Practice Questions (2214C Exam 03)

The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? "I'm letting my husband do most of the cooking, but I help plan the menus." "Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my home easier." "My husband is getting used to having sex only once a month." "I worry about what's going to happen to me if my husband cannot take care of me, but he says he'll hire someone if he must."

"My husband is getting used to having sex only once a month." The client's comment that her husband is getting used to sex only once a month could indicate negative body image or depression; additional open-ended questions by the nurse are required.

A client with thrombocytopenia is being discharged. Which instruction would the nurse include in a teaching plan for this client? "Avoid large crowds." "Use a soft-bristled toothbrush." "Drink at least 2 L of fluid per day." "Elevate your lower extremities when sitting."

"Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia.Avoiding large crowds reduces the risk for infection but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration but is not particularly relevant to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema but is not specific to the client with thrombocytopenia.

The pediatric nursing instructor asks a nursing student to prioritize care for a child diagnosed with sickle cell disease. Which student response correctly identifies the priority of care? 1.Fatigue 2.Hypoxia 3.Delayed growth 4.Avascular necrosis

2.Hypoxia

Which factors are possible transmission routes for human immune deficiency virus (HIV)? Select all that apply. Breast-feeding Anal intercourse Mosquito bites Toileting facilities Oral sex

Breast-feeding Anal intercourse Oral sex

The school nurse is teaching a group of adolescents about risk factors for lung cancer and lung disease. Which of these would be included in the discussion? Alcohol consumption Cocaine use Cigarette smoking Heroin use

Cigarette smoking Cigarette smoking is highly addictive and is the number-one risk factor for lung cancer and chronic obstructive pulmonary disease.Alcohol can cause some cancers and liver disease and can increase risky behaviors, but it is not a major cause of lung cancer. Cocaine use, while highly addictive, poses a risk for cardiovascular disorders such as ACS, MI, or stroke. Heroin use does not increase one's risk of developing lung disease or lung cancer.

A client who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action does the nurse take next? Infuse normal saline at 200 mL/hr. Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously. Discontinue infusing the antibiotic. Give diphenhydramine (Benadryl) 100 mg IV.

Discontinue infusing the antibiotic. The nurse's first action should be to discontinue the antibiotic. The antibiotic is the most likely cause of the client's apparent anaphylactic reaction.Infusing normal saline and administering epinephrine and diphenhydramine may be indicated, but these are not the nurse's first action.

The nurse in the clinic is following up on diagnostic testing for a client recently diagnosed with metastatic lung cancer and back pain. Which of these findings does the nurse expect to uncover? Hyperkalemia Hyperglycemia Hypercalcemia Hypernatremia

Hypercalcemia Hypercalcemia is the result of increasing parathyroid hormone as a paraneoplastic complication of cancer as well as bone metastasis. Bone metastasis should be suspected in the presence of back pain.Paraneoplastic syndromes are manifested by Cushing's syndrome, weight gain and dilution of electrolytes (SIADH) with resulting hyponatremia. Gynecomastia and hypoglycemia may also occur. Hyperkalemia most typically occurs with tumor lysis syndrome where multiple electrolyte imbalances develop impaired renal function and oliguria.

The nurse is caring for a client with sickle cell disease. Which nursing action is most effective in reducing the potential for sepsis in this client? Check vital signs every 4 hours Administer prophylactic drug therapy Monitor for abnormal laboratory values Perform frequent and thorough handwashing

Perform frequent and thorough handwashing The most effective nursing action to reduce the risk for sepsis in a client with sickle cell anemia is to perform frequent and thorough handwashing. Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance.Taking vital signs every 4 hours will help with early detection of infection but is not prevention. Drug therapy is a major defense against infections that develop in the client with sickle cell disease but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention.

A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? "Drinking alcoholic beverages should be avoided." "The health care provider should be notified 3 months before a planned pregnancy." "Any side effects of this drug will be mild." "I will avoid any live vaccines."

"Any side effects of this drug will be mild." Further teaching is needed if the client states that, "Any side effects of this drug will be mild." Methotrexate can have devastating side effects and toxic effects, and the client should be carefully monitored when taking this drug.

A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? Select all that apply. "Ask her how she is feeling." "Ask her if she needs anything." "Tell her to be brave and to not cry." "Tell her what you know about leukemia." "Talk to her as you normally would when you haven't seen her for a long time."

"Ask her how she is feeling." "Ask her if she needs anything." "Talk to her as you normally would when you haven't seen her for a long time."

The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? "When I injected heroin, I was exposed to HIV." "I don't understand how the antiretroviral drugs work." "I remember to take my antiretroviral drugs almost every day." "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."

"I remember to take my antiretroviral drugs almost every day." It is important that clients take these drugs consistently, because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains. The nurse would immediately assess the reasons why the client does not take the medications daily and then would implement a plan to improve adherence.The nurse would assess whether the client is still injecting drugs and would make certain the client understands the risks for infection with another strain of HIV or other blood borne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. The nurse must provide further education about how the medications work and assess how the lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.

The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? "I need to know my HIV status, so I must get tested before caring for any clients." "Putting on a gown and gloves will cover up the itchy sores on my elbows." "Washing my hands and putting on a gown and gloves is what I must do before starting care." "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."

"Washing my hands and putting on a gown and gloves is what I must do before starting care." Standard Precautions include hand hygiene and whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes.Knowing HIV status is important for preventing transmission of HIV, but is not part of the Standard Precaution Protocol. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication? 1.Should always be taken with food or antacids 2.Should be double-dosed if 1 dose is forgotten 3.Causes orange discoloration of sweat, tears, urine, and feces 4.May be discontinued independently if symptoms are gone in 3 months

3.Causes orange discoloration of sweat, tears, urine, and feces

A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder? 1.Hyperthyroidism 2.Pernicious anemia 3.Cardiopulmonary disorders 4.Systemic lupus erythematosus (SLE)

4.Systemic lupus erythematosus (SLE)

The nurse plans to assess a client with type I hypersensitivity for which clinical manifestation? Poison ivy Autoimmune hemolytic anemia Allergic asthma Rheumatoid arthritis

Allergic asthma Allergic asthma is a clinical manifestation of type I hypersensitivity.Poison ivy is a type IV delayed mechanism of hypersensitivity. Autoimmune hemolytic anemia is a type II cytotoxic mechanism of hypersensitivity. Rheumatoid arthritis is a type III immune complex-mediated mechanism of hypersensitivity.

A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client? Clean toothbrushes once a week. Bathe daily using an antimicrobial soap. Eat salad at least once a day. Wash dishes in cool water.

Bathe daily using an antimicrobial soap. Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin.Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. Salads and raw fruits and vegetables could be contaminated and should be avoided. Dishes should be washed in hot, soapy water or in a dishwasher.

Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? Report the need for desensitization therapy. Convey the need for pharmacologic therapy to the health care provider. Communicate the need for avoidance therapy to the health care team. Discuss symptomatic therapy with the health care provider.

Communicate the need for avoidance therapy to the health care team. The best nursing action is to communicate the need for avoidance therapy to the health care team. Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins.Desensitization therapy is administered via allergy shots when allergens have been identified and cannot easily be avoided. Discussing the need for pharmacologic therapy might be indicated if signs of type I or type IV hypersensitivity exist, but this is not a preventive measure. Symptomatic therapy interventions such as an epinephrine pen, antihistamines, and corticosteroids are not preventive but are effective only after the hypersensitivity reaction has already occurred.

The mother of a child with leukemia who has not had varicella (chickenpox) receives a telephone call from the school nurse, who tells her that one of her child's classmates has contracted chickenpox. Which instruction to the mother by the nurse is most appropriate? Contacting the child's pediatrician Monitoring her child closely for signs of infection Encouraging her child to wear a mask while in school Keeping her child out of school until the child with varicella recovers

Contacting the child's pediatrician RATIONALE: Chickenpox can be deadly to the immunocompromised child, whose body may not be able to fight varicella adequately. If a child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96 hours of exposure. Therefore, the mother is advised to contact the child's pediatrician. It is unnecessary to keep the child out of school or to have the child wear a mask while in school. Although the mother should monitor her child for signs of infection, this is not the most appropriate instruction of those provided in the options.

The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition? Dry eyes Abdominal bloating after eating Excessive production of saliva in the mouth Intermittent episodes of diarrhea

Dry eyes Clients with Sjögren's syndrome experience dry eyes

Which nursing intervention most effectively protects a client with thrombocytopenia? Take rectal temperatures Avoid the use of dentures Apply warm compresses on trauma sites Encourage the use of an electric shaver

Encourage the use of an electric shaver The most effective nursing intervention that protects a client with thrombocytopenia is encouraging the client to use an electric shaver. This client must be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time.To prevent rectal trauma, rectal thermometers would not be used. Oral or tympanic temperatures would be taken. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. Ice (not heat) would be applied to areas of trauma.

The nurse is caring for a client who is in sickle cell crisis. What action would the nurse perform first? Provide pain medications as needed. Apply cool compresses to the client's forehead. Increase food sources of iron in the client's diet. Encourage the client's use of two methods of birth control.

Provide pain medications as needed. The action the nurse would perform first for a client in sickle cell crisis is to provide pain medications as needed. Analgesics are needed to treat sickle cell pain.Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.

A client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? Epinephrine (Adrenalin) Fexofenadine (Allegra) Cromolyn sodium (Nasalcrom) Zileuton (Zyflo)

Epinephrine (Adrenalin) The most appropriate drug for the nurse to give in this situation is epinephrine (Adrenalin). The client is experiencing an anaphylactic reaction, and epinephrine is a first-line sympathomimetic drug used to treat anaphylaxis.Fexofenadine (Allegra) is a nonsedating antihistamine and is not a first-line drug to treat anaphylaxis. Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug used to prevent symptoms of allergic rhinitis. It is not useful during an acute episode. Zileuton (Zyflo) is a leukotriene antagonist also used to prevent symptoms of allergic rhinitis, but is also not useful during an acute episode.

A client who has recently relocated to the United States from Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? Contact the health care provider for tuberculosis (TB) medications. Perform a TB skin test. Place a respiratory mask on the client. Test all family members for TB.

Place a respiratory mask on the client. The nurse's first action is to place a respiratory mask on the client. The concern is that this client has a high risk for TB having recently immigrated from overseas. Client with symptoms consistent with TB should be considered infectious until the disease is ruled out.Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. Tell the client that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.

A tuberculin skin test is administered to a client infected with human immunodeficiency virus (HIV). Forty-eight hours after the test is administered, the nurse checks the skin test site and notes an area of induration 5 mm in diameter. How does the nurse interpret this finding? Positive result Negative result Inconclusive result Inaccurate result requiring a repeat test

Positive result RATIONALE: An area of induration of 5 mm or greater represents a positive reaction in a child with an immunosuppressive condition or HIV infection. Therefore the other options are incorrect.

A client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client's discharge teaching plan? Wash fruits and vegetables with mild soap and water before eating. Intermittent exposure to known allergens will produce immunity. Remove cloth drapes, carpeting, and upholstered furniture. Be cautious when eating unprocessed honey.

Remove cloth drapes, carpeting, and upholstered furniture. The most important discharge instruction to give this client is to remove cloth drapes, carpet, and upholstery in order to reduce airborne pollen, dust mites, and mold.Washing fruits and vegetables pertains to food allergies. Clients do not develop immunity to known allergens by direct intermittent exposure. Some common interventions include avoidance therapy, desensitization therapy, and symptomatic therapy. Honey is said to help some people with allergies to pollen only; it does not have an impact on airborne allergens.

A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? Anxiety Urticaria Pruritus Stridor

Stridor The symptom that requires the most immediate action by the nurse is stridor which indicates airway involvement and warrants immediate intervention, such as use of oxygen and administration of epinephrine. Maintaining the client's airway is the highest priority.Anxiety, urticaria, and pruritus may be symptoms of a reaction, but are not the nurse's highest priority when the client is in respiratory distress.

The nurse is explaining the plan of care to a group of certified nursing assistants (CNAs) who will be caring for a client hospitalized with active tuberculosis (TB). Several of the CNAs are expressing concerns regarding caring for a client with TB. A CNA asks the nurse how long the disease will be communicable to others. The nurse realizes teaching has been effective if the other CNAs make which statement? The disease is communicable until the cough subsides. The disease is no longer communicable once medication has been started. The disease is usually no longer communicable after medication has been taken for 2 to 3 weeks. The disease is communicable for the duration of medication therapy, which is usually 9 months.

The disease is usually no longer communicable after medication has been taken for 2 to 3 weeks. RATIONALE: The client with TB is instructed to follow the medication regimen exactly as prescribed, and the nurse must stress the importance of compliance. Telling the client that the disease is not communicable after the cough subsides, that it is not communicable once the medication has been started, or that it is communicable for the duration of the medication therapy is incorrect. The client must be told that the disease is usually no longer communicable after the medication has been taken for 2 to 3 consecutive weeks and clinical improvement is seen; however, the client must take the prescribed medication for 6 months or longer, as prescribed.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? Combination medication therapy is effective in eliminating cough and fever. Combination medication therapy improves adherence. Combination medication therapy has fewer side effects, particularly liver damage. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.

The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms. The nurse tells the client that multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Combination drug therapy is the most effective method for treating TB and preventing transmission.As the disease responds to treatment, the symptoms will decrease, but they are not eliminated. Combination drug therapy does not improve adherence to drug therapy. Isoniazid, rifampin, and pyrazinamide may cause liver damage.

The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target?Select all that apply. Breast cancer survivors Those in the local prison Homeless adults Recent immigrants to the United States Those who have received bacille Calmette-Guérin (BCG) vaccine

Those in the local prison Homeless adults Recent immigrants to the United States The groups the nurse plans to educate include those adults who live in crowded areas such as prisons and homeless shelters, and those who are recent immigrants to the USA. Other groups at higher risk for tuberculosis include those who abuse injection drugs or alcohol and those groups of lower socioeconomic status.Breast cancer survivors who are no longer undergoing immunocomprising therapy have the same risk as the general population. Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.

In teaching a client about primary prevention of skin cancer, which instruction does the nurse include? "Avoid sun exposure between 11 a.m. and 3 p.m." "Examine your skin quarterly for possible cancerous or precancerous lesions." "Keep a total body spot and lesion map." "If you feel you must tan, use a tanning bed."

"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. A total body spot and lesion map is used for secondary prevention. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

The nurse is educating a group of young women who have sickle cell disease (SCD). Which statement from a class member indicates further teaching is necessary? "The pneumonia vaccine is protection that I need." "Getting an annual 'flu shot' would be dangerous for me." "I must take my penicillin pills as prescribed, all the time." "Frequent handwashing is an important habit for me to develop."

"Getting an annual 'flu shot' would be dangerous for me." Further teaching is needed when a young women with sickle cell disease says, "Getting an annual 'flu shot' would be dangerous for me." The client with SCD can receive annual influenza and pneumonia vaccinations. This helps prevent the development of these infections, which could cause a sickle cell crisis.The pneumonia vaccine is also appropriate for the client with sickle cell disease to receive. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications? "I am here to receive the yearly pneumonia shot again." "I am here to get my yearly flu shot again." "I should avoid large gatherings during cold and flu season." "I should cough into my upper sleeve instead of my hand."

"I am here to receive the yearly pneumonia shot again." The statement by the client, "I am here to receive the yearly pneumonia shot again" indicates a need for further teaching. The CDC recommends that adults older than 65 years be vaccinated with two vaccines, first with Prevnar 13 followed by Pneumovax about 6 to 12 months later. Adults who have already received the Pneumovax would have Prevnar 13 about a year or more later, but not annually.Older clients are encouraged to receive a flu shot annually because the vaccine is formulated annually, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. Recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? "I must wear a medical alert bracelet stating that I am allergic to bee stings." "I need to carry epinephrine with me." "My spouse must learn how to give me an injection." "I am immune to bee stings now that I have had a reaction."

"I am immune to bee stings now that I have had a reaction." More teaching is needed if the client states, "I am immune to bee stings now that I have had a reaction." No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe.The client should carry epinephrine (EpiPen) at all times and always wear a medical alert bracelet that states all allergies. Someone (spouse, neighbor, or family member) must learn how to give the client an injection in case the client is unable to self-administer the injection.

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." "The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." "It results in release of mediators, especially histamine, because of the reaction of immunoglobulin E (IgE) antibody on mast cells." "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."

"The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." The best statement by the student describing type IV hypersensitivity reaction is that the reaction of sensitized T cells with antigen and release of lymphokines is a delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity).A reaction of IgG with the host cell membrane or antigen describes a type II hypersensitivity reaction. A release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells describes a type I hypersensitivity reaction. An immune complex of antigen and antibodies deposited in the walls of blood vessels describes a type III hypersensitivity reaction.

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information would the nurse explain to the parents about the risk of a child having sickle cell disease? "Sickle cell disease will be inherited by your children." "The sickle cell trait will be inherited by your children." "Your children will have the disease, but your grandchildren will not." "Your children will not have the disease, but your grandchildren could."

"The sickle cell trait will be inherited by your children." The statement that explains to parents about the risk of a child having sickle cell disease is that the children of the client with sickle cell disease will inherit the sickle cell trait but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.The children of the client with sickle cell disease will inherit the sickle cell trait but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.

A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? "With this treatment, I probably cannot spread this virus to others." "This treatment does not kill the virus." "This medication prevents the virus from replicating in my body." "Research has shown the effectiveness of this therapy if I do not forget to take any doses."

"With this treatment, I probably cannot spread this virus to others." HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids.HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance.

The nurse reviews the laboratory results of a client receiving chemotherapy and notes that the white blood cell count is extremely low. The nurse asks a nursing student assigned to care for the client to place the client on neutropenic precautions. The nurse determines the need to review the procedures for neutropenic precautions if the student nurse took which action? 1.Removes the water pitcher from the client's room. 2.Removes fresh cut flowers from the client's room. 3.Places a box of face masks at the entrance to the client's room. 4.Leaves fresh pears and apples brought to the client by a family member in the client's room.

4.Leaves fresh pears and apples brought to the client by a family member in the client's room.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? "You will not spread the disease unless you stop taking your medication." "You will not pose an increased risk of disease to the people you have been living with." "You will have to take these medications for at least 1 year." "Your sputum may turn a rust color as your condition gets better."

"You will not pose an increased risk of disease to the people you have been living with." The nurse tells the client that he/she will not be contagious to the people he/she lives with. The people the client has been living with have already been exposed and need to be tested. They cannot become at higher risk simply because the diagnosis has now been confirmed.The client with active tuberculosis is contagious, even while taking medication. However, the risk for transmission is reduced after the infectious person has received proper drug therapy for 2 to 3 weeks, clinical improvement occurs, and acid-fast bacilli (AFB) in the sputum are reduced. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should be resumed gradually. 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1.Activities should be resumed gradually. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply 1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. 4.Keep the client supine regardless of the blood pressure readings. 5.Leave the client briefly to contact a primary health care provider (PHCP). 6.Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. Rationale: An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the PHCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per PHCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal.

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1.Cough 2.Dyspnea 3.Weight gain 4.High-grade fever 5.Chills and night sweats

1.Cough 2.Dyspnea 5.Chills and night sweats

The nurse is told that a client with cancer is experiencing thrombocytopenia secondary to the side effects of chemotherapy. The nurse should plan to monitor the results of which laboratory study most closely? 1.Platelet count 2.White blood cell (WBC) count 3.Antinuclear antibody (ANA) titer 4.Erythrocyte sedimentation rate (ESR)

1.Platelet count

A client is suspected of having discoid lupus erythematosus (DLE). Which diagnostic test will primarily confirm the diagnosis? 1.Skin biopsy 2.Anti-Smith test 3.Extractable nuclear antigens 4.Anti-deoxyribonucleic acid (DNA)

1.Skin biopsy

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1.Use nonlatex gloves. 2.Use medications from glass ampules. 3.Place the client in a private room only. 4.Keep a latex-safe supply cart available in the client's area. 5.Avoid the use of medication vials that have rubber stoppers. 6.Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1.Use nonlatex gloves. 2.Use medications from glass ampules. 4.Keep a latex-safe supply cart available in the client's area. 5.Avoid the use of medication vials that have rubber stoppers Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

The client with multiple severe allergic reactions is prescribed an epinephrine autoinjector to prevent an anaphylactic reaction. What should the nurse include when providing medication instructions? Select all that apply. 1."Store your epinephrine in the refrigerator." 2."You should inject the medication into your outer thigh." 3."Inject this medication as soon as early symptoms appear." 4."After injecting the medication, get medical help, even if all symptoms are relieved." 5."All the medicine should be injected; if any remains, you can use the remaining medication at another time."

2."You should inject the medication into your outer thigh." 3."Inject this medication as soon as early symptoms appear." 4."After injecting the medication, get medical help, even if all symptoms are relieved."

The nurse receives the assigned clients for the day. With which client should the nurse follow up first? 1.A client with emphysema has a pulse oximetry level of 91% 2.A client on chemotherapy has a temperature of 100.4° F (38° C) 3.A client receiving external beam radiation therapy has reddened skin at the site 4.A client with chronic obstructive pulmonary disease (COPD) has prolonged expiration (1:4 ratio)

2.A client on chemotherapy has a temperature of 100.4° F (38° C) Rationale: Any temperature elevation in a client receiving chemotherapy who is potentially experiencing neutropenia is considered a sign of infection. Bone marrow suppression results in neutropenia. The other options are expected findings.

An 11-year-old child is admitted to the hospital in vaso-occlusive sickle cell crisis. The nurse plans for which priority treatments in the care of the child? 1.Splenectomy, correction of acidosis 2.Adequate hydration, pain management 3.Frequent ambulation, oxygen administration 4.Passive range-of-motion exercises, adequate hydration

2.Adequate hydration, pain management Rationale: During vaso-occlusive sickle cell crisis, the care focuses on adequate hydration and pain management. Adequate hydration with intravenous normal saline and oral fluids maintains blood flow and decreases the severity of the vaso-occlusive crisis. Analgesics for pain management are necessary during a vaso-occlusive crisis. Splenectomy would not be done with a vaso-occlusive crisis. Acidosis is not present. Oxygen can be administered to increase tissue perfusion but is not the priority treatment for a vaso-occlusive crisis. Passive range of motion is not recommended; bed rest is prescribed initially.

A client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse should take? 1.Place the client on 100% oxygen and prepare for intubation. 2.Assess for anaphylaxis and prepare for emergency treatment. 3.Teach the client about the relationship between asthma and allergies. 4.Obtain an arterial blood gas and immunoglobulin E (IgE) blood level.

2.Assess for anaphylaxis and prepare for emergency treatment.

A client begins experiencing wheezing, anxiety, swelling, and hives after eating shellfish and is brought to the emergency department. Which immediate action should the nurse implement? 1.Administer epinephrine. 2.Maintain a patent airway. 3.Administer a corticosteroid. 4.Apply a MedicAlert bracelet

2.Maintain a patent airway. Rationale: Swelling, hives, lowered blood pressure, anxiety, and wheezing are indicative of anaphylaxis. If the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive epinephrine. Corticosteroids may also be prescribed. The client will need to be instructed about obtaining and wearing a MedicAlert bracelet, but this is not the immediate action.

The nurse is reviewing the laboratory blood test results for a client and notes that the hemoglobin S (Hgb S) value is elevated. The nurse determines that this laboratory finding is associated with which condition? 1.Aplastic anemia 2.Sickle cell anemia 3.Infectious mononucleosis 4.Acute lymphocytic leukemia

2.Sickle cell anemia

A client is hospitalized and is being treated for active tuberculosis (TB). The nurse should provide which information to the client related to preventing transmission to family members? 1.The family members will need to take medication to prevent infection even though the client will not be contagious after 1 continuous week of medication therapy. 2.The family members will need to take medication to prevent infection even though the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. 3.The family members will not need to take medication to prevent infection because the TB cannot be transmitted once the client has taken TB medications for 1 month. 4.The family members will not need to take medication to prevent infection because the TB cannot be transmitted once the client has taken TB medications for 6 consecutive weeks.

2.The family members will need to take medication to prevent infection even though the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Rationale: Family members or others who have been in close contact with a client diagnosed with TB are given prophylactic therapy with isoniazid. The client's TB is usually not communicable after the client takes medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy for 6 months or longer to prevent reinfection or drug-resistant TB.

A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs? 1.Five sputum cultures are negative. 2.Three sputum cultures are negative. 3.A sputum culture and a chest x-ray are negative. 4.A sputum culture and a tuberculin skin test are negative.

2.Three sputum cultures are negative. Rationale: The client must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of 3 sputum cultures are negative because the client is considered noninfectious at that point. Therefore, the remaining options are incorrect. A negative chest x-ray does not mean that the client is noninfectious. A positive tuberculin skin test never reverts to negative.

Adalimumab is added to the medication regimen for a client with severe rheumatoid arthritis. The nurse provides instructions to the client about the medication and should most appropriatelyprovide what information to the client? 1.The medication never needs to be refrigerated. 2.The medication is available in an oral liquid form only. 3.The medication is used to slow the progression of joint damage and can be coadministered with an analgesic. 4.The medication is used to slow the progression of joint damage but cannot be coadministered with an analgesic

3.The medication is used to slow the progression of joint damage and can be coadministered with an analgesic.

The nurse has provided instructions to the mother of a child with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures? 1."My child needs to avoid any exercise." 2."My child needs to avoid increasing any fluid intake." 3."My child needs to avoid going outdoors in warm weather." 4."My child needs to avoid situations that may lead to an infection."

4."My child needs to avoid situations that may lead to an infection." Rationale: The child should avoid infections, which can increase metabolic demands and cause dehydration, precipitating a sickle cell crisis. Fluids are important to prevent dehydration, which could lead to sickle cell crisis. Warm weather and mild exercise do not need to be avoided, but measures need to be taken to avoid dehydration during these conditions.

A client arrives at the emergency department with complaints of hives, itching, and difficulty swallowing and says, "My throat feels as though it is closing off." The client states that they were visiting a relative who has two cats and two dogs and believes that he is allergic to cats. The nurse ensures that the client has a patent airway and then prepares the client for which initial intervention? 1.Application of ice to the throat 2.Administration of normal saline solution 3.Administration of an intravenous (IV) glucocorticoid 4.Administration of a subcutaneous injection of epinephrine

4.Administration of a subcutaneous injection of epinephrine

A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication? 1.Alopecia 2.Chest pain 3.Pulmonary fibrosis 4.Orthostatic hypotension

4.Orthostatic hypotension Rationale: An adverse effect specific to etoposide is orthostatic hypotension. Etoposide should be administered slowly over 30 to 60 minutes to avoid hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? 1.Allow the client to deal with the disease in an individual fashion. 2.Ask family members whether they wish a psychiatric consultation. 3.Encourage the client to visit with the pastoral care department's chaplain. 4.Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

4.Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

A client is hospitalized with active tuberculosis (TB) and is being transported to the radiology department. What is the most appropriate action by the nurse to ensure a safe environment? 1.The nurse should wear a mask, gown, and gloves. 2.No mask is needed because hospital air is circulated frequently. 3.Cancel the radiology prescription, as the client cannot leave the hospital room. 4.The client should wear a high-efficiency particulate air (HEPA) respiratory mask.

4.The client should wear a high-efficiency particulate air (HEPA) respiratory mask.

Before administering prednisone IV push to a middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the client's random blood glucose level is 139 mg/dl (7.7 mmol/L). Which action is most important for the nurse to take? Instruct the client to drink diet soda to prevent elevation of blood sugar. Administer the prescribed prednisone on schedule. Notify the health care provider of the random blood glucose result. Review the client's antinuclear antibody (ANA) level.

Administer the prescribed prednisone on schedule. For this client, giving the medication per schedule is essential in treating the disease. Blood sugar is only slightly elevated and the blood glucose value will be monitored regularly because the client is receiving prednisone.

An alert, middle-aged client is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the "ABCs" for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? Raise the lower extremities. Start intravenous (IV) administration of normal saline. Reassure the client that appropriate interventions are being instituted. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.

Apply oxygen using a high-flow non-rebreather mask at 40% to 60%. The most immediate priority is for the nurse to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Assessing respiratory status is the most important assessment priority.Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.

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 or reducing skin exposure to sunlight Avoiding tanning beds Being aware of skin markings and performing skin self-examination Wearing SPF 40 sunscreen

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.

A 56-year-oldclient admitted with a diagnosis of acute myelogenous leukemia (AML) has been prescribed intravenous (IV) cytosine arabinoside and an IV infusion of daunorubicin. The client develops an infection. Which action would the nurse take to determine that the appropriate antibiotic has been prescribed to treat this condition? Monitor the client's white blood cell (WBC) count level Evaluate the client's liver function tests (LFTs) and serum creatinine levels Recognize that vancomycin (Vancocin) is the drug of choice used to treat all infections in clients with AML Check the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection

Check the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection The best action the nurse takes to determine if the appropriate antibiotic has been prescribed is to check the culture and sensitivity test results to be sure that the prescribed antibiotic is effective against the organism causing the infection. Drug therapy is the main defense against infections that develop in clients undergoing therapy for AML. Agents used depend on the client's sensitivity to various antibiotics for the organism causing the infection.Although the WBC count is elevated in infection, this test does not influence which antibiotic will be effective in fighting the infection. Although LFTs and kidney function tests may be influenced by antibiotics, these tests do not determine the effectiveness of the antibiotic. Vancomycin may not be effective in all infections. Culturing of the infection site and determining the organism's sensitivity to a cohort of drugs are needed. This will provide data on drugs that are capable of eradicating the infection in this client.

A community health nurse is preparing a poster for an educational session for a group of women with whom she will be discussing the risk factors for breast cancer. Which factors increase the risk for breast cancer and should be listed on the poster? Select all that apply. Multiparity Early menarche Early menopause Family history of breast cancer Exposure of the chest to high-dose radiation Previous cancer of the breast, uterus, or ovaries

Early menarche Family history of breast cancer Previous cancer of the breast, uterus, or ovaries RATIONALE: Risk factors for breast cancer include family history; age; early or late menarche; late menopause; previous cancer of the breast, uterus, or ovaries; nulliparity or late first birth; exposure of the chest to high-dose radiation.

The nurse assigned to care for a client with systemic lupus erythematosus (SLE) is regarding the client's medical history and physical report. Which sign/symptom of SLE should the nurse expect to see documented in the chart? Pallor Weight gain Hypothermia Erythema of the face

Erythema of the face RATIONALE: SLE is a chronic, progressive, systemic inflammatory disease of connective tissue that can cause the failure of major organs and systems. Immune complexes form in serum and organ tissues, resulting in inflammation and damage. This in turn leads to necrosis of blood vessels, lymph nodes, the gastrointestinal tract, and pleura. Signs/symptoms include a butterfly-patterned erythema of the face; a dry scaly, raised rash on the face or upper body, erythema of the palms; fever; weakness; malaise and fatigue; anorexia and weight loss; photosensitivity; joint pain; and anemia.

Which individuals are at an increased risk for latex allergy? Select all that apply. Hairdresser Computer operator Blood laboratory technician Individual who is allergic to pineapple Secretary who works in a pediatrician's office

Hairdresser Blood laboratory technician RATIONALE: Latex allergy is hypersensitivity to latex. Signs/symptoms range from mild contact dermatitis to moderately severe symptoms of rhinitis, conjunctivitis, urticaria, and bronchospasm to life-threatening anaphylaxis. Those at risk include health care workers, individuals employed in the manufacture of latex products, individuals with spina bifida, individuals who wear gloves frequently (e.g., food handlers, hairdressers, auto mechanics), and individuals who are allergic to kiwis, bananas, pineapple, tropical fruits, avocados, potatoes, hazelnuts, or chestnuts.

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? Hypoxia Infection Hemorrhage Fluid overload (overhydration)

Infection Avoiding infection is the priority potential problem when caring for a newly diagnosed client with leukemia.Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.

A client has had a melanoma lesion removed. For secondary prevention, what is most important for the nurse to teach the client? Ensure that all lesions are reviewed by a dermatologist or a surgeon. Avoid sun exposure. Have any new lesions genetically tested. Perform a total skin self-examination monthly with a partner.

Perform a total skin self-examination monthly with a partner. The nurse teaches the client that performing a monthly total skin self-examination with another person is the best secondary preventive measure.If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. Genetic testing of lesions is performed to determine whether targeted therapy will be effective.

A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? Collaborate with the client to select foods that are high in calories. Provide oral care to the client before meals to enhance appetite. Assess the perianal area every 8 hours for signs of skin breakdown. Discuss the need to avoid foods that are spicy or irritating.

Provide oral care to the client before meals to enhance appetite. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants.Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice, and would be done by licensed staff.

Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? Plan the schedule for desensitization therapy for a client with allergies. Monitor the client who has just received skin testing for signs of anaphylaxis. Educate a client with a latex allergy about other substances with cross-sensitivity to latex. Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.

Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing. The most appropriate action for the allergy clinic nurse to delegate to a nursing assistant is to remind the client about safety policies. This is within the scope of practice of a nursing assistant.Planning care and assessing for complications require broader education and scope of practice and should be done by the registered nurse. Client education is a registered nursing responsibility, requiring broader education and scope of practice.

A client recently admitted to the hospital with a UTI is to receive the first dose of an antibiotic intravenously. Before checking the five rights prior to administration, what is the nurse's first action? Review the clinical records and ask the client about any known allergies. Check with the pharmacy for any known allergies for this client. Check the client's identification band for any allergies. Ask the nurse who previously cared for the client about any known allergies.

Review the clinical records and ask the client about any known allergies. The nurse's first action is to check the client's clinical record for any known hypersensitivities as well as asking the client about any known allergies.The pharmacy is not responsible for obtaining information on all of the client's known allergies. Checking the client's identification band for allergies is part of the "five rights" process at the bedside before the medication is given. Asking the previous nurse is not an appropriate safety measure before medication administration.

The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition? Glaucoma Hypertension Hypothyroidism Sulfa allergy

Sulfa allergy Sulfasalazine contains sulfa and is contraindicated in clients with sulfa allergies.