

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

✅Answer: A, B, C, D, E Rationale: All choices place the client at a risk for infection because each factor can impair the client's immune status Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

Physiological Integrity When caring for a client who become ill while mountain climbing, which assessment finding requires immediate nursing intervention? Select all that apply. A. Blue nail beds B. Lung crackles C. Tachypnea at rest D. Pink, frothy sputum E. Persistent dry cough F. Pulmonary infiltrates per x-ray G. Increased pulmonary artery pressure

✅Answer: A, B, C, D, F, G Rationale: Important clinical indicators of high-altitude pulmonary edema (HAPE) include a persistent dry cough and cyanosis of the lips and nail beds; tachycardia and tachypnea that occur at rest; crackles in one or both lungs; pink, frothy sputum (a late sign); pulmonary infiltrates and pulmonary edema per x-ray; and increased pulmonary artery pressure due to pulmonary edema. All of these signs and symptoms require immediate nursing intervention. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Physiological Adaptation Nursing Process Step: Assessment/Evaluation Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

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

✅Answer: A, B, D Rationale: The client requires contact precautions because C. difficile is transmitted by direct contact with stool. Therefore, a gown, gloves, and meticulous hand hygiene is required. A mask (Choice C) is not required because the client does not have an infection transmitted via the respiratory tract. Choice E (goggles) would only be needed if body fluids are splashed and could be transmitted via mucous membranes. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

Health Promotion and Maintenance What teaching will the nurse provide to an older adult who has a history of heat exhaustion? Select all that apply. A. Take frequent rest breaks when doing activities B. Drink caffeinated beverages before going in the sun C. Wear dark clothing to protect the skin from burning D. Stay indoors in an air-conditioned room when possible E. Take warm baths or showers to regulate the body temperature

✅Answer: A, D, E Rationale: To prevent further instances of heat exhaustion, the nurse will teach the client to take frequent rest breaks when doing activities; to drink plenty of water (and to avoid caffeine); to wear loose, light-colored or white clothing that does not absorb heat; to stay indoors in an air-conditioned environment if possible; and to take cool baths or showers to help reduce body temperature. Cognitive Level: Analysis Client Needs Category: Health Promotion and Wellness Nursing Process Step: Implementation Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

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

✅Answer: A​ Rationale: One day of missing the drugs is not good but is unlikely to cause drug resistance if 90% of the drugs within any 1 month are taken on time and at proper dosages. The client should not be taught that anything under 4 days of missing drugs is okay. Doubling the next day's doses does not make up for missing doses. The viral load will not change in this short of a time period. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

The client at stage HIV-III (AIDS) reports a large painful "pimple" in the perineal area. How does the nurse respond to this report? A. Inspect the area for indications of infection. B. Ask the client whether this causes pain during intercourse. C. Remind the client to clean the area carefully after every stool. D. Explain that this is a small matter and document the report as the only response.

✅Answer: A​​ Rationale: With the greatly reduced immunity response of AIDS, even an infected "pimple" can lead to cellulitis and systemic infection. The nurse must determine the degree of infection and inform the immunity health care provider so proper interventions can be initiated to prevent a more serious infection. Cognitive Level: Applying or higher​​​ Client needs category: Physiological Integrity Nursing Process Step: Assessment Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

Safe and Effective Care Environment: Safety and Infection Control After a mass casualty event, which client will the nurse triage with a yellow tag? A. 29-year old with third-degree burns over 80% of the body B. 36-year old with closed fractures of both legs C. 48-year old with wheezing and difficulty breathing D. 52-year old with multiple abrasions and contusions

✅Answer: B Rationale: The client with closed fractures of both legs can wait a bit of time before treatment, but definitely needs intervention soon. This client will receive a yellow tag. The client with third-degree burns over 80% of the body would receive a black tag; the client with wheezing and difficulty breathing would receive a red tag; and the client with multiple abrasions and contusions would receive a green tag. Cognitive Level: Analysis Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control Nursing Process Step: Assessment/Evaluation Chapter 12- Concepts of Disaster Preparedness

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour? A. 12 mEq (mmol) B. 15 mEq (mmol) C. 18 mEq (mmol)mEq (mmol) D. 20 mEq (mmol)

✅Answer: B Rationale: 100 in 1000 mL = 0.10 mEq/mL (mmol/mL) x 150 = 15 mEq/hr (mmol/hr) Cognitive Level: Understanding Client needs category: Safe and effective care environment Nursing Process Step: NA Chapter 13 - Concepts of Fluid and Electrolyte Balance

​A nurse interviewing an 82-year-old somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year too as a booster." B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

✅Answer: B Rationale: A is incorrect because each year's influenza vaccine is composed of some different strains of antigen and is not really a booster. C is incorrect because the older vaccination may not contain the viral antigens most likely to cause influenza this season. The nasal mist vaccination is not recommended for anyone over age 49 years. Cognitive Level: Applying or higher Client Needs Category:​Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 28 ///Chapter 31 -Concepts of Care for Patients With Infectious Respiratory Problems

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

✅Answer: B Rationale: Entry inhibitors work by binding to and blocking the CCR5 receptors on CD4+ T-cells, the main target of HIV. In order to successfully enter and infect a host cell, the virus must have its gp120 protein attach to the CD4 receptor and have its gp41 bind to the CD4+ T cell's CCR5 receptor. Viral binding to both receptors is required for infection. By blocking the HIV's attachment to the CCR5 receptor, infection is inhibited. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm? A. "This year I will get the pneumonia vaccination in addition to a flu shot." B. "Now I will try to rest as much as possible and avoid any unnecessary exercise." C. "Maybe drinking a supplement will help me retain weight and have more energy." D. "Perhaps using a spacer with my metered dose inhaler will make the drug work better."

✅Answer: B Rationale: Many clients mistakenly believe that performing no exercise will reduce COPD symptoms. Exercising did not cause the increase in disease severity, but inactivity can by making muscles weaker, including the muscles used in breathing. Exercise for conditioning and pulmonary rehabilitation can improve function and endurance in clients with COPD, even those at a GOLD 3 class. The client should receive the pneumonia vaccination and should have an annual influenza vaccination. Drinking supplements can add calories to the diet and may have a positive effect on both weight and energy levels. Using a spacer with an MDI is the preferred method for this type of drug delivery system and can improve the likelihood that the drug will reach the lower airways. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

​A client newly diagnosed with Stage I nonsmall cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response? A. "This drug will only work on those lung cancers that have the right target and your tumor does not have it." B. "This drug is approved for use in client's whose lung cancer has metastasized not for early stage cancers." C. "Why would you want to take a drug for months when you may be cured by surgery alone?" D. "You need to talk about this with your oncologist and your surgeon."

✅Answer: B Rationale: Pembrolizumab is a type of immunotherapy that helps control lung cancer but does not cure it. It is approved only for use in clients whose cancers are positive for PD-L1 or 2 and have metastasized to the extent that they are at Stage IV. Although this client's cancer cells may have been tested for PD-L levels, his cancer stage does not qualify for the therapy. His best chances for cure at a stage I is complete tumor removal by surgery. Although C sounds like a correct response, it sounds very judgmental. The nurse can give accurate information to the client about the immunotherapy drug. It is not necessary to keep the information from him until he speaks to the oncologist or the surgeon. Cognitive Level: ​Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

A client who is 5 days post-operative from radical neck surgery for head and neck cancer tells the nurse that he is worried because his right shoulder is lower than the left and does not go back into place when he tries to raise it. What is the nurse's best response? A. "I will notify the surgeon right away because some left over tumor must be pressing on the nerve." B. "The nerve to the shoulder was removed during surgery. Physical therapy will help you to use other muscles to regain some motion." C. "This problem is not related to your surgery. If it persists after you go home you will need to see your primary health care provider about it." D. "Your time under anesthesia was long and you are not yet fully recovered. It is likely you will regain full motion in that shoulder by the end of the week."

✅Answer: B Rationale: Radical neck dissection for head and neck cancer includes the removal of lymph nodes, the sternocleidomastoid muscle, the jugular vein, the 11th cranial nerve, and surrounding soft tissue. Shoulder drop is expected after extensive surgery. Although physical therapy can help ease the shoulder drop by using other muscle groups. However, full shoulder motion does not return. The problem is not related to pressure on the nerve or the length of anesthesia. Cognitive Level: Applying or higher Client Needs Category: Psychosocial Integrity Nursing Process Step: Implementation Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy? A. Avoid injecting it in a site near a cutaneous lesion. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because it causes extreme drowsiness.

✅Answer: B Rationale: The drug is a monoclonal antibody given parenterally. It is composed of some foreign proteins and has been known to cause anaphylaxis even 2 hours after administration. Thus, it must be given by a health care professional in a setting capable of handling an anaphylactic emergency. It must not be self-administered. The drug is not available in tablet form. Belimumab does not induce drowsiness and can be administered at any time of day. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? A. Encourage the client to use the incentive spirometer hourly. B. Increase her O2 flow rate by 2 L and re-assess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action.

✅Answer: B Rationale: The low oxygen saturation and the client's confusion suggests hypoxia and a possible worsening of the client's condition. The increased respiratory rate supports this possibility. Increasing the oxygen flow rate and re-assessing in 5 minutes helps the nurse to determine whether the hypoxia responds to increased oxygen. If more oxygen is going to help, it will do so quickly. Even if the oxygen saturation increases with more oxygen, the health care provider needs to be informed of these events urgently. The incentive spirometer is not likely to be performed correctly with a confused client and would not immediately improve the client's hypoxia. Increasing the flow rate of the antibiotic also is not going to help the hypoxia immediately. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment/Evaluation Chapter 28 ///Chapter 31 -Concepts of Care for Patients With Infectious Respiratory Problems

The nurse assessing an 88-year-old client notices a severe kyphosis that curves the client's spine to the right and bends her forward. Which change in respiratory function does the nurse expect as a result of this age-related change? A. Decreased gas exchange as a result of reduced airway elasticity. B. Decreased gas exchange as a result of ineffective chest movement. C. Reduced pulmonary perfusion as a result of decreased alveolar diffusion capacity. D. Reduced pulmonary perfusion as a result of decreased blood return to the right atrium.

✅Answer: B Rationale: The severe skeletal change of the spine reduces the size of the chest cavity on the right and limits its mobility. As a result, ventilation is compromised on this side and gas exchange will be reduced. The spinal deformity does not affect airway elasticity or pulmonary perfusion, only ventilation. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: Assessment Chapter 24 /Chapter 27 - Assessment of the Respiratory System

The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling. C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system. D. No action is needed because these responses are normal for the first post-op day after lobectomy.

✅Answer: B Rationale: The tip of the chest tube could be lying against tissue, becoming occluded and causing the burning pain. Repositioning the client can change the position of the chest tube tip, relieving the pain and allowing drainage to continue. A is incorrect because although no bubbling means no drainage and could lead to a tension pneumothorax, troubleshoot quickly before call the rapid response team. If repositioning does not solve the problem, then call the rapid response team. C is incorrect. Identifying the cause of the pain is critical in this situation. Although it is important to relieve pain, wait to see how the repositioning affects the problem. The client needs to be completely alert to report how the sensation has changed (or not changed) as a result of the repositioning. D is incorrect. Neither the burning pain nor the lack of bubbling in the water seal chamber are normal at this stage of postoperative recovery. Cognitive level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation/Evaluation Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

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

✅Answer: C Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin moist. The skin actually needs to be kept clean and dry, and moisture can provide an environment for bacteria to continue to thrive. The nurse does not need to intervene when the client understands that clothing should not be shared, that the shingles vaccine is indicated for individuals over 50, and that fever and chills should be reported to the primary health care provider. Cognitive Level: Application Client Needs Category: Physiological Integrity Nursing Process Step: Implementation  Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

Safe and Effective Care Environment What is the appropriate nursing response when asked to report to work to assist with a mass casualty event? A. Report to work when asked by a supervisor B. Refrain from working to care for family members C. Refer to the ANA Code of Ethics for Nurses for direction D. Agree to work for several hours until other nurses arrive to assist

✅Answer: C Rationale: Nurses may experience ethical and moral conflict when asked to assist in response to a disaster, based upon their own professional, personal, and family obligations. The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (2015) offers general guidance that can be helpful to nurses who need to make important decisions at a time such as this. Each nurse has to make a personal choice about whether to be involved in helping during the emergency or when to become involved. Cognitive Level: Application Client Needs Category: Safe, Effective Care Environment: Management of Care Nursing Process Step: Implementation Chapter 12- Concepts of Disaster Preparedness

The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4 degrees F (39.7 degrees C). What is the nurse's primary concern for this client? A. The client may not be taking the prescribed antiviral drug correctly B. A second strain of influenza is likely C. Pneumonia may be present D. The client may be dehydrated Answer: C

✅Answer: C Rationale: A major and relatively common complication of severe seasonal influenza is development of pneumonia. It is likely this client's influenza was severe because hospitalization was required. The client would no longer be receiving the antiviral drug after discharge. A second strain of influenza is not likely in this context. Temperature elevation from dehydration is usually less dramatic. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Assessment Chapter 28 ///Chapter 31 -Concepts of Care for Patients With Infectious Respiratory Problems

Which respiratory side effect does the nurse teach the client who is now prescribed an angiotensin-converting enzyme (ACE) inhibitor to expect? A. Wheezing on exertion B. Increased secretions C. Persistent dry cough D. Orthopnea

✅Answer: C Rationale: ACE inhibitors cause a persistent dry cough for the duration of this drug therapy in about 80% of people who are prescribed the drug. For some people, especially those who have other conditions that cause chronic coughing, the coughing can be severe enough to change the drug therapy. For others, the cough is milder and not disruptive to the client's lifestyle. ACE inhibitors do not cause wheezing, increased secretions, or orthopnea although nonspecific beta blockers can cause any of these effects by inducing bronchoconstriction. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 24 /Chapter 27 - Assessment of the Respiratory System

Which action will the nurse perform first for a client in anaphylaxis to prevent harm? A. Applying oxygen by nonrebreather mask B. Administering IV diphenhydramine C. Injecting epinephrine D. Initiating IV access

✅Answer: C Rationale: All actions are appropriate interventions for the client having an anaphylactic reaction. The first and most important action is to inject the epinephrine to stop the attack. Administering oxygen is helpful in supporting the client but will not stop this extremely rapid response and will take time away from administering the epinephrine. Giving diphenhydramine is a second line therapy for anaphylaxis. Initiating IV access is important but may not even be possible if the blood pressure is too low during anaphylaxis. Time should not be wasted on this action. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

Physiological Integrity Which normal physiologic process contributes most to the need for acid-base balance? A. Continuous organ production of bicarbonate from carbonic acid B. Continuous alveolar exchange of oxygen and carbon dioxide C. Continuous metabolic production of free hydrogen ions D. Continuous kidney formation of urine from blood

✅Answer: C Rationale: All normal metabolism results in the removal of hydrogen ions from more complex compounds to use in the generation of cellular energy. Normal alveolar exchange of oxygen and carbon dioxide actually are part of acid-base balance mechanisms and do not contribute to imbalance. No normal or pathologic condition causes the excess formation of bicarbonate. Normal kidney formation of urine from blood is part of the balance mechanisms and does not contribute to the need for balance. Cognitive Level: Understanding Client Needs Category: Physiological Function Nursing Process Step: N/A Chapter 14 - Concepts of Acid-Base Balance

In reviewing the electrolytes of a client, the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth

✅Answer: C Rationale: Electrical conduction through the heart is reduced with any degree of hyperkalemia and the condition can lead to heart block or lethal dysrhythmias. It is the most important assessment to perform for a client with an elevated serum potassium level. Respiratory rate and depth are more affected by hypokalemia because of the accompanying muscle weakness. The reduction then affects oxygen saturation. Although deep tendon reflexes may be increased with hyperkalemia, cardiac changes are more critical. Cognitive Level: Applying or higher Client needs category: Safe and effective care environment Nursing Process Step: Evaluation Chapter 13 - Concepts of Fluid and Electrolyte Balance

Safe and Effective Care Environment The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema? A. Foot and ankle B. Forehead C. Sacrum D. Chest

✅Answer: C Rationale: In a client who is confined to bed, the most dependent area is the sacrum. This is the area that will show skin turgor changes first for dependent edema. The forehead, chest, and feet are not dependent what a client is in a recumbent position. Cognitive Level: Applying or higher Client needs category: Safe and effective Care environment Nursing Process Step: Assessment Chapter 13 - Concepts of Fluid and Electrolyte Balance

Which action does the nurse take care to avoid while suctioning a client's tracheostomy tube? A. Twirling the catheter while applying suction B. Applying suction only when withdrawing the catheter C. Performing oral suctioning before suctioning the artificial airway D. Lubricating the suction catheter with sterile saline before insertion

✅Answer: C Rationale: Infection is possible during tracheal suctioning because each catheter pass introduces bacteria into the trachea. Sterile technique is used for suctioning and the mouth or nose is suctioned only after suctioning the artificial airway. Tissue injury is prevented by lubricating the catheter with sterile water or saline before insertion, applying continuous suction only during catheter withdrawal, and using a twirling motion during withdrawal to prevent grabbing of the mucosa. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Intervention Chapter 25/Chapter 28 - Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy

25-2. The SpO2 of a client receiving oxygen therapy by nasal cannula at 6L/minute has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to promote gas exchange before reporting the change to the primary health care provider? A. Tighten the straps on the nasal cannula B. Increase the oxygen flow rate to 8L/minute C. Check the tubing for kinks, leaks, or obstructions D. Check to determine whether the oxygen deliver system is adequately humidified

✅Answer: C Rationale: Oxygen tubing is flexible and has a narrow lumen. Tubing that is kinked or obstructed or has a leak can interfere with oxygen delivery to the client and result in desaturation. The maximum flow rate is 6 L/minute for a nasal cannula and increasing the rate above this value does not result in an increase in oxygen delivery to the client. Tightening the straps on the nasal cannula can make the client uncomfortable and does not increase oxygenation. Humidifying the oxygen prevents drying of mucous membranes but does not increase the actual amount of oxygen delivered. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation Chapter 25/Chapter 28 - Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy

The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment one hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team

✅Answer: C Rationale: Progressive skeletal muscle weakness is associated with increasing severity of the acidosis. Muscle weakness can lead to severe respiratory insufficiency. Measuring pulse and blood pressure are appropriate but do not need to be done first. Applying oxygen is not going to help reduce a metabolic acidosis. Calling the rapid response team is needed if the client's gas exchange status is impaired. Cognitive level:​Applying or higher Client Needs Category:​Safe and Effective Care Environment Nursing Process Step: Implementation Chapter 14 - Concepts of Acid-Base Balance

Safe and Effective Care Environment A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm? A. Hold the next dose of the prescribed antidiarrheal drug B. Assess bowel sounds in all four abdominal quadrants C. Assess the client's response to the Chvostek test D. Increase the IV flow rate of the normal saline infusion

✅Answer: C Rationale: Severe diarrhea can cause excessive calcium loss and result in hypocalcemia. Symptoms of hypocalcemia include tingling of the lips and mouth, muscle cramps (especially in the presence of hypoxia), positive responses to the Trousseaus' and Chvostek's test, and seizures. It is critical to identify whether the client has hypocalcemia before the condition progresses to seizures. Holding the drug may make the hypocalcemia worse. Listening to bowel sounds will no provide new information. Increasing the IV flow rate of normal saline will not help identify the problem or improve the serum calcium level. Cognitive Level: Applying or higher Client needs category: Safe and effective care environment Nursing Process Step: Evaluation Chapter 13 - Concepts of Fluid and Electrolyte Balance

​A client with severe angioedema and tongue swelling from a drug allergy, has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare? A. Nasal CPAP B. Tracheotomy C. Cricothyroidotomy D. Endotracheal intubation

✅Answer: C Rationale: Stridor is a sound made from a laryngeal obstruction, not just an oral obstruction. The fact that her oxygen saturation is so low indicates this is a critical emergence and that her airway is going to become completely obstructed very soon. Nasal biPAP is not at all helpful here and it is unlikely that endotracheal intubation would be successful with this much edema. A tracheotomy would work but takes more time. Also, because this is a temporary condition that should respond well to drug therapy, the cricothyroidotomy is the best choice and this is what the nurse should have prepared for the Rapid Response Team. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Intervention Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

​A nursing home client who has completed a 2 week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheel chair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."

✅Answer: C Rationale: The client is no longer contagious after completing the course of antibiotics and is just in the recovery phase of the illness. If he feels rested enough to be up in a wheel chair, there is no reason he must be isolated physically or socially. A face mask is not needed to protect others. Cognitive Level: Applying or higher Client Needs Category: Psychosocial Integrity Nursing Process Step: Intervention Chapter 28 ///Chapter 31 -Concepts of Care for Patients With Infectious Respiratory Problems

​A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm? A. pH from 7.21 to 7.20 B. HCO3- remains the same at 31 mEq/L C. PaCO2 from 45 mmHg to 68 mmHg D. PaO2 from 88 mmHg to 86 mmHg

✅Answer: C Rationale: The rise in PaCO2 represents acute hypercapnia that could rapidly lead to respiratory failure. Although the oxygen level has dropped slightly, which is never good, it is the dramatic rise in carbon dioxide level that requires immediate action to determine the cause and intervene to prevent a worsening of the client's condition. The decrease in pH supports the identification of hypercapnia but this change alone does not warrant immediate action. The bicarbonate level is unchanged, which supports that the hypercapnia is an acute problem. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

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

✅Answer: C Rationale: Use of a biologic therapy can depress the immune system. The client who has a cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to immediately intervene by completing an assessment, and then reporting this finding to the health care provider immediately. Cognitive Level: Application Client Needs Category: Physiological Integrity Nursing Process Step: Assessment/Evaluation Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

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

✅Answer: C​​ Rationale: Fosamprenavir, a protease inhibitor, contains sulfa. A client who is allergic to sulfa drugs is highly likely to also be allergic to fosamprenavir and have a serious or life-threatening reaction to the drug. Cognitive Level: Applying or higher​​​ Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

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

✅Answer: C​​​​​ Rationale: A diagnosis of AIDS (HIV-III) requires that the adult be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 (0.2 X 109/L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3 [0.2 X 109/L]) or an opportunistic infection. Once HIV-III (AIDS) is diagnosed, even if the patient's T-cell count improves or if the percentage rises above 14%, or the infection is successfully treated, the AIDS diagnosis remains. Cognitive Level: Applying or higher​​​ Client Needs Category: Health Promotion and Maintenance​ Nursing Process Step: Implementation Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

Safe and Effective Care Environment In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake? A. Apply ice to the site of the wound B. Extract venom by sucking the wound C. Apply a tourniquet to the affected arm D. Immobilize the extremity at the level of the heart

✅Answer: D Rationale: In addition to having the client call 911, the nurse will instruct the client to immobilize the extremity at the level of the heart. The client should not be told to apply ice, to extract venom by incising or sucking at the wound, or to apply a tourniquet. The actions can further complicate the situation by compromising circulation or opening the skin to further risk for infection. Cognitive Level: Application Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control Nursing Process Step: Implementation Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

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

✅Answer: D Rationale: The nurse will teach that carbon monoxide prevention requires having carbon monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning. Cognitive Level: Application Client Needs Category: Physiological Integrity Nursing Process Step: Implementation Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

Physiological Integrity When caring for four clients, which does the nurse identify as at the highest risk for frostbite? A. 19-year old who takes antihistamines B. 28-year old who is a vegetarian C. 41-year old who is being treated for hypothyroidism D. 57-year old who drinks 4-5 beers per day

✅Answer: D Rationale: Risk factors for development of frostbite include acute illness, traumatic injury, shock states, immobilization, frequent exposure to outdoor environments, older age, use of certain medications (such as phenothiazines, barbiturates), alcohol use, substance use, malnutrition, hypothyroidism, and possession inadequate clothing or shelter. The nurse will identify the client who drinks 4-5 beers daily as the at the highest risk for frostbite. Antihistamine use is not associated with a higher risk; vegetarianism is not associated with a higher risk; and the client who has hypothyroidism is being treated for this condition. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Assessment/Evaluation Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

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

✅Answer: D Rationale: A shave biopsy is accomplished by taking a razor blade and moving it across the skin's surface gently to obtain a sample. An excisional biopsy is done by using a scalpel to remove a deep sample of skin which is then sutured closed. A punch biopsy involves the use of a circular cutting instrument to remove a small plug of tissue. Cognitive Level: Application Client Needs Category: Physiological Integrity: Physiological Adaptation Nursing Process Step: Implementation Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

Which action does the nurse use to prevent harm by loss of tracheal tissue integrity in a client with a tracheostomy? A. Providing meticulous oral care every 8 hours B. Deflating the cuff for 15 minutes every 2 hours C. Feeding the client liquids rather than solid foods D. Maintaining cuff inflation pressure less than 25 cm H2O

✅Answer: D Rationale: An overinflated cuff can cause tissue injury and necrosis of the tracheal tissue. Although cuff pressure must be adequate to prevent leaks, it is critical to keep the pressure lower than 25 cm H2O. Meticulous oral care can help maintain tissue integrity of oral muscous membranes but does not help tracheal tissue integrity. Neither liquids nor solid foods should enter the trachea. Deflating the cuff reduces the effectiveness of the tracheostomy for adequate ventilation. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation Chapter 25/Chapter 28 - Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy

Which nursing action has the highest priority when caring for a client with any type of facial or laryngeal trauma? A. Managing pain. B. Providing nutrition. C. Assessing self-image. D. Maintaining a patent airway.

✅Answer: D Rationale: Facial and laryngeal trauma have the potential to interfere with breathing by occluding the upper airways. This can occur from swelling, tissue displacement, bleeding, emesis, or as a response to therapy. Maintaining a patent airway remains a nursing priority until the trauma has healed. Cognitive Level: Applying or higher Client Needs Category:​Safe and Effective Care Environment Nursing Process Step: Implementation Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

Safe and Effective Care Environment With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia? A. 72-year-old taking the diuretic spironolactone for control of hypertension B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hour C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

✅Answer: D Rationale: Insulin increases the activity of the sodium-potassium pump and forces more potassium from the extracellular fluid into the intracellular fluid. Although this is a desired response when managing hyperkalemia, the drug can cause hypokalemia in a client whose serum potassium level is initially normal. Spironolactone is a potassium-sparing diuretic that has the potential to raise serum potassium levels, not lower them. Ringer's lactate contains potassium and would not dilute serum potassium below normal. Infusions of red blood cells usually raise serum potassium levels, not lower them, because some blood cells are damaged during the infusion and release intracellular potassium. Cognitive Level: Applying or higher Client needs category: Safe and effective care environment Nursing Process Step: Assessment Chapter 13 - Concepts of Fluid and Electrolyte Balance

Which set of client arterial blood gas (ABG) values indicates to the nurse that some mechanisms are working to partially compensate for an acid-base imbalance? A. pH 7.42; PaO2 92 mm Hg; CO2 41 mm Hg; HCO3− 28 mEq/L (mmol/L) B. pH 7.46; PaO2 98 mm Hg; CO2 38 mm Hg; HCO3− 30 mEq/L (mmol/L) C. pH 7.22; PaO2 60 mm Hg; CO2 80 mm Hg; HCO3− 22 mEq/L (mmol/L) D. pH 7.29; PaO2 78 mm Hg; CO2 82 mm Hg; HCO3− 36 mEq/L (mmol/L)

✅Answer: D Rationale: The ABG values listed for D indicate chronic respiratory acidosis with partial compensation. The PaO2 is low and the PaCO2 is quite high, which would lower the pH. However, the pH is not as low as would be expected by these values because the HCO3− level is elevated to compensate. This compensation is only partial because the pH is still below normal, indicating acidosis is still present. The values listed in C indicate an acute respiratory acidosis (low pH, low PaO2 and high PaCO2 coupled with a normal bicarbonate level) in which no compensation has occurred. The values listed in A are all totally normal showing no imbalance and no compensation. The values listed in B show a slight metabolic alkalosis (elevated pH) with normal oxygen and carbon dioxide values accompanied by a slightly elevated bicarbonate level. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluation Chapter 14 - Concepts of Acid-Base Balance

A client has just come to the floor after an inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse's priority action? A. Administer the prescribed anti-emetic by the intravenous or rectal route. B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team. C. Cut the wires holding his jaws together, and carefully remove them from the mouth. D. Reposition the client to the side and suction the mouth mouth with a large-bore catheter.

✅Answer: D Rationale: The client is in danger of aspirating the vomitus. Repositioning to side-lying and suctioning the vomitus are the most important first actions for preventing this potentially life-threatening complication. The risk for aspiration is immediate and the anti-emetic will not stop the current episode of vomiting. If repositioning and suctioning are not effective, cutting the wires would be appropriate second action. Notifying other health care professionals is not correct because aspiration could occur before any of them get to the bedside. Positioning and suctioning are nursing actions that are likely to prevent the immediate complication. Cognitive level:​Application Client Needs Category:​Physiological Integrity Nursing Process Step: Implementation/Intervention Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

​A client who is six feet two inches tall and weighs 205 lb is having an anaphylactic reaction. Which dose of epinephrine will the nurse prepare for this client? A. 0.3 mL of a 1:10,000 solution B. 0.5 mL of a 1:10,000 solution C. 0.3 mL of a 1:1000 solution D. 0.5 mL of a 1:1000 solution

✅Answer: D Rationale: The dosage of epinephrine needed to be of benefit during an anaphylactic reaction is based on size. Adults are prescribed doses ranging from 0.3 mL to 0.5 mL of a 1:1000 solution. A solution of 1:10,000 will be ineffective unless the dose is massive. This client is larger than average and needs a larger dose of the solution. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

​Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? A. The client has calf muscle cramping. B. The serum chloride level is low. C. The urine specific gravity is high. D. The hematocrit is 52%.

✅Answer: D Rationale: The serum sodium level is elevated, indicating hypernatremia. The elevation could be from an actual increase in sodium, or from a loss of fluids only. A relative hypernatremia can occur as a result of dehydration (excessive fluid loss) without sodium loss. Such dehydration is usually accompanied by hemoconcentration. The higher than normal hematocrit suggests hemoconcentration. Cognitive Level: Applying or higher Client Needs Category:​Physiological integrity Nursing Process Step: Assessment Chapter 13 - Concepts of Fluid and Electrolyte Balance

When assessing the client 2 hours after a thoracentesis, the nurse notes the skin around the puncture site is swollen and a crackling is felt and heard when pressure is applied to the area. What is the nurse's best action? A. Assess the client's SPO2 levels at two separate sites. B. Obtain a prescription to culture the site. C. Document the finding as the only action. D. Notify the respiratory health care provider.

✅Answer: D Rationale: The skin symptoms reflect subcutaneous emphysema with air being forced into the tissue layers, most often caused by a persistent air leak. These are not indications of infection and no culture is needed. Depending on the severity of the problem, the client's airway could be in jeopardy. The respiratory health care provider needs to evaluate the problem. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Evaluation Chapter 24 /Chapter 27 - Assessment of the Respiratory System

When making rounds, the nurse observe that a cognitively impaired client has a partial airway obstruction from inspissation. What is the nurse's priority action? A. Place the bed in reverse Trendelenburg position apply humidified oxygen by nasal cannula. B. Check the flow sheet to assess for trends in the client's oxygen saturation patterns. C. Determine which nursing assistant provided this client's morning care today. D. Immediately provide complete oral care to this client.

✅Answer: D Rationale: Thickly crusted oral and nasopharyngeal secretions, a condition formally called inspissated secretions or mucoid impaction. It is most often caused by poor oral hygiene with thickened and hardened oral secretions that can completely block the airway and lead to death. A partial obstruction can quickly lead to a complete obstruction and asphyxiation. The priority action is to clear the obstruction. In this case proper nursing care with complete oral hygiene done immediately can eliminate prevent this partial obstruction from becoming a complete obstruction. Inspissation occurs over time and this client's oral hygiene has been neglected, requiring that the nurse address this issue with all care personnel to ensure it does not happen again. However, the first priority is removing the obstruction. Applying oxygen by any route does not resolve the issue nor dose placing the client in reverse Trendelenburg position. Checking trends in oxygen saturation patterns does not help the immediate problem and only delays critical action. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Implementation Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

Psychosocial Integrity What is the appropriate nursing action when assessing that a client scored 40 on the IES-R? A. Triage with a black tag B. Prepare for discharge to home C. Administer oxygen and assess saturation D. Refer to a psychiatrist or mental health counselor

✅Answer: D Rationale: The Impact of Event Scale—Revised (IES-R) a 22-item self-administered questionnaire that includes several subscales. It is helpful in assessing the affect of stressors and trauma. The nurse whose client scored a 40 on this assessment would refer to a psychiatrist or mental health counselor, as any score of 33 or above can indicate PTSD. Cognitive Level: Application Client Needs Category: Psychosocial Integrity Nursing Process Step: Implementation Chapter 12- Concepts of Disaster Preparedness

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

✅Answer: D Rationale: The nurse will teach that multiple routes of escape should be planned in case the primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a central location. The client should never smoke around home oxygen. The water heater temperature should be set below 120°F (49°C.) or burns may occur. Cognitive Level: Application Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation  Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

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

✅Answer: D​​ Rationale: Raltegravir is teratogenic and can cause birth defects. Although most cART drugs are prescribed during pregnancy and significantly reduce the risk for transmitting HIV to the infant, raltegravir is suspended during pregnancy. Cognitive Level: Understanding​​​ Client Needs Category: Safe and Effective Care Environment Nursing Process Step: N/A Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

​Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor in order to prevent harm from this therapy? A. Examine your skin and the whites of your eyes daily for a yellow appearance. B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum. C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination. D. Go to your primary health care provider immediately if you develop a fever or other sign of infection.

✅Answer:​ A Rationale: This combination gene therapy drug is an oral medication taken once daily. Both drugs used in the combination can impair liver function. Thus a priority precaution for patients on this drug is to be aware of and report any symptom specific for impaired liver function. Jaundice of the skin or sclera is a major symptom of liver impairment. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

When performing a medication reconcilliation for a newly admitted client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm? A.​Record and display the information in a prominent place within the client's medical record. B.​Ask the client how long the drugs have been prescribed and how well the asthma is controlled. C.​Collaborate with the surgeon to arrange for continuation of this therapy in the postoperative period. D.​Ensure that parenteral forms of these drugs are prescribed for use while the client remains NPO after surgery.

✅Answer:​ C Rationale: Asthma is a common disorder and adults admitted to the hospital for other health problems or surgery may also have asthma. For optimal control continuing the asthma drug therapy, is a priority regardless of setting. Although the length and effectiveness of therapy are important for evaluating an asthma treatment plan, the information is not the priority for this situation. Ensuring this information is included in the client's medical record is important but ensuring that the drugs are continued as prescribed during this client's hospitalization has a higher priority. The drugs are administered by inhalation and a parenteral form is not needed for a client who is NPO. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Intervention Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

When creating a personal emergency preparedness plan, which does the nurse include? Select all that apply. A. Assembling a "go bag" B. Arranging for child care C. Determining who will care for pets D. Noting who will be called when the plan is activated E. Identifying how long the emergency is expected to last F. Noting where a nurse is expected to report if the emergency plan is activated G. Collecting names, addresses, and telephone numbers to be used if a crisis occurs

✅Answers: A, B, C, D, F, G Rationale: When creating a personal emergency preparedness plan, the nurse includes assembly of a "go bag"; arrangements for child and pet care; making notation of who should be called when the plan is activated; knowing where to report when the plan is activated; and collecting names and contact information to be used if needed. The nurse does not identify how long the emergency is expected to last, because this will be determined based upon scope and resources available. Cognitive Level: Analysis Client Needs Category: Safe, Effective Care Environment: Safety and Infection Control Nursing Process Step: Implementation Chapter 12- Concepts of Disaster Preparedness

​Which statement(s) regarding type I hypersensitivity reactions is/are true? Select all that apply. A. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine. B. The response is characterized by the five cardinal symptoms of inflammation. C. Type I responses are usually directed against nonself but the response is excessive. D. Susceptibility for developing a type I hypersensitivity response follows an X-linked recessive pattern of inheritance. E. This type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus. F. Responses always occur within minutes of exposure to the allergen. G. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

✅Answers: B, C, G Rationale: Type I responses Type I reactions result from the increased production of the immunoglobulin E (IgE) antibody class that cause the release of mediators including histamine, bradykinin, leukotriene, and others that result in the five cardinal symptoms of inflammation (pain, swelling, warmth, redness, and loss of function). The reactions are directed against appropriate nonself targets rather than against self cells but the responses are excessive. The second phase of type I reactions are caused by accumulation of bradykinin deep within the skin tissue layers, which is the major mechanism of angioedema. Antihistamines are helpful with a type I hypersensitivity reaction because the major mediator is histamine. Although the susceptibility to type I reactions is genetic, no specific pattern of inheritance has been identified. Many type I reactions do occur rapidly after exposure to the allergen; however, angioedema is a pure type I reaction and may not occur until days, weeks, months, and even years after continual exposure to the allergen. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

​The nurse teaching clients precautions to use with drug therapy for primary pulmonary arterial hypertension (PAH) instructs the female clients to use two reliable forms of contraception while taking which drugs? Select all that apply. A. Ambrisentan B. Bosentan C. Epoprostenol D. Iloprost E. Macitentan F. Riociguat G. Selexipag H. Sildenafil I. Tadalafil J. Treprostinil

✅Answers: A, B, E, F Rationale: All the endothelin-receptor antagonists, including ambrisentan, bosentan, and macitentan, have been demonstrated to have teratogenic properties that can cause birth defects. Riociguat also has teratogenic properties. These drugs are contraindicated for use in women who are pregnant and when used by women of child-bearing age who are sexually active, two reliable methods of contraception are needed. The prostacyclin agonists (epoprostenol, iloprost, treprostinil, and selexipag), as well as the phosphodiesterase inhibitor-based guanylate cyclase inhibitors (sildenafil and tadalafil), are not associated with an increased risk for birth defects. Cognitive Level: Applying or Higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

Safe and Effective Care Environment: Management of Care Which assignment will the ED charge nurse make when nurses from within the hospital are floated to the ED to care for clients affected by an earthquake? Select all that apply. A. GI laboratory nurse assigned to clients needing sedation B. Psychiatric nurse assigned to care for clients with lacerations C. Orthopedic nurse assigned to accompany clients to radiology D. Nurse administrator assigned to sit with loved ones in the waiting room E. Medical-surgical nurse assigned to health care worker who is feeling overwhelmed

✅Answers: A, C, D Rationale: Nurses who must be floated during a disaster will perform best when given an assignment that closely resembles their area of expertise. The charge nurse will ask the GI laboratory nurse to care for clients needing sedation, since is a familiar role for a nurse whose GI patients undergo sedation prior to diagnostic testing. The orthopedic nurse is familiar with radiography procedures, and the nurse administrator who may not be in direct patient care can help greatly by sitting with loved one in a waiting room. The psychiatric nurse would be more effective in caring for the healthcare worker who is feeling overwhelmed, and the medical-surgical nurse would be better assigned to care for clients with lacerations. Cognitive Level: Analysis Client Needs Category: Safe and Effective Care Environment: Management of Care Nursing Process Step: Assessment/Evaluation Chapter 12- Concepts of Disaster Preparedness

What teaching will the nurse provide to the client who just had a skin biopsy taken and sutures placed to close the wound? Select all that apply. A.​Use antibiotic ointment as prescribed B.​Return for suture removal in 2-3 days C.​Report redness to the healthcare provider D.​Keep dressing moist so skin does not dry out E.​Use tap water or saline to remove any crusting

✅Answers: A, C, E Rationale: Following a biopsy, the nurse will teach the client to care for the wound to reduce the risk for infection. Teaching includes using antibiotic ointment as prescribed, returning for suture removal in 7-10 days, reporting redness or excessive drainage to the healthcare provider, keeping the dressing dry, and using tap water or saline to remove dried blood or crusting. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Implementation Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply. A. Calcium B. Chloride C. Hydrogen D. Potassium E. Sodium F. Sulfate

✅Answers: A, D Rationale: Within cells and the blood, magnesium levels are related to the levels of potassium and calcium and help maintain proper balance of these electrolytes Cognitive Level: Understanding Client needs category: Physiological integrity Nursing Process Step: NA Chapter 13 - Concepts of Fluid and Electrolyte Balance

Safe and Effective Care Environment Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply. A. Blood pressure B. Deep tendon reflexes C. Hand-grip strength D. Pulse rate and quality E. Skin turgor F. Urine output

✅Answers: A, D, F Rationale: The most important body fluid compartment to maintain for function is the plasma volume of circulating blood. The most reliable indicators for effectiveness of IV fluid replacement to increase this volume are blood pressure and pulse. Urine output is also very sensitive to changes in plasma volume and is a reliable indicator of adequacy of fluid replacement therapy. Skin turgor changes do not occur quickly enough to use for evaluation of fluid replacement adequacy. Hand-grip strength and deep tendon reflex changes are less reliable and are affected by other factors. Cognitive Level: Applying or higher Client needs category: Safe and effective care environment Nursing Process Step: Evaluation Chapter 13 - Concepts of Fluid and Electrolyte Balance

​Which statement(s) regarding type III hypersensitivity reactions is/are true? Select all that apply. A. Type III responses are usually directed against self cells and tissues. B. Susceptibility for developing a type III hypersensitivity response follows an autosomal dominant pattern of inheritance. C. The hypersensitivity starts as a type II reaction that progresses to a type III reaction. D. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. E. Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity. F. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

✅Answers: A, E Rationale: Type III reactions are responsible for the generation of autoantibodies that attack self cells and tissues as part of autoimmune disorders. Rheumatoid arthritis is a classic example of a type III response generating autoimmunity. Although this type of reaction results from a genetic susceptibility combined with a triggering event, the pattern of inheritance is not discernable and most likely represents a polygenic effect. A type II response is generated by a foreign cell or protein that attaches to a normal body cell. When the antigen is attacked, the normal cell attached to it also is attacked. It does not progress to a type III autoimmune response. Although macrophages may be involved in some aspect of tissue injury with autoimmune disorders, the main mechanism is the development of autoantibodies from B-cells. Bradykinin and angioedema are features of a type I hypersensitivity and are not associated with type III responses. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera

✅Answers: A, G Rationale: The drug ethambutol can cause optic neuritis that can lead to blindness. The drug should be stopped and the patient's vision evaluated immediately. Yellowing of the sclera is associated with jaundice from liver problems, which can be serious and life-threatening. The client's liver status must be evaluated immediately. Although nausea when drinking alcohol is an expected side effect of ethambutol, it is a priority to report this change to the health care provider at this time. The nurse needs to explain the side effect to the client and remind him or her that alcohol must be avoided during TB therapy to prevent liver problems. This change only needs to be reported to the health care provider if the client continues to consume alcohol. Difficulty sleeping may or may not be associated with the TB drug therapy. It does not require immediate attention. Red-tinged urine is an expected side effect of rifampin. The nurse reinforces this information to the client to relieve his or her anxiety. The drug pyrazinamide increases photosensitivity. Sunburn is a common side effect that the nurse needs to instruct the client to prevent but does not require immediate attention from the healthcare provider. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention  Chapter 28 ///Chapter 31 -Concepts of Care for Patients With Infectious Respiratory Problems

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

✅Answers: B, C Rationale: Nurses can delegate tasks to unlicensed assistive personnel (UAP) that are within the scope, understanding, and training of the UAP. The nurse always remains responsible to supervise the delegated task. The UAP is able to help the client bathe and brush teeth. Assessment in the form of taking a history and determining cognitive function or physical limitations is within the scope of the nurse, not the UAP. The nurse's role - not the UAP's - also includes interventions such as consulting with members of the interprofessional team and teaching the client and family members. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Basic Care and Comfort Nursing Process Step: Implementation Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

Which conditions or changes indicate to the nurse that a client with a tracheostomy requires suctioning? Select all that apply. A. The client has a fever. B. Crackles and wheezes are heard on auscultation. C. The client requests that suctioning be performed. D. Suctioning was last performed more than 3 hours ago. E. The tracheostomy dressing has a moderate amount of serosanguious drainage. F. The skin around the tracheostomy is puffy and makes a crunching sound when touched.

✅Answers: B, C Rationale: To avoid tissue injury, tracheostomy suctioning is performed only when indication are present that it is needed. Such indications include when crackles and/or wheezes are heard on auscultation, secretions in the airways that the client cannot clear are audible, restlessness is increased along with elevations of heart rate or respiratory rate, the client requests to be suctioned, and when the ventilator peak airway pressure is increased. Suctioning is not performed on a scheduled basis. Subcutaneous emphysema and drainage on the dressing are not indications of suctioning need. In addition, suctioning is not an appropriate response to the presence of a fever. Cognitive Level: Applying or Higher Client Needs Category: Safe and Effective Health Care Environment Chapter 25/Chapter 28 - Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy

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

✅Answers: B, C, D Rationale: Using the Skin Cancer Foundation's ABCDE approach to assessment of skin lesions, the nurse must intervene if a skin lesion has any of the following characteristics: • Asymmetry of shape • Border irregularity • Color variation within one lesion • Diameter greater than ¼ of an inch or 6 mm • Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting) Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

​Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. A,​21-year-old college student living in a dorm at a Canadian university B. 38-year-old with AIDS who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

✅Answers: B, C, D, E Rationale: Active tuberculosis is most likely to develop in adults who are heavily exposed to the organism, such as those living in crowded conditions (prison), from less affluent foreign countries, and anyone who is immunosuppressed (has AIDS and is not taking antiretroviral therapy). Adults who use/abuse injection drugs are also at increased risk because of life style and reduced cognition while under the influence of the drugs. This can result in choices that increase his or her exposure to the organism and may reduce immunity. A healthy 21-year-old living in a dorm in an affluent country is not at increased risk for TB. Having moderate to severe COPD alone does not increase risk for TB unless immunity is greatly reduced. Cognitive Level: Applying or higher Client Needs Category: Physiological integrity Nursing Process Step: N/A Chapter 28 ///Chapter 31 -Concepts of Care for Patients With Infectious Respiratory Problems

3 of 18 Which cancer type does the nurse interpret from a client's pathology report that indicates "stage 2 rhabdomyosarcoma"? Muscle Brain Bone Breast

✅Bone The term "rhabdomyo" refers to bone and "sarcoma" refers to connective tissue. Thus an osteogenic sarcoma arises from actual bone tissue. Brain cancers are neurogenic or glial; breast cancer is a type of carcinoma; bone cancer is an osteogenic sarcoma Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

Which information is most relevant for the nurse to teach a client about CPAP therapy for OSA? Select all that apply. A. Avoid alcoholic beverages or drugs that make you sleepy within 3 hours of bed time. B. Clean the mask device daily. C. Ensure your mask device fits tightly enough to prevent airleaks. D. Keep open flames such as candles out of the room when CPAP is in use. E. Seal the mask edges to your face with petroleum jelly. F. Use only sterile water in the humidifier tank. G. Use the CPAP during all sleep periods, especially in bed. H. Do not share your mask or tubing system with others.

✅Answers: B, C, G, H Rationale: CPAP is effective only when the mask device can provide positive pressure to the upper airways, which requires a mask that fits tightly enough to prevent airleaks. However, sealing the mask with any type of gel or cream is not recommended. Such products can damage the mask and the skin (when pressure is present). The respiratory tract is moist and harbors many microorganisms. The moisture can promote growth of such organisms. The mask should be cleaned daily according to manufacturer's directions. Clean the tubing system as often as the manufacturer recommends. The mask and tubing system should not be shared with anyone else to prevent acquiring an infection. Most humidification tanks are to be filled with distilled water but the water does not need to be sterile. Open flames are not restricted because CPAP uses only room air and does not involve increased oxygen levels. CPAP should be used whenever the client sleeps in a prone position. Some respiratory health care providers also recommend its use even when the client naps in a chair. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

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

✅Answers: B, F, G​ Rationale: Although the patient is fatigued, some nursing care actions are essential to prevent immediate and potentially lethal complications. Most of these involve infection prevention activities and include administering prescribed drug therapy, culturing body fluids or lesions when infection is suspected, performing pulmonary hygiene to prevent or manage respiratory infections, and performing meticulous oral care to prevent infections. It is not immediately helpful to have the client ambulate in the hall or receive a complete bed bath (just inspect and clean the perineal and axillary areas). Teaching performed when the client is extremely fatigue has little effect or retention. Cognitive Level: Applying or higher Client Needs Category: Physiological Integrity Nursing Process Step: Evaluating Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply. A. Client who has been NPO for 36 hours without fluid replacement B. Client receiving a rapid infusion of normal saline C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours E. Client having a sudden and severe asthma attack F. Client with uncontrolled diabetes mellitus

✅Answers: C, D Rationale: Metabolic alkalosis is caused by a loss of hydrogen ions and/or excessive bicarbonate ions. With continuous gastric suction, hydrochloric acid is removed, and the concentration of free hydrogen ions can get too low. Clients who ingest sodium bicarbonate daily are at risk for having metabolic alkalosis from excess bicarbonate. Being NPO for 36 hours can lead to ketoacidosis, as can uncontrolled diabetes mellitus rather than alkalosis. A severe asthma attack would result in respiratory acidosis, not alkalosis. Receiving a rapid infusion of normal saline could cause fluid overload but not alkalosis. Cognitive Level: Applying or higher Client Needs Category: Safe and Effective Care Environment Nursing Process Step: Assessment Chapter 14 - Concepts of Acid-Base Balance

Which statements about oxygen and oxygen therapy are true? Select all that Apply. A. An oxygen concentrator reduces the amount of carbon dioxide in atmospheric air. B. Clients must provide informed consent to receive oxygen therapy. C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease. D. In non-emergency situations, a health care provider's prescription is needed for oxygen therapy. E. Oxygen can explode when handled improperly. F. Oxygen is a beneficial element but can harm lung tissue. G. The liquid form of oxygen is a drug to manage hypoxia, whereas the gaseous form is only an atmospheric element. H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.

✅Answers: C, D, F, H Rationale: An oxygen concentrator reduces the amount of nitrogen in atmospheric air, which has the highest concentration of all gases in the atmosphere. Oxygen is a drug that requires a prescription but not informed consent. Excessive oxygen can form reactive oxygen species that injures lung tissue but does not cause COPD. Oxygen is a gas that promotes combustion but does not explode. Only oxygen gas is directly inhaled to improve gas exchange. Liquid oxygen must first be converted to a gas before it can be used. When oxygen is delivered without humidification, especially at higher flow rates, respiratory mucous membranes can become dry and irritated. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 25/Chapter 28 - Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy

Why are the terminal bronchioles more prone to collapse than are the other airways? Select all that apply. A. The cartilage is an incomplete C-shape rather than a true ring. B. The mucous membrane lining contains minimal active cilia. C. Lung elastic recoil is the only force that keeps them patent. D. Their walls are too thick to permit gas exchange. E. They are surrounded by capillaries. F. The lumens have a small diameter. G. Their walls contain no cartilage.

✅Answers: C, F, G Rationale: The terminal bronchioles are inherently prone to collapse because they have a small diameter and contain no cartilage (not even C-shaped cartilage) to passively hold them open. The only force that maintains patency is the elastic recoil of the lungs. Although they contain little if any cilia, are too thick to permit gas exchange, and are surrounded by capillaries, these anatomic structures have no bearing on their patency. Cognitive Level: Understanding Client Needs Category: Physiological Integrity Nursing Process Step: N/A Chapter 24 /Chapter 27 - Assessment of the Respiratory System

​In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side effects does the nurse teach the client to expect? Select all that apply. A. Scalp and eyebrow alopecia B. Taste sensation loss or changes C. Bloody and purulent sinus drainage D. Increased risk for skin breakdown E. Moderate weight gain F. Increased risk for cavities G. Gastroesophageal reflux H. A persistent blue-tinge color to the skin and mucous membranes around the mouth

✅Answers: D, B, F Rationale: Radiation therapy is local and side effects appear in the tissues and organs that are in the radiation path. The tongue and teeth will receive some radiation, as will the salivary glands, causing some degree of dry mouth. The tooth irradiation and the dry mouth increase the risk for dental cavities. The tongue irradiation leads to taste loss or change. The skin in the radiation field or path is damaged and remains at high risk for skin breakdown for the time of radiation therapy and for months after this therapy is complete. Although the skin and mucous membranes in the radiation field are irritated, they do not become cyanotic. The eyebrows, scalp, and sinuses are not in the path and will not be affected. Weight is more often lost rather than gained because of taste changes and general soreness of the area. The treatment does not result in changes in the lower esophagus and does not increase the risk for gastroesophageal reflux. Cognitive Level: Applying or higher Client Needs Category: Health Promotion and Maintenance Nursing Process Step: Intervention Chapter 26/Chapter 29 - Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

A client with primary pulmonary arterial hypertension (PAH) receiving treprosinil by continuous IV infusion now has a fever of 101.6 degrees F (38.7 degrees C). Which actions will the nurse perform to prevent harm? Select all that apply. A. Administer the prescribed antipyretic B. Ask the client whether a productive cough is present C. Apply oxygen by nasal cannula D. Culture the IV site E. Determine whether a durable power of attorney has been signed F. Increase the treprostinil flow rate G. Initiate a second IV access and administer prescribed antibiotic H. Place the client in protective isolation

✅Answers: D, F, G Rationale: Clients with PAH receiving continuous IV drug therapy are at high risk for developing sepsis because of the long-term direct access line. Any client with a fever is considered to have sepsis until proven otherwise, not pneumonia or any other respiratory infection. Also, clients with PAH who develop sepsis are less likely to survive it. The critical actions to prevent harm are to give oxygen to promote better gas exchange, initiate a second IV (only the prostacyclin agonist is administered through the long-term continuous line) and give the prescribed antibiotic immediately, increase the treprostinil flow rate (as prescribed) to prevent the pulmonary pressure from becoming higher. Culturing the IV site instead of the blood is unlikely to provide useable information in a timely manner. Placing the client in protective isolation will not help fight the sepsis. A durable power of attorney is not going to prevent harm. Administering the antipyretic will not prevent harm and is not the priority. Cognitive Level:​Applying or Higher Client Needs Category: Safe and Effective Health Care Environment Nursing Process Step: Implementation Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

15 of 18 Which type of drug therapy will the nurse prepare a client in the early disseminated stage of Lyme disease to take for control or cure of this disease? Convalescent serum Corticosteroids Biological response modifiers Antibiotics

✅Antibiotics The goal of therapy during the initial and disseminated stages of Lyme disease is to eradicate the organism causing the infection with antibiotic therapy. Common antibiotics prescribed, sometimes for up to 30 days, include doxycycline, amoxicillin, and erythromycin. None of the other types of therapy listed are focused on this outcome. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

10 of 20 A client is being admitted to the burn unit from another hospital. According to the client's medical record, the client has an intraosseous IV that was started 2 days ago. Which nursing action is most appropriate? Start an epidural IV. Call the previous hospital to verify the date. Anticipate an order to discontinue the intraosseous IV. Immediately discontinue the intraosseous IV.

✅Anticipate an order to discontinue the intraosseous IV. The admitting nurse would first anticipate an order to discontinue the intraosseous IV and then start an epidural IV. The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management. The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken. Chapter 15 - Concepts of Infusion Therapy

3 of 13 A client just had an excisional skin lesion biopsy as an outpatient procedure. Which intervention will the nurse assign to an LPN/LVN? Teach about signs of incisional infection. Complete the written discharge instructions. Apply an antibiotic ointment and place a sterile dressing on the incision. Instruct about how to do dressing changes.

✅Apply an antibiotic ointment and place a sterile dressing on the incision. Wound care is included in practical nursing education. Client teaching and instruction and completing discharge teaching are within the RN's scope of practice Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

19 of 20 The nurse is starting a peripheral IV catheter on a client who was recently admitted. What actions does the nurse perform before insertion of the line? (Select all that apply.) Select all that apply. Apply povidone-iodine to clean skin, dry for 2 minutes. Prepare the skin with 70% alcohol or chlorhexidine. Clean the skin around the site. Wear clean gloves and touch the site only with fingertips after applying antiseptics. Shave the hair around the area of insertion.

✅Apply povidone-iodine to clean skin, dry for 2 minutes. ✅Prepare the skin with 70% alcohol or chlorhexidine ✅Clean the skin around the site. Povidone-iodine (Betadine) is applied to the selected insertion site before insertion. The solution is allowed to dry, which takes about 2 minutes. The insertion site should be cleansed before the antiseptic skin preparations are completed. After soap and water cleansing, prepping with 70% alcohol or chlorhexidine is done. Clipping, rather than shaving, hair around the selected IV site is done. Shaving is abrasive and makes the skin more vulnerable to infection (i.e., microbial invasion). The insertion site should not be palpated again after it has been prepped; this mistake is frequently made with IV starts. Chapter 15 - Concepts of Infusion Therapy

9 of 16 Which action does the nurse expect is most likely to help restore acid-base balance in a client whose arterial blood pH is 7.17 immediately after a grand mal seizure? Administering bicarbonate orally or intravenously Providing hydration with IV normal saline Administering insulin Applying oxygen

✅Applying oxygen The severe acidosis seen immediately following a grand mal seizure is both respiratory and metabolic in origin (a combined acidosis). The client does not breathe during the actual seizure, which causes a huge retention of carbon dioxide (respiratory acidosis). The carbon dioxide level is very high because the seizing muscles are working hard under anaerobic conditions creating lots of lactic acid and hydrogen ions (metabolic acidosis), which are then converted to carbon dioxide through the carbonic anhydrase reaction. If the client stops having seizure activity, he or she will return to acid-base balance without intervention. This return occurs earlier when oxygen is applied. Bicarbonate is not lost during a seizure and most definitely should not be replaced. Hydration and insulin do nothing to restore acid-base balance in this situation. Chapter 14 - Concepts of Acid-Base Balance

4 of 18 Which action is the priority for the nurse to take to prevent harm for the alert 58-year-old client who is admitted to the emergency department with wheezing, dyspnea, angioedema, blood pressure of 70/52 mm Hg, and an irregular apical pulse of 122 beats/min? Asking about exposure to possible allergens Applying oxygen via a high-flow nonrebreather mask at 90% to 100% Reassuring the client that appropriate interventions are being instituted Starting an IV infusion of normal saline

✅Applying oxygen via a high-flow nonrebreather mask at 90% to 100% The immediate priority is to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

9 of 16 Which type of immunity will the nurse initiate by administering an infusion of IV immunoglobulin to a client? Natural active immunity Artificial passive immunity Artificial active immunity Natural passive immunity

✅Artificial passive immunity The client will be receiving antibodies made in the body of another person and thus, is not actively involved in the production of these antibodies. That makes the immunity passive rather than active. Because the client is making the antibodies in response to an injection (vaccination) rather than in response to actually being sick with influenza, the immunity is artificial. Chapter 16 - Concepts of Inflammation and Immunity

6 of 17 What is the most relevant technique for the nurse to use when assessing a client for dyspnea? Checking oxygen saturation by pulse oximetry Observing the client's rate, depth, and ease of inhalation and exhalation Comparing previous respiratory assessment information with current data Asking the client about whether any breathlessness is present

✅Asking the client about whether any breathlessness is present Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea. The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.) Assess and document the client's vital signs. Restart the IV with a 22-guage needle. Verify with another nurse the blood type and Rh of the packed RBCs. Hang a bag of lactated Ringer's IV solution. Change IV tubing to a set that has a filter.

✅Assess and document the client's vital signs is correct. The nurse should assess and document the client's vital signs prior to initiating a blood transfusion to obtain a baseline for comparison. Monitoring the client's vital signs helps the nurse identify adverse reactions to the packed RBCs and identify if the client is tolerating the volume of the prescribed blood product. Restart the IV with a 22-gauge needle is incorrect The nurse should ensure that the client has a 20-gauge or larger needle for administration of packed RBCs to prevent the formation of blood clots during the transfusion. ✅Verify with another nurse the blood type and Rh of the packed RBCs is correct The nurse should verify the blood type and Rh of the packed RBCs with another RN and compare with the client's information for compatibility. This action decreases the risk of an ABO incompatibility reaction. Hang a bag of lactated Ringer's IV solution is incorrect. The nurse should hang a bag of 0.9% sodium chloride IV solution for administration with the packed RBCs. Lactated Ringer's solution is not used because it causes clotting and hemolysis of the blood cells. ✅Change IV tubing to a set that has a filter is correct The nurse should administer packed RBCs through IV tubing that has a filter to prevent the administration of aggregates and possible contaminants. RN Learning System Medical-Surgical: Final Quiz

What is the appropriate initial action after a school nurse has treated injuries related to a school shooting? Reflect on the event for process improvement. Assess own individual feelings. Listen to students' perspectives. Facilitate community cohesion.

✅Assess own individual feelings. After injuries have treated, the school nurse needs to first assess his/her own individual feelings. One cannot be an effective caregiver if one's own needs are not met. Active listening, reflecting on the events for process improvement, and facilitating community cohesion are important, but are not what needs to be done first. Chapter 12- Concepts of Disaster Preparedness

8 of 20 The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What will the nurse do first? Check connections. Check the infusion rate. Assess the insertion site. Discontinue the IV and start another.

✅Assess the insertion site. The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move "up" the line from the insertion site to the tubing, to the tubing's connection to the bag. Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection Chapter 15 - Concepts of Infusion Therapy

A client comes to the emergency department (ED), reporting being bitten by a scorpion. Which action will the nurse perform first? Contact the poison control center. Apply an ice pack to the sting site. Assess vital signs. Administer a tetanus shot.

✅Assess vital signs. The first priority for the nurse to perform is vital sign assessment and continuous monitoring for several hours. This is done in the hospital ED or critical care unit to enable rapid intervention if symptoms progress. Although important, administration of a tetanus shot and application of ice packs are not the immediate priority. Calling the poison control center is a secondary priority after the client's vital signs have been assessed Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

11 of 18 Which cancer screening or prevention activity is most important for the nurse to include when assessing a 20-year-old client who has Down syndrome? Assessing his skin for bruises and petechaie Teaching him how to perform self-testicular examination Testing his stool for occult blood Encouraging him to eat more fruit and leafy, green vegetables

✅Assessing his skin for bruises and petechaie All of the screening and prevention activities are appropriate; however, people with Down syndrome have an increased life-time risk for the development of leukemia. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? Monitoring 24-hour urine output Monitoring the serum calcium levels Assessing the blood pressure hourly Asking the client whether a headache is present

✅Assessing the blood pressure hourly Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate because hypotension is a sign/symptom of hypermagnesemia that could occur when too much has infused. Most clients who have fluid and electrolyte problems will be monitored for intake and output; however, changes will not immediately indicate problems with magnesium overdose. Headaches are not associated with hypermagnesemia. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity. Chapter 13 - Concepts of Fluid and Electrolyte Balance

9 of 13 Which method does the nurse use to assess skin lesions for cancer? Wood's light examination for fluorescence Size and location of lesions Presence of inflammation or exudate Asymmetry, border, color, diameter, evolving

✅Asymmetry, border, color, diameter, evolving The ABCDE (asymmetry, border, color, diameter, evolving) method is the appropriate technique for assessing skin lesions. Inflammation and exudate indicate infection. A Wood's light examination is not necessary to use to assess a lesion; it is used to see skin infections. Size and location of lesions is not specific for cancer screening. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

According to the Centers for Disease Control and Prevention, which of the following best describes the recommended ages to administer the measles, mumps, and rubella vaccine? At 6 months and at 12 months of age At birth, 3 months, 9 months, and 15 months of age At 3 months, 6 months, and at 12 months of age At 12 months and at 4 to 6 years of age

✅At 12 months and at 4 to 6 years of age According to the CDC, children should receive the MMR vaccine at the ages of 12 to 15 months and again at 4 to 6 years of age. The CDC lists current recommendations for vaccines for children according to the type of vaccine and the age of the child. At 6 months and at 12 months of age This is too early and too frequent. At 3 months, 6 months, and at 12 months of age This is too early and too frequent. At birth, 3 months, 9 months, and 15 months of age This is too early and too frequent

Postoperative Fever At day 1 postoperatively, which of the following is the most common cause of fever? Drugs Pulmonary Embolism Atelectasis Urinary Tract Infection from Catheter Allergic Reaction Deep Vein Thrombosis (DVT)

✅Atelectasis Day 1 post-operatively, the most common cause of fever is atelectasis. Thus patients should have chest X-ray and incentive spirometry done.

A client with lymphoma is preparing to undergo a bone marrow transplant. The client will be using bone marrow taken from their own body. Which type of transplant is this referred to? Autologous Syngeneic Xenogeneic Allogeneic

✅Autologous A client who undergoes a bone marrow transplant may use bone marrow taken from the client's own body as the donor marrow. This is known as an autologous transplant. The bone marrow is collected prior to the transplant and before administration of chemotherapy or radiation. The new marrow replaces the diseased marrow that has been destroyed by the chemotherapy and radiation prior to the transplant. Allogeneic This refers to tissue donated by a sibling or relative with a similar tissue type, or from an unrelated person. Syngeneic This refers to tissue donated by an identical twin. Xenogeneic This refers to transplantation of tissue from an animal to a human. An example would be a porcine heart valve transplantation.

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include? Avoid IM injections. Assess the client for ecchymosis once per shift. Do not allow the client to have visitors. Encourage daily flossing between teeth.

✅Avoid IM injections. The nurse should identify that the client's platelet count of 48,000/mm3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures, such as an IM injection, which can increase the client's risk for bleeding. Assess the client for ecchymosis once per shift. The nurse should assess the client for indications of bleeding, including ecchymosis, at least every 4 hr. Do not allow the client to have visitors. The nurse should limit visitors for a client who has neutropenia, but does not need to disallow visitors. Encourage daily flossing between teeth. The nurse should promote safe oral hygiene, but should instruct the client to avoid flossing due to the risk for bleeding. RN Learning System Medical-Surgical: Final Quiz

The nurse is caring for a client who reports being bitten by a brown recluse spider. What assessment finding does the nurse anticipate? (Select all that apply.) Select all that apply. Tiny papule at the site of the bite Systemic neuromuscular complications Nausea and vomiting Hypertension Central bite mark with edema and erythema Severe abdominal pain Center of the bite turning bluish-purple

✅Central bite mark with edema and erythema ✅Center of the bite turning bluish-purple The bite of a brown recluse spider has a central bite mark with edema and erythema that turns bluish-purple. All other findings are consistent with the bite of a black widow spider. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

13 of 18 The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include? Avoiding tanning beds Wearing SPF 40 sunscreen Being aware of skin markings and performing skin self-examination Avoiding or reducing skin exposure to sunlight

✅Avoiding or reducing skin exposure to sunlight Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily. Avoiding tanning beds is significant, but is not the most important technique. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

What medication class is ultra-short acting, is used for anesthesia induction, short surgical procedures, and does not provide analgesia? Benztropine Donepezil Benzodiazepines Fluranes Barbiturates Opioids

✅Barbiturates Barbiturates are ultra-short-acting IV anesthetics. Thiopental, a barbiturate, has high potency and lipid solubility for rapid entry to the brain. It is used for anesthesia induction and short surgical procedures, however it does not provide analgesia, just unconciousness. Its rapid recovery is due to redistribution to less vascular peripheral tissues from the CNS. Side effects include respiratory and cardiovascular depression. IV Anesthetics

2 of 13 The nurse is caring for a client with skin breakdown due to inadequate hygiene. Which intervention is appropriate for the RN to delegate to the nursing assistant? Teach the client and family about the importance of good hygiene in skinfolds. Evaluate the client's ability to provide skin hygiene independently. Bathe the client, and apply a protective barrier to skinfolds and perineum. Check the client's skin weekly for areas of redness or breakdown.

✅Bathe the client, and apply a protective barrier to skinfolds and perineum. Assisting clients with bathing and personal hygiene is included in nursing assistant education. Assessment, teaching, and evaluation are more skills that require the education and scope of practice of licensed nursing staff. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

A client is scheduled for abdominal surgery and during the preoperative assessment, it is revealed that the client has a stoma. The nurse knows that which of the following is important to do in terms of prepping this client? Select all that apply. Be sure the prep is appropriate for an open area Be sure to clean the stoma twice with the prep Notify the surgeon of the stoma Clean the stoma separately from the abdominal area Clean from cleanest to least clean

✅Be sure the prep is appropriate for an open area Only specific preps can be used on open areas. ✅Clean the stoma separately from the abdominal area This is an appropriate prepping action. ✅Clean from cleanest to least clean This is an appropriate action when prepping a surgical site that includes a contaminated area Be sure to clean the stoma twice with the prep This is not a necessary action. The stoma should be prepped with a specific prep and separate from the abdominal area. The prep should be clearest to least clean to keep the area clean. Notify the surgeon of the stoma This is not a necessary action in terms of prepping. 02.06 Surgical Prep

After receiving a change-of-shift report, the client with which condition would be assessed by the emergency department (ED) nurse first? Severe muscle cramps after running Suspected spider bite with a red and swollen forearm Bite on the hand from a stray dog with minimal bleeding Bee sting on the jawline with difficulty swallowing

✅Bee sting on the jawline with difficulty swallowing The nurse would first assess the client who was stung by a bee and having difficulty swallow. This client is showing potential signs of respiratory compromise and needs immediate assessment and intervention. Neither the client with the spider bite nor the dog bite has life-threatening injuries. The current tetanus immunization status would be checked for each client and administered if needed. The client bitten by the dog might also require rabies vaccination follow-up. The client with muscle cramping after running would need to be assessed thoroughly yet this client's status is not as urgent as the client with the sting who is having difficulty swallowing. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

Question 7 of 10 Etanercept is a subcutaneous injection given for rheumatoid arthritis. The nurse understands that this drug does which of the following? Decreases the pain threshold Reduces substance P in the tissues Increases endogenous endorphins Blocks tumor necrosis factor receptors

✅Blocks tumor necrosis factor receptors Etanercept binds with tumor necrosis factor (TNF) and blocks the TNF receptors on the cells, decreasing the symptoms of the disease. This reduces swelling and inflammation, therefore improving symptoms for the client with RA. Decreases the pain threshold Etanercept improves symptoms. It does not decrease the pain threshold of a client. Increases endogenous endorphins The drug works by binding to TNF but does not increase endorphins. Reduces substance P in the tissues Substance P is a type of amino acid peptide thought to be involved in the pain response. This is not affected by etanercept.

During an admission assessment of a client with rectal cancer, the nurse recognizes which of the following as a symptom directly related to this type of cancer? Pain during peristalsis Blood in the stool An increase in hemorrhoids Clay-colored stools

✅Blood in the stool Manifestations of rectal cancer include some sort of bleeding in the stool, and differences in stool character. The stool may change to diarrhea or malformed stool, or a combination of the two due to the tumor blockage at the rectum. An increase in hemorrhoids Hemorrhoids do not indicate the presence of rectal cancer. Pain during peristalsis If pain is present with rectal cancer, it is generalized abdominal pain and indicates advanced disease. Rectal cancer does not cause pain with peristalsis. Clay-colored stools Clay-colored stools indicate a problem with the biliary system, not rectal cancer.

8 of 18 The nurse recognizes that a client's hemangiosarcoma originated in which tissue? Epithelial tissue Blood vessel Skeletal muscle Cartilage

✅Blood vessel The prefix "hemangio-" is included when cancers of the blood vessel are named. The prefix "rhabdo-" is used when cancers of the skeletal muscle are named. The prefix "chondro-" is included when cancers of cartilage are named. The prefix "adeno-" is included when cancers of epithelial tissues are named. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

Which of the following is a break in sterile technique while setting up a sterile field? Select all that apply. Leaving a one inch boarder around the sterile field Touching a non-sterile item to a sterile item Placing hands below the waist Breathing over the sterile field Keeping the doors to the room closed

✅Breathing over the sterile field Breathing over a sterile field introduces microbes and is a break in the sterile field. ✅Placing hands below the waist Placing any object below the waste is considered a break in sterile field. Leaving a one inch boarder around the sterile field This action is considered a part of aseptic technique. ✅Touching a non-sterile item to a sterile item Only sterile items may touch sterile items or it breaks aseptic technique. Keeping the doors to the room closed This action is considered a part of aseptic technique. 02.07 Sterile Field

A nurse is assisting the anesthesiologist to prepare to intubate a client just before surgery. Which of the following injuries is most commonly associated with endotracheal intubation as part of general surgery? Broken teeth Prolonged oxygen deprivation Allergic reaction Fractured cervical spine

✅Broken teeth Intubation is often required as part of an operative procedure when a client needs general anesthesia. Endotracheal intubation involves placing a breathing tube into the client's trachea to assist with breathing and oxygenation throughout the procedure. Only an experienced provider should perform intubation, as it can have risks when done incorrectly. One of the most common injuries that may occur is broken teeth when the handle of the laryngoscope inadvertently hits the clients teeth during tube insertion. Fractured cervical spine This is not a risk of endotracheal intubation. Prolonged oxygen deprivation Intubation is necessary so the client will be properly oxygenated during the procedure. There may be a moment during the passing of the tube into the lungs in which the client is not taking a breath, but this is over quickly and oxygenated air is immediately introduced into the lungs following intubation. cancel Allergic reaction A client may be allergic to certain drugs used in anesthesia, but not to the procedure of intubation. 02.01 Intubation in the OR

A provider suspects that the 67-year-old client in the nurse's care may have lung cancer. Which type of diagnostic test would most likely be used to diagnose this condition? Antinuclear antibody test CT angiogram Bronchoscopic lung biopsy Chest ultrasound

✅Bronchoscopic lung biopsy Lung cancer is a common form of cancer but is often not caught until it has progressed. Some tests used to look for lung abnormalities include imaging tests such as an X ray or CT scan, sputum cytology, and a biopsy. A biopsy of lung tissue is performed by bronchoscopy. An official diagnosis of cancer can only be made by biopsy or histological exam. CT angiogram A CT angiogram can be used to detect lung masses. It is performed by injecting dye into circulation and then looking at the pulmonary artery with a CT scan. The test is used to look for blockages or problems that cause shortness of breath, which could be related to lung cancer, but is not used to diagnose lung cancer. Chest ultrasound Imaging such as a CT scan or X ray is used, but an ultrasound is not used to look for lung cancer. Antinuclear antibody test This test is used to evaluate a person for autoimmune disorders, not lung cancer.

5 of 20 A 22-year-old client presents with appendicitis and is preparing for surgery. What gauge catheter will the ED nurse select for this client? A. 22 B. 14 C. 18 D. 24

✅C. 18 An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs. Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein. Chapter 15 - Concepts of Infusion Therapy

The nurse is caring for a client with a prescription for fentanyl. Which of the following is a condition that is appropriate for this medication to treat? Anxiety Cancer pain Myasthenia gravis Bowel obstruction

✅Cancer pain Fentanyl is an extremely potent pain medication, most commonly prescribed for breaththrough cancer pain. The client with a prescription for fentanyl is taking the medication for pain that cannot be managed by other less potent drugs. Anxiety Fentanyl is not prescribed for anxiety. Bowel obstruction Fentanyl is an opioid analgesic, and will slow the bowel. It is not indicated for a client with decreased bowel motility or obstruction. Myasthenia gravis Medications for myasthenia gravis include corticosteroids and acetylcholinesterase inhibitors. Potent pain medications are not necessary as myasthenia gravis is not a painful condition. 02.02 General Anesthesia

Question 1 of 10 Which of the following is an example of a topical agent that may be applied for arthritis relief? Dexpanthenol Zinc oxide Lanolin Capsaicin

✅Capsaicin Capsaicin (Salonpas Hot) is a type of compound that comes from chili peppers and is used for relief of some types of pain. This is usually applied topically, where it first stimulates pain receptors and then diminishes the intensity of pain signals in the body to provide some relief from pain. Lanolin This is an emollient used for dry, cracked skin. Zinc oxide This is a substance used for minor skin irritations. Dexpanthenol This is a substance used for minor skin irritations. Nursing Care and Pathophysiology for Rheumatoid Arthritis (RA)

6 of 16 Which body system will the nurse assess first to prevent harm for a client who has severe metabolic acidosis? Gastrointestinal system Respiratory system Cardiovascular system Autonomic nervous system

✅Cardiovascular system During acidosis, the body attempts to bring the pH closer to normal by moving free hydrogen ions into cells in exchange for potassium ions. This exchange can cause hyperkalemia, which alters all excitable membranes. In the heart, hyperkalemia can block electrical conduction through the heart and cause severe bradycardia and even cardiac arrest. Although all body systems are affected to some degree, the cardiovascular system must be assessed first to institute actions to prevent death. Chapter 14 - Concepts of Acid-Base Balance

3 of 20 The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters will the nurse choose most often? Cephalic vein of the forearm Palmer side of the wrist Back of the hand Subclavian vein

✅Cephalic vein of the forearm The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow. Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters are not inserted into the palmar side of the wrist because the median nerve is located close to this area. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse. Chapter 15 - Concepts of Infusion Therapy

10 of 18 A client has an odorous, purulent wound, and reports feeling embarrassed. Which nursing intervention is appropriate? Place room deodorizers in the room. Change the dressing frequently. Suggest whirlpool therapy. Encourage a diet high in protein.

✅Change the dressing frequently. The nurse knows that frequent dressing changes help with healing and help the client feel clean. This is the appropriate nursing intervention. A diet high in protein does not address the client's feelings of embarrassment. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

6 of 20 A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened 20 hours ago. What action will the nurse take? Change the set in about 4 hours. Nothing; the set is for long-term use. Change the set immediately. Change the set in the next 12 to 24 hours.

✅Change the set in about 4 hours. Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours. It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours. Chapter 15 - Concepts of Infusion Therapy

14 of 18 What is the pathophysiologic basis for Lyme disease progression to stage III? Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels Failure of the immune system to recognize the causative organism as non-self, allowing it to become a systemic infection Triggering of antibodies against infected cells that lead to autoimmune disease The special ability of Borrelia burgdorferi to burrow deeply into joint, cardiac, and neurons causing direct damage to these tissues.

✅Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels The causative organisms can switch out parts of its unique surface proteins, which changes the ability of immune sensitized system cells and antibodies to recognize the existing infecting organism allowing it to "hide." Every time a switch occurs, the immune system treats them like a new infection, and develops new antibodies and inflammatory responses to them, resulting in keeping all general and specific immunity actions in continual but ineffective attack mode through all stages of the disease process. This prolonged and continuous process results in persistent and enhanced damage to a variety of tissues and organs. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

12 of 20 The nurse is administering a drug to a client through an implanted port. Before giving the medication, what will the nurse do to ensure safety? Check for blood return. Administer 5 mL of a heparinized solution. Flush the port with 10 mL of normal saline. Palpate the port for stability.

✅Check for blood return. To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished. If no blood return is observed, the drug should be held until patency is re-established. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety. Chapter 15 - Concepts of Infusion Therapy

Question 6 of 10 A client who is recovering from surgery has developed a fever and the nurse notes that the client has significant pain and the incision site is red and warm. Which response from the nurse is most appropriate? Clean the incision site with chlorhexidine Apply gentle suction to the incision site Remove the sutures from the incision site Check the client's CBC

✅Check the client's CBC The client may have developed a surgical site infection (SSI) based on the symptoms demonstrated. An SSI is an infection that develops at the site within 30 days of surgery. If the client develops signs of infection, the nurse should first check a CBC to determine if white blood cells are elevated. Clean the incision site with chlorhexidine The nurse should not attempt to clean the site with chlorhexidine. If surgical site infection is suspected, the provider may order a culture of the incision site. Chlorhexidine or another antiseptic cleanser would affect these results. Apply gentle suction to the incision site The question does not describe any wound exudate or discharge. If the discharge was present, the nurse would apply a dressing rather than suction the site. Remove the sutures from the incision site The nurse would not remove sutures without a provider order. 03.02 Postoperative (Postop) Complications

7 of 13 The nurse notices yellowing at the corners of the sclera in an African-American client. What further assessment will the nurse perform? Gently percuss the liver. Examine the feet soles. Check the oral mucosa. Assess the palms of the hands.

✅Check the oral mucosa. After assessing an African-American client's sclera for jaundice, the nurse would then check for a yellow tinge to the oral mucous membranes, especially the hard palate. The nurse does not percuss the liver; this will be done by the health care provider. The feet soles and palms of the hands of a client with dark skin may appear yellow, even if jaundice is not present. Therefore, these are not areas of assessment that will be useful in determining if the client has jaundice. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

You are a perioperative nurse and have just been hired to work for private practice. The healthcare provider that you are working for has informed you that the next client will be under moderate sedation and you will be giving the drugs to the patient. Which of the following is the best next action to take? Gather the medications that will be necessary to administer Check the state board of nursing guidelines to verify scope of practice Take your client's vital signs and verify informed consent Assess your client's allergies, mental status, and current medications

✅Check the state board of nursing guidelines to verify scope of practice It is necessary to know if this is in your scope of practice. Assess your client's allergies, mental status, and current medications Although you will eventually do this you must first verify your scope of practice. Gather the medications that will be necessary to administer Although you will eventually do this you must first verify your scope of practice. Take your client's vital signs and verify informed consent Although you will eventually do this you must first verify your scope of practice. 02.04 Moderate Sedation

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? Checking pulse oximetry Measuring blood pressure Listening to bowel sounds in all four quadrants Observing the ECG for flat T-waves

✅Checking pulse oximetry Although all assessment actions listed are important, the most critical one to perform is assessing respiratory function effectiveness. Skeletal muscle weakness can make respiratory movements ineffective, leading to respiratory failure and death. Although cardiac changes can occur. Chapter 13 - Concepts of Fluid and Electrolyte Balance

4 of 18 During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first? Apply a barrier cream to the area. Clean and dry the client's skin. Assess the area for skin breakdown. Place the client in a side-lying position.

✅Clean and dry the client's skin. Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection. Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

The emergency department charge nurse is making client assignments and delegating care immediately following a mass casualty event. Which client will be delegated to an assistive personnel (AP)? Client with multiple left rib fractures and reports dyspnea Client reporting severe left anterior chest pain Client with a femoral fracture and palpable distal pulses Client who is unconscious with massive aortic bleeding

✅Client who is unconscious with massive aortic bleeding The client who is unconscious with massive aortic bleeding is unlikely to survive and would be "black-tagged" and assigned to an AP for comfort. The client with rib fractures and dyspnea, the client with chest pain, and the client with a femoral fracture with palpable pulses are likely to survive and would not be delegated to assistive personnel; they need care performed by a registered nurse. Chapter 12- Concepts of Disaster Preparedness

The surgeon working with the nurse has asked that the client be placed in the right lateral position. The nurse knows that which of the following positioning techniques can apply to this request? Select all that apply Client will be right side down Axillary roll will be used for positioning Client will be side lying Pillows may be placed between knees Client will be right side up

✅Client will be side lying Lateral means "side-lying". ✅Axillary roll will be used for positioning Axillary rolls are common for positioning the lateral client. ✅Client will be right side down Right lateral means the clients will be right side down. Client will be right side up Right lateral means the clients will be right side down. ✅Pillows may be placed between knees Padding is necessary will positioning. 02.08 Intraoperative Positioning

12 of 14 Which client will the nurse responding to a mass casualty event provide with a yellow tag? (Select all that apply.) Select all that apply. Client with a foot injury who cannot walk Client with multiple lacerations and contusions Client with a missing lower extremity and hemorrhage Client with an open leg fracture and normal vital signs Client with a head injury and confusion Client with chest trauma from a blast injury and chest pain

✅Client with a foot injury who cannot walk ✅Client with an open leg fracture and normal vital signs In the disaster triage tag system, black tags are issued to clients who are expected (and allowed) to die (or are dead); green tags are given to clients with nonurgent conditions who can walk (the "walking wounded"); red tags are given to clients with emergent needs; and yellow tags are given to client who can wait a short time (30 minutes to 2 hours) for care. The client with an open leg fracture and normal vital signs, and a client with a foot injury who cannot walk, both can wait for a short time for care, so they will be issued a yellow tag. The client with a missing lower extremity and hemorrhage will be issued a black tag. The client with a head injury and confusion will be issued a red tag, as will the client with chest trauma and pain. The client with multiple lacerations and contusions will be issued a green tag Chapter 12- Concepts of Disaster Preparedness

1 of 13 The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN? Client with a stage I pressure injury who requires turning every 2 hours. Client who needs grafting of a second-degree burn on the right leg. Client who needs discharge teaching after receiving steroids for Stevens-Johnson syndrome. Client with a sutured facial tear after falling off a bike.

✅Client with a sutured facial tear after falling off a bike. An LPN/LVN is an appropriate choice to care for an adult client with a facial suture. This nurse would be familiar with wound monitoring for potentially contaminated wounds and would recognize signs of infection. Conducting discharge teaching is a more complex nursing action that requires RN-level education and scope of practice. The client with stage I pressure injuries who needs to be turned every 2 hours could be cared for by a nursing assistant. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

7 of 16 For which client does the nurse remain alert for the possibility of respiratory acidosis? Client with increased urinary output Client who is anxious and breathing rapidly Client receiving IV normal saline bolus Client with multiple rib fractures

✅Client with multiple rib fractures A client with multiple rib fractures may have poor gas exchange from shallow breathing because of pain and because the rib fractures may inhibit adequate chest expansion. A client who is anxious and breathing rapidly is at risk for respiratory alkalosis, not acidosis. A normal saline bolus does not result in respiratory acidosis. An increased urinary output would not be a stimulus for a respiratory acid-base imbalance. Chapter 14 - Concepts of Acid-Base Balance

11 of 14 Which statements about the transmission of HIV are true? (Select all that apply.) Select all that apply. Clients with HIV-III and no drug therapy are very infectious. Even with appropriate drug therapy, most clients infected with HIV live only about 5 years after diagnosis. HIV may be transmitted only during the end stages of the disease. The most common transmission route is casual contact. Newly infected clients with a high viral load are very infectious. HIV-positive clients who have an undetectable viral load appear to not transmit the disease.

✅Clients with HIV-III and no drug therapy are very infectious. ✅Newly infected clients with a high viral load are very infectious ✅HIV-positive clients who have an undetectable viral load appear to not transmit the disease. In the first 4 to 6 weeks after infection, the viral numbers in the bloodstream and genital tract are high and sexual transmission is possible. Clients at the end stage of HIV disease (HIV-III [AIDS]) without drug therapy have a high viral load and are particularly infectious. An undetectable viral load now means noninfectious and therefore, not transmittable. Casual contact does not transmit the infection. With appropriate drug therapy, clients with HIV disease live for decades. Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

The nurse is caring for a client who is scheduled to have a total knee replacement. The nurse knows that which of the following preoperative instructions can play a role in possibly preventing surgical site infections? Select all that apply. Exfoliating the surgical site Prepping the surgical site Bathing with a soap preoperatively Clipping the surgical site Shaving the surgical site

✅Clipping the surgical site This action can play a role in preventing surgical site infections. Shaving the surgical site This action has shown to increase the chance of surgical site infections as it can cause cuts and a place for infection to enter. ✅Prepping the surgical site This action can play a role in preventing surgical site infections because it allows for proper cleaning of the site. ✅Bathing with a soap preoperatively This action can play a role in preventing surgical site infections because the area will be cleaned preoperatively. Exfoliating the surgical site This action has not shown to prevent surgical site infections. 02.06 Surgical Prep

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? Coarse crackles Wheezes Rhonchi Friction rub

✅Coarse crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing. Wheezes The client who has wheezes will manifest a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway. Rhonchi The client who has rhonchi will manifest coarse, loud, low-pitched sounds during inspiration or expiration. Coughing often clears the airway and stops the sound. Friction rub The client who has a friction rub will manifest loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

The nurse is providing reminders to a community group about safety procedures to prevent drowning. Which situation does the nurse identify that poses the greatest risk for drowning? A couple swimming together at a local lake College students going to a swimming party at a boat house Families gathering at someone's house to swim Children swimming at the community pool

✅College students going to a swimming party at a boat house The college party at the boat house is the situation that poses the greatest risk for drowning, due to the potential presence of alcohol or other mood-altering substances. The use of alcoholic beverages when swimming, boating, or near water increases the risk of water-related injuries and death. The couple swimming in the local lake is using the "buddy system." This situation does not present the greatest risk. Community pools frequently have life guards and safety equipment present. Because adults will be present at the family gathering, this situation does not present the greatest risk. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

The clinic nurse is reviewing the plan of care for a 50-year-old client. The nurse recognizes that which of the following is the diagnostic tool of choice for colorectal cancer screening? Sigmoidoscopy Colonoscopy Stool DNA test Virtual colonoscopy

✅Colonoscopy This is the preferred screening for colon cancer, because it is a thorough screening that also allows the provider to perform a biopsy on suspicious tissue and remove polyps during the screening. In a client without an increased risk, it is recommended to start routine colonoscopies at age 50, and repeat every 10 years. Stool DNA test This is one way to screen for colorectal cancer, but is not the preferred screening method. Virtual colonoscopy This is done with a CT, but is not the diagnostic tool of choice for colorectal cancer screening. Sigmoidoscopy A sigmoidoscopy is a shorter colonoscopy that stops at the sigmoid colon. A complete colonoscopy is more comprehensive.

6 of 14 Which concept is the highest priority for the nurse to consider in planning care for the client with HIV-III who has candidial stomatitis? Cellular regulation Gas exchange Comfort Nutrition

✅Comfort Candidial stomatitis causes considerable oral discomfort and difficulty eating and swallowing. Ice chips and cool liquids can help reduce the discomfort until prescribed antifungal agents have reduced the infection symptoms. Some clients may have pain to the point that opioid analgesics are needed. Gas exchange and cellular regulation are not directly affected by the problem. Although nutrition is negatively affected, it is the pain that interferes most with nutrition. Chapter 17 - Concepts of Care for Patients With HIV Disease

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation? Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) Assessing for furrows on the tongue to determine dryness of oral mucous membranes Comparing blood pressure measurements in the lying, sitting, and standing positions Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

✅Comparing blood pressure measurements in the lying, sitting, and standing positions When caring for an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure changes. Comparisons of blood pressures obtained with the client lying, then sitting, and finally standing can detect postural changes. If the standing blood pressure is significantly lower than that obtained while the client was in the lying or sitting positions, insufficient blood flow to the brain may cause hypotension with light-headedness and dizziness, which increase the risk for falls. Comparing apical to radial pulse rates does not provide information to detect degree of dehydration. Although assessment of oral mucous membranes can detect symptoms of dehydration, it does not provide information for falls risk. Dehydration usually results in an elevated serum potassium level, not a decreased level. Chapter 13 - Concepts of Fluid and Electrolyte Balance

A client who has recovered from cancer surgery requires lymphedema therapy. Which best describes an activity that would occur with this type of therapy? Pain medication administration Cognitive-behavioral therapy Upper arm strengthening Compression garment wear

✅Compression garment wear Lymphedema is the swelling that sometimes occurs following certain types of surgery. It most often develops in the groin, arms, legs, or neck. Compression garments are used to control edema and fluid, and to promote venous return of blood to the heart. Compression garments are typically fitted by a professional who can educate the client about their use. Upper arm strengthening When a client has lymphedema, strengthening is not a treatment goal. Upper arm exercises can be done to increase lymphatic drainage, but the idea behind the exercise is lymph drainage, not strengthening. This is done in a controlled manner with compression sleeves in place with therapy assistance. Pain medication administration Pain medication is given for comfort, but is not a therapy activity. Cognitive-behavioral therapy Cognitive-behavioral therapy is not a treatment given to clients with lymphedema.

1 of 20 The nurse is checking an IV fluid order and questions accuracy. What nursing action is appropriate? Ask the charge nurse about the order. Start the fluid as ordered. Contact the pharmacy for clarification. Contact the prescribing health care provider.

✅Contact the prescribing health care provider. First, the nurse will contact the health care provider who ordered the fluids. The nurse is legally and professionally responsible for accuracy and has the duty to verify the order with the health care provider who ordered it. The nurse can consult the charge nurse, but this is not the definitive action that the nurse should take. Contacting the pharmacy is not the best action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate and could possibly harm the client. Chapter 15 - Concepts of Infusion Therapy

​Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy? A. Avoid breathing into the inhaler or getting it wet. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because of the extreme drowsiness it causes.

✅Correct Answer: B Rationale: The drug is a monoclonal antibody given parenterally. It is composed of some foreign proteins and has been known to cause anaphylaxis even 2 hours after administration. Thus it must be given by a health care professional in a setting capable of handling an anaphylactic emergency. It must not be self administered. The drug is not in an inhaled or tablet form. Benralizumab does not induce drowsiness and can be administered at any time of day. Cognitive Level: ​Applying or higher Client needs category: Health Promotion and Maintenance Nursing Process Step: Implementation Chapter 27/Chapter 30 - Concepts of Care for Patients With Noninfectious Lower Respiratory Problems

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

✅Correct Answer: C Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as the priority; there may be other skin lesions that need attention. Once this is done, the nurse can then query whether other lesions are bothersome, teach about avoidance of sun and tanning beds, and refer the client to a dermatologic health care provider. Cognitive Level: Analysis Client Needs Category: Physiological Integrity Nursing Process Step: Implementation  Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

Which statements made by a 62-year old client alerts the nurse to the possibility that the he may be at increased genetic risk for cancer development? Select all that apply. A.​An older aunt died from a brain tumor while she had breast cancer B.​He had two benign colon polyps removed during his most recent routine colonoscopy C.​His sister died from cancer of the appendix D.​His brother is being treated for breast cancer E.​His daughter 32-year-old daughter has been recently diagnosed with cervical cancer F.​One person in each of the previous three generations of his family has died from lung cancer

✅Correct Answers: C, D Rationale: Lung cancer and cervical cancers are considered environmentally-induced cancers and really do not have a specific genetic predisposition. The fact that one person in each of three family generations developed lung cancer is not considered excessive. Breast cancer in older women is common and often spreads to the brain. Two benign colon polyps are common for the age group and do not indicate a genetic predisposition. The brother has a cancer that is rare for the gender and the sister has an extremely rare cancer type. Both of these cancers in first degree relatives are "red flags" for the possibility of an increased genetic risk for cancer. Cognitive Level: Applying or higher Client needs category: ​​Health Promotion and Maintenance Nursing Process Step: ​​Assessment Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

Question 3 of 10 A 68-year-old client suffers from rheumatoid arthritis in the joints of her arms, legs, and hands. The doctor has prescribed oral corticosteroid treatment for the client's condition. Which information should the nurse include about how this medication works to treat arthritis? Corticosteroids prevent the body from releasing the stress hormone cortisol Corticosteroids counteract many neurotransmitters secreted by the brain Corticosteroids stimulate opioid receptors to increase pain control Corticosteroids decrease prostaglandin levels that affect inflammation

✅Corticosteroids decrease prostaglandin levels that affect inflammation Corticosteroids are drugs commonly prescribed for the management of inflammatory conditions such as rheumatoid arthritis. They mimic the effects of the hormone cortisol in the body and decrease in prostaglandin levels, which are responsible for inflammation. They may be taken as oral tablets, used as topical treatments, or injected for relief of arthritis symptoms. Corticosteroids stimulate opioid receptors to increase pain control Corticosteroids do not have an effect on pain receptors. Corticosteroids prevent the body from releasing the stress hormone cortisol Cortisol is a corticosteroid hormone. Corticosteroids counteract many neurotransmitters secreted by the brain While both corticosteroids and neurotransmitters are stress hormones, they do not counteract each other.

1 of 18 The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which teaching will the nurse include? Cover the infected area with a clean, dry bandage. Take daily tub baths using a mild soap. Wash the infected areas first, then wash the uninfected areas. Use bath sponges or puffs when bathing.

✅Cover the infected area with a clean, dry bandage. The nurse includes the instruction that the infected area should be covered with a clean, dry bandage to prevent the spread of infection. The client should shower rather than take a tub bath, using an antibacterial soap. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. Bath sponges or puffs should be avoided because they cannot be laundered. Washcloths should be used only once before laundering. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

Question 13 of 16 Which client health problems will the nurse identify as an infectious process along with inflammation rather than inflammation alone? (Select all that apply.) Select all that apply. Tendonitis Appendicitis Asthma Cystitis Anaphylaxis Sepsis

✅Cystitis Cystitis is a bladder infection most often with a bacterial infection causes are commonly caused by bacterial and viral infections. ✅Appendicitis Appendicitis is most commonly the result of an infectious process (usually bacterial), ✅Sepsis as is sepsis, although a widespread inflammatory response can accompany sepsis. Asthma is an irritant/allergic reaction, not an infection although a respiratory infection makes asthma worse Anaphylaxis is an allergic response, not an infection Tendonitis usually is a result of a closed or overuse injury and is characterized by inflammation without infection. . Chapter 16 - Concepts of Inflammation and Immunity////Chapter 17 Principles of Inflammation and Immunity

The nurse is teaching a female client about breast self examination (BSE). The client asks where a lump is most likely to be found. Which location would be the most accurate response by the nurse? D- left upper outer quadrant of the breast B- right lower inner quadrant of the breast C- right upper inner quadrant of the breast A-left lower outer quadrant of the breast

✅D Masses in the breast are most commonly found in the upper outer quadrant of the breast, where breast tissue is thicker. These masses often extend into the axilla, putting the client at risk for metastases to the lymph nodes in that area. Although this is the most common location, tumors can develop anywhere in the breast tissue. A Although the upper outer quadrant is the most common location, tumors can develop anywhere in the breast tissue. Therefore, clients should be taught to examine the entire breast, not just this area. B Although the upper outer quadrant is the most common location, tumors can develop anywhere in the breast tissue. Therefore, clients should be taught to examine the entire breast, not just this area. C Although the upper outer quadrant is the most common location, tumors can develop anywhere in the breast tissue. Therefore, clients should be taught to examine the entire breast, not just this area.

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low? Decreased blood volume; increased blood osmolarity Increased blood volume; decreased blood osmolarity Decreased blood volume; decreased blood osmolarity Increased blood volume; increased blood osmolarity

✅Decreased blood volume; decreased blood osmolarity The action of aldosterone, known as the water- and sodium-saving hormone, increases the kidney reabsorption of both water and sodium to maintain blood volume and osmolarity. Clients who have low levels of aldosterone secretion lose large amounts of sodium and water in the urine, which results in low blood volume and low blood osmolarity. Chapter 13 - Concepts of Fluid and Electrolyte Balance

13 of 13 The nurse is caring for an older hospitalized client. Which physiologic age-related change(s) increase(s) the client's risk for infection? (Select all that apply.) Select all that apply. Increased cough and gag reflexes Urinary incontinence Decreased intestinal motility Decreased immune response Thinning skin

✅Decreased intestinal motility ✅Decreased immune response ✅Thinning skin Older clients have a decreased immune system, decreased intestinal motility, and thinning skin which make them at risk for infection, especially when hospitalized. Urinary incontinence is not a physiologic change of aging; it is a health problem that can be managed. Cough and gag reflexes are decreased rather than increased, which makes older adults at high risk for respiratory infections. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

Perioperative hypothermia is a complication that all surgical clients are at risk for and the nurse is aware of the importance of decreasing these complications because all except which of the following can occur? Increased risk of infection Decreased vasoconstriction Coagulopathy Extended PACU stay

✅Decreased vasoconstriction Increased vasoconstriction is a risk of perioperative hypothermia, not decreased vasoconstriction. Remember in hypothermia our bodies will vasoconstrict to keep the heat in closer to the core body. Coagulopathy This is a risk of perioperative hypothermia. Hypothermia results in worsening acidosis, which contributes to the severity of coagulopathy. Extended PACU stay This is a risk of perioperative hypothermia. A client that is hypothermic will stay longer in PACU to stabilize. Increased risk of infection This is a risk of perioperative hypothermia. Hypothermia decreases blood flow and movement through the vessel which increases the risk of infection. The body can not "fight" as effectively. 02.09 Intraoperative (Intraop) Complications

A nurse is providing teaching to a client who has tuberculosis and prescriptions for rifampin and ethambutol. The nurse should identify which of the following findings as an adverse effect of these medications that the client should report to the provider? Red-orange discoloration of urine Unexpected weight gain Ringing in the ears Decreased visual acuity

✅Decreased visual acuity The nurse should identify optic neuritis as an adverse effect of ethambutol. The nurse should instruct the client to monitor for changes in visual acuity or color identification as indications of optic neuritis to report to the provider. This adverse effect necessitates termination of ethambutol therapy because irreversible blindness can result. Red-orange discoloration of urine The nurse should instruct the client that rifampin commonly causes a red-orange discoloration of body fluids. This adverse effect is considered harmless and does not require reporting to the provider. Unexpected weight gain The nurse should identify anorexia resulting in possible weight loss, rather than weight gain, as an adverse effect of both rifampin and ethambutol. Ringing in the ears The nurse should identify that, while low-frequency hearing loss is a potential adverse effect of rifampin, tinnitus is not an adverse effect associated with either of these medications. RN Learning System Medical-Surgical: Final Quiz

Question 10 of 10 A nurse is caring for a client postoperatively that has just had abdominal surgery. The nurse knows that surgical clients are at risk for certain surgical issues like dehiscence. The nurse knows that which of the following statements are true regarding dehiscence? Select all that apply. Infection increases the risk of wound dehiscence The healthcare provider should be notified within 2 days of dehiscence Clients with a low BMI have increased risk Decreases in abdominal pressure increase risk Dehiscence is the separation of a surgical incision

✅Dehiscence is the separation of a surgical incision This is a true statement. Dehiscence is when a surgical wound separates and opens. Infection increases the risk of wound dehiscence This is true regarding wound dehiscence. If there is an infection it can cause swelling and inflammation and an irritated wound site that could dehisce. Clients with a low BMI have increased risk Obesity increases the risk of dehiscence, so a high BMI would increase this risk. Decreases in abdominal pressure increase risk Increases in abdominal pressure increase the risk of dehiscence. The healthcare provider should be notified within 2 days of dehiscence The healthcare provider should be notified immediately. We don't want to leave a wound opened for this long. We need to notify the provider so that we can get further orders. 03.02 Postoperative (Postop) Complications

A nurse is caring for a client in the recovery room who has developed post-operative nausea and vomiting as a result of anesthesia. Which of the following is a complication of post-operative nausea and vomiting? Select all that apply. Dehydration Blood clots Pulmonary aspiration Cardiac arrhythmias Increased intracranial pressure

✅Dehydration Some clients who undergo anesthesia develop nausea and vomiting after the procedure. The condition can lead to dehydration, cardiac arrhythmias, and the potential for pulmonary aspiration. These risks are lessened with proper nursing care. If a client is vomiting postoperatively, the nurse should reposition the client in a side-lying position to prevent aspiration. The client may also be connected to IV fluids and/or telemetry to monitor cardiac status, as ordered. Cardiac arrhythmias can develop when the client's electrolyte balance is compromised due to excessive vomiting. Increased intracranial pressure Increased intracranial pressure (ICP) can lead to vomiting, but post-op nausea and vomiting does not lead to any significant increase in ICP. ✅Pulmonary aspiration Some clients who undergo anesthesia develop nausea and vomiting after the procedure. There is potential for pulmonary aspiration. If a client is vomiting postoperatively, the nurse should reposition the client in a side-lying position to prevent aspiration. ✅Cardiac arrhythmias Cardiac arrhythmias can develop when the client's electrolyte balance is compromised due to excessive vomiting. Blood clots Vomiting does not lead to an increased risk for blood clots. However, blood clots are an increased risk in the surgical client, so care must be taken to follow post-operative orders for anti-coagulation and/or sequential compression devices to improve circulation.

8 of 18 A client with obesity requires frequent dressing changes for an infection on the foot. Which nursing assessment is the priority? Provide the necessary dressing materials. Determine whether the client can reach the affected area. Demonstrate how to change the dressing. Ask the client if he or she is squeamish.

✅Determine whether the client can reach the affected area. Whether the client can access the affected area is the priority to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to independently perform frequent dressing changes at home. All other assessments can be performed after determining if the client can reach the affected area. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

15 of 17 Which action will the nurse safely assign to an experienced assistive personnel (AP) to perform with a client who returned an hour ago to the medical-surgical unit after a bronchoscopy? Offering clear liquids when gag reflex returns Determining level of consciousness Assessing breath sounds Monitoring blood pressure and pulse

✅Determining level of consciousness The best nursing action for the nurse to assign to the experienced AP is monitoring blood pressure and pulse. An experienced AP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia. Evaluating breath sounds, gag reflex, and determining level of consciousness are considered nursing assessments and require the skill and knowledge of a higher-level provider or professional nurse. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

2 of 17 For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation? Difficulty swallowing Dry respiratory tract membranes Development of nasal polyps Frequent episodes of tonsillitis

✅Dry respiratory tract membranes When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes. This anatomical problem does not influence the development of tonsillitis or difficulty swallowing. Nasal polyps can contribute to nasal obstruction but is not caused by a septal deviation. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

A client who has suffered from severe rheumatoid arthritis for 10 years has decided not to have surgery after injuring a leg in a fall. Which of the following describes how the nurse would advocate for this client in this case? Select all that apply. Develop an alliance between the client and the provider Notify the anesthesiologist about the client's need for pain control Seek to educate the client about the procedure Contact the client's family to suggest talking to the client Discuss the case with hospital administrators who can convince the client to change her mind

✅Develop an alliance between the client and the provider A nurse must act as a client advocate, even if the nurse does not agree with all of the client's decisions. In this case, the nurse should continue to provide client care by acting as a liaison between the provider and the client. ✅Seek to educate the client about the procedure A nurse must act as a client advocate, even if the nurse does not agree with all of the client's decisions. In this case, the nurse should continue to provide client care by continuing to educate the client about treatment options and outcomes. Contact the client's family to suggest talking to the client This action undermines the client's autonomy to make a choice, so they do not demonstrate client advocacy. Notify the anesthesiologist about the client's need for pain control This action undermines the client's autonomy to make a choice, so they do not demonstrate client advocacy. Discuss the case with hospital administrators who can convince the client to change her mind This action undermines the client's autonomy to make a choice, so they do not demonstrate client advocacy. Nursing Care and Pathophysiology for Rheumatoid Arthritis (RA)

7 of 17 Which precaution to prevent harm is most important for the nurse to teach a client who is newly prescribed nicotine replacement therapy (NRT)? Immediately report any change in thought process or suicide ideation because this drug can alter behavior. Avoid crowds and people who are ill because your immunity is reduced while on this drug. Do not smoke cigarettes or use nicotine in any form while on this drug because the risk for heart attack or stroke is increased. Be sure to remain in an upright position for an hour after taking the drug to avoid esophageal reflux and ulceration.

✅Do not smoke cigarettes or use nicotine in any form while on this drug because the risk for heart attack or stroke is increased. NRT contains nicotine and cannot be used when smoking or with nicotine use in any other form because this will greatly increase circulating nicotine levels and the risk for stroke or heart attack. NRT does not have psychotropic properties and does not increase feelings of self-harm or suicide ideation. NRT does not induce esophageal irritation or ulcers nor does it reduce immunity. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

12 of 17 Which teaching point is most important for the nurse to emphasize for a client who is scheduled to undergo pulmonary function testing (PFT)? Avoid strenuous physical activity for 24 hours before the procedure. Use your bronchodilating inhaler right before arriving for the procedure. Do not smoke for 6 hours before the test. Eat only clear liquids for 12 hours before the procedure.

✅Do not smoke for 6 hours before the test. The essential teaching point for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results. Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Encouraging fluid intake does not have an effect on PFT testing. Supplemental oxygen is not required and will alter the results of PFT. However, oxygen may be given if the client develops distress during testing Chapter 24 /Chapter 27 - Assessment of the Respiratory System

9 of 18 What precaution is most important for the nurse to teach the client with systemic lupus erythematosus (SLE) prescribed to take 45 mg of a corticosteroid daily for 2 weeks to manage an SLE flare? Check all your stools for the presence of blood or a black, tarry appearance. Do not suddenly stop taking the drug when your flare is over. Be sure to take this drug with food. Take 30 mg in the morning and 15 mg at night.

✅Do not suddenly stop taking the drug when your flare is over. All of the precautions are correct and important. However, the most critical precaution is to not suddenly stop taking the drug, which could lead to acute adrenal insufficiency and even death. This dose of the drug (45 mg daily) would need to be tapered down over a period of weeks to prevent adrenal insufficiency. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

9 of 18 The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. What precaution will the nurse take while performing this dressing change? Apply a mask. Don disposable gloves. Place soiled dressings directly in the trash. Use sterile technique.

✅Don disposable gloves. The nurse will wear disposable gloves as a precaution to avoid contact with the infection. Disposable gloves are necessary when changing a dressing on a wound infected with MRSA to prevent transmission to others. It is not necessary to wear a mask, since the infection is spread by direct contact with the infected material. Sterile technique is not indicated. Soiled dressings should be placed in a sealed plastic bag before discarding. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

Question 3 of 5 The client in the PACU is waking from anesthesia after having a bilateral mastectomy with drain placement. The nurse knows that which of the following is true regarding drains? Select all that apply. A penrose drain is an example of a closed suction system. Drains can be made of polyvinyl chloride (PVC) Drains evacuate the operative site Drains can allow entry of infectious organisms Drains can signal hemorrhage

✅Drains can signal hemorrhage This is a true statement regarding drains. Remember drains evacuate a site so if the drain is filling quickly with blood or with a large amount this could indicate a hemorrhage. We have to monitor the blood loss occurring from the drain. ✅Drains can be made of polyvinyl chloride (PVC) This is a true statement regarding drains. ✅Drains can allow entry of infectious organisms This is a true statement regarding drains. Remember this is an open area so infectious organisms could enter the main site. A penrose drain is an example of a closed suction system. A Penrose is an open system drain. ✅Drains evacuate the operative site This is a true statement regarding drains. Drains help evacuate blood and fluids from the operative site 03.03 Surgical Incisions & Drain Sites

2 of 14 Which signs and symptoms does the nurse expect to find in a client diagnosed with Pneumocystis jiroveci infection? Dyspnea, tachypnea, persistent dry cough, and fever Substernal chest pain and difficulty swallowing Fever, persistent cough, and vomiting blood Cough with copious thick sputum, fever, and dyspnea

✅Dyspnea, tachypnea, persistent dry cough, and fever P. jiroveci causes pneumonia with dry cough, shortness of breath, breathlessness, and fever. Thick sputum and vomiting blood are not present. Substernal chest pain and difficulty swallowing are associated with an oral and esophageal candida infection. Vomiting blood is not associated with any type of pneumonia. Chapter 17 - Concepts of Care for Patients With HIV Disease

18 of 18 Which assessment findings will the nurse expect to see in a client who is suspected to have systemic lupus erythematosus (SLE)? (Select all that apply.) Select all that apply. Anemia Joint pain and swelling Hair loss Fever Fatigue Facial redness

✅Each of these assessment findings has been associated with systemic lupus erythematosus (SLE). Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

12 of 13 The nurse is caring for a client with hypoxia. Which assessment finding in the fingernails does the nurse anticipate? (Select all that apply.) Select all that apply. Yellowish color Early clubbing Beau lines Blue discoloration Koilonychias Pitting

✅Early clubbing ✅Blue discoloration Blue discoloration and early clubbing are findings associated with hypoxia. Yellowish color is often seen in clients with jaundice, or bacterial or fungal infection of the nails. Koilonychias are found in clients with iron deficiency, poorly controlled diabetes, and psoriasis. Beau lines are found in clients with an acute, severe illness, prolonged febrile state, or isolated periods of severe nutrition. Pitting is found in clients with psoriasis or alopecia areata. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

The surgical nurse is taking care of a client who is undergoing colon resection. The perioperative team recognizes that the client has lost an excessive amount of blood during the procedure. The nurse is aware that this complication can lead to which of the following? Select all that apply Perioperative hyperthermia Electrolyte disturbances Hypovolemia Increased risk of infection Impaired tissue integrity

✅Electrolyte disturbances Electrolyte disturbances can occur from fluid balance issues during surgery. ✅Hypovolemia Hypovolemia can occur from fluid balance issues during surgery as blood is lost. Impaired tissue integrity This can be associated with the pooling of blood around the client and not necessarily the blood loss itself. Perioperative hyperthermia Perioperative hypothermia can occur from excessive blood loss. Increased risk of infection An increased risk of infection is not associated with excessive blood loss but more so perioperative hypothermia. 02.09 Intraoperative (Intraop) Complications

17 of 18 A client with a foot ulcer says, "I feel helpless." What is the appropriate nursing response? (Select all that apply.) Select all that apply. State,"I know how you feel." Encourage participation in care of the wound. Assure that everything will be OK. Suggests inviting visitors to come. Ask what coping strategies have worked in the past.

✅Encourage participation in care of the wound. ✅Ask what coping strategies have worked in the past. The nurse's appropriate responses are to encourage client participation in wound care, and to ask how the client has coped with feelings like this in the past. Participation in wound care gives the client a sense of autonomy. Learning what coping strategies worked in the past alerts the nurse to whether the client copes with healthy or unhealthy coping mechanisms. Encouraging visitors is not the right suggestion for this client at this time; he or she needs to participate in self-care first. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing and nontherapeutic. Assuring the client that everything will be all right not only fails to address the underlying issue—but it also minimizes the client's feelings, and may give false hope. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

11 of 20 The nurse is to administer a unit of whole blood to a postoperative client. What will the nurse do to ensure the safety of the blood transfusion? Ensure that another qualified health care professional checks the unit before administering. Check the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed. Make certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit. Ask the client to both say and spell his or her full name before starting the blood transfusion.

✅Ensure that another qualified health care professional checks the unit before administering. To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses. Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products. Chapter 15 - Concepts of Infusion Therapy

5 of 18 When educating a client with B-cell lymphoma, a nurse tells the client that a virus can contribute to the development of their cancer. Which virus is linked with B-cell lymphoma? Human lymphotrophic virus type II Human papilloma virus Epstein-Barr virus Hepatitis B virus

✅Epstein-Barr virus The Epstein-Barr virus has been associated with B-cell lymphoma, Burkitt lymphoma, and nasopharyngeal carcinoma. Hepatitis B, human papilloma virus, and human lymphotrophic virus type II are associated with other cancers, but are not associated with B-cell lymphoma Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

A client comes to the emergency department covered with an unknown substance. What action will the nurse take first? Administer medication as prescribed. Provide emotional support. Triage for care. Escort to a decontamination room.

✅Escort to a decontamination room. Decontamination must precede triage. Only the most basic life-sustaining interventions would be performed before or during decontamination. After decontamination, the client can be triaged, the nurse can provide emotional support, and medication (if prescribed) can be administered. Chapter 12- Concepts of Disaster Preparedness

The medical command physician has appointed the nurse as the triage officer. Which duty does the nurse anticipate performing in this role? (Select all that apply.) Select all that apply. Serve as a liaison between hospital administration and the media. Evaluate clients who are brought to the hospital with a tag. Draw media away from the assigned clinical areas. Evaluate clients who come to the hospital without a tag. Assume all leadership for implementing the institutional disaster plan.

✅Evaluate clients who are brought to the hospital with a tag. ✅Evaluate clients who come to the hospital without a tag. The triage officer will evaluate clients with and without a tag who come (or are brought) to the hospital. The communications officer draws media away from the clinical area, and serves as a liaison between hospital administration and the media. The hospital incident commander assumes overall leadership for implementing the institutional disaster plan. Chapter 12- Concepts of Disaster Preparedness

15 of 18 Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? Every 2 hours, reposition a client who has had a stroke and is incontinent. Use the Braden Scale to determine pressure injury risk for a newly admitted client. Complete daily sterile dressing changes for a client with a venous leg ulcer. Admit a newly transferred client who had pedicle flap surgery 1 week ago.

✅Every 2 hours, reposition a client who has had a stroke and is incontinent. The nurse can delegate repositioning a client to a nursing assistant. A nursing assistant has the education and scope of practice to perform such a task. Using the Braden Scale, changing a sterile dressing, and client admissions are actions that should be done by licensed nursing staff who have broader education and scope of practice. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

4 of 17 How will the nurse document the client's respiratory assessment findings on auscultation that are heard as popping, discontinuous, high-pitched sounds at the end of exhalation? Coarse crackles Rhonchi Wheezes Fine crackles

✅Fine crackles Fine crackles are heard as popping, discontinuous sounds that are high-pitched heard at the end of inhalation. Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

A nurse is teaching a client with cancer about safety when receiving chemotherapy drugs. The nurse wants the client to understand about how chemotherapy can be harmful to healthy people who live with the client. Which action should the nurse counsel the client to perform after receiving chemotherapy that would most likely protect those who live with the client? If the client vomits, close the door to the area and allow it to dry before cleaning Use a separate set of flatware and dishes that are not used by others in the family Flush the toilet twice with the lid down after using Wash all clothes that have body fluids on them by hand

✅Flush the toilet twice with the lid down after using Chemotherapy, which is a treatment for clients with cancer, can be harmful for others who live with the client. Chemotherapy can cause abnormalities in the DNA of healthy people when they are exposed to the substance. The nurse should teach the client to take measures to protect others living in the home from being exposed. An example is to close the lid of the toilet and flush it twice after using it to reduce the risk of contamination when chemotherapy agents are eliminated from the body. If the client vomits, close the door to the area and allow it to dry before cleaning Vomit and other body waste should be cleaned up immediately, linens washed in hot water separately from other items, and basins washed with hot water and detergent. Wash all clothes that have body fluids on them by hand Items should be washed in a washing machine using hot water. Use a separate set of flatware and dishes that are not used by others in the family Dishes do not need to be quarantined, and can be cleaned in a dishwasher with hot water afterwards.

1 of 14 Which part of the HIV infection process is disrupted by the antiretroviral drug class of nucleoside reverse transcriptase inhibitors (NRTIs)? Clipping the newly generated viral proteins into smaller functional pieces Activating the viral enzyme "integrase" within the infected host's cells Binding of the virus's gp120 protein to one of the CD4+ coreceptors Forming counterfeit bases that prevent DNA synthesis and viral replication

✅Forming counterfeit bases that prevent DNA synthesis and viral replication The NRTIs have a similar structure to the four bases of DNA, making them "counterfeit" bases. They fool the HIV enzyme reverse transcriptase into using these counterfeit bases so that viral DNA synthesis and replication are suppressed. Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

14 of 16 Where do free hydrogen ions normally come from in the human body? (Select all that apply.) Select all that apply. Free hydrogen ions are produced by-products of carbohydrate and protein metabolism. Heavy exercise and muscle work produce hydrogen ions in the form of lactic acid. Ingestion of spicy food increases the concentration of uncontrolled free hydrogen ions. The kidney produces hydrogen ions when a urinary tract infection is present. Humans breathe in free hydrogen ions in the atmosphere from the buildup of greenhouse gases. Hydrochloric acid is produced in the stomach and is a normal source of free hydrogen ions.

✅Free hydrogen ions are produced by-products of carbohydrate and protein metabolism. ✅Heavy exercise and muscle work produce hydrogen ions in the form of lactic acid. Normal metabolic functions such as metabolism of carbohydrates, proteins, and fats for fuel all result in products that contribute to the free hydrogen ion concentration. Hydrochloric acid in the stomach is broken down into free hydrogen ions and chloride ions. Exercising muscles produce some lactic acid, which also contributes to normal hydrogen ion production. The hydrogen ions present in the urine during a urinary tract infection are produced by the bacteria, not the kidney. Greenhouse gases are not a normal source of free hydrogen ions and neither is the ingestion of spicy foods. Chapter 14 - Concepts of Acid-Base Balance

What is the main role of the incident commander in a disaster? Implements and oversees the emergency plan. Notify the media of hospital capacity. Contact other facilities to arrange transfers. Call in extra staff.

✅Implements and oversees the emergency plan. The main role of the incident commander in a disaster is to implement and oversee the emergency plan. The role of calling in extra staff would be delegated, as would contacting other facilities if transfers are needed. The public information officer would serve as media liaison. Chapter 12- Concepts of Disaster Preparedness

The nurse is caring for a client with a neutrophil count of 490. Which of the following actions should the nurse implement? Select all that apply. Place the client in a private room Perform meticulous hand hygiene Initiate contact precautions Encourage fresh fruit and vegetable intake Frequent IV site inspection

✅Frequent IV site inspection This client is unable to fight transmittable diseases due to the client's low neutrophil count. The IV site is an area where infection could occur, so frequent site inspection is necessary to catch any infection early. ✅Place the client in a private room This client is immunocompromised and should be placed on neutropenic precautions. Neutropenic precautions includes thorough hand washing, a low microbial diet (no fresh salads, fruits, vegetables, uncooked meats), a daily room cleaning, frequent inspection of the IV site, no rectal temperatures or suppositories, dedicated equipment for the client, a private room, and a mask worn by persons entering the room if they have any respiratory symptoms. Initiate contact precautions Contact precautions are not necessary. The client does not have a multi-drug resistant organism, but rather, is susceptible to getting an infection due to a compromised immune system. ✅Perform meticulous hand hygiene This client is immunocompromised, and is therefore very susceptible to infections. The client will be placed on neutropenic precautions, which means the nurse must take extra precautions not to expose this client to infectious agents, including meticulous hand hygiene. Encourage fresh fruit and vegetable intake The client should avoid fresh fruits and vegetables due to potential microbes contained in these foods.

The nurse is caring for a chemotherapy client who has reached his nadir. Which of the following behaviors will the nurse ensure are followed by the client? Frequent handwashing Getting adequate rest Intake of potassium-rich foods Monitor for diarrhea, and take an anti-diarrheal if needed

✅Frequent handwashing A client's nadir refers to the point in chemotherapy treatment in which the client's absolute neutrophil count is at the lowest level it will reach. This client is extremely vulnerable to infections, which are life-threatening during this period. The client must be taught to wash hands frequently to avoid contamination from pathogens, avoid certain foods, and avoid being around people who are sick. Intake of potassium-rich foods A nadir refers to the lowest absolute neutrophil count achieved during chemotherapy. The client will be extremely vulnerable to infection during this time, but not at risk for a low potassium level. Getting adequate rest While adequate rest is important for any client who is receiving chemotherapy treatment, the most important behavior for a client who has reached their nadir is infection prevention. Handwashing is the most effective defense against infection. Monitor for diarrhea, and take an anti-diarrheal if needed While chemotherapy can cause diarrhea, a client's nadir is not related to changes in bowel movements.

18 of 18 A client is diagnosed with melanoma. Which areas would the nurse anticipate that this client's tumor might metastasize? (Select all that apply.) Select all that apply. Kidneys Liver Gastrointestinal tract Lymph nodes Brain Lungs

✅Gastrointestinal tract ✅Lymph nodes ✅Brain ✅Lungs Typical sites of metastasis for melanoma include brain, lymph nodes, lungs, and the gastrointestinal tract. Liver and kidneys are not typical sites for melanoma metastasis Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

While on the school playground, a teacher is stung on the hand by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What is the appropriate nursing action? Administer an epinephrine pen. Gently scrape stinger out with a credit card. Remove the bee and save it for identification. Place an occlusive dressing over the sting.

✅Gently scrape stinger out with a credit card. The nurse needs to quickly remove the stinger by gently scraping or brushing it off with the edge of a knife blade, credit card, or needle. An occlusive dressing should not be applied to the wound. Unless the teacher has had an allergic reaction in the past, an epinephrine pen would not be used. The bee does not need to be saved for identification. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

6 of 13 A client with a stage 1 pressure injury has slipped to the bottom of the bed. What action does the nurse take first? Get help to lift the client. Assess for broken skin areas. Pad the bony prominences. Move the client gently upward.

✅Get help to lift the client. The first action by the nurse would be to get help, and then and gently lift the client with a sheet. Pulling or dragging the client should be avoided. Looking for broken skin areas or padding bony prominences are not the priorities of care, and can be accomplished after the client is positioned appropriately. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

7 of 20 A male client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work where he received 12 hours of IV fluids. On assessment, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How will the nurse document the assessment? Grade 2 phlebitis Grade 3 phlebitis Grade 1 phlebitis Grade 4 phlebitis

✅Grade 3 phlebitis Grade 3 phlebitis indicates pain at the access site with erythema and/or edema and streak formation with a 1' palpable cord. Grade 1 indicates only erythema with or without pain; the client has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the client has additional symptoms. Grade 4 indicates pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch (2.5 cm), and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch (2.5 cm) in length. Chapter 15 - Concepts of Infusion Therapy

Which of the following is the most likely effect in a patient being administered ketamine? Flushing Hallucinations Kidney Stones Anorexia Flu-Like Symptoms Lacrimation

✅Hallucinations These drugs are cardiovascular stimulants that increase cerebral blood flow and may result in disorientation, distortions of reality, and bad dreams, especially in adults. IV Anesthetics

The nurse is educating a client on post chemotherapy care. Which of the following teaching points is the priority? Exercise Types of water to drink Hand washing Foods to eat

✅Hand washing Washing hands is the priority because the client will have a weakened immune system, and pathogens are very commonly spread by the hands. It is important to educate the client on all of the answers, but washing hands is the most important Foods to eat This is an important educational topic, but hand washing is the most urgent idea for the client to grasp. Exercise This is an important educational topic, but hand washing is the most urgent idea for the client to grasp. Types of water to drink This is an important educational topic, but hand washing is the most urgent idea for the client to grasp.

3 of 16 Which assessment finding on a client with no other health problems does the nurse consider the greatest potential threat to the client's immune system? Has old scar formation related to an appendectomy. Has poor oral hygiene and numerous dental caries. Displays orthostatic hypotension and is mildly dehydrated. Displays occasional skipped heartbeats during auscultation.

✅Has poor oral hygiene and numerous dental caries. Poor oral hygiene and untreated dental carries are sources of infectious organisms with access to the blood (because mucous membranes are no longer intact). This is a potential threat to immunity because the condition can cause chronic inflammation and a constant transfer of microorganisms to the bloodstream, which increases the risk for systemic infection. Chapter 16 - Concepts of Inflammation and Immunity

Your client has a known family history of malignant hyperthermia. The nurse knows that which of the following ways would keep the client safe? Select all that apply. Have dantrolene available Have epinephrine available Identify the location of the malignant hyperthermia cart Have chilled IV solutions available Establish a plan with the anesthesia team

✅Have dantrolene available This is a treatment of malignant hyperthermia. ✅Identify the location of the malignant hyperthermia cart The cart location should be identified in order to ensure it is available and ready if an emergency occurs. ✅Establish a plan with the anesthesia team This is a way to keep the client safe. ✅Have chilled IV solutions available This is a treatment of malignant hyperthermia. Have epinephrine available This is not a treatment for malignant hyperthermia. 02.05 Malignant Hyperthermia

13 of 18 Which actions or behaviors represent to the nurse that a client is engaging in secondary cancer prevention practices? (Select all that apply.) Select all that apply. Eating a diet high in fiber and low in animal fat Having a health checkup, including chest x-ray, annually Obtaining a colonoscopy every 5 years Electing to have both ovaries removed a person who has a BRCA2 mutation Getting a mammogram or breast MRI annually Having a mole removed from the neck

✅Having a health checkup, including chest x-ray, annually ✅Getting a mammogram or breast MRI annually Removal of at-risk tissue or a precancerous lesion (such as a mole, colon polyp, or ovaries when a person has a specific mutation in a BRCA2 gene) represents primary cancer prevention, as does eating a diet that is high in fiber and low in animal fats. Mammograms and health check-ups represent secondary prevention in the form of possible early detection. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

14 of 18 Which conditions does the nurse teach a client are some of the seven warning signs of cancer? (Select all that apply.) Select all that apply. Heavy nosebleeds independent of trauma to the nasal mucosa Menstrual bleeding that has decreased Increased pigmentation with deeper coloring in a mole Difficulty starting the stream of urine for the past 6 months Indigestion regardless of food type eaten Thickening of breast tissue in one area

✅Heavy nosebleeds independent of trauma to the nasal mucosa ✅Increased pigmentation with deeper coloring in a mole ✅Difficulty starting the stream of urine for the past 6 months ✅Indigestion regardless of food type eaten ✅Thickening of breast tissue in one area The seven warning signs of cancer include persistent changes in bladder habits, unusual bleeding without trauma, obvious change in a wart or mole, chronic or persistent indigestion (especially if not associated with any food type), and the presence of a lump or thickening (often in the breast but can be anywhere). Reduced menstrual flow is not associated with a malignancy. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

The nurse is caring for a client who was admitted after a diving accident in a lake. Which task is appropriate to delegate to an experienced assistive personnel (AP)? Assessing the client's lung sounds and neurologic status Notifying the flight team of a possible transfer Drawing arterial blood gases (ABGs) and communicating results to the health care provider Helping to maintain cervical spine stability during transfer to a stretcher

✅Helping to maintain cervical spine stability during transfer to a stretcher Transferring and positioning clients is included in an AP's scope of practice. An experienced AP would be able to help with maintenance of cervical spine stability while under the supervision of licensed nursing staff. Nursing activities such as making assessments, arranging for client transfers, and communicating laboratory results to the health care provider require the scope of practice of an RN. The drawing of ABGs is usually done by a respiratory therapist. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

A nurse is working in the recovery room of the surgical unit in a hospital. A client is brought in who just underwent a single-lung transplant without complications. The client is intubated and requires a ventilator for breathing. Which of the following outcomes should the nurse strive to achieve during the time this client is in the recovery room? Establishment of central venous access Hemodynamic stabilization Extubation to room air Management and control of intracranial pressure

✅Hemodynamic stabilization A client who has had a lung transplant requires numerous measures of support during the post-operative period. The client will remain intubated for a period of time to be allowed to rest. During the initial post-op period, the nurse ensures that the client is hemodynamically stable (blood pressure, pulse, oxygenation) and focuses on preventing infection and rejection of the transplanted tissue. Extubation to room air The client should not be extubated in the recovery room. Once the client has been allowed to rest on the ventilator, is stable, and has been assessed by the provider and determined that extubation is appropriate, the tube will be removed. Establishment of central venous access The client will already have appropriate venous access prior to surgery. Management and control of intracranial pressure Intracranial pressure is not affected by a lung transplant 02.01 Intubation in the OR

Which of the following is most likely a drainage device associated with wound drainage? Hemovac Ewald Tube Salem Sump G-Tube Levin Tube Sengstaken-Blakemore

✅Hemovac A surgeon may place a hemovac drain, which is similar to a JP drain. However, this system can hold more fluid. Wound Drainage Types and Devices

13 of 17 Which sign or symptom will the nurse report immediately to the pulmonary health care provider to prevent harm for a client who had a percutaneous lung biopsy 2 hours ago? Bruising at the puncture site Lateral displacement of the trachea Oxygen saturation of 97% Pink-tinged sputum

✅Lateral displacement of the trachea The trachea should always be midline. Lateral displacement after a percutaneous lung biopsy is associated with complications, especially pneumothorax, which requires immediate intervention. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

A client is being treated for advanced lung cancer. Which of the following dietary considerations is the most appropriate for this diagnosis? High fiber, low potassium High-calorie, high-protein Low residual, low protein Low phosphorus, low protein

✅High-calorie, high-protein A high calorie, high protein diet is necessary as these clients can fatigue very easily and may experience poor appetites. Therefore any and all nutrition should contain as much protein and calorie as possible. High fiber, low potassium Fiber is important if the client may be experiencing diarrhea, but there is no effect on potassium. This is not the most appropriate diet, specifically, for lung cancer. Low residual, low protein Low residual would be important for colon cancer, however, clients with cancer should have high protein diets because of the risk for fatigue and loss of appetite. Low phosphorus, low protein Low phosphorous, low protein diets may be most beneficial for clients with kidney failure, but this is not the most appropriate diet for a client with advanced lung cancer.

7 of 18 Which of the drugs or supplements taken daily taken by a client who is newly diagnosed with drug-induced systemic lupus erythematosus (SLE) does the nurse suspect is most likely to have caused this problem? Vitamin D Lisonopril Aspirin Hydralazine

✅Hydralazine Hydralazine is a blood pressure medication that has been found to cause drug-induced SLE. None of the other drugs are associated with drug-induced SLE, although lisinopril, an angiotensin-converting enzyme inhibitor, is associated with development of angioedema. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

Question 4 of 10 Which of the following is an example of a short-acting corticosteroid used for the management of arthritis? Hydrocortisone Dexamethasone Triamcinolone Prednisone

✅Hydrocortisone Hydrocortisone is a short-acting, low potency corticosteroid that may be used as an oral tablet in the treatment of arthritis. Hydrocortisone can work quickly to reduce inflammation by mimicking the effects of the hormone cortisol in the body. The risk of adverse side effects increases as the potency and duration of treatment increases with corticosteroids. Therefore, the goal of steroid therapy is to maintain the lowest dosage that results in adequate symptom control and to taper off when the client's condition allows. Prednisone This is a long-acting corticosteroid. Dexamethasone This is a long-acting corticosteroid. Triamcinolone This is is an intermediate-acting steroid.

In a patient being administered benzodiazepines for IV anesthesia, which of the following is most likely to be seen? Hyperthermia Kussmaul respirations Hemolytic Anemia Hypotension Hepatotoxicity Peripheral Neuropathy

✅Hypotension Another side effect of benzodiazepines includes decreased blood pressure, and overdose may be treated with flumazenil. IV Anesthetics

A healthcare office provides immunizations for children and adults in the community. The nurse is preparing vaccine information sheets (VIS) to give to clients about the vaccines. Another nurse says, "Those forms are optional. You do not have to give those out if you do not want to." Which response from the nurse is accurate? I will give out copies of insurance coverage forms instead I won't put any out unless someone asks for one I have to give them out to clients when I give them a vaccine I will leave some here if anyone wants to take them

✅I have to give them out to clients when I give them a vaccine Vaccine Information Sheets (VIS) are informational forms that consist of a single sheet of paper with the information the client needs to know about the vaccine they receive. The VIS contains information about how the drug is given and potential side effects of the drug, as well as other pertinent information. When administering a vaccine, a nurse is required to give the client a copy of the VIS. I will leave some here if anyone wants to take them It is required by law for the nurse to give the client a copy of the VIS. Passively having them available is not following the appropriate protocol. I won't put any out unless someone asks for one It is required by law for the nurse to give the client a copy of the VIS. Passively having them available is not following the appropriate protocol. I will give out copies of insurance coverage forms instead Insurance coverage forms are not related to the requirement of giving the client a VIS.

11 of 13 The nurse recognizes that handwashing is the best method for preventing infection. Which action(s) by the Centers for Disease Control (CDC) about hand hygiene are recommended? (Select all that apply.) Select all that apply. If hands are not visibly soiled, use an alcohol-based hand rub. Wash hands before and after wearing gloves. If hands are visibly soiled, wash them with soap and water. Use only soap and water for hand hygiene when planning client contact. Wash hands before performing any invasive client procedure.

✅If hands are not visibly soiled, use an alcohol-based hand rub. ✅Wash hands before and after wearing gloves. ✅If hands are visibly soiled, wash them with soap and water. ✅Wash hands before performing any invasive client procedure. All of these choices are best practices except for using only soap and water for hand hygiene before client contact. An alcohol-based hand rub is also acceptable for direct or indirect client contact. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

The circulating nurse in the operating room notices that the surgeon touched his back against the scrub tech's sterile hand as they were moving positions. The nurse knows that which of the following is the best immediate action? Ask the surgeon if the scrub tech's glove needs to be removed Have the scrub tech remove the glove and place on the sterile field Immediately have the scrub tech remove the glove Do nothing as the surgeon's gown is sterile

✅Immediately have the scrub tech remove the glove The glove is now contaminated and should be removed immediately. Do nothing as the surgeon's gown is sterile he back of a sterile gown is not considered sterile. Ask the surgeon if the scrub tech's glove needs to be removed It's everyone's responsibility to maintain a sterile field and because the nurse witnessed the event the nurse can require the removal of the glove. Have the scrub tech remove the glove and place on the sterile field The contaminated glove needs to be dropped to an unsterile area. 02.07 Sterile Field

Based on the nurse's knowledge of local anesthesia the nurse realizes that the type of local anesthesia is chosen by the provider with all of the following in mind except which of the following? Immunization status Surgical site Patient's health status Desired action

✅Immunization status The choice of local anesthesia is not based on a client's immunization status. Desired action The choice of local anesthesia is based on this. Surgical site The choice of local anesthesia is based on this. Patient's health status The choice of local anesthesia is based on this. 02.03 Local Anesthesia

3 of 17 When performing an assessment on an older client, which finding is most important for the nurse to assess further? Soft speaking voice Slight kyphoscoliosis Inability to state name and date of birth Need to rest after activity

✅Inability to state name and date of birth The nurse would further assess the client who is unable to state name and date of birth. The older client has a higher risk for hypoxemia than a younger client, and often becomes confused during acute respiratory conditions. The other assessment findings are considered normal age-related conditions in an older client and do not warrant additional investigation. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

A patient with lupus needs to take corticosteroids for control of symptoms but has developed an electrolyte deficit as a side effect of the drug. Which nutrition strategy should the nurse recommend for the patient that would help to combat this side effect? Try to include one protein source per day Increase potassium intake by eating bananas and potatoes Chew food slowly and sip fluid between bites Decrease calcium intake to prevent kidney stones

✅Increase potassium intake by eating bananas and potatoes Nutrient deficiency often develops as a side effect of the medication. Common deficiencies include potassium, calcium, and sodium, electrolytes whose excretion is altered by the kidneys in long term use of corticosteroids. Chew food slowly and sip fluid between bites The effect of corticosteroids on the body is a lack of regulation by the kidneys. Eating food more slowly will not help this problem, but increasing the intake of electrolytes will help. Try to include one protein source per day A corticosteroid use does not result in a protein deficiency. Decrease calcium intake to prevent kidney stones Rather than decrease calcium, the nurse wants to encourage calcium intake, because corticosteroid use decreases calcium levels.

The preoperative nurse is doing a preoperative assessment on a client who is scheduled for a procedure under moderate sedation. The client state that they drink 8 beers a day. Which of the following is correct about alcohol and receiving moderate sedation? Increase sedation demands Have no effect on sedation demands Client will have to be administered general anesthesia Decrease sedation demands

✅Increase sedation demands Excessive alcohol use can increase sedation demands. Decrease sedation demands Excessive alcohol use can increase sedation demands. Have no effect on sedation demands Excessive alcohol use can increase sedation demands. Client will have to be administered general anesthesia The client can still have moderate sedation. Sedation demands might increase. 02.04 Moderate Sedation

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures? Decreased osmotic pressure; decreased hydrostatic pressure Decreased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; decreased hydrostatic pressure

✅Increased osmotic pressure; increased hydrostatic pressure The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but also the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to an increased hydrostatic pressure in the plasma volume. Chapter 13 - Concepts of Fluid and Electrolyte Balance

A perioperative nurse is aware that surgical clients are at risk for injuries related to positioning. Decreasing this risk is an intraoperative nursing priority and the nurse knows that all except which of the following can be a result of improper positioning of the client? Nerve injury Increased risk of infection Shearing Pressure related injuries

✅Increased risk of infection This is not a risk of improper positioning. Shearing This is a risk of improper positioning. Shearing can cause friction to the skin. Nerve injury This is a risk of improper positioning. Nerve injury and pressure related injuries can occur from poor position of the body. Pressure related injuries This is a risk of improper positioning. Nerve injury and pressure related injuries can occur from poor position of the body. 02.10 Intraoperative Nursing Priorities

11 of 16 What type of health problem will the nurse expect to see in a client who has very few regulator T cells? Increased severity of allergic and other hypersensitivity reactions Decreased ability to recognize non-self cells Decreased immunoglobulin production Increased risk for cancer development

✅Increased severity of allergic and other hypersensitivity reactions Regulator T-cells (Tregs) function to limit the actions of general and specific responses. These cells prevent over-responses to the presence of "foreign proteins" within a person's environment. People who are deficient in these cells have more severe hypersensitivity reactions, allergies, and autoimmune responses. Chapter 16 - Concepts of Inflammation and Immunity

8 of 16 Which client laboratory response indicates to the nurse that granulocyte colony-stimulating factor therapy is successful? Increased lymphocytes Increased white blood cells Increased platelets Increased red blood cells

✅Increased white blood cells Granulocyte colony-stimulating factor is a growth factor that stimulates the increased production and maturation of neutrophils. This action increases the circulating number of neutrophils and has minimal effect on other blood cell types. Chapter 16 - Concepts of Inflammation and Immunity

Question 5 of 10 A client takes medication for rheumatoid arthritis. The nurse reviews the client's list of medications and knows that which of the following medications is used to treat and manage rheumatoid arthritis? Inderal Indomethacin Immodium Imdur

✅Indomethacin This is an antirheumatic medication used most often for clients with rheumatoid arthritis. Immodium This is an antidiarrheal medication. Ibuprofen is a non-steroidal anti-inflammatory agent that treats mild to moderate pain and inflammation. Imdur This is a nitrate medication that helps to prevent angina. Inderal This is a beta blocker that is used to treat HTN, angina, arrhythmias, and heart attacks.

Postoperative Fever On postoperative days 5-7, which of the following is most likely a cause for the development of fever? Atelectasis Pulmonary Embolism (PE) Drugs DVT (Deep Vein Thrombosis) Pneumonia Infection

✅Infection On postoperative days 5-7, the development of fever may point to wound involvement. The surgical site must be observed to determine if there is an abscess, gangrene or cellulitis.

A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via continuous IV infusion. Which of the following actions should the nurse include in the plan of care? Infuse the heparin using an electronic IV pump. Administer vitamin K if the client has indications of hemorrhage. Adjust the dosage of heparin based on the client's PT levels. Inform the client that the heparin will dissolve the thrombus.

✅Infuse the heparin using an electronic IV pump. The nurse should administer heparin using an electronic IV pump, rather than by gravity, to prevent an accidental increase or change in the rate of infusion. Administer vitamin K if the client has indications of hemorrhage. The nurse should monitor the client for indications of hemorrhage and administer protamine sulfate as an antidote to heparin if this adverse effect occurs. Adjust the dosage of heparin based on the client's PT levels. The nurse should monitor the client's aPTT levels and adjust the dosage as prescribed. Inform the client that the heparin will dissolve the thrombus. While thrombolytic medications can dissolve a thrombus, heparin does not. The nurse should inform the client that heparin prevents enlargement of the thrombus and further clot formation. RN Learning System Medical-Surgical: Final Quiz

8 of 14 With which antiretroviral drug class will the nurse teach clients to prevent harm by reporting any new onset muscle weakness and muscle pain to the immunity health care provider? Fusion inhibitors Integrase inhibitors Nucleoside reverse transcriptase inhibitors Protease inhibitors

✅Integrase inhibitors The integrase inhibitor class of drugs can cause muscle breakdown (rhabdomyolysis) especially in adults taking a "statin" (type of lipid-lowering drug). The first symptoms of rhabdomyolysis are muscle pain and weakness. None of the other classes of antiretroviral drugs have this side effect. Chapter 17 - Concepts of Care for Patients With HIV Disease

11 of 13 Which characteristic of a skin lesion will the nurse report to the health care provider? (Select all that apply.) Select all that apply. Dark red color Irregular border Asymmetry Round and raised appearance Size increase from last month 1-mm ecchymotic area on the upper extremity

✅Irregular border ✅Asymmetry ✅Size increase from last month A lesion with one or more of the ABCDE (asymmetry, border irregularity, color variation, diameter, evolving) features should be evaluated by a dermatologist or a surgeon. Therefore, the nurse will report these findings to the health care provider. Ecchymosis is a bruise and is not necessarily problematic; it is common after minor trauma. A dark red color or a round and raised appearance is not necessarily problematic. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

As the circulating nurse, it is important to maintain the sterile field by doing all except which of the following? It is appropriate to walk between sterile fields It is ok to touch the back of sterile providers for gowning Do not reach over the sterile field It is appropriate to approach the sterile field directly

✅It is appropriate to walk between sterile fields It is inappropriate to do this as a circulating nurse who is not sterile. Do not reach over the sterile field It is important for the circulating to not do this to maintain a sterile field. It is appropriate to approach the sterile field directly It is important for the circulating to do this to maintain a sterile field. It is ok to touch the back of sterile providers for gowning It is ok for the circulating nurse to do this because the back of a gown is not sterile 02.07 Sterile Field

Which of the following is most likely a drainage device associated with wound drainage? Foley Levin Tube Jackson-Pratt (JP) NG Tube J-Tube Ewald Tube

✅Jackson-Pratt (JP) This device is typically placed when a surgeon does not want fluid to build up around a surgical site after a surgery. There is a bulb that is connected to a tube, which is placed in the wound. It works by creating a negative pressure when the bulb is squeezed flat and then connected to the tube. Wound Drainage Types and Devices

17 of 18 After a client is hospitalized for an anaphylactic reaction to a bee sting, a nurse is teaching the client about the use of an epinephrine autoinjector. Which instruction/ instructions should be included in client education? (Select all that apply.) Select all that apply. Keep the device with you at all times . After administering the device, hospital monitoring is necessary. Use the device before calling 911. If the drug becomes discolored, order a replacement device. The device CANNOT be given through clothing. Inject the device into your arm or your leg.

✅Keep the device with you at all times. ✅After administering the device, hospital monitoring is necessary. ✅Use the device before calling 911. ✅If the drug becomes discolored, order a replacement device Instruct the client to utilize the device at the first symptom of anaphylactic reaction before calling 911. Hospital monitoring is always necessary after utilizing epinephrine for anaphylaxis. The device should be available at all times, as allergens can be encountered in all life situations. For client safety if the drug becomes discolored, it needs to be replaced. The device CAN be given through a thin layer of clothing. The ideal injection site for an epinephrine automatic injector is in the upper thigh Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

The nurse is working on an oncology unit with a client who is currently receiving chemotherapy, and is finishing a bed bath. What is the priority? Labeling and properly disposing of waste Ensuring the IV pumps are plugged in to the wall to preserve battery life Changing out the enteral feeding tubing Letting the family know they can come back in the room

✅Labeling and properly disposing of waste A client who is actively receiving chemotherapy must have bodily waste labeled appropriately and disposed of in a proper manner. The nurse must ensure that this is done as a part of client care. Most facilities require chemotherapy waste to be handled with specific gloves and trash bags. Letting the family know they can come back in the room This is not a priority until the nurse is ready. The nurse is ready once the task is completed and the waste is disposed of in the correct manner. Ensuring the IV pumps are plugged in to the wall to preserve battery life This task is unrelated to the bed bath. The next action for the nurse to take is to dispose of the waste created by the bed bath for the client on chemotherapy precautions. Changing out the enteral feeding tubing If the client has a feeding tube, changing the tubing is not a part of the bed bath process. This is not the priority.

12 of 14 Which practices are generally recommended to prevent sexual transmission of HIV? (Select all that apply.) Select all that apply. Oral contraceptives taken consistently Natural-membrane condoms for genital and anal intercourse Latex gloves for finger or hand contact with the vagina or rectum Latex dental dam genital and anal intercourse Water-based lubricant with a latex condom Latex or polyurethane condoms for genital and anal intercourse

✅Latex gloves for finger or hand contact with the vagina or rectum ✅Latex dental dam genital and anal intercourse ✅Water-based lubricant with a latex condom ✅Latex or polyurethane condoms for genital and anal intercourse Latex or polyurethane condoms, dental dams, and gloves for genital and anal intercourse can prevent HIV from contacting susceptible tissues. Water-based lubricants must be used instead of oil-based or greasy lubricants because these can easily rub holes in the condoms. Oral contraceptives provide no protection against transmission of HIV or any other sexually transmitted infection Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

Question 1 of 2 A nurse is caring for a client who just underwent a left mastectomy with lymph node removal. Which of the following precautions need to be implemented? Select all that apply. Right limb alert Bleeding precautions Standard precautions Left limb alert Contact precautions

✅Left limb alert When lymph nodes are removed, there is increased risk for lymphedema. Therefore, IV starts, injections, blood pressure monitoring, as well as any needle sticks at all must be avoided in the arm on the side of the lymph node removal. ✅Standard precautions All clients are placed in standard precautions, which require the nurse to wear gloves if they will come into contact with bodily fluids. Because the client just had surgery and will likely have dressing changes, standard precautions are definitely required. Bleeding precautions There is no indication that this client is on anticoagulants or any other indication for bleeding precautions. Contact precautions There is no indication that this client requires contact precautions. This would be for things like MRSA or C. difficile. Right limb alert The limb alert should be placed on the side of the mastectomy.

A client is hospitalized for complications of lupus. Which of the following principles are associated with promoting this client's level of self-care? Select all that apply. Developing policies that support interdisciplinary involvement with the client's self-care needs Leaving the client alone to complete tasks Supporting the client's right to make healthcare choices Letting the client make his own decisions about self-care Educating the client so that he can learn to perform many tasks independently

✅Letting the client make his own decisions about self-care Client empowerment supports client autonomy and the ability to make decisions regarding a person's own care. The nurse can better empower the client by respecting choices and using education to help the client perform his or her own self-care tasks. Leaving the client alone to complete tasks This does not show that the client was enabled to perform self care. Before leaving a client alone, they must be instructed on tasks to complete. This creates a feeling of empowerment instead of a feeling of abandonment. ✅Supporting the client's right to make healthcare choices This will positively impact a client's desire for self care. Developing policies that support interdisciplinary involvement with the client's self-care needs Empowerment is about independence and choices. This does not correlate with increased involvement from various disciplines to assist a client in self care. ✅Educating the client so that he can learn to perform many tasks independently This will positively impact a client's desire for self care.

3 of 18 The nurse is teaching a client with loss of sensation and movement in the lower extremities secondary to spinal cord injury. Which daily prevention strategy to protect skin integrity does the nurse include in the teaching plan? Eat a low-fat, low-protein diet. Massage reddened areas several times daily. Lift hips off the chair at least every hour. Complete a pressure map to identify areas of concern.

✅Lift hips off the chair at least every hour. The daily prevention strategy the nurse includes in the client's teaching plan is that the client will lift the hips off the chair at least every hour to relieve pressure and help prevent pressure injuries. Eating a low-fat diet is not a daily prevention strategy for skin integrity. Reddened areas should never be massaged. Pressure mapping is not a daily activity and is not performed by the client Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

A client presents to the emergency department (ED) stating, "I got bit by something when I was cleaning out the basement." On assessment, the nurse notices a bite mark with a bluish-purple center on the client's posterior calf. What treatment would the nurse anticipate delivering? Elevation of affected extremity Direct application of ice to bite Localized wound care Initiation of transfer to trauma center

✅Localized wound care The nurse anticipates providing localized wound care for this client. A brown recluse spider bite is characterized by a wound that develops a bluish-purple center. Since the bite has already developed a dark center, this type of wound care needs to be initiated as soon as possible. Although cold compresses are beneficial initially, applying ice directly to a wound can potentially cause more tissue damage. Elevation of the extremity is beneficial in the early stages immediately after the bite, not at the time of presentation to the ED. This client does not require transfer to a trauma center for surgical intervention at this time, although the bite must be monitored for further tissue destruction and the need for debridement. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

The post-anesthesia care unit (PACU) nurse knows that which of the following can be expected to learn about the client from the peri-operative nurse during hand-off report? Select all that apply Location of catheters Surgical procedure performed Medications given by surgeon during procedure Estimated blood loss ASA classification of patient

✅Location of catheters This is typically communicated to the PACU RN by the perioperative RN during the hand-off report. ASA classification of patient This is not typically communicated by the perioperative RN but by the PACU RN. ✅Medications given by surgeon during procedure This is typically communicated to the PACU RN by the perioperative RN during the hand-off report. Estimated blood loss This is not typically communicated by the perioperative RN but by the PACU RN. ✅Surgical procedure performed This is typically communicated to the PACU RN by the perioperative RN during the hand-off report. 03.01 Post-Anesthesia Recovery

18 of 19 Which type of drug does the nurse identify that is contraindicated for a client who was stung by a scorpion? (Select all that apply.) Select all that apply. Acetaminophen Lorazepam Secobarbitol Tetanus toxoid Hydrocodone

✅Lorazepam ✅Secobarbitol ✅Hydrocodone Medications contraindicated for a client with a scorpion sting include barbiturates (e.g., secobarbitol), benzodiazepines (e.g., lorazepam), and opiates (e.g., hydrocodone). These medications need to be avoided because they can cause a loss of airway reflexes and can precipitate respiratory airway failure. It is safe to administer acetaminophen to a client with a scorpion sting for fever and pain. Because the scorpion sting is a puncture wound, tetanus toxoid would be administered. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

The nurse is caring for a client who has recently finished chemotherapy. The client asks if it is appropriate to begin exercising. Under which conditions would exercise be contraindicated for this client? Select all that apply. Low blood urea nitrogen Low white blood cells Low sodium Low potassium Low red blood cells

✅Low red blood cells If a client has finished chemotherapy but their lab work shows low RBCs (anemia), low WBCs, or abnormal electrolytes such as sodium or potassium, it is contraindicated for the client to exert themselves. Once these blood levels became more stable, it is appropriate to begin an exercise program. ✅Low white blood cells This is a contraindication for exertion in this client. ✅Low potassium This is a contraindication for exertion in this client. ✅Low sodium This is a contraindication for exertion in this client. Low blood urea nitrogen Chemotherapy has the potential to increase BUN due to the effect on the kidneys, but a decrease in this lab value is not due to chemotherapy and is not a contraindication for exercise.

A hiker begins to feel ill within 48 hours of climbing a mountain. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment will the telehealth nurse recommend? Lower altitude Acetazolamide sodium Bedrest for 24 hours Oxygen therapy

✅Lower altitude The most effective intervention to manage an altitude-related illness is gradual descent to a lower altitude. Diamox needs to be taken before and during the trip for prevention, but will not help after symptoms of altitude-related illness have begun. Bedrest for 24 hours will not address an altitude-related illness. Oxygen is not the most effective treatment. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? Provide oxygen. Place the client in a side-lying position. Provide privacy. Lower the client to the floor.

✅Lower the client to the floor. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect him from injury. Provide oxygen. The nurse might need to provide oxygen to the client during the postictal phase; however, there is another action the nurse should take first. Place the client in a side-lying position. The nurse should place the client in a side-lying position if possible to keep the airway clear; however, there is another action the nurse should take first. Provide privacy. The nurse should provide privacy by closing the privacy curtain or the door to the client's room; however, there is another action the nurse should take first. RN Learning System Medical-Surgical: Final Quiz

15 of 18 Which common cancers will the nurse inform clients are related to tobacco use? (Select all that apply.) Select all that apply. Lung cancer Cancer of the larynx Bladder cancer Cancer of the tongue Skin cancer Cardiac cancer

✅Lung cancer ✅Cancer of the larynx ✅Bladder cancer ✅Cancer of the tongue Organs exposed to the carcinogens in tobacco (lungs, tongue, larynx) are most likely to develop cancer. Bladder cancer is also associated with cigarette smoking because many of the carcinogens in tobacco are filtered into the urine and come into contact with the urinary bladder. Oral cancer is also a risk with "smokeless" tobacco. The heart does not contain cells that divide; therefore, cardiac cancer is unlikely. Skin cancer generally is related to repeated sun and other ultraviolet exposure, such as that found with tanning beds. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

The nurse is caring for a client with breast cancer who underwent radiation therapy four weeks ago. The nurse should tell the client to look for what potential late effects of radiation therapy following the treatment? Select all that apply. Swelling of breast tissue Lymphadema Delayed wound healing Broken blood vessels under the skin Softer breast tissue

✅Lymphadema Radiation side effects are divided into two categories: Acute effects (from treatment time to 2-3 weeks after treatment) and chronic effects (from 3 weeks after treatment to years later). Acute effects include mucositis or ulceration of mucous membranes, yeast or bacterial infections, dry or darkening skin, and temporary cessation of function to the sweat and oil glands. Chronic effects include lymphadema, broken blood vessels under the skin, and delayed wound healing, as well as fibrotic muscle tissue in the area exposed to radiation. Dry mouth is a chronic effect if the radiation was placed near the neck. ✅Broken blood vessels under the skin This is one chronic side effect of radiation that may occur. ✅Delayed wound healing Delayed wound healing can become a chronic issue after radiation. Softer breast tissue Fibrous tissue can occur, but softer tissue is not side effect of radiation. Swelling of breast tissue Swelling of breast tissue is not side effect of radiation.

A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What action will the nurse take first? Stabilize the spine. Palpate to check for the presence of a pulse. Apply a dressing over the skin burn where the lightning entered. Immediately begin cardiopulmonary resuscitation.

✅Palpate to check for the presence of a pulse. Initially, the nurse will stabilize the spine to give priority attention to an adequate airway, and then palpate to check for the presence of a pulse. The most lethal initial effect of the massive current discharge of lightning on the cardiopulmonary system is cardiac arrest. If the client does not have a pulse, CPR will then be started utilizing BLS protocols. The skin burn can be addressed last. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

A client has just been transferred from the OR into the recovery room and the nurse notes that the endotracheal tube is still in place. The client is beginning to breathe on her own but is not awake and alert yet. Which of the following interventions should the nurse perform next? Maintain the ET tube until the nurse determines the client has adequate spontaneous ventilation Turn the client on her side Remove the ET tube and insert an oral airway Keep the client's mouth open with a padded tongue depressor

✅Maintain the ET tube until the nurse determines the client has adequate spontaneous ventilation When a client is brought into the recovery room after surgery, she may still have an ET tube in place. This is likely because the anesthesiologist preferred to have the client be more awake before removing the tube. The ET tube should stay in place until the nurse determines that the client is awake enough that she can breathe on her own. Only then should the nurse remove the tube. Turn the client on her side Turning a client on their side is appropriate if she is vomiting after surgery, but not solely due to having an ET tube in place. Remove the ET tube and insert an oral airway Since the client is just beginning to breathe, removing the tube should wait until the nurse has determined that the client has appropriate spontaneous ventilation. Keep the client's mouth open with a padded tongue depressor There is no need to keep the client's mouth open when the ET tube is in place. 02.01 Intubation in the OR

2 of 18 The nurse observes an assistive personnel (AP) interacting with a client with a pressure injury. Which AP action requires intervention by the nurse? Repositions the client every 1 to 2 hours. Uses a moisturizing lotion on skin without pressure injuries. Avoids touching reddened areas. Massages bony prominences.

✅Massages bony prominences. Massaging bony prominences should be avoided in clients with pressure injuries because they are at high risk for skin tears. Reddened areas should not be touched because this can damage capillary beds and increase tissue necrosis. The client should be repositioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure injuries. Using a moisturizing lotion on the rest of the skin is appropriate Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

The circulating nurse in the operating room receives notification that a client is coming from the emergency room for an open appendectomy procedure. With the nurse's knowledge of surgical incisions, which of the following types of incisions would be expected for the surgeon to perform? Thoracotomy incision Wilde's incision McBurney incision Collar incision

✅McBurney incision This is a common incision for an open appendectomy. Collar incision This is not an incision for an open appendectomy. This is used for thyroidectomy. Wilde's incision This is not an incision for an open appendectomy. This is used for mastoiditis. Thoracotomy incision This is not an incision for an open appendectomy. This is used for lung and heart surgeries. 03.03 Surgical Incisions & Drain Sites

A 37-year-old client with pancreatic cancer is experiencing chemotherapy-induced nausea and vomiting (CINV) after his latest round of medication. Which drug would most likely be prescribed for the control of CINV? Metoclopramide (Reglan) Morphine Lorazepam (Ativan) Tramadol (Ultram)

✅Metoclopramide (Reglan) CINV is a common and very debilitating side effect of chemotherapy treatment for cancer. A client may learn about lifestyle changes and methods to control CINV and to avoid complications, but sometimes medications are needed to best manage the condition. Anti-nausea medications such as dimenhydrinate, midazolam, and metoclopramide are commonly administered. Morphine This drug does not have antiemetic properties. Lorazepam (Ativan) This benzodiazepine can be given for CINV, but not until other drugs have been attempted. Tramadol (Ultram) This drug is not an antiemetic.

14 of 20 A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the charge nurse teach the new nurse to use for this client? Short peripheral catheter Midline catheter Peripherally inserted central catheter Tunneled percutaneous central catheter

✅Midline catheter For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice. Tunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion. Chapter 15 - Concepts of Infusion Therapy

What is the most important action to prevent harm for the nurse to perform after a client's oral and facial swelling from an angiotensin-converting enzyme inhibitor (ACEI) have resolved? Teaching the client about symptoms to report immediately to the primary health care provider Instructing the client to discard the offending drug after being discharged Monitoring the client for return of symptoms for at least the next 2 to 4 hours Assessing the vein above the IV infusion site for a firm, cordlike texture

✅Monitoring the client for return of symptoms for at least the next 2 to 4 hours All actions are important, although phlebitis is not likely to occur from IV therapy for angioedema. The ACEI class of drugs have a longer half-life and remain in the body longer than does the corticosteroid infusion used to treat the angioedema. As a result, symptoms can recur after first resolving when corticosteroid therapy is stopped. The client remains at risk and must be monitored for at least 2 to 4 hours for return of angioedema Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

6 of 16 Which differential count will the nurse report to the primary health care provider for a client whose white blood count indicates a total count of 10,000 cells/mm3 (10 × 109/L)? Eosinophils 200/mm3 (0.2 × 109/L) Lymphocytes 2100/mm3 (2.1 × 109/L) Segmented neutrophils 6000/mm3 (6 × 109/L) Monocytes 2000/mm3 (2 × 109/L)

✅Monocytes 2000/mm3 (2 × 109/L) The normal monocyte population in peripheral blood should be not greater than 5%. A monocyte count of 2000 in 10,000 white blood cells represents 20% of the total and indicates a significant increase. Chapter 16 - Concepts of Inflammation and Immunity

7 to 10 The nurse is caring for a client who had surgery yesterday afternoon. The client is now complaining of abdominal pain and the nurse notes the abdomen is firm. The nurse reviews the provider orders seen in the graphic. Which of the following is most likely the cause of the client's condition? Lactate ringers at 100mL/hr NGtube to LIWS. Keep patient NPO except ice chips 10 mg morphine for pain given at 1000. Pt has no other complaints at this time A. IV Fluids B. Morphine C. NG Tube D. Ice chips

✅Morphine After surgery, clients are at risk for developing a paralytic ileus. This is due to effects from the anesthesia and can be compounded and made worse when the client is administered an opioid analgesic such as Morphine. NG Tube These would contribute to relieving abdominal pain and distention, not causing it. IV Fluids It is unrelated to abdominal distention. If the client had developed ascites due to volume overload, that could possibly be exacerbated by IV fluids, but in that case the abdomen would not be firm, it would have a positive fluid wave test. Ice chips These would contribute to relieving abdominal pain and distention, not causing i 03.02 Postoperative (Postop) Complications

While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. After ensuring the client's airway is clean, what is the team nurse's next action? Move the player to the shade. Give salt tablets. Provide a cool electrolyte fluid drink. Place warm packs under the arms.

✅Move the player to the shade. After ensuring the ABC's are intact, the nurse would first move the player into the shade. After the player is in the shade, the nurse would place ice packs—not warm packs—under the arms as well as in the groin to cool the client. Due to a diminished level of consciousness, nothing would be given by mouth to prevent aspiration. Salt tablets are not to be given. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

What mechanism of action or pharmacological action is best associated with ketamine? NMDA Receptor Antagonist Blocks Glycine and GABA Release GABA Analog Acts on BZ1 GABA receptor 5-HT Agonist Potentiates GABA-A

✅NMDA Receptor Antagonist Arylcyclohexylamines, including ketamine, are PCP analogs that act by blocking the effects of glutamic acid at NMDA receptors. This interferes with pain transmission in the spinal cord, and also leads to a dissociative amnesia.

A nurse providing moderate sedation to a client undergoing a surgical procedure is assessing vital signs, sedation level, and level of consciousness. The nurse realizes the client is not responding to the nurse's questions. Which of the following administrations would be necessary? Select all that apply. Narcan Romazicon Propofol Versed Ketamine

✅Narcan This is a reversal agent for moderate sedation. ✅Romazicon This is a reversal agent for moderate sedation. Versed This is not a reversal agent for moderate sedation. Ketamine This is not a reversal agent for moderate sedation. Propofol This is not a reversal agent for moderate sedation. 02.04 Moderate Sedation

8 of 16 Which condition does the nurse consider as most likely to have caused a client's arterial blood gas value to show an increased pH? Water retention Partial airway obstruction Nasogastric suction Diabetic ketoacidosis

✅Nasogastric suction Nasogastric suction results in alkalosis from overelimination of hydrogen ions when stomach hydrochloric acid removed by the continuous suction. Chapter 14 - Concepts of Acid-Base Balance

The nurse's hospital was affected by a hurricane. When explaining the disaster response, how does the nurse identify this type of disaster? (Select all that apply.) Select all that apply. Nuclear Natural Internal Biologic External Chemical

✅Natural ✅External A hurricane is an external, natural disaster. External disasters take place outside the health care facility or campus, somewhere in the community. A natural disaster is one such as a hurricane, earthquake, tornado, or volcano. Internal disasters take place inside a health care facility or campus. NBC disasters (nuclear, biologic, chemical) are labeled according to the substance involved in the disaster. Chapter 12- Concepts of Disaster Preparedness

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? Nose and ears have a slightly yellow-tinged appearance. Neck veins are now distended in the sitting position. Breath sounds can be heard in the right lower lung lobe. Weight is unchanged from that obtained yesterday.

✅Neck veins are now distended in the sitting position. Neck veins are normally distended when a client is in the supine position and are flat when a client is sitting or standing. When hypervolemia worsens the neck veins are distended even when the client is upright. Hearing breath sounds in the lower lung lobes is a positive sign, not one that indicates the condition is worsening. An unchanged weight indicates the client's condition is stable, not worsening. The color of the ears and nose is not related to hydration status. Chapter 13 - Concepts of Fluid and Electrolyte Balance

A client is scheduled for a gynecological procedure and will be placed in the lithotomy position. The nurse knows that which of the following concerns is specific to this type of positioning? Pressure ulcers to lower extremities Shearing to upper and lower extremities Nerve damage to upper extremities Nerve damage to lower extremities

✅Nerve damage to lower extremities This presents the biggest concern when the client is in lithotomy. The lithotomy position is when the client is in stirrups so this can cause nerve damage and damage to lower extremities. Nerve damage to upper extremities This is not the most concerning when the client is in the lithotomy position. The lithotomy position is when the client is in stirrups so this can cause nerve damage and damage to lower extremities. Shearing to upper and lower extremities his is not the most concerning when the client is in the lithotomy position. The lithotomy position is when the client is in stirrups so this can cause nerve damage and damage to lower extremities. Shearing would not occur to the upper extremities when the client is in the lithotomy position. Pressure ulcers to lower extremities This is not the most concerning when the client is in the lithotomy position. The client is not in position long enough to cause pressure ulcers. The lithotomy position is when the client is in stirrups so this can cause nerve damage and damage to lower extremities. 02.08 Intraoperative Positioning

A nurse is caring for a client with a history of acute myelogenous leukemia. Which of the following is a true statement regarding neutropenia and the complete blood cell count? Select all that apply. Neutrophils are the first line of defense in infection Acute infection causes a left shift, which is an increase in immature neutrophils Neutrophil levels should increase during times of infection Neutrophils ingest foreign pathogens and debris Monocytes are the immature form of neutrophils

✅Neutrophils are the first line of defense in infection Neutrophils are normally the first line of defense in the body when infection occurs. ✅Acute infection causes a left shift, which is an increase in immature neutrophils Immature neutrophils are known as bands and an increase in bands during infection is called a left shift. Neutrophils are normally the first line of defense in the body when infection occurs. ✅Neutrophils ingest foreign pathogens and debris This is an accurate description of the way neutrophils help clear the body of infection. ✅Neutrophil levels should increase during times of infection Neutrophils are a type of white blood cell that are responsible for protecting the body by upholding the immune system. Immature neutrophils increase during infection. Monocytes are the immature form of neutrophils A monocyte is a type of white blood cell, but is not an immature neutrophil. An immature neutrophil is called a band.

The nurse is caring for a client who has been placed on neutropenic precautions. The nurse knows that this includes which of the following? Select all that apply. No cooked meat No flowers No fresh vegetables No salt No suppositories

✅No suppositories Neutropenic precautions include thorough hand washing, a low microbial diet (no fresh salads, fruits, vegetables, uncooked meats), a daily room cleaning, nothing per rectum, dedicated equipment for the client, and a private room. ✅No flowers This is not allowed for a client on neutropenic precautions. No cooked meat Uncooked meat is not allowed, but cooked meat is allowed. ✅No fresh vegetables This is not allowed for a client on neutropenic precautions. No salt Salt is allowed with neutropenic precautions.

1 of 16 How do immune system cells differentiate between normal, healthy body cells and non-self cells within the body? All normal, healthy body cells are considered a part of the immune system. Immune system cells recognize normal healthy body cells by the presence of the nucleus, a structure that is lacking in non-self cells. Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as "foreign" by immune system cells. Non-self cells are easily identified by the immune system cells because non-self cells are much larger than normal, healthy body cells.

✅Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as "foreign" by immune system cells. Normal, healthy body cells all express surface proteins that are unique to the person, coded by the major histocompatibility genes. Non-self cells express different cell surface proteins. Immune system cells can distinguish between their own surface proteins and all others. Chapter 16 - Concepts of Inflammation and Immunity

A 50-year-old client has arrived for a colonoscopy, and states she is worried that the gastroenterologist will find cancer. Which assessment finding would the nurse expect for a client who is in the early stages of colon cancer? Ascites Nothing, because colon cancer is asymptomatic in the early stages Rectal bleeding Abdominal tenderness

✅Nothing, because colon cancer is asymptomatic in the early stages Unfortunately, early colon cancer is only detected through colon cancer screenings. Abdominal tenderness Abdominal tenderness is a late-stage symptom of colon cancer. Early-stage colon cancer is asymptomatic. Ascites This is a late-stage symptom of colon cancer. Rectal bleeding This is a symptom of colon cancer that is not seen until the disease has progressed past the early stage.

You are the circulating nurse and when speaking to the client they casually state that a long time ago their mother had to be "cooled down" during surgery. Having knowledge of the risks associated with malignant hyperthermia, which of the following would be the best next action? Notify the pharmacy that you need cold IV solution available Notify anesthesia of the possibility of malignant hyperthermia Tell the client you suggest they cancel their procedure Have Dantrolene available in the operating room

✅Notify anesthesia of the possibility of malignant hyperthermia This is the next best action. Tell the client you suggest they cancel their procedure This an inappropriate response to the client. This procedure can still occur but anesthesia needs to be aware of the possible risk. Have Dantrolene available in the operating room Although this is an important treatment for malignant hyperthermia it is not the best next action. Notify the pharmacy that you need cold IV solution available Although this is an important treatment for malignant hyperthermia it is not the best next action 02.05 Malignant Hyperthermia

The nurse is caring for a client scheduled to have general anesthesia. While reviewing their chart the nurse notices that the client told the preoperative nurse that one of their family members temperature "went up really high" during surgery. Which of the following is the best next action for the nurse to take? Notify the surgeon of the possibility of malignant hyperthermia Ask the client for more information regarding this comment Call the director of surgery and request the case be cancelled Notify the anesthesia team of a possibility of malignant hyperthermia

✅Notify the anesthesia team of a possibility of malignant hyperthermia This is the most important action so the anesthesia team is aware of the risk. Notify the surgeon of the possibility of malignant hyperthermia Although this would be important to do it is more important to notify anesthesia first so they can be prepared and assess further. Ask the client for more information regarding this comment Although you would do this it is most important to notify anesthesia of the possibility of malignant hyperthermia. Call the director of surgery and request the case be cancelled This is not the correct action to take because surgery can still occur, but anesthesia needs to be aware of the risk. 02.02 General Anesthesia

5 of 18 An older adult client who is bedridden has a documented history of protein deficiency. For which condition will the nurse monitor and attempt to prevent? Decreased wound healing Melanoma Pressure injury development Bed bugs

✅Pressure injury development This client is at risk for developing pressure injuries related to protein deficiency if he or she remains bedridden. Melanoma and bed bugs have no correlation with this client's protein deficiency. The client does not have a wound that needs monitoring. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

The nurse receives a client to the unit from the post-anesthesia care unit for a craniotomy for a tumor biposy. The client was extubated approximately 45 minutes before arrival to the unit. The client has a right internal jugular central venous catheter and left radial arterial line that were placed during the case. The client's vitals are SpO2 89%, BP 95/60, HR 123, temp 97.5F oral, and RR 29. The client reports moderate chest discomfort, rating 6/10. As the nurse completes the client assessment, accessory muscle use during inspiration and expiration is noted. What is should be the nurse's first action? Discontinuation of the radial arterial line Notifying the provider of a possible pulmonary embolism STAT head CT without contrast STAT CBC

✅Notifying the provider of a possible pulmonary embolism This client has the classic presentation of a pulmonary embolism, including chest pain, accessory muscle use, and oxygen level <90%. The provider must be notified immediately for appropriate orders. STAT head CT without contrast This client is not demonstrating signs of a stroke, so a stat head CT is not indicated. Without an order from the provider, the nurse is not able to get a STAT head CT, as this is outside of the scope of practice of a registered nurse. Discontinuation of the radial arterial line There is no reason to discontinue the arterial line based on this client's signs and symptoms, and removing an arterial line without provider orders is outside of the scope of practice of a registered nurse. STAT CBC The nurse will need an order from the provider in order to obtain a STAT CBC. 03.02 Postoperative (Postop) Complications

10 of 13 Which nursing actions aid in the prevention and early detection of infection in a client at risk? (Select all that apply.) Select all that apply. Obtain cultures as needed. Remove unnecessary medical devices. Monitor the red blood cell (RBC) count. Inspect the skin for coolness and pallor. Promote sufficient nutritional intake. Encourage fluid intake, as appropriate.

✅Obtain cultures as needed. ✅Remove unnecessary medical devices ✅Promote sufficient nutritional intake. Promoting sufficient nutritional intake helps prevent and detect early infection in at risk clients. Nutrition has a direct correlation to improvement of general health. Malnutrition, especially protein-calorie malnutrition, places clients at increased risk for infection. Blood cultures would be used to detect a possible systemic infection. Advocating for the removal of unnecessary medical devices (e.g., intravascular or urinary catheters, endotracheal tubes, synthetic implants) may also interfere with normal host defense mechanisms and may help prevent infection. Inspecting the skin does not prevent or detect systemic infections. Fluid intake is important but does not directly relate to prevention or detection of infection. Monitoring the RBC count does not prevent, nor would it detect, infection. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? Omega-3 fatty acids Antioxidants Vitamins A, D, and C Beta-carotene

✅Omega-3 fatty acids Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels. Antioxidants Antioxidants are substances that occur naturally in many fruits and vegetables, as well as in nuts, grains, and even some meat, poultry, and fish. Beta-carotene, vitamins A, C, E, and selenium are some of the most commonly known antioxidants. Studies have suggested that antioxidants can slow or even prevent the development of cancer; however, they are not found in fish oil. Vitamins A, D, and C Vitamins A, D, and C are not substances found in fish oil. Beta-carotene Beta-carotene is the precursor to vitamin A. Beta-carotene functions as a fat-soluble antioxidant, which can help protect the body from deleterious free-radical reactions. It is not found in fish oil. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

The perioperative nurse is creating a sterile environment and is aware that sterile drapes create the sterile field. The nurse knows that which of the following is true of sterile drapes? Select all that apply. Once sterile drapes are applied they should not be moved Sterile drapes should be checked for holes or tears in the packaging before applying Sterile drapes are only applied to the operative client Sterile drapes should only be applied by a sterile provider Nothing on the client should show after sterile drapes are applied

✅Once sterile drapes are applied they should not be moved This is a true statement regarding sterile drapes. ✅Sterile drapes should only be applied by a sterile provider This is a true statement regarding sterile drapes. ✅Sterile drapes should be checked for holes or tears in the packaging before applying This is a true statement regarding sterile drapes. Nothing on the client should show after sterile drapes are applied The operative area should be able to be seen once the drapes are applied. Sterile drapes are only applied to the operative client Sterile drapes are also applied to a table for instruments and supplies. 02.07 Sterile Field

What medication class is given preoperatively with inhalation and IV anesthetics to help reduce pain?" Benztropine Opioids Fluranes Lidocaine Donepezil Ketamine

✅Opioids Opioids include morphine and fentanyl, and are given preoperatively together with inhalation and IV anesthetics to help reduce pain. IV Anesthetics

13 of 16 Which mechanism will the nurse consider the most likely cause of pure acute respiratory acidosis in a client who has bilateral pneumonia? Underelimination of bicarbonate ions Underproduction of hydrogen ions Overelimination of bicarbonate ions Overelimination of hydrogen ions Overproduction of hydrogen ions Underelimination of hydrogen ions Underproduction of bicarbonate ions Overproduction of bicarbonate ions

✅Overproduction of hydrogen ions Unlike metabolic acidosis, respiratory acidosis results from only one cause—retention of CO2, causing overproduction of free hydrogen ions. Bicarbonate is not involved as a cause or as a compensatory mechanism. Recall that carbon dioxide and hydrogen ions are directly related in human physiology. An increase in one always causes an increase in the other. Retention of CO2 is the problem, not failure of the body to directly eliminate hydrogen ions. Chapter 14 - Concepts of Acid-Base Balance

Which of the following types of wound drainage is most likely green, dark yellow, or brown in color and has a foul smell? Purulent Mucinous Pustulent Erythematous Serous Chronic

✅Purulent Purulent fluid indicates an infection. Characterized by green, dark yellow, and/or brown pus. Typically the wound would have a foul smell. Notify the provider if this is found on a patient. Wound Drainage Types and Devices

4 of 18 What effect does a "passenger" mutation in a gene have on cancer development? Passenger mutations do not affect cancer development but can serve as targets for specific cancer therapies. These mutations enhance the effectiveness of carcinogens causing direct DNA damage of a normal cell, increasing the likelihood of cancer development. These mutations protect against cancer development by reversing the effects of initiation. Passenger mutations are another term for proto-oncogene gene mutations.

✅Passenger mutations do not affect cancer development but can serve as targets for specific cancer therapies. Although passenger mutations are often found along with driver mutations in later cancer stages, they appear to have no effect on initial cancer development or cancer cell survival. Their presence can be used to identify advanced cancer types and may also be used as "targets" for newer cancer therapies Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

The PACU nurse is waiting for the client to arrive to the recovery unit from surgery. Based on nursing knowledge of postoperative clients, which of the following is the most important nursing action to perform first? Assess your client's surgical site Receive hand-off report from the anesthesia provider Perform an initial assessment that includes airway Receive hand-off report from perioperative nurse

✅Perform an initial assessment that includes airway This would be the most important initial nursing action when the client is first entering the post-anesthesia recovery unit. We must assess that the airway is patent, remember ABCs. Receive hand-off report from the anesthesia provider This would not be the most important initial nursing action. We must assess that the airway is patent, remember ABCs so performing an assessment that includes the airway would be the priority. Receive hand-off report from perioperative nurse This would not be the most important initial nursing action. We must assess that the airway is patent, remember ABCs so performing an assessment that includes the airway would be the priority. Assess your client's surgical site This would not be the most important initial nursing action. We must assess that the airway is patent, remember ABCs so performing an assessment that includes the airway would be the priority. 03.01 Post-Anesthesia Recovery

A 71-year-old client presents for care of exacerbation of lupus symptoms. Which of the following cardiac abnormalities should the nurse assess for that are most closely associated with lupus? Pericarditis Sinus bradycardia Ventricular tachycardia Cardiomyopathy

✅Pericarditis Systemic lupus erythematosus is an autoimmune disease that causes fatigue and skin changes, but can also be manifested in a number of different body systems, including the cardiovascular system. Potential cardiac abnormalities that may be noted with lupus include most commonly pericarditis, or inflammation of the sac surrounding the heart, vasculitis, or inflammation of the blood vessels, as well as myocarditis and myocardial infarction. Sinus bradycardia Lupus is a disease of inflammation, and bradycardia is not caused by the disease. Ventricular tachycardia Ventricular tachycardia is not a finding associated with lupus. Cardiomyopathy Cardiomyopathy is not caused by lupus.

17 of 18 Which warning signs of cancer would the nurse specifically teach in a wellness course directed to a group of older adults? (Select all that apply.) Select all that apply. Persistent hoarseness Severe heartburn Chronic diarrhea Loss of skin turgor Curd-like vaginal discharge Difficulty swallowing with meals

✅Persistent hoarseness ✅Severe heartburn ✅Chronic diarrhea ✅Difficulty swallowing with meals Change in bowel habits, persistent hoarseness, indigestion or difficulty swallowing are all potential warning signs of cancer. A curd-like vaginal discharge represents a yeast infection. Loss of skin turgor is a normal response to aging. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take? Recap the needle on the syringe. Schedule a nurse to administer future injections for this client. Explain to the client that the syringe should be disposed of in the bathroom trash can. Place the syringe in a puncture-proof disposal container.

✅Place the syringe in a puncture-proof disposal container. The nurse should place the uncapped syringe in a puncture-proof sharps disposal container or rigid plastic container to prevent a needlestick injury. The nurse should keep the syringe uncapped to prevent a needlestick injury while placing the cap on the needle. The nurse should then provide client education on safety and proper disposal of syringes. Recap the needle on the syringe. The nurse should not recap the needle because of the risk of a needlestick injury during this action. Schedule a nurse to administer future injections for this client. The nurse should not schedule another nurse to administer future injections for this client. The nurse should teach the client about potential injuries and infections that can result from a needlestick injury. After exploring the client's reasons for nonadherence to safety measures, the nurse should review appropriate methods of disposal for used syringes. Explain to the client that the syringe should be disposed of in the bathroom trash can. The nurse should not instruct the client to dispose of used syringes in a bathroom trash can due to the risk for a needlestick injury when handling the trash. RN Learning System Medical-Surgical: Final Quiz

2 of 16 Which cell types provide protective responses during inflammation? Natural killer cell Basophils Eosinophils Platelets Macrophages Neutrophils

✅Platelets Macrophages and neutrophils initiate and complete phagocytosis against invading microorganism, providing the body with protection against infection. Natural killer cells are not particularly active during inflammation. Eosinophils and basophils are responsible for vascular changes, not protection. Platelets have no direct role in the protection provided by inflammation. Chapter 16 - Concepts of Inflammation and Immunity

Postoperative Fever Which of the following diseases or disorders may most likely occur within postoperative days 1-3? Hypervolemia C. Difficile Pulmonary Embolism (PE) Pneumonia Candida Deep Vein Thrombosis (DVT)

✅Pneumonia Within postoperative days 1-3 pneumonia is usually the next diagnosis if atelectasis does not resolve after treatment. In order to diagnose pneumonia, we look for infiltration on chest X-ray, and obtain sputum culture in order to treat with antibiotics.

14 of 16 With which client conditions will the nurse expect an inflammatory response without infection? (Select all that apply.) Select all that apply. Poison ivy rash Otitis media Welt formation after a bee sting Blister formation from a burn Blister from a cold sore Acute myocardial infarction

✅Poison ivy rash ✅Welt formation after a bee sting ✅Blister formation from a burn ✅Acute myocardial infarction Inflammation is nonspecific response to tissue injury, irritation, and invasion by organisms or allergens. Options A, B, C, and E have tissue injury, irritation, or invasion as the pathophysiologic mechanism causing the response. Otitis media is an inflammation occurring with a bacterial or viral infection. Blister formation with a cold sore occurs as in response to the presence of the Herpes simplex virus and is highly infectious. Chapter 16 - Concepts of Inflammation and Immunity////Chapter 17 Principles of Inflammation and Immunity

The parents of a 6-month-old infant have brought the child in for a routine well-child check. The parents want to know what immunizations their child should get at this visit. According to the Centers for Disease Control and Prevention recommendations, which vaccines should the child get at this age? Select all that apply. Polio Hepatitis B DTaP Varicella MMR

✅Polio The Centers for Disease Control and Prevention have recommendations for the type of immunizations a person should get based on age. A 6-month-old client should receive different immunizations when compared to an older child. For a 6-month old infant, the nurse would most likely need to administer DTaP, polio, Hib, and yearly influenza, as well as hepatitis B if the child has not received it. ✅Hepatitis B A 6-month-old client should receive the Hepatitis B immunization. ✅DTaP A 6-month-old client should receive the DTaP immunization. MMR The MMR immunization is routinely given at the 12 month visit. Varicella The Varicella immunization is routinely given at the 12 month visit.

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? Position the client supine with his legs elevated when in bed. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr. Tell the client to sit with his legs dependent after ambulating. Instruct the client to wear knee-length socks for 2 weeks after surgery.

✅Position the client supine with his legs elevated when in bed. The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr. The nurse should encourage the client to ambulate 5 to 10 min every hour while awake to prevent venous stasis. Tell the client to sit with his legs dependent after ambulating. The nurse should discourage the client from sitting or standing for any duration to prevent venous stasis. Feet should be elevated above the heart to prevent venous stasis. Instruct the client to wear knee-length socks for 2 weeks after surgery. The nurse should instruct the client to wear graduated compression stockings for up to 1 week after surgery to promote venous return. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

Question 1 of 10 A client has just finished surgery and is coming to the PACU for recovery. Postoperative hypothermia is a complication of the surgical client and the nurse knows that which of the following is true regarding this complication? Select all that apply. Evisceration can cause postoperative hypothermia Shorter surgeries increase the risk of postoperative hypothermia Postoperative hypothermia can prolong recovery time Anesthesia can cause postoperative hypothermia Fluid shift during surgery can cause postoperative hypothermia

✅Postoperative hypothermia can prolong recovery time This is true of postoperative hypothermia. If the client is hypothermic this will prolong the recovery as the client is rewarmed. ✅Anesthesia can cause postoperative hypothermia This is true of postoperative hypothermia. ✅Fluid shift during surgery can cause postoperative hypothermia This is true of postoperative hypothermia. As blood is lost from surgery this causes heat loss. Evisceration can cause postoperative hypothermia Evisceration does not cause postoperative hypothermia. This is the removal of organs which will not cause hypothermia. Shorter surgeries increase the risk of postoperative hypothermia Longer surgeries increase the risk of postoperative hypothermia. The longer the client is in surgery the more of a chance for increased blood loss, longer anesthesia, and the client is "open" longer which will increase heat loss. 03.02 Postoperative (Postop) Complications

What mechanism of action or pharmacological action is best associated with propofol? NMDA Receptor Agonist Potentiates GABA-A NMDA Receptor Antagonist Increased Acetylcholine 5-HT Agonist Increased Duration of Cl- Channel Opening

✅Potentiates GABA-A Propofol potentiates GABA-A, and leads to rapid anesthesia induction.

The perioperative nurse is aware that surgical clients are at risk for complications associated with fluid volume and know the reasons why are which of the following? Select all that apply Blood loss Preoperative NPO Status Stress response of surgery Preoperative antibiotics Fluid shifts

✅Preoperative NPO Status This is a reason surgical clients are at risk for fluid volume issues. They have not eaten or drank anything for several hours so they start off dehydrated. ✅Fluid shifts This is a reason surgical clients are at risk for fluid volume issues. In surgery, the tissue is cut so fluid shifts out from the intravascular space. ✅Stress response of surgery This is a reason surgical patients are at risk for fluid volume issues. The stress response can cause fluid to be retained which could cause complications. ✅Blood loss This is a reason surgical patients are at risk for fluid volume issues. Clients lose blood in surgery which is part of their fluid volume. Preoperative antibiotics This is not a reason surgical patients are at risk for fluid volume issues 02.09 Intraoperative (Intraop) Complications

A perioperative nurse works in surgery and is prepping a client for the procedure. The nurse understands that prepping the surgical site properly with no contaminated areas means which of the following? Prepping from the periphery to the incision site Prepping from the "dirty" area to the "clean" area Prepping from the incision site to the periphery Prepping from cleanest to least clean

✅Prepping from the incision site to the periphery This is the proper way to prep an area that does not include an area of contamination. Prepping from the periphery to the incision site This is not cleaning the dirt away from the site, instead, it is bringing it towards the site. Prepping from the "dirty" area to the "clean" area This is the improper way to prep an area that does not include an area of contamination. Prepping from cleanest to least clean This is an appropriate action when prepping a surgical site that includes a contaminated area. 02.06 Surgical Prep

A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? Raising the bed linens off the client's feet to prevent plantar flexion Keeping the client's heels off the bed to prevent pressure ulcers Positioning the client off of the operative site while in bed Preventing dislocation of the hip during position changes or movement

✅Preventing dislocation of the hip during position changes or movement Following surgery, the nurse should use an abduction pillow to prevent dislocation of the new hip joint. The nurse should place the wedge-shaped pillow between the client's legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body during position changes or client movement, which can lead to subluxation or total dislocation of the hip joint Raising the bed linens off the client's feet to prevent plantar flexion If the client is at risk for plantar flexion resulting in foot drop, the nurse should place a foot cradle at the foot of the bed to raise the bed linens off the feet. Keeping the client's heels off the bed to prevent pressure ulcers The nurse should use regular bed pillows to keep the client's heels off the bed to prevent shearing and skin breakdown. Positioning the client off of the operative site while in bed The nurse should use regular pillows and rolled blankets to position the client off of the operative site while in bed. RN Learning System Medical-Surgical: Final Quiz

There are four clients in the preoperative holding area who are scheduled for a procedure under moderate sedation. The nurse knows that a client with which of the following would be most concerning to the anesthesiologist for proper ventilation during the procedure? A surgical history of a tonsillectomy History of ovarian cancer and hypertension A BMI of 20 and missing teeth Previous cervical fusion and BMI of 35

✅Previous cervical fusion and BMI of 35 Neck extension issues and elevated BMI can create ventilation concerns. This is more weight around the neck and more weight on the client as well as a cervical fusion that might make tilting the head difficult. A surgical history of a tonsillectomy This client with the given information does not have ventilation concerns. A BMI of 20 and missing teeth Even though this client does have missing teeth which can create issues with ventilation, the client with a cervical infusion would have concerns about neck extension for proper ventilation as well as increased weight. cancel History of ovarian cancer and hypertension This client with the given information does not have ventilation concerns. Ventilation concerns would be a client that has a cervical fusion and elevated BMI.

The nurse is caring for a client who is in respiratory distress and is at a high risk of losing the airway. The doctor decides to intubate the client. The nurse knows that which medication will be given first? Vecuronium Rocuronium Propofol Succinylcholine

✅Propofol Propofol is a non-barbituate intravenous anesthetic, and is given first. After this, a neuromuscular paralytic will be given. Rocuronium This is a paralytic, given after the client has received propofol. Succinylcholine This is a commonly used paralytic in anesthesia induction, and is given after the client has received propofol for sedation. Vecuronium This is a paralytic medication that can be used to facilitate intubation, but is given after sedation. 02.01 Intubation in the OR

A nurse in the ICU is caring for a client who is intubated and sedated on a ventilator after a motor vehicle collision. The client requires significant pain control, but is ready to be extubated. Which medication order should be clarified before the client is extubated? 5 mg oxycodone PO q6hr PRN 50 mcg fentanyl IV q1hr PRN 1 mg hydromorphone IV q4hr PRN Propofol 10 mcg/kg/min IV

✅Propofol 10 mcg/kg/min IV Propofol is an anesthetic/sedative and should NOT be administered to anyone without an advanced airway. This order needs to be clarified and discontinued before the client is extubated. 50 mcg fentanyl IV q1hr PRN This order would be appropriate for pain management for a client after an MVC. The nurse would simply need to monitor the client's respiratory status related to the opioid use. 5 mg oxycodone PO q6hr PRN This order would be appropriate for pain management. The priority would simply be to ensure the client can safely swallow before administering medications PO. 1 mg hydromorphone IV q4hr PRN This would be appropriate for a client who has been in a motor vehicle collision. The nurse would need to monitor respiratory status. 02.01 Intubation in the OR

A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? Prothrombin time WBC count Platelet count Hematocrit

✅Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time. WBC count The nurse should review the client's WBC count if there is a possible infection. Platelet count The nurse should review the client's platelet count following administration of platelets. Hematocrit The nurse should review the client's hematocrit following the administration of packed red blood cells. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

10 of 13 The nurse observes multiple small pits in all of a client's fingernails. The nurse suspects that the client may have which condition? Prolonged febrile illness Cystic fibrosis Psoriasis Iron deficiency anemia

✅Psoriasis Pitting of the fingernails may be seen in clients with psoriasis and alopecia areata. It can involve several or all of the fingernails and also be associated with plate thickening and onycholysis. Late clubbing of the fingernails is a sign of cystic fibrosis. Spoon nails (koilonychias) are a sign of iron deficiency anemia. Beau grooves are a sign of prolonged febrile illness. Chapter 22 //Chapter 24 -Assessment of the Skin, Hair, and Nails

16 of 25 Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? Chvostek sign is negative. Respiratory rate is 22 breaths/min. Pulse rate is 76 beats/min and regular. Hematocrit is 42%.

✅Pulse rate is 76 beats/min and regular. Hyperkalemia affects cardiac conduction inducing tall T-waves, widened QRS complexes, absent P waves, prolonged PR intervals, bradycardia, and heart block. A heart rate that is regular and within the client's normal range for rate indicates resolution of the hyperkalemia. The normal respiratory rate does not indicate resolution of the hyperkalemia. Chvostek sign is present with hypocalcemia, not hyperkalemia. The hematocrit is not affected by hyperkalemia or its management. Chapter 13 - Concepts of Fluid and Electrolyte Balance

The nurse is caring for a client who is newly diagnosed with prostate cancer. The client asks the nurse which treatment will be recommended. Which of the following treatments are targeted therapy usually used for this type of cancer? Select all that apply. Radiation Surgery Immunotherapy Chemotherapy Hormone therapy

✅Radiation This is targeted therapy used for localized prostate cancer. ✅Surgery This is targeted cancer treatment that is used for both localized and metastatic disease. Hormone therapy Hormone therapy is a systemic therapy used for clients whose prostate cancer has metastasized to other areas of the body. Chemotherapy Chemotherapy is used in systemic cancer, but not typically utilized in localized prostate cancer. Immunotherapy This is a type of cancer treatment used in systemic cancers.

Question 2 of 3 The PACU nurse understands that the success of discharge teaching can depend greatly on which of the following? Select all that apply Readiness of the client to learn Pain level of the client Environment free from distractions Age of the client Education level of client

✅Readiness of the client to learn ✅Pain level of the client ✅Environment free from distractions ✅Age of the client ✅Education level of client These are factors that can determine the success of discharge teaching. The age of the client will determine if they are capable of receiving the instructions. The client must be in a state that is ready to learn so they will obtain the information and be able to listen. The client's pain level should be comfortable so they do not have distractions from education. And the environment must be free of distractions for learning. 03.04 Discharge (DC) Teaching After Surgery

11 of 17 What is the nurse's best first action on finding the client's oxygen saturation by pulse oximetry on the finger is 84%? Apply supplemental oxygen by mask or nasal cannula. Notify the Rapid Response Team immediately. Assess the client's cognitive function. Recheck the value on the forehead.

✅Recheck the value on the forehead. Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented Chapter 24 /Chapter 27 - Assessment of the Respiratory System

16 of 17 Which client conditions will the nurse recognize as most likely to cause a "right shift" of the oxyhemoglobin dissociation curve? (Select all that apply.) Select all that apply. Reduced blood and tissue levels of oxygen Alkalosis Increased metabolic demands Reduced blood and tissue levels of diphosphoglycerate (DPG) Increased body temperature Reduced blood and tissue pH

✅Reduced blood and tissue levels of oxygen ✅Increased metabolic demands ✅Increased body temperature ✅Reduced blood and tissue pH The oxyhemoglobin dissociation curve is shifted to the right when conditions are present that increase overall oxygen needs. This right shift makes it easier for oxygen to dissociate from the hemoglobin molecule. Such conditions are those associated with higher metabolism and oxygen need. These include increased body temperature, increased metabolic demand, hypoxia, and acidosis (low pH with higher concentration of hydrogen ions. Reduced DPG and alkalosis (fewer hydrogen ions) are associated with increased oxygen need and a left shift in the oxyhemoglobin dissociation curve. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

1 of 17 How will the nurse expect a client's age-related decreased skeletal muscle strength to affect gas exchange? Reduced gas exchange as a result of decreased alveolar surface Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue

✅Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

10 of 14 The nurse is preparing a personal readiness "go bag". Which essential item will the nurse include for personal preparedness? (Select all that apply.) Select all that apply. Regional map Potable water Fruit Personal identification materials Cell phone Laptop computer Radio

✅Regional map ✅Potable water ✅Personal identification materials ✅Cell phone ✅Radio The "go bag" contains items that will help the nurse participate in a rapid response for disaster staffing coverage. The items that should be contained in a "go bag" include items in Table 12-3. Fruit is perishable and should not be included. The nurse will not have room for a laptop computer, yet should bring a cell phone and charger. Chapter 12- Concepts of Disaster Preparedness

15 of 16 Which precautions are most important for the nurse to teach as part of health promotion for inflammation and immunity to an 88-year-old client? (Select all that apply.) Select all that apply. Report any temperature elevation to your primary health care provider immediately. Get an influenza vaccination every year. Wear gloves when working in your garden. Avoid performing any level of aerobic exercise. Consider moving into an assisted living facility. Be sure to have a tuberculosis skin test every year.

✅Report any temperature elevation to your primary health care provider immediately. ✅Get an influenza vaccination every year. ✅Wear gloves when working in your garden. Older clients have overall reduced immunity and a higher risk for developing influenza and any other respiratory tract infection. They should receive annual influenza vaccinations. The skin of older adults is thinner, drier, and a greater risk for injury and infection. Wearing gloves when gardening can help prevent injury and reduce the risk for infection. Older clients often do not have greatly elevated temperatures during infection, which contributes to the infection being overlooked until it becomes serious. Thus, older clients should report any increase in temperature above their normal range to identify infections at earlier stages. TB skin tests may be falsely negative in older clients with reduced immunity and annual testing is of no real benefit. Healthy older clients who are cognitively intact and able to care for themselves have no need to change their living arrangements unless they so desire. Older clients can still engage in low-impact aerobic exercise under the supervision of their primary health care provider. Chapter 16 - Concepts of Inflammation and Immunity////Chapter 17 Principles of Inflammation and Immunity

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? Reports having a bowel movement daily. ECG shows an inverted T wave. Fasting blood glucose level is 106 mg/dL. Two lb weight gain during the past week.

✅Reports having a bowel movement daily. Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. Gaining 2 lb in a week does not indicate effective management for hypokalemia. An inverted T-wave is associated with worsening hypokalemia. The fasting blood glucose level is not related to recovery from hypokalemia. Chapter 13 - Concepts of Fluid and Electrolyte Balance

In a patient being administered benzodiazepines for IV anesthesia, which of the following side effects is most likely to be seen? Hyperthermia Respiratory Depression Bizarre Sleep Behaviors Kussmaul Respirations CNS Stimulation Hypertension

✅Respiratory Depression Midazolam, used as amnestic with other anesthetics, has a side effect of severe postoperative respiratory depression. IV Anesthetics

11 of 16 Which acid-base disturbance will the nurse remain alert for when caring for a client who has chest burns with tight eschar banding the chest? Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

✅Respiratory acidosis The tight eschar on the chest can limit chest movement and make breathing less effective with hypoventilation. This problem results in inadequate oxygenation and retention of carbon dioxide, causing respiratory acidosis. Respiratory alkalosis is caused by hyperventilation, increased rate or depth of breathing, causing carbon dioxide to be eliminated in excess. Metabolic acid-base disturbances are usually caused by nonrespiratory issues. Chapter 14 - Concepts of Acid-Base Balance

In which activity does the nurse anticipate participating in during a disaster event debriefing? (Select all that apply.) Select all that apply. Review of staff performance during the disaster Triage of affected clients according to injury type Collaboration regarding system effectiveness for improvement Calling in specialty-trained providers to assist with efforts Contact with the medical command physician to ensure staffing

✅Review of staff performance during the disaster ✅Collaboration regarding system effectiveness for improvement Two general types of debriefing, or formal systematic review and analysis, occur after a mass casualty incident or disaster. The first type entails bringing in crisis support teams to provide sessions for small groups of staff to promote effective coping strategies. The second type of debriefing involves an administrative review of staff and system performance during the event to determine whether opportunities for improvement in the emergency management plan exist. Contact with the medical command physician to ensure staffing, calling in specialty-trained providers to assist with efforts, and triaging of affected clients takes place during the disaster response, not during a disaster event debriefing. Chapter 12- Concepts of Disaster Preparedness

Which of the following types of wound drainage is bright red and is associated with active bleeding, poor wound healing, or reinjury? Sanguineous Seropurulent Serous Mucinous Malignant Purulent

✅Sanguineous Sanguineous fluid is bright red drainage. Can indicate active bleeding and can signify poor wound healing or reinjury. Can happen after a dressing change if the dressing is stuck to the wound. If there is an increase in the amount of drainage, notify the provider. Wound Drainage Types and Devices

11 of 18 Which precaution is a priority to prevent harm for the nurse to teach a client with systemic lupus erythematosus (SLE) who is newly prescribed to take hydroxychloroquine for disease management? See your ophthalmologist for visual field testing every 6 months. Report a reduction of joint swelling to your rheumatology health care provider immediately. Report a worsening of joint swelling to your rheumatology health care provider immediately. See your ophthalmologist for intraocular pressure measurement every 6 months.

✅See your ophthalmologist for visual field testing every 6 months. Hydroxychloroquine has both immunomodulating and anticlotting effects that can be beneficial to clients with SLE. A major complication of this drug is its toxicity to retinal cells causing retinitis that can lead to an irreversible loss of central vision. Clients prescribed hydroxychloroquine are instructed to have frequent eye examinations with visual field testing (before starting the drug and every 6 months thereafter). If retinal toxicity is suspected, the drug is discontinued to preserve the remaining vision. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

4 of 20 The nurse is preparing to insert a peripheral venous catheter. What action will the nurse take? Select the most distal site. Look near the elbow joint first. Palpate for hardness of a vein. Use the client's dominant arm for insertion.

✅Select the most distal site. The nurse will choose the most distal site and make all subsequent venipunctures proximal to previous sites. The nurse will not palpate for hard or cordlike veins as these are not ideal for cannulation. The nurse will use the client's nondominant arm and avoid areas of joint flexion. Chapter 15 - Concepts of Infusion Therapy

The community health nurse is teaching a class on early detection of testicular cancer. The nurse accurately teaches the class all of the following points except which? Self-exams should begin at age 20 A feeling of fullness in the pelvis is a sign of later stages of testicular cancer The sooner testicular cancer is detected, the less aggressive treatment will be needed A hard, non-movable lump is concerning for cancer

✅Self-exams should begin at age 20 This is not an accurate teaching point. Testicular self-exams are recommended to start at puberty. A hard, non-movable lump is concerning for cancer If the client notices a change to the testicle, and there is a hard mass or lump that does not move, the client needs to be seen for an evaluation because this is suspicious for cancer. The sooner testicular cancer is detected, the less aggressive treatment will be needed This statement is a helpful teaching point. When caught early, this type of cancer is highly curable with minimal treatment. A feeling of fullness in the pelvis is a sign of later stages of testicular cancer This is an accurate statement regarding testicular cancer.

17 of 17 For which symptoms would a nurse assess a client who worries a thoracentesis earlier today may have caused a pneumothorax? (Select all that apply.) Select all that apply. Slowing heart rate Sensation of air hunger Pain at the insertion site Cyanosis of oral mucous membranes Wheezing on inhalation and exhalation Tracheal deviation

✅Sensation of air hunger Signs and symptoms of a pneumothorax include sensation of air hunger, tracheal deviation, and cyanosis. Other symptoms include pain on the affected side (not at the needle insertion site), rapid heart rate, rapid, shallow respirations, prominence of the affected side that does not move in and out with respiratory effort, and new onset of "nagging" cough. Wheezing is a bronchial and bronchiolar problem. It is not produced as a result of a pneumothorax. Chapter 24 /Chapter 27 - Assessment of the Respiratory System

11 of 18 The nurse is evaluating the effectiveness of interventions for pressure injury management. Which laboratory will the nurse monitor? Calcium Serum albumin Numbers of immature white blood cells (WBCs) Hematocrit

✅Serum albumin Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian. Calcium, hematocrit, and WBC readings do not relate to successful pressure injury management. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

10 of 16 Which laboratory value will the nurse check immediately to prevent harm for a client with metabolic alkalosis who now has a positive Chvostek sign? Serum calcium Serum magnesium Serum glucose level Serum sodium

✅Serum calcium A positive Chvostek sign is associated with alkalosis accompanied by a low serum calcium level. The hypocalcemia cause overexcitement of the nervous system with dizziness, agitation, confusion, and hyperreflexia, which may progress to seizures. Tingling or numbness may occur around the mouth and in the toes. If the client has hypocalcemia, the nurse must report the finding immediately to the health care provider so actions can be taken to prevent harm. Chapter 14 - Concepts of Acid-Base Balance

A nurse is working with a client who wants to quit smoking. Which of the following information should the nurse advise for the client that may be more likely to help with smoking cessation? Each year, give yourself a reward for staying tobacco free If a relapse occurs, you did something that couldn't overcome the desire to smoke Set a formal date to quit smoking Choose something to eat instead of smoking

✅Set a formal date to quit smoking Health and wellness promotion are common topics of nursing education and many nurses must give information to clients who desire to improve their lives by making healthy decisions. If the nurse is working with a client who is trying to quit smoking, the nurse can help set clear goals, such as by setting a date to quit and then sticking with it, providing rewards after staying tobacco free for short periods, or understanding that relapses are common. Choose something to eat instead of smoking Replacing smoking with a food can turn into a food addiction. The client should not be encouraged to replace one bad habit with another. Each year, give yourself a reward for staying tobacco free Going an entire year for a reward puts too much time in between rewards, but smaller, more frequent rewards can be more effective. If a relapse occurs, you did something that couldn't overcome the desire to smoke Relapses are expected, and the client should not be set up for a sense of failure if this occurs.

A client is scheduled for a procedure that requires stirrup positioning. The perioperative nurse is aware that certain complications occur. Which of the following can result from this positioning? Select all that apply Pressure injury Excessive blood loss Deep vein thrombosis Shearing Nerve injury to the extremities

✅Shearing This is a complication of positioning. Shearing is caused by friction as the client slides. Nerve injury occurs because the stirrups can pinch a nerve. Excessive blood loss This is a complication of surgery but not of this positioning. ✅Nerve injury to the extremities This is a complication of positioning. Nerve injury can occur from legs s being in a still bent position that could pinch a nerve ✅Deep vein thrombosis This is a complication of positioning. Deep vein thrombosis occurs because of the legs being in a still bent position. ✅Pressure injury This is a complication of positioning. Pressure injuries can occur from positions being used that cause a lack of blood flow and the client is not moving to relieve that pressure. 02.09 Intraoperative (Intraop) Complications

9 of 20 The nurse is teaching a course about the special needs of older adults receiving IV therapy. What teaching will the nurse include? To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter improves success with venipuncture. Placement of the catheter on the back of the client's dominant hand is preferred. When the catheter is inserted into the forearm, excess hair should be shaved before insertion. Skin integrity can be compromised easily by the application of tape or dressings.

✅Skin integrity can be compromised easily by the application of tape or dressings. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity. Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping, and not shaving, the hair around the insertion site typically is necessary only for younger men. Chapter 15 - Concepts of Infusion Therapy

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? Sodium 132 mEq/L (mmol/L) Potassium 3.5 mEq/L (mmol/L) Sodium 148 mEq/L (mmol/L) Potassium 5.3 mEq/L (mmol/L)

✅Sodium 148 mEq/L (mmol/L) Normal serum sodium ranges between 136 and 145 mEq/L (mmol/L). Hypernatremia is a serum sodium value greater than 145 mEq/L (mmol/L). In option A, the serum potassium is normal. In options C, the serum potassium value is above normal and indicates hyperkalemia. In option B, the serum sodium value is low, reflecting hyponatremia. Chapter 13 - Concepts of Fluid and Electrolyte Balance

A 21-year-old client slipped and fell into the community swimming pool, and does not resurface. What does the lifeguard, who is a nurse, do after the rescue when the client is unconscious? Initiate airway clearance. Deliver abdominal thrusts to clear lungs of water. Begin chest compressions. Stabilize the spine.

✅Stabilize the spine. The appropriate action by the lifeguard, who is a nurse, is to initiate airway clearance. Stabilizing the spine is not necessary for all drowning victims; only those at high risk for spine trauma. No attempt should be made to remove water from the lungs. Chest compressions would not be delivered unless indicated. Chapter 11 - Concepts of Care for Patients With Common Environmental Emergencies

16 of 20 When flushing a client's central line with normal saline, the nurse feels resistance. Which action will the nurse take first? Decrease the pressure being used to flush the line. Use "push-pull" pressure applied to the syringe while flushing the line. Obtain a 10-mL syringe and reattempt flushing the line. Stop flushing and try to aspirate blood from the line.

✅Stop flushing and try to aspirate blood from the line. The nurse's first step is to stop flushing and try to aspirate blood from the line. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus. Decreasing the pressure to flush the line is not appropriate. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation Chapter 15 - Concepts of Infusion Therapy

7 of 18 Which client circumstance would prompt the nurse to create a three-generation pedigree to more fully explore the possibility of increased genetic risk for cancer? Smoked for 20 years but quit 5 years ago Personal history of excessive sun exposure Most family adult members are overweight Strong family history of breast cancer

✅Strong family history of breast cancer Breast cancer can be sporadic, familial, or inherited. A strong family history of breast cancer should be explored for ages of breast cancer discovery and any discernable pattern of inheritance to determine whether genetic counseling is appropriate. Smoking, sun exposure, and being overweight are all considered environmental or lifestyle risks for cancer, not an increased genetic risk. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

During a mass casualty, which client condition does the nurse prioritize for care? Open fracture of the left forearm Sucking chest wound Sprained ankle Abdominal evisceration

✅Sucking chest wound A sucking chest wound receives care first during a mass casualty. This type of injury is a red tag, or emergent, injury because it can be quickly resolved until further help can be given. The abdominal evisceration would be considered a black tag because of the amount of time it would require to provide adequate care. The open fracture of the left forearm would be yellow tagged. The injury requires care but can wait. The sprained ankle would be green tagged and considered "walking wounded." Chapter 12- Concepts of Disaster Preparedness

Which of the following treatment modalities is not recommended for a patient with late-stage Small Cell Lung Cancer? Surgical Removal Chemotherapy Palliative Care Radiation Therapy

✅Surgical Removal Radiation Therapy Chemotherapy Palliative Care

A nurse caring for a client diagnosed with lung cancer knows that which of the following treatment modalities is not recommended for a client with late-stage small cell lung cancer? Surgical removal Palliative care Radiation therapy Chemotherapy

✅Surgical removal Lung cancer metastasizes too quickly, and clients are often not surgical candidates at the time of diagnosis. A client with late-stage small cell lung cancer would not be a surgical candidate. Radiation therapy Clients with many types of late-stage cancers benefit from the localized effects of radiation. Chemotherapy Late-stage cancers are often treated with chemotherapy because it is systemic, meaning that it circulates through the entire body targeting widely spread cancer cells. Palliative care Clients with all stages are a candidate for palliative care, which includes symptom management and survivorship care.

A 92-year-old client with a history of smoking and COPD is found to have developed prostate cancer. The cancer is localized. The nurse knows that prostate cancer in this type of client will most likely be treated in which of the following ways? Symptom management Radical prostatectomy Chemotherapy and radiation only No treatment will be recommended

✅Symptom management An older adult who develops prostate cancer is usually treated for symptom management only. This client has COPD, and likely will not tolerate general anesthesia for surgery. Aggressive treatment is rarely sought or recommended in the older adult population. Radical prostatectomy This client is considered to have a low-grade prostate cancer. A client of advanced age who develops this type of cancer is rarely treated aggressively, because this will alter the client's ability to urinate normally, as well as create problems with activities of daily living. Symptom management is usually recommended rather than removal of the prostate. Chemotherapy and radiation only The client may receive radiation for symptom management, but systemic chemotherapy would be difficult for this client to recover from due to advanced age and comorbidities. No treatment will be recommended The treatment strategy for an older adult client with comorbid conditions and a localized cancer is usually symptom management for urinary symptoms and pain.

The nurse is assessing a client and observes a butterfly rash. The nurse knows that this is a sign of which of the following conditions? Multiple sclerosis Sickle cell crises Systemic lupus erythematosis Rheumatoid arthritis

✅Systemic lupus erythematosis A butterfly rash is a rash over the nose and cheeks, and is a sign of systemic lupus erythematosis. Sickle cell crises Signs of sickle cell crisis include swollen hands and feet, fatigue, jaundice and pain due to the anemia and clumping of red blood cells. Multiple sclerosis Signs of MS include tremors, fatigue and pain. Rheumatoid arthritis Signs of RA include pain and stiffness in the joints.

You are the perioperative nurse caring for a client under general anesthesia. The nurse anesthetist is concerned that the client is showing signs of malignant hyperthermia. You would expect to see which of the following signs and symptoms? Select all that apply. Metabolic alkalosis Tachycardia Bradycardia Rigidness Increase in body temperature

✅Tachycardia This is a sign of malignant hyperthermia. Bradycardia This is not a sign of malignant hyperthermia. Tachycardia is a sign of malignant hyperthermia. ✅Increase in body temperature This is a sign of malignant hyperthermia. ✅Rigidness This is a sign of malignant hyperthermia. Metabolic alkalosis This is a not a sign of malignant hyperthermia, metabolic acidosis is a sign 02.05 Malignant Hyperthermia

7 of 14 Which laboratory test does the nurse analyze to determine the effectiveness of combination antiretroviral drug therapy in an HIV-positive client? Viral load testing Enzyme-linked immunosorbent assay Fourth generation testing Western blot analysis

✅Viral load testing Only viral load testing directly measures the actual amount of HIV viral RNA particles present in 1 mL of blood. Changes in the number indicate therapy effectiveness. Higher numbers indicate lack of effectiveness and lower numbers indicate the drugs are working. The other tests are used to determine whether the client is infected with HIV and do not change with therapy. Chapter 17 - Concepts of Care for Patients With HIV Disease

7 of 13 Which information does the nurse include when teaching a client about antibiotic therapy for infection? Take antibiotics until symptoms subside, and then stop taking the drugs. Share antibiotics with family members who develop the same infection. Take all antibiotics as prescribed, unless adverse effects develop. Take antibiotics when symptoms of infection develop.

✅Take all antibiotics as prescribed, unless adverse effects develop. Antibiotics should be taken as prescribed until they are gone. Teach the client about possible side effects and allergic manifestations. The primary health care provider must be contacted immediately if any adverse effects develop. Antibiotics must be taken until they are gone, even if the client feels better or when symptoms of infection appear. They should be taken only by the person for whom they are prescribed and not shared with anyone else. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which activity is most important for the emergency department (ED) charge nurse to initiate at this time? Evaluate staff members for increased stress. Follow up with survivors to determine the need for additional referrals. Analyze the ED response to the mass casualty incident. Take inventory and restock the ED with supplies and equipment.

✅Take inventory and restock the ED with supplies and equipment. The most important priority for the ED charge nurse at this time is to take inventory and restock the ED to return to normal operation. Analysis of the ED response, evaluating staff members for stress, and follow-up with survivors and referrals can occur after the ED is restored to operational status. Chapter 12- Concepts of Disaster Preparedness

The nurse knows that ventilation and oxygenation are critical when the surgical client is under general anesthesia. The nurse knows that which of the following safety measures are taken to ensure client safety during intubation? Select all that apply. Apply tape to eyes to protect the client from corneal abrasions Tape the endotracheal tube to patient Inflate the cuff of the endotracheal tube Check for condensation in the tube Check placement of the endotracheal tube

✅Tape the endotracheal tube to patient This is a safety measure that applies to intubation. ✅Inflate the cuff of the endotracheal tube This is a safety measure that applies to intubation. ✅Check placement of the endotracheal tube This is a safety measure that applies to intubation. ✅Check for condensation in the tube This is a safety measure that applies to intubation. Apply tape to eyes to protect the client from corneal abrasions Although this is important it is not directly related to intubation. 02.01 Intubation in the OR

The nurse is caring for a client who stepped on a rusty nail. The client does not want to receive medications if possible. The nurse educates the client on which of the following important medications to receive? Vancomycin Morphine Bacitracin Tdap

✅Tdap The Tdap vaccine provides immunity against tetanus, diptheria, and pertussis. Tetanus is a bacteria that enters through a broken skin barrier when exposed to a contaminated item. Tetanus is in soil, dust, and manure, and once colonized, causes the continuous contraction of muscles, or tetany. Morphine A client can refuse any medical treatment or medication. If the client does not want pain medication, they will be in pain. However, the tetanus vaccine is most important to give. Bacitracin This is an antibiotic ointment, but would not be effective against tetanus if the client has a deep puncture wound. The client needs the tetanus shot, found in the Tdap vaccine as the priority. Vancomycin Vancomycin is not effective against tetanus.Antibiotics that may be used include penicillin G, metronidazole and doxycycline.

A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect? Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. The client is experiencing premature ventricular complexes at 12/min. Telemetry monitoring shows pacing spikes with no QRS complexes. The client is experiencing hiccups.

✅Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min, because the client's intrinsic rate overrides the set rate of the pacemaker. The client is experiencing premature ventricular complexes at 12/min. The nurse should report when the client is displaying frequent premature ventricular complexes because this is a complication that can indicate a lead wire is displaced in the ventricle. Telemetry monitoring shows pacing spikes with no QRS complexes. The nurse should report when the client has pacer spikes without QRS complexes because this complication can indicate noncapture of the pacemaker. The client is experiencing hiccups. The nurse should report when the client experiences hiccups because this complication can indicate a lead wire is displaced and is stimulating the diaphragm. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz

A client with cancer has just had a Portacath placed by outpatient surgery. The nurse is discharging this client to go home. Which of the following instructions would the nurse give to this client about care of a Portacath? Select all that apply. The client will need a prescription for dressing supplies for the Portacath The client can shower and swim with the Portacath The client should call the physician if infection develops around the Portacath site The Portacath should be flushed at least once a month The dressing on the Portacath will need to be changed weekly

✅The Portacath should be flushed at least once a month A Portacath is a type of central line in which the access port is completely under the skin. It must be flushed every four weeks if it is not being used. ✅The client can shower and swim with the Portacath The Portacath is under the skin, therefore the client may swim or bathe as usual. ✅The client should call the physician if infection develops around the Portacath site The skin should be routinely inspected for redness or drainage, but once the site heals it does not need a dressing. The dressing on the Portacath will need to be changed weekly The skin should be routinely inspected for redness or drainage, but once the site heals it does not need a dressing. The client will need a prescription for dressing supplies for the Portacath A prescription is not needed for dressing supplies. Once the port site has healed, no dressing is necessary.

A client with lupus has been using corticosteroids. Which of the following must the nurse consider if this client must undergo surgery? Select all that apply. The client is at risk of adrenal suppression The client may develop low blood pressure The client has an increased susceptibility to infection The client will most likely experience more pain The client may develop a spike in blood glucose levels

✅The client is at risk of adrenal suppression This type of medication cause adrenal atrophy with prolonged use. ✅The client may develop a spike in blood glucose levels Corticosteroids are medications used for the management of various conditions as prescribed by the provider, including reducing inflammation in the client with lupus. If the client taking corticosteroids is undergoing surgery, the nurse must keep in mind potential complications. Corticosteroids reduce the body's ability to withstand stress due to adrenal atrophy. They also affect blood glucose levels and reduce the body's immune response to infection. ✅The client has an increased susceptibility to infection Corticosteroids affect a client's immune system, increasing their susceptibility to infection. The client may develop low blood pressure Corticosteroid use does not cause hypotension. The client will most likely experience more pain A client's pain experience is not affected by corticosteroids.

7 of 16 What is the nurse's interpretation of a laboratory result that indicates a client has a high blood concentration of IgG directed against the human papilloma virus? The client is at risk for major hypersensitivity reactions to attenuated vaccines. The client is mounting an appropriate response to a recurrent exposure to the virus. The client is in the midst of his or her first response to human papilloma infection. The client is at increased risk for becoming ill from opportunistic infectious organisms.

✅The client is mounting an appropriate response to a recurrent exposure to the virus. When naive B-cells become sensitized to a specific microorganism, they divide forming plasma cells and memory cells, both of which retain the antigen sensitization. The plasma cell immediately begins to secrete antibodies in the form of immunoglobulin M (IgM) against the microorganism. Upon later re-exposure to the same antigen, memory cells will secrete immunoglobulin G (IgG) against it. Therefore the presence of high concentrations of specific IgG in the blood indicates a normal immune response to recurrent infection to the same viral infection. The client is mounting an appropriate response to a recurrent exposure to the virus. Option B is incorrect because IgG does not mediate hypersensitivity reactions. The client is at risk for major hypersensitivity reactions to attenuated vaccines. Option A is incorrect because an initial exposure would be indicated by increased IgM levels against the microorganism, not IgG. The client is at increased risk for becoming ill from opportunistic infectious organisms. Option D is incorrect because the presence of high levels of IgG does not indicate a decline in the client's immune status. Chapter 16 - Concepts of Inflammation and Immunity

10 of 17 Which type of ADL assistance will the nurse plan for a client with long-standing pulmonary problems who has Class IV dyspnea? Dyspnea is minimal and no assistance is required. The client is severely dyspneic at rest and cannot participate in any self-care. The client may complete ADLs without assistance but requires rest periods during performance. The client is severely dyspneic with activity and requires assistance for bathing and dressing.

✅The client is severely dyspneic with activity and requires assistance for bathing and dressing. Class IV dyspnea occurs during usual activities, such as showering and dressing, and requires assistance from others. Dyspnea is usually not present at rest, but is with minimal exertion Chapter 24 /Chapter 27 - Assessment of the Respiratory System

4 of 16 How will the nurse interpret a client's white blood cell count that has a total count of 9000 cells/mm3 (9 x 109/L) with a lymphocyte count of 4200 cells/mm3 (4.2 × 109/L)? The count indicates the client has an increased risk for infection. The client most likely has a viral infection. The count is completely normal. The client most likely has a bacterial infection.

✅The client most likely has a viral infection. Although the total white blood cell count is within the normal range, the lymphocyte count is elevated. The most common cause of lymphocyte count elevation is an actual viral infection. Bacterial infections are associated with higher total counts and higher neutrophil counts. Chapter 16 - Concepts of Inflammation and Immunity

A client with end-stage COPD has requested a do-not-intubate (DNI) order. The nurse understands that this means which of the following? The client does not want any treatment if he becomes incapacitated The client prefers use of a nasal pharyngeal tube for breathing rather than an endotracheal tube The client wants only rescue breathing without a ventilator or CPR if needed The client wants CPR if necessary, but no intubation

✅The client wants CPR if necessary, but no intubation As part of an advanced directive, a client can choose to have a do-not-intubate (DNI) order. This means that in the event of an emergency, the client does not want to be intubated with an endotracheal tube. The client may choose to have other life-saving measures taken, such as CPR, but does not want an endotracheal tube placed that would potentially mean that the client could remain on a ventilator for a long period of time. The client does not want any treatment if he becomes incapacitated This describes a "Do not resuscitate" order, or DNR. The client wants only rescue breathing without a ventilator or CPR if needed This is a specific wish of a client that does not fall under a DNR or DNI order. The client prefers use of a nasal pharyngeal tube for breathing rather than an endotracheal tube This is a specific wish of a client that does not fall under a DNR or DNI order. 02.01 Intubation in the OR

A nurse is educating a client with a history of lung cancer who is preparing to undergo a pneumonectomy. Which information should the nurse provide this client about post-op care after this surgery? The client will require TPN for nutrition after surgery The client will need to perform arm and shoulder exercises The client will have telemetry monitoring for 24 hours The client will have a chest tube after the procedure

✅The client will need to perform arm and shoulder exercises Following a pneumonectomy, the client will need to do strengthening and range of motion exercises of the affected upper extremity. These exercises are done to prevent stiffening on the affected side, help lessen pain after surgery, and improve the client's strength. The client will have a chest tube after the procedure A chest tube is not often necessary after a pneumonectomy. The client will require TPN for nutrition after surgery Total parenteral nutrition (TPN) is not needed after a pneumonectomy. TPN is indicated when a client does not have the ability to absorb nutrients in the GI tract, which is unrelated to the respiratory system. The client will have telemetry monitoring for 24 hours A pneumonectomy does not necessitate telemetry monitoring, unless there is an underlying cardiac issue.

A nurse is working with a family whose mother is dying of lymphoma. Which information would the nurse give to the family about respite care that is accurate? The family can utilize respite care after the client has passed away The family should know that respite care usually involves an inpatient hospital stay The family may need respite just to get a break from the intensity of caregiving The family should only use respite care for short periods in case the mother gets worse

✅The family may need respite just to get a break from the intensity of caregiving Respite care is an option for some families who are struggling to care for a loved one. It involves placement of the client in an approved facility for the relief of the primary caregiver, for a maximum of 5 days each time. Respite provides a break from the intensity of care giving. The nurse in this situation may be able to give the family options about the type of respite care they need so they can take a break. The family can utilize respite care after the client has passed away The purpose of respite care is to give the caregiver a break, so it does not apply after the client has passed away. The family should only use respite care for short periods in case the mother gets worse The family can use respite care for the maximum time allowed. If the primary caregiver experiences burnout, the client will suffer, so respite is designed to alleviate this risk. The family should know that respite care usually involves an inpatient hospital stay A respite care stay is not the same thing as an inpatient hospital stay, because the client does not have an acute illness or decline in health status

16 of 18 Which statement(s) regarding type IV hypersensitivity reactions is/are true? (Select all that apply.) Select all that apply. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. Type IV responses are usually directed against non-self but the response is excessive. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema. The secondary phase, when prolonged, is primarily responsible for autoimmune disorders. Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine.

✅The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. ✅Type IV responses are usually directed against non-self but the response is excessive. ✅Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction. ✅Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine Type IV delayed hypersensitivity reactions have T-lymphocytes (T-cells) as the activated immune system component triggering the excessive responses. A classic example is allergy to poison ivy. Sensitized T-cells (from a previous exposure) respond to an antigen by releasing chemical mediators and triggering macrophages to destroy the antigen; however, histamine is not one of the mediators, making antihistamines of minimal benefit. A type IV response with edema, induration, ischemia, and tissue damage at the site of the exposure typically occurs hours to days after exposure. Angioedema is a type I response, not a type IV response. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

The nurse is preparing to discharge the client after a carpal tunnel procedure. Which of the following is true regarding the discharge process of postoperative surgical clients? Select all that apply The client should receive written discharge instructions The family should not be involved in the discharge process The nurse should provide a learning environment The client's readiness to learn should be assessed Discharge planning should begin when the client enters PACU

✅The nurse should provide a learning environment ✅The client's readiness to learn should be assessed ✅The client should receive written discharge instructions This is true regarding the discharge process. Written instructions will give the client something to refer to later. 03.04 Discharge (DC) Teaching After Surgery

The clinic nurse is performing an assessment on a 35-year-old male client who presents to the clinic with a painless testicular lump and pain in the pelvis. The nurse carefully assesses the client's lungs and asks if the client has had any trouble breathing. Which of the following explains the actions of the nurse? The client's symptoms are indicative of lymphoma and the nurse is assessing for pneumonia The nurse suspects testicular cancer and is checking for metastases The client's symptoms are indicative of prostate cancer and the nurse is preparing the client for a digital rectal exam The nurse suspects a pelvic fracture and is checking for a fat embolism

✅The nurse suspects testicular cancer and is checking for metastases The lungs are the most common area for metastases from testicular cancer. This client's presenting symptoms and age indicate a high likelihood for testicular cancer, and this nurse is proactively assessing for lung symptoms. The client's symptoms are indicative of lymphoma and the nurse is assessing for pneumonia The client's symptoms do not indicate lymphoma. The nurse suspects a pelvic fracture and is checking for a fat embolism A client with a pelvic fracture will not have a painless testicular lump. Rather, the client would present with extreme pelvic pain with movement. The client's symptoms are indicative of prostate cancer and the nurse is preparing the client for a digital rectal exam The client's presenting symptoms and age would cause the nurse to suspect testicular cancer, not prostate cancer.

The circulating nurse understands the importance of intraoperative positioning and knows that which of the following is important to remember when positioning the client for surgery? Select all that apply The circulating nurse chooses the position The operative site must be accessible All bony areas must be padded The client must be protected from injury The safety strap must be applied over the knees

✅The operative site must be accessible This is a requirement of intraoperative positioning so that the healthcare provider has access to operate on the site. ✅The client must be protected from injury This is a requirement of intraoperative positioning. Client safety is always important. The safety strap must be applied over the knees The safety strap should be 2 inches above the knees not over the knees ✅All bony areas must be padded This is a requirement of intraoperative positioning. This is to protect client skin from breakdown. The circulating nurse chooses the position The surgeon will choose the appropriate intraoperative position 02.08 Intraoperative Positioning

Question 6 of 10 A client with potential rheumatoid arthritis is having laboratory testing and requires an ESR blood test. Which of the following best describes the ESR? The amount of by-product produced with muscle breakdown The level of antibodies present in response to an inflammatory antigen The rate at which blood cells settle to the bottom of a tube containing blood The presence of a gene that increases rheumatoid factor

✅The rate at which blood cells settle to the bottom of a tube containing blood A client with rheumatoid arthritis may have a laboratory test of an ESR (erythrocyte sedimentation rate), or 'sed rate' to determine the amount of inflammation present. Inflammation causes red blood cells to clump. When the cells clump, they become denser and sink to the bottom of the tube more quickly. The ESR is the rate at which blood cells settle to the bottom of a tube containing blood. The amount of by-product produced with muscle breakdown This describes a creatinine level, not the ESR. The level of antibodies present in response to an inflammatory antigen This describes a person's immune response, not the ESR. The presence of a gene that increases rheumatoid factor The ESR is the rate at which red blood cells clump and turn to sediment at the bottom of a tube. It does not reveal genes related to RA.

2 of 18 How will the nurse interpret the finding on a client's pathology report that indicates a cancerous tumor is aneuploid? The tumor is completely undifferentiated. The tumor is fast growing. Metastasis has already occurred. The tumor has an abnormal number of chromosomes.

✅The tumor has an abnormal number of chromosomes. A tumor that is aneuploid has an abnormal number of chromosomes. It is not related to how fast the tumor cells divide or whether any differentiated functions remain. The presence or absence of metastasis cannot be determined by the ploidy. Although usually less differentiated cancers are aneuploid, that is not the definition Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

6 of 18 How will the nurse interpret the finding on a client's pathology report that a cancerous tumor has a mitotic index of 8%? The tumor has not yet undergone carcinogenesis. The tumor is slow-growing. Metastasis has already occurred. The tumor has an abnormal number of chromosomes.

✅The tumor is slow-growing. A mitotic index of 8% means that only 8% of the cells within the tumor sample are actively dividing, which represents a low or slow growth rate. The presence or absence of metastasis cannot be determined by the mitotic index. By definition, a cancerous tumor has already undergone carcinogenesis, which is not determined by the mitotic index. When a tumor has an abnormal number of chromosomes, it is aneuploid, which is not related to the mitotic index. Chapter 19 - Concepts of Cancer Development//Chapter 22 Care of Patients With Cancer

A client with a spinal tumor has been having a difficult time sleeping. Which best explains how a tumor can make sleep more difficult for a client with cancer? The tumor disrupts melatonin production, which prevents sleep The tumor causes cognitive changes that can affect the ability to fall asleep The tumor increases the risk of insomnia, which can lead to depression The tumor may place pressure on parts of the body that can be uncomfortable

✅The tumor may place pressure on parts of the body that can be uncomfortable Sleep problems are common among cancer clients. The medications, treatments, and the illness itself can cause multiple problems with a client getting to sleep and staying asleep. When a client has a tumor, the growth can make sleep difficult when it compresses some parts of the body, leading to discomfort. A tumor may also be painful, it can cause a fever, or itching, or it may leave a person feeling very tired but unable to sleep. The tumor causes cognitive changes that can affect the ability to fall asleep A tumor on the spine does not normally cause cognitive changes in a client, unless there is neurological metastatic activity. The tumor disrupts melatonin production, which prevents sleep A spinal tumor has not been reported to disrupt melatonin production. The tumor increases the risk of insomnia, which can lead to depression Cancer can result in a difficult time coping in many clients. However, depression can lead to insomnia, rather than insomnia leading to depression in this situation.

15 of 20 Which nursing assessment data indicate the need for immediate nursing intervention? Client states, "It really hurt when the nurse put the IV in." Transparent dressing was changed 5 days ago. Tubing for the IV was last changed 72 hours ago. The vein feels hard and cordlike above the insertion site.

✅The vein feels hard and cordlike above the insertion site. A hard, cordlike vein suggests phlebitis at the IV site and indicates an immediate need for nursing intervention. The IV should be discontinued and restarted at another site. It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours. Chapter 15 - Concepts of Infusion Therapy

1. The nurse is administering a pneumococcal conjugate vaccine to a client. Which of the following is true regarding this type of vaccine? Select all that apply. The vaccine is given once during childhood, with a booster shot in early adulthood The vaccine is most commonly given to infants and children Clients who are allergic to eggs should not receive this vaccine Side effects include erythema, swelling and pain at the injection site This vaccine is given to prevent pneumonia

✅This vaccine is given to prevent pneumonia The pneumococcal conjugate vaccine is used to prevent invasive pneumococcal disease in infants and children and is given several times in childhood. ✅The vaccine is most commonly given to infants and children This is true of the pneumococcal conjugate vaccine. ✅Side effects include erythema, swelling and pain at the injection site These are side effects that may be experienced when the vaccine is administered. The vaccine is given once during childhood, with a booster shot in early adulthood This vaccine requires several administrations during early childhood years. Clients who are allergic to eggs should not receive this vaccine A person allergic to eggs may receive the pneumococcal conjugate vaccine.

3 of 14 What is the first action a nurse should take after sustaining a needlestick injury after injecting a client who is known to be HIV positive? Send the syringe and needle to the laboratory for analysis of viral load. Inform the charge nurse. Thoroughly scrub and flush the puncture site. Go to the employee clinic for postexposure prophylaxis.

✅Thoroughly scrub and flush the puncture site. Although the nurse would also inform the charge nurse and go to the employee clinic to initiate postexposure prophylaxis, the first action is to clean the puncture site by washing it thoroughly with soap and water for at least 1 minute as recommended by the CDC. Viral load cannot be determined by analyzing the syringe and needle. Chapter 17 - Concepts of Care for Patients With HIV Disease

The circulating nurse is prepping a client's abdomen prior to an abdominal hysterectomy and notices there is a pool of betadine prep that ran under the client. Based on the nurse's knowledge of intraoperative complications which of the following might the client be at risk for? Fluid volume imbalance Pressure injury Shearing Tissue breakdown

✅Tissue breakdown This is a complication associated with the pooling of prep solutions around the client. Shearing This is not an associated complication in this scenario. Shearing occurs from friction against the client with movement. Pressure injury This is not an associated complication in this scenario. Pressure injury occurs from poor position and when good blood flow is constricted to an area and skin breakdown from the pressure can occur. Fluid volume imbalance This is not an associated complication in this scenario. Fluid volume imbalance would indicate that the client is dehydrated and has not received sufficient fluids. 02.09 Intraoperative (Intraop) Complications

The infusion nurse is reviewing the schedule of chemotherapy clients for the day. The nurse knows that chemotherapy is given for which of the following scenarios? Select all that apply. To eliminate BRCA-1 and BRCA-2 To delay the progression of cancer To make a client with cancer more comfortable To prevent cancer To cure the client of cancer

✅To cure the client of cancer If a client has cancer, chemotherapy is a treatment modality, usually used in combination with other treatments, to cure cancer. ✅To delay the progression of cancer In a client with advanced age or illness, chemotherapy may be used to delay the progression of cancer rather than cure it. ✅To make a client with cancer more comfortable In some clients, chemotherapy is used as a palliative treatment to reduce the size of a tumor rather than cure it. To prevent cancer Chemotherapy is not used prophylactically. To eliminate BRCA-1 and BRCA-2 BRCA-1 and BRCA-2 are genetic mutations that are linked to cancer, but it is impossible to eliminate these.

A 48-year-old client has been diagnosed with pancreatic cancer. The client asks the nurse, "How could this have happened to me?!" Which of the following has been shown to be a risk factor for development of pancreatic cancer? Select all that apply. Exposure to certain pesticides A history of eating disorders Tobacco use Asian ethnicity Female gender

✅Tobacco use Cancer of the pancreas is a life-threatening condition with a poor prognosis, because clients who are diagnosed with pancreatic cancer usually have a large tumor by the time symptoms appear. Risk factors for this type of cancer include such factors as tobacco use, a high-fat diet, alcohol use, diabetes mellitus, and exposure to certain toxic chemicals, such as pesticides. Increased age is also a risk factor. A history of eating disorders This is not a risk factor for the development of pancreatic cancer. ✅Exposure to certain pesticides This is a risk factor for pancreatic cancer. Female gender This is not a risk factor for the development of pancreatic cancer. Asian ethnicity This is not a risk factor for the development of pancreatic cancer.

14 of 18 The nurse is caring for a client who has several infected lesions on both arms. The client is afebrile and does not have enlarged regional lymph nodes. The nurse notifies the provider who will most likely order which medication? Topical mupirocin IV vancomycin Oral amoxicillin Oral linezolid

✅Topical mupirocin Topical mupirocin is an antibiotic that is most likely to be ordered for a client with a mild bacterial skin infection without fever or lymphadenopathy. Recurrent or severe infections may be treated with oral amoxicillin. Clients with methicillin-resistant Staphylococcus aureus infections should be treated with oral linezolid or clindamycin or intravenous vancomycin if the infection is severe. Chapter 23//Chapter 25 - Concepts of Care for Patients With Skin Problems

13 of 14 Which laboratory results does the nurse expect to decrease in a client who has untreated HIV-III (AIDS)? (Select all that apply.) Select all that apply. Total white blood cell count Viral load CD8+ T-cell HIV antibodies CD4+ T-cell Lymphocytes

✅Total white blood cell count ✅CD4+ T-cell ✅Lymphocytes The immune target of HIV is the CD4+ T-cell. With infection of this cell, its circulating levels decline and immune function is reduced over time. As a result, total white blood cell counts decrease and circulating lymphocytes decrease. CD8+ T-cell counts are unaffected. HIV antibodies and viral load increase. Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement? Medical command physician Hospital incident commander Triage nurse Communications officer

✅Triage nurse When the triage officer is incapacitated, the triage nurse is the best choice for replacement. When physician resources are limited, an experienced nurse may assume this role. The communications officer serves as the liaison between the health care facility and the media. The hospital incident commander and the medical command physician are too busy to serve as triage officer as well. Chapter 12- Concepts of Disaster Preparedness

9 of 13 The nurse is preparing to draw blood from a client receiving a course of vancomycin about 30 minutes before the next scheduled dose. For what laboratory test would the blood specimen be most likely tested? Trough drug level Blood culture and sensitivity White blood cell (WBC) count Peak drug level

✅Trough drug level When clients receive some intravenous antibiotics, it is essential that the levels of the drug stay consistent within a therapeutic range. To determine if that is the case, peak and trough levels are drawn. A trough level indicates the lowest level of drug available in the blood and is drawn shortly before the next scheduled drug dose. A peak level is assessed 30 to 60 minutes after the drug is given. A culture and sensitivity would not be done while the client is on antibiotics. The WBC count should be decreasing as a result of antibiotic therapy. Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

You are the PACU nurse for a client who just had abdominal surgery. During hand-off report from the circulating nurse, you are informed the client has a paramedian incision. As the nurse, you expect to see the incision in which of the following places? Vertical incision lateral to the midline area Oblique incision above the xiphoid process that extends laterally Transverse incision above the symphysis pubis Vertical midline incision

✅Vertical incision lateral to the midline area This is the description of a paramedian incision. Vertical midline incision This is not the description of a paramedian incision. This would be in a laparotomy. This is known as Kustner's incision. Transverse incision above the symphysis pubis This is not the description of a paramedian incision. This would be a horizontal incision in the lower abdomen, used in a c-section. Oblique incision above the xiphoid process that extends laterally This is not the description of a paramedian incision 03.03 Surgical Incisions & Drain Sites

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? Turn the client from side to side. Elevate the height of the dialysate bag. Lower the head of the client's bed. Advance the catheter approximately 2.5 cm (1 in) further.

✅Turn the client from side to side. The nurse should assist the client in turning from side to side to facilitate removal of peritoneal drainage. This action helps ensure there are no kinks in the tubing or an air lock in the peritoneal catheter. Elevate the height of the dialysate bag. The nurse should raise the height of the dialysate bag to increase the rate of inflow; however, this action will not promote outflow of peritoneal fluid. Lower the head of the client's bed. The nurse should elevate the head of the client's bed to promote the outflow of the peritoneal fluid. Advance the catheter approximately 2.5 cm (1 in) further. The nurse should not push the peritoneal catheter further into the peritoneal cavity because this action introduces bacteria into the peritoneal cavity and increases the client's risk for peritonitis. RN Learning System Medical-Surgical: Final Quiz

2 of 18 Which type of hypersensitivity reaction will the nurse suspect in a client who develops as circular rash on the skin underneath a new necklace worn for 3 days? Type IV Type I Type II Type III

✅Type IV A type IV delayed hypersensitivity reaction occurs when sensitized T-cells respond to an antigen by releasing chemical mediators and triggering macrophages. This reaction causes a rash as seen in a metal allergy exposure. A type I reaction occurs rapidly after exposure and is mediated by immunoglobulin E (IgE). Type II reactions occur when the body makes autoantibodies directed against self-cells and attack those cells. Type III reactions occur when an abundance of immune complexes are made and they get stuck in small vessels causing inflammation. Chapter 18 - Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity///Chapter 20 Care of Patients With Hypersensitivity (Allergy) and Autoimmunity

A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a potential malignancy of a mole? Ulceration Blanching of surrounding skin Dimpling Fading of color

✅Ulceration Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month. Blanching of surrounding skin Redness or swelling of the skin around a mole, rather than blanching, is an indication of potential malignancy. Dimpling Dimpling is not an indication of a mole's potential malignancy. Fading of color Darkening of a mole, rather than fading, is associated with potential malignancy. RN Learning System Medical-Surgical: Dermatological Practice Quiz

The nurse is caring for a postoperative client who just underwent an orchiectomy. The nurse understands that which of the following is a risk factor for this client's condition? Cycling Trauma Undescended testicle Horseback riding

✅Undescended testicle An orchiectomy is surgical removal of a testicle, and is performed when a client has a testicular tumor. Some risk factors for testicular cancer include a family history of this type of cancer, an undescended testicle at birth, a history of testicular cancer, and young age. Trauma Trauma to the perineal area is not a risk factor for this type of cancer. Horseback riding This is not a risk factor for testicular cancer. Cycling Although there may be high-profile cyclists who have had this type of cancer, cycling is not a risk factor for the condition.

A 78-year-old client is being admitted to the hospital for surgery. The client has a history of lymphoma that has returned twice after undergoing chemotherapy treatments, and has a DNR order in place in case of cardiac arrest. What is a true statement regarding a DNR order? Select all that apply. Unless the DNR order is in the client's record, the nurse must initiate CPR if cardiac arrest occurs. A DNR order is a type of advance directive known as a provider order A DNR order is the same as a do not intubate order The DNR order can be signed by the power of attorney if the client goes into cardiac arrest The client's wishes for DNR must be communicated to the staff and a written copy of the order must be placed in the client's chart

✅Unless the DNR order is in the client's record, the nurse must initiate CPR if cardiac arrest occurs. A DNR order can be confusing to caregivers and family members who are present if a client is dying. ✅The client's wishes for DNR must be communicated to the staff and a written copy of the order must be placed in the client's chart An advance directive specifies the client's decisions ahead of time before the client becomes unable to do so, and may include a DNR order. ✅A DNR order is a type of advance directive known as a provider order A DNR order is part of an advance directive that is known as a provider order, in which the client has given specific directions not to have CPR. A DNR order is the same as a do not intubate order A person can have a "Do not intubate" order, but still require CPR if cardiac arrest occurs. If a person has a DNR order, CPR is NOT initiated in the event of cardiac arrest. The DNR order can be signed by the power of attorney if the client goes into cardiac arrest A DNR order must be in place prior to the cardiac arrest event, or staff is required to begin CPR and other life-saving measures. A DNR order is not initiated after cardiac arrest occurs.

The oncology nurse is discussing the concept of survivorship with a client with cancer. Which of the following correctly describes when survivorship begins? Upon receiving the diagnosis of cancer When a client's PET scan is negative When a client receives the last dose of chemotherapy When the client has been in remission for 2 years

✅Upon receiving the diagnosis of cancer Survivorship is a mindset that clients begin the moment they receive a diagnosis of cancer. They have already been through a struggle, and they are considered a survivor from the beginning of their cancer journey. When a client's PET scan is negative A client becomes a survivor as soon as they are diagnosed with cancer. When a client receives the last dose of chemotherapy While this is a moment to celebrate, it is not when the client becomes a survivor. Survivorship begins at diagnosis. When the client has been in remission for 2 years This client is said to be in remission, but survivorship begins at the beginning of the client's cancer journey.

16 of 16 Which types of problems will the nurse expect to find more frequently in a client who does not make adequate amounts of immunoglobulin A (IgA)? (Select all that apply.) Select all that apply. Upper respiratory infections Cystitis Excessive bleeding Contact dermatitis Anaphylaxis Diarrhea

✅Upper respiratory infections ✅Cystitis ✅Diarrhea IgA is the secretory immunoglobulin that is present in highest concentrations in the secretions of the mouth, gastrointestinal tract, and genitourinary tract. IgA helps prevent infections in these body areas and does not circulate in significant amounts. It is not associated with any types of allergic reactions such as anaphylaxis or contact dermatitis. It plays no role in the blood clotting cascade. Chapter 16 - Concepts of Inflammation and Immunity////Chapter 17 Principles of Inflammation and Immunity

A 63-year-old female client complains of urinary retention and an inability to empty her bladder. The nurse understands that the client is likely experiencing which of the following conditions? Select all that apply. Urethral stricture Uterine prolapse Vaginal pemphigus Vulvovaginitis Bladder tumor

✅Urethral stricture A urethral stricture is one of the common causes of urinary tract obstruction in women. ✅Bladder tumor Based on the client's symptoms of retention and an inability to empty the bladder completely, the nurse knows she is experiencing urinary tract obstruction. Urinary tract obstruction develops as a result of something blocking the flow of urine. Some common causes of obstruction in women include uterine prolapse, urethral stricture, a bladder tumor, an ovarian cyst, uterine fibroids, or a cystocele. Treatment of urinary tract obstruction centers on correcting the cause of the blockage, and often involves surgical correction of the underlying cause. ✅Uterine prolapse Uterine prolapse can lead to urinary tract obstruction. Vulvovaginitis This is an infection of the vagina that does not lead to urinary tract obstruction. Vaginal pemphigus This is an infection that causes blisters and lesion, but does not lead to urinary tract obstruction.

Postoperative Fever At days 3-5 postoperatively, which of the following is most likely a common cause of fever? Urinary Tract Infection from Catheter Atelectasis Pulmonary Embolism (PE) Pneumonia Allergic Reaction DVT (Deep Vein Thrombosis)

✅Urinary Tract Infection from Catheter Fever which develops 3-5 days postoperatively can be attributed to UTI from prolonged catheterization. Urinalysis and urine cultures should be done before moving on to treatment with antibiotics and catheter replacement.

A nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. Which of the following instructions should the nurse include in the teaching? Use pursed-lip breathing during periods of dyspnea. Limit fluid intake to 1,500 mL per day. Practice chest breathing each day. Wear home oxygen to maintain an SaO2 of at least 94%.

✅Use pursed-lip breathing during periods of dyspnea. The nurse should instruct the client about the use of pursed-lip breathing during periods of dyspnea to slow expiration, increase airway pressure, and facilitate effective gas exchange. Limit fluid intake to 1,500 mL per day. The nurse should instruct the client to drink 2,000 to 3,000 mL of fluids a day to keep respiratory secretions thin and easier to expectorate. Practice chest breathing each day. The nurse should instruct the client to practice diaphragmatic or abdominal breathing, which helps to reduce the respiratory rate and increases alveolar ventilation. Wear home oxygen to maintain an SaO2 of at least 94%. The nurse should instruct the client to maintain an SaO2 of at least 88%. The client who has emphysema has chronic hypercarbia, resulting in the need for a lower arterial oxygen level to maintain the drive to breathe. Maintaining an SaO2 of 94% or greater could suppress the client's breathing. RN Learning System Medical-Surgical: Final Quiz

20 of 20 The nurse is revising an agency's recommended central line-associated bloodstream infection (CLABSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) Select all that apply. During insertion, draping just the area around the site with a sterile barrier Making certain that observers of the insertion are instructed to look away during the procedure Using chlorhexidine for skin disinfection Thorough hand hygiene before insertion Removing the client's venous access device (VAD) when it is no longer needed

✅Using chlorhexidine for skin disinfection ✅Thorough hand hygiene before insertion ✅Removing the client's venous access device (VAD) when it is no longer needed As soon as the VAD is deemed unnecessary, it needs to be removed to reduce the risk for infection. Thorough handwashing is a key factor in insertion and maintenance of a central line device. Quick handwashing is not sufficient. Chlorhexidine is recommended for skin disinfection because it has been shown to have the best outcomes in infection prevention. During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier. Draping only the area around the site will increase risk for infection. Looking away will not reduce the risk for infection. Reducing the number of people in the room and having everyone wear a mask will help reduce the risk for infection Chapter 15 - Concepts of Infusion Therapy

14 of 14 Which conditions or factors will the nurse teach at a community seminar as probable transmission routes for HIV? (Select all that apply.) Select all that apply. Using injection drugs Sitting on public toilets Changing a diaper on an HIV positive child Having unprotected intercourse with multiple partners Breast-feeding Being bitten by mosquitos

✅Using injection drugs ✅Having unprotected intercourse with multiple partners ✅Breast-feeding HIV can be transmitted via breast milk from an infected mother to the child. Unprotected intercourse with an HIV positive adult is a major transmission route. HIV is not spread by mosquito bites or by other insects. It is not transmitted by casual contact. Sharing toilet facilities with an HIV-positive adult does not cause transmission of HIV. Use of injection drugs is a common transmission route. Casual contact such as changing a diaper, even with feces and urine (unless there is significant blood in these excretions), is not a probable transmission route. Chapter 17 - Concepts of Care for Patients With HIV Disease////Chapter 19 Care of Patients With Problems of HIV Disease

The circulating nurse plays a huge role in protecting the client through intraoperative nursing priorities. Which of the following actions by the nurse decreases the risk of injury to the client? Select all that apply Verifying that prepping solutions have not pooled around the client Perform surgical counts at the beginning of the procedure only Using cold solutions to keep the client cool Verifying that all items used on the sterile field are sterile Perform a surgical "time out" at the end of the procedure

✅Verifying that prepping solutions have not pooled around the client This decreases the risk of injury to the client. This decreases the risk of skin breakdown occurring. ✅Verifying that all items used on the sterile field are sterile This decreases the risk of injury to the client. Sterile equipment decreases the risk of infection. Using cold solutions to keep the client cool Warm solutions should be used to decrease injury. Cold solutions can cause hypothermia. Perform surgical counts at the beginning of the procedure only Surgical counts are also performed during the procedure and before closure. Perform a surgical "time out" at the end of the procedure The "time out" should be performed before incision. 02.10 Intraoperative Nursing Priorities

The perioperative nurse and you have been assigned as the preceptor for a nursing student. The student is observing the case of a client under moderate sedation. The nursing student understands that sedation levels must be assessed in these clients but does not know how. Which of the following is the best response by the nurse? We use the ASA Physical Status Classification to assess sedation We use the ACE scale to assess sedation We use the Ramsay Sedation Scale to assess sedation We use the Glasgow Coma Scale to assess sedation

✅We use the Ramsay Sedation Scale to assess sedation This is a common sedation scale used We use the ASA Physical Status Classification to assess sedation This is used to assess the client's health prior to surgery. We use the ACE scale to assess sedation This scale assesses abuse and neglect. We use the Glasgow Coma Scale to assess sedation This is not a scale for assessment of sedation but assesses a client's state of consciousness. 02.04 Moderate Sedation

2 of 13 While in the hospital, a client developed a methicillin-resistant infection in an open foot ulcer. Which nursing action would be appropriate for this client? Wear a gown and gloves to prevent contact with the client or client-contaminated items. Have the client wear a surgical mask when being transported out of the room. Wear a mask when working within 3 feet (91 cm) of the client. Assign the client to a private room with a negative airflow.

✅Wear a gown and gloves to prevent contact with the client or client-contaminated items. Caregivers should wear a gown and gloves to prevent contact with the client or contaminated items when caring for a client with this infection. This is the best way to prevent the spread of infection. Gloves should also be worn when entering the room. The client does not require a private room or respiratory isolation, and does not need to wear a surgical mask when being transported out of the room because the infection is not airborne. Use of a mask is not the best way to prevent the spread of this infection Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

5 of 13 Which precaution is appropriate for the nurse to take to prevent the transmission of Clostridium difficile infection? Carefully wash hands that are visibly soiled. Wear a mask with eye protection and perform proper handwashing. Wear gloves when in contact with the client's body secretions or fluids. Wear a mask and gloves when in contact with the client.

✅Wear gloves when in contact with the client's body secretions or fluids. The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids. C. difficile infection requires Contact Precautions. Hands must be properly washed before and after any contact with the client with C. difficile infection. Alcohol-based hand rubs are not effective for hand hygiene in the care of clients with C. difficile. Hands must be washed even if not visibly soiled. It is not necessary to wear a mask when caring for clients with C. difficile infection. A mask and eye protection are not necessary to prevent transmission of C. difficile Chapter 21/Chapter 23 - Concepts of Care for Patients With Infection

A client is having difficulty breathing while coming out of anesthesia following surgery. The nurse inserts an oral airway to assist with this client's breathing. Which of the following items that are true regarding placement of an oral airway? Select all that apply. When inserting the airway, the curved end should first be pointed upward The airway should be measured from the corner of the mouth to the top of the nose The flange of the airway should be outside of the client's mouth The airway should be rotated 180 degrees once the end reaches the back of the client's mouth during placement An oral airway should only be used in a client who is awake

✅When inserting the airway, the curved end should first be pointed upward A client who is recovering from anesthesia may benefit from the placement of an oral airway, which is designed to keep the mouth open to facilitate easier breathing. This type of airway is only used in the unconscious client with no cough or gag reflex, due to the risk of vomiting and laryngospasm that can result from placement. The oral airway is partially inserted and then rotated to follow the structure of the palate. ✅The airway should be rotated 180 degrees once the end reaches the back of the client's mouth during placement The oral airway is partially inserted and then rotated to follow the structure of the palate. ✅The flange of the airway should be outside of the client's mouth The flange should stop outside the client's mouth. An oral airway should only be used in a client who is awake The airway is designed to keep the tongue down and the mouth opens for breathing in the unconscious client. Placement can stimulate vomiting and retching and is not used in the conscious client. The airway should be measured from the corner of the mouth to the top of the nose These are the wrong anatomical landmarks for measurement. Measurement is done from the front teeth to the cheek. When the curve of the airway reaches the angle of the jaw, it is the correct size.

A nurse is caring for a 78-year-old client with severe, debilitating rheumatoid arthritis who lives at home with the spouse. The nurse assesses the client's level of safety in the home. Which aspects should be included as part of this home safety assessment? Select all that apply. Whether there are stairs in the home Whether the home has ceiling fans Whether there is space available for a caregiver to help with the client Whether there is sufficient lighting Whether there are changes in floor levels

✅Whether there is sufficient lighting When caring for a client in the home, the nurse may notice safety hazards that could protect the client if changed. The client should be able to move about in the home and have assistive devices, such as grab bars in the bathroom, levers instead of round handles, and railings on stairs. The nurse should point out any obvious hazards so they can be changed as soon as possible. ✅Whether there is space available for a caregiver to help with the client When caring for a client in the home, the nurse may notice safety hazards that could protect the client if changed. The client should be able to move about in the home and have assistive devices, such as grab bars in the bathroom, levers instead of round handles, and railings on stairs. The nurse should point out any obvious hazards so they can be changed as soon as possible. Whether the home has ceiling fans Ceiling fans are not related to ease of mobility around the house. ✅Whether there are changes in floor levels When caring for a client in the home, the nurse may notice safety hazards that could protect the client if changed. The client should be able to move about in the home and have assistive devices, such as grab bars in the bathroom, levers instead of round handles, and railings on stairs. The nurse should point out any obvious hazards so they can be changed as soon as possible. ✅Whether there are stairs in the home When caring for a client in the home, the nurse may notice safety hazards that could protect the client if changed. The client should be able to move about in the home and have assistive devices, such as grab bars in the bathroom, levers instead of round handles, and railings on stairs. The nurse should point out any obvious hazards so they can be changed as soon as possible.

The nurse is caring for a client that has a history of fibromyalgia and lupus. The client complains of pain. The nurse knows that which of the following would be an inappropriate question to assess the client's pain? Why are you in pain? Where is the pain located? What number would you rate your pain? What helps this type of pain for you?

✅Why are you in pain? It is not appropriate to ask the client why they are in pain. Where is the pain located? Assessing the location of the pain is appropriate. Asking "Why are you in pain?" is inappropriate. What number would you rate your pain? Assessing pain rating is appropriate. Asking "Why are you in pain?" is inappropriate. What helps this type of pain for you? Asking what the client usually does to help this pain is appropriate to determine treatment for this pain. Asking "Why are you in pain?" is inappropriate.

A client is being taken back to the operating room when they surprisingly tell the nurse that they haven't seen their surgeon since the first office visit. The nurse knows that which of the following is a risk for the client? Postoperative infection Anesthesia reactions Retained surgical item Wrong site surgery

✅Wrong site surgery If the client hasn't seen the surgeon than the surgical site has not been marked and increases the risk of wrong-site surgery. Retained surgical item This is not a risk in this situation. Since the client has not seen the surgeon then the site has not been marked and the client is at risk for wrong-site surgery. Postoperative infection This is not a risk in this situation. Since the client has not seen the surgeon then the site has not been marked and the client is at risk for wrong-site surgery. cancel Anesthesia reactions This is not a risk in this situation. Since the client has not seen the surgeon then the site has not been marked and the client is at risk for wrong-site surgery. 02.10 Intraoperative Nursing Priorities

A client is preparing to undergo a radical prostatectomy. During the pre-operative visit, the client asks the nurse, "When do I get to eat again?" Which response from the nurse is accurate? You will most likely have something to drink starting soon after your surgery You will be able to eat breakfast the next morning after your surgery The surgeon will decide when you will be able to eat, I can't estimate when that will be I will begin to give you food after you leave the recovery room

✅You will most likely have something to drink starting soon after your surgery A client who undergoes surgery is not allowed to eat or drink before the procedure. Afterward, the client may not be ready to eat a meal right away because of factors such as the effects of medications administered, or the complexity of the surgery. In most cases, the client may start with liquids soon after surgery and if these are tolerated, the client can advance to eating solid foods. The surgeon will decide when you will be able to eat, I can't estimate when that will be In general, the nurse is able to estimate that the client may begin to drink and eat after the procedure. The surgeon will be the one to advance the diet, but the nurse notes clinical signs that indicate the client is ready to advance to eating food, and will report this information so the surgeon can write an order to advance to the next step. You will be able to eat breakfast the next morning after your surgery There are many factors that affect when a client will be able to eat, including type of surgery, time of day the surgery is performed, length of surgery, and client's response to anesthesia. It may not necessarily be breakfast the next morning. I will begin to give you food after you leave the recovery room The nurse would not begin to give the client food unless he or she has first tolerated clear liquids, then the client can advance to crackers or something easily digestible.

A nurse is counseling a client who has abdominal pain. The client says to the nurse, "My father died of colon cancer and now that I'm over 50, I'm sure that I have it, too!" Which of the following responses from the nurse is most appropriate? Your age and family history do put you at greater risk, but we should look at your test results before coming to further conclusions You are experiencing symptoms consistent with colon cancer. Because of your family history, we should run some more tests Having a family member with colon cancer will not increase your risk of developing it Just because your father had it does not mean that you will get it, too. Everyone is different

✅Your age and family history do put you at greater risk, but we should look at your test results before coming to further conclusions The client in this situation understands the higher risk of colorectal cancer because of familial history of the condition, as well as the fact that being over 50 years old increases risk. However, it does not mean that this is the cause of the abdominal pain. The nurse should talk with the client about risks but also focus on the current situation. Just because your father had it does not mean that you will get it, too. Everyone is different While this is a true statement, the fact that the client has abdominal pain combined with a family history and age of the client does put the client at risk. The nurse should not make the situation seem harmless when there is a real risk. Having a family member with colon cancer will not increase your risk of developing it This statement is not true. You are experiencing symptoms consistent with colon cancer. Because of your family history, we should run some more tests Abdominal pain does not equal colon cancer, and the nurse should avoid such an ominous statement.

The nurse is caring for a client whose absolute neutrophil count is 100/mm3. The parent asks what this means. The nurse accurately responds with which of the following statements? Your child is moderately at risk for infection Your child is severely at risk for bleeding Your child is severely at risk for infection Your child is moderately at risk for bleeding

✅Your child is severely at risk for infection The absolute neutrophil count is measuring the number of neutrophils in the body. An ANC of 1,500/mm3 is considered normal, while an ANC of 500/mm3 or less is considered neutropenic which indicates a risk for an infection rather than bleeding. Your child is severely at risk for bleeding The Absolute Neutrophil Count is measuring the number of neutrophils in the body. An ANC of 1,500/mm3 is considered normal, while an ANC of 500/mm3 or less is considered neutropenic which indicates a risk for infection, not bleeding. Your child is moderately at risk for bleeding A child with an ANC of <500/mm3 is considered to be neutropenic with a severe risk of infection. Your child is moderately at risk for infection An ANC of <500/mm3 is considered to be neutropenic with a severe risk of infection.

A mother has brought her 5-year-old son into the healthcare clinic for a physical to prepare for kindergarten. The nurse is reviewing the child's immunization history and notes that the child has had one prior MMR vaccine. Which response from the nurse is most appropriate? Your child will need one more MMR before starting kindergarten Your child appears to be up to date on all of his immunizations Your child will need one MMR now and one more when he turns 12 You child is very behind on his vaccinations. We will put him on a schedule to catch him up right away

✅Your child will need one more MMR before starting kindergarten The measles, mumps, and rubella (MMR) vaccine is recommended as a two-dose administration schedule. The first injection should be given at 12 to 15 months of age and the second injection is given between 4 and 6 years. In this situation, if the 5 year old has not had the second MMR, then he will need the second shot before he starts school. It is often given during a physical exam in preparation for kindergarten. Your child appears to be up to date on all of his immunizations The child needs one MMR vaccination. Your child will need one MMR now and one more when he turns 12 The child needs one MMR now, and then the series is complete. You child is very behind on his vaccinations. We will put him on a schedule to catch him up right away The child is not very far behind schedule, but is due for the next vaccination.

A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. Available is a blood administration set that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) gtt/min

✅x= 10 gtt/min Dimensional Analysis STEP 1: What is the unit of measurement the nurse should calculate? gtt/min STEP 2: What is the quantity of the drop factor that is available? 10 gtt/mL STEP 3: What is the total infusion time? 4 hr STEP 4: What is the volume the nurse should infuse? 250 mL STEP 5: Should the nurse convert the units of measurement? Yes (hr does not equal min) 1 hr/60 min STEP 6: Set up an equation and solve for X. X gtt/min = Quantity/1 mL x Conversion (hr)/Conversion (min) x Volume (mL)/Time (min) X gtt/min = 10 gtt/1 mL x 1 hr/60 min x 250 mL/240 min X = 10.4 gtt/min STEP 7: Round if necessary. 10.4 gtt/min = 10 gtt/min STEP 8: Reassess to determine whether the amount to administer makes sense. If the prescription reads packed RBCs (250 mL) X 10 gtt/mL to infuse over 240 min, it makes sense to administer 10 gtt/min. The nurse should set the manual IV infusion to deliver packed cells (250 mL) to infuse at 10 gtt/min. RN Learning System Medical-Surgical: Cardiovascular and Hematology Practice Quiz