Review Questions (8-12)

Which interventions are considered conservative treatments for hemorrhoids? (Select all that apply.) A. Hemorrhoid creams and ointments B. Sitz baths C. Over-the-counter analgesics D. Cryosurgery E. Rubber-band ligation

a, b, c Treatment of hemorrhoids is usually conservative and involves relief of symptoms and associated pain. Cold packs and sitz baths (warm water baths covering the hips and buttocks) three or four times a day reduce some swelling and pain. There are a number of over-the-counter preparations available in creams and suppositories used to treat hemorrhoids. Rubber band ligation and cryosurgery are surgical interventions for higher grade hemorrhoids

A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a.Distended abdomen b.Temperature of 100.0 F (37.8 C) c.Loose and bloody stool d.Lower abdominal cramps

a.Distended abdomen The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn's disease.

The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse's priority action? a.Place the client in a high Fowler's position. b.Prepare the client for elective intubation. c.Administer oxygen via a nasal cannula. d.Auscultate for breath sounds.

b.Prepare the client for elective intubation. Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

The nurse is assessing a client diagnosed with gastroesophageal reflux disease. Which of the following should be included in this assessment? a.Degree of mouth burning b.Difficulty swallowing c.Presence of pyrosis (heartburn) d.Painful swallowing

c.Presence of pyrosis (heartburn) Mouth burning is not a symptom of gastroesophageal reflux disease. Difficulty swallowing or dysphagia is not associated with gastroesophageal reflux disease. Pain when swallowing is associated with esophagitis, not acid reflux disease. Presence of pyrosis or heartburn should be assessed in this client.

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/mL. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L). The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

In a patient with cirrhosis, the nursing diagnosis "Risk for injury and bleeding related to prolonged clotting factors" is most appropriate related to which disorder? A. Pruritus B. Vitamin K deficiency C. Hyponatremia D. Ascites

B. Vitamin K deficiency Without vitamin K they can't make clotting factors which means they bleed easier

Elevated ammonia levels can lead to hepatic encephalopathy. Which provider order best reduces this risk in patients with cirrhosis? A. Administer furosemide and spironolactone B. Administer antibiotics C. Restrict protein intake D. Restrict caloric intake

C. Restrict protein intake More protein means more ammonia from the breakdown

When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. White blood cell count d. Hemoglobin (Hgb) level

d. Hemoglobin (Hgb) level Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a persons clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

The nurse is instructing a client diagnosed with a hiatal hernia on ways to reduce the symptoms. Which of the following should be included in these instructions? a.Eat large meals to keep the stomach full. b.Drink lots of liquids so that the stomach does not have to work so hard. c.Avoid lying down after meals. d.Lie down after eating.

c.Avoid lying down after meals. Sitting upright or sleeping with the head of the bed elevated helps keep the stomach contents in the stomach. The meal size should be smaller, and meals should be eaten more often so as not to overfill the stomach.

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a.Sedate the client to prevent tube dislodgement. b.Maintain balloon pressure at 15 and 20 mm Hg. c.Irrigate the gastric lumen with normal saline. d.Assess the client for airway patency.

d.Assess the client for airway patency. Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders

b. Screening for malignancy Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

What does the nurse recognize as physical signs of approaching death? (Select all that apply.) a.Mottling of skin b.Decreased sleeping c.Cheyne-Stokes respirations d.Loss of the sense of hearing e.Decreased appetite and thirst

a, c, e Physical signs of approaching death include mottling of skin, Cheyne-Stokes respirations, and decreased appetite and thirst. Sleeping increases, not decreases, and hearing is the last sense to fail.

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot

a. A 2-cm nontender supraclavicular node Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

a. A 36-year-old woman with aortic stenosis Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

The nurse is administering medications to a patient. Which medications should the nurse understand is being given to suppress C-reactive protein levels? a. Aspirin and steroids b. Antibiotics and diuretics c. Epinephrine and antihistamines d. Antihypertensives and antineoplastic agents

a. Aspirin and steroids A normal C-reactive protein level is less than 10 mg/L; an elevated level is present in rheumatoid arthritis, cancer, and systemic lupus erythematosus (SLE). This level is suppressed by aspirin and steroids. These medications are not used to suppress C-reactive protein levels.

The nurse is assessing a 31-year-old female patient with abdominal pain. The nurse, who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing's sign. c. McBurney sign. d. Grey-Turner's sign.

a. Cullen sign. Cullen sign is ecchymosis around the umbilicus. Rovsing's sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis. Grey Turner's sign refers to bruising of the flanks

A patient is experiencing delirium. Which group of medications should the nurse consider administering to help reduce delirium? a. Neuroleptics b. Benzodiazepines c. NSAIDs d. Opioids

a. Neuroleptics Neuroleptics such as Haldol help reduce the symptoms of delirium. Benzodiazepines are used for sedation and to prevent seizures. NSAIDs are helpful for treating inflammation, pain, and fever rather than delirium. Opioids are used for relief of pain and dyspnea.

A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate? a. The cancer involves only the cervix. b. The cancer cells look almost like normal cells. c. Further testing is needed to determine the spread of the cancer. d. It is difficult to determine the original site of the cervical cancer.

a. The cancer involves only the cervix. Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a.Truvada does not reduce the need for safe sex practices. b.This drug has been taken off the market due to increases in cancer. c.Truvada reduces the number of HIV tests you will need. d.This drug is only used for postexposure prophylaxis.

a.Truvada does not reduce the need for safe sex practices. Truvada is a new drug used for pre-exposure prophylaxis (PrEP) and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.

Which BP finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure? a. 108/64 mm Hg b. 128/76 mm Hg c. 140/90 mm Hg d. 136/ 82 mm Hg

b. 128/76 mm Hg The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. Premature ventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

b. Atrial fibrillation Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Premature ventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

A patient with gout has been instructed on the prescribed medication allopurinol (Zyloprim). Which patient statement indicates understanding of the action of this medication? a. Excretes proteins. b. Blocks formation of uric acid. c. Increases formation of purines. d. Increases metabolism of purines.

b. Blocks formation of uric acid. Allopurinol decreases uric acid production. Allopurinol (Zyloprim) does not excrete proteins or increase the formation or metabolism of purines.

A patient is being started on a blood transfusion. For how many minutes should the nurse stay with the patient during this transfusion? a. 5 b. 10 c. 15 d. 20

c. 15 The nurse should stay at the bedside with a patient for the first 15 minutes of any blood transfusion to detect signs of a reaction. The nurse needs to stay longer than 5 or 10 minutes. The nurse does not need to stay beyond 15 minutes.

A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time. d. prothrombin time.

b. bleeding time. The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

Nutritional support and management are essential across the entire continuum of CKD. Which statements would be considered true related to nutritional therapy? (select all that apply) a.Fluid is not usually restricted for patients receiving peritoneal dialysis. b.Sodium and potassium may be restricted in someone with advanced CKD. c.Decreased fluid intake and a low potassium diet are hallmarks of the diet for a patient receiving hemodialysis. d.Decreased fluid intake and a low potassium diet are hallmarks of the diet for a patient receiving peritoneal dialysis. e.Increased fluid intake and a diet with potassium-rich foods are hallmarks of a diet for a patient receiving hemodialysis.

a, b, c Water and any other fluids are not routinely restricted before Stage 5 end-stage renal disease (ESRD). Patients receiving hemodialysis have a more restricted diet than do patients receiving peritoneal dialysis. Patients receiving hemodialysis are frequently educated about the need for a dietary restriction of potassium- and phosphate-rich foods. However, patients receiving peritoneal dialysis may require replacement of potassium because of the higher losses of potassium with peritoneal dialysis. Sodium and salt restriction is common for all patients with CKD. For those receiving hemodialysis, as their urinary output diminishes, fluid restrictions are enhanced. Intake depends on the daily urine output. In general, 600 mL (from insensible loss) plus an amount equal to the previous day's urine output is allowed for a patient receiving hemodialysis. Patients are advised to limit fluid intake so that weight gains between dialysis sessions (i.e., interdialytic weight gain) are no more than 1 to 2 kg. For the patient who is undergoing dialysis, protein is not routinely restricted. The beneficial role of protein restriction in CKD stages 1 through 4 to reduce the decline in kidney function is controversial. Historically, dietary counseling often encouraged restriction of protein for individuals with CKD. Although there is some evidence that protein restriction has benefits, many patients find these diets difficult to adhere to. For CKD stages 1 through 4, many clinicians encourage a diet with normal protein intake. However, patients must be taught to avoid high-protein diets and supplements because they may overstress the diseased kidneys.

The nurse is assessing a client diagnosed with irritable bowel syndrome (IBS). Which of the following characteristics are associated with this disorder? (Select all that apply.) a.Recurrent abdominal pain b.Abdominal pain that improves with defecation c.Pain associated with a change in stool frequency d.Pain associated with a change in stool appearance e.Pain that occurs only during defecation f.Pain associated with passing flatus

a, b, c, d IBS is relatively common and is a motility disorder of the gastrointestinal tract. It is characterized by recurrent abdominal pain that improves with defecation. The pain will also appear with a change in stool frequency. The pain is also associated with a change in stool appearance. The pain of IBS does not occur only during defecation and is not associated with passing flatus.

A client is diagnosed with progressive systemic sclerosis. Which of the following will the nurse most likely assess in this client? (Select all that apply.) a. Telangiectasia b. Sclerodactyly c. Difficulty swallowing d. Painful cold hands and fingers e. Small white calcium deposits under the skin f. Hematuria

a, b, c, d, e In progressive systemic sclerosis, the skin, muscle, joints, lungs, esophagus, heart, digestive system, and kidneys are often affected in the diffuse subcutaneous form, often termed as CREST. Clinical manifestations include Calcinosis, or small white calcium deposits under the skin; Raynaud's syndrome, or painful cold hands and fingers; alteration in Esophageal movement, or difficulty swallowing; Sclerodactyly of the fingers and toes; and Telangiectasia or permanent dilation of the capillaries, arterioles, and venules. Hematuria is not seen in this disorder.

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? a.Calling the Rapid Response Team b.Delegating taking a set of vital signs c.Instituting bleeding precautions d. Placing the client on bedrest

a.Calling the Rapid Response Team With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or putting the client back into bed is important, but the critical action is to call for immediate medical attention.

Patients with CKD experience an increased incidence of cardiovascular disease related to (select all that apply) a.Hypertension b.Vascular calcifications c.A genetic predisposition d.Hyperinsulinemia causing dyslipidemia e.Increased HDL levels

a, b, d CKD patients have traditional cardiovascular (CV) risk factors, such as hypertension and elevated lipids. Hyperinsulinemia stimulates hepatic production of triglycerides. Most patients with uremia develop dyslipidemia. CV disease may be related to nontraditional CV risk factors, such as vascular calcification and arterial stiffness, which are major contributors to CV disease in CKD. Calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels. The mechanisms involved are multifactorial and incompletely understood, but they include (1) change of vascular smooth muscle cells into chondrocytes or osteoblast-like cells, (2) high total-body amounts of calcium and phosphate as a result of abnormal bone metabolism, (3) impaired renal excretion, and (4) drug therapies to treat the bone disease (e.g., calcium phosphate binders).

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a.Which food types cause an exacerbation of symptoms? b.Where is your pain and what does it feel like? c.Have you lost a significant amount of weight lately? d.Are your stools soft, watery, and black in color? e.Do you experience nausea associated with defecation?

a, b, e The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the client's pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color.

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

a, b, e, f A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is on the high side of normal and the serum creatinine level is normal.

After the nurse has finished teaching a patient with ulcerative colitis about sulfasalazine (Azulfidine), which patient statement indicates that the teaching has been effective? a. I will need to use a sunscreen when I am outdoors. b. I will need to avoid contact with people who are sick. c. The medication will need to be tapered if I need surgery. d. The medication will prevent infections that cause the diarrhea.

a. I will need to use a sunscreen when I am outdoors. Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

The spouse of a patient with terminal cancer visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, I'm busy at work, but otherwise things are fine. Which nursing diagnosis is most appropriate? a. Ineffective coping related to lack of grieving b. Anxiety related to complicated grieving process c. Caregiver role strain related to feeling overwhelmed d. Hopelessness related to knowledge deficit about cancer

a. Ineffective coping related to lack of grieving The spouse's behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious.

The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

a. immobilize the joint. The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

When caring for a patient who has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months, the nurse will plan to teach the patient about a. medication use. b. fluid restriction. c. enteral nutrition. d. activity restrictions.

a. medication use. Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. The nurse will plan to a. place the patient on NPO status. b. administer IV metoclopramide (Reglan). c. teach the patient about total colectomy surgery. d. administer cobalamin (vitamin B12) injections.

a. place the patient on NPO status. An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. Metoclopramide increases peristalsis and will worsen symptoms.

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states, "Whew! I was really worried about that result." What action by the nurse is most important? a.Assess the client's sexual activity and patterns. b.Express happiness over the test result. c.Remind the client about safer sex practices. d.Tell the client to be retested in 3 months.

a.Assess the client's sexual activity and patterns. The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client's sexual behavior further to determine the proper response. The other actions are not the most important but discussing safer sex practices is always appropriate.

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a.Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b.Client with Bruton's agammaglobulinemia who is waiting for discharge teaching c.Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d.Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

a.Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, I do not want to take this medication because it causes diarrhea. How should the nurse respond? a.Diarrhea is expected; that's how your body gets rid of ammonia. b.You may take Kaopectate liquid daily for loose stools. c.Do not take any more of the medication until your stools firm up. d.We will need to send a stool specimen to the laboratory.

a.Diarrhea is expected; that's how your body gets rid of ammonia. The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a.Give the client pain medication if it is time for another dose. b.Instruct the client not to request pain medication too early. c.Request the provider leave a prescription for a placebo. d.Tell the client it is too early to have more pain medication.

a.Give the client pain medication if it is time for another dose. Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the client's pain. Giving placebos is unethical.

A nurse instructs her client who has had a hemorrhoidectomy not to used Sitz bath until at least 12 hours postoperatively to avoid which of the following complications? a.Hemorrhage b.Rectal Spasm c.Constipation d.Urinary retention

a.Hemorrhage Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements.

The nurse is caring for a client diagnosed with irritable bowel syndrome (IBS) who is experiencing diarrhea. What medication would the nurse expect to administer? a.Loperamide (Imodium) b.Docusate sodium (Colace) c.Lorazepam (Ativan) d.Haloperidol (Haldol)

a.Loperamide (Imodium) Antidiarrheal agents like Imodium can be given prophylactically or symptomatically on an as-needed basis. Docusate sodium (Colace), lorazepam (Ativan), and haloperidol (Haldol) are not indicated to treat this disorder.

When the nurse is caring for a patient whose HIV status in unknown, which of these patient exposures is most likely to require postexposure prophylaxis? a.Needle stick with a needle and syringe used to draw blood b.Splash into the eyes when emptying a bedpan containing stool c.Contamination of open skin lesions with patient vaginal secretions d.Needle stick injury with a suture needle during a surgical procedure

a.Needle stick with a needle and syringe used to draw blood Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

A 12-year-old child has failed several courses of chemotherapy. An experimental drug is available that his parents want him to receive. He has told his parents and the oncologists that he is ready to die and does not want any more chemotherapy. The nurse recognizes what to be true? a.Parents and child both need support in the decision making. b.Twelve-year-olds are minors and cannot give consent or refuse treatments. c.The oncologists needs to make the decision because the parents and child disagree. d.The parents have the right and responsibility to make decisions for their children younger than age 18 years.

a.Parents and child both need support in the decision making. This is a family issue that requires support to help both parents and child resolve the conflict. Because the child has little chance of survival, many institutions support the child's right to refuse or assent to therapy. The institution can obtain a court order to support the child's decision if verified by the oncologists. Twelve-year-olds can give consent for therapy under certain conditions, including being an emancipated minor and receiving therapy for birth control and sexually transmitted infections. Right to self-determination is also accepted if the child is fully aware of the consequences of the actions. The practitioners cannot take the responsibility for decision making from the parent or child. Parents have the responsibility for decision making, but certain circumstances do limit their authority.

A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client? a.Suction the client to remove secretions. b.Turn and reposition the client every 2 hours. c.Measure urinary output every 30 minutes. d.Administer prescribed anticholinergic drugs as needed.

a.Suction the client to remove secretions. Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important. The other interventions do not relate to the administration of atropine.

A major advantage of peritoneal dialysis is a.The diet is less restricted, and dialysis can be performed at home. b.The dialysate is biocompatible and causes no long-term consequences. c.High glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss. d.No medications are required because of the enhances efficiency of the peritoneal membrane in removing toxins.

a.The diet is less restricted, and dialysis can be performed at home. Advantages of peritoneal dialysis include fewer dietary restrictions and the possibility of home dialysis.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a.Urine output via indwelling urinary catheter is 20 mL/hr b.Blood pressure increases from 110/58 to 120/62 mm Hg c.Respiratory rate decreases from 18 to 14 breaths/min d.A decrease in the client's weight by 6 kg

a.Urine output via indwelling urinary catheter is 20 mL/hr Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.

A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in the right knee. During the initial care of the patient, the nurse should a.immobilize the knee. b.apply heat to the joint. c.assist the patient with light weight bearing. d.perform passive range of motion to the knee.

a.immobilize the knee. The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

The nurse explains that the most beneficial diet for a person with inflammatory bowel disease (IBD) is a _____ diet. a.low-fat, low-fiber. b.high-fiber, low-protein. c.mechanical soft, low-sodium. d.low-protein, low-calorie.

a.low-fat, low-fiber. A low-fat, low-fiber, high-protein, high-calorie diet is recommended for the patient with IBD to make up for the loss of fluid and nutrients in the frequent stools.

For the patient with a hiatal hernia, the nurse recommends avoidance of fats because fats: a.relax the sphincter, allowing reflux. b.may cause nausea and vomiting. c.cause hypermobility of the colon. d.may initiate the strangulation of the hernia.

a.relax the sphincter, allowing reflux. Hiatal hernia is the result of a defect in the wall of the diaphragm where the esophagus passes through. A hiatal hernia is formed by the protrusion of part of the stomach or the lower part of the esophagus up into the thoracic cavity. Intake of alcohol, chocolate, caffeine, and fatty food is limited, and smoking should be avoided. Ingestion of fats relaxes the sphincter, allowing reflux.

The nurse is performing an assessment on a patient with amyotrophic lateral sclerosis (ALS). Which of the following symptoms would the nurse expect to find? (Select all that apply) a.Urinary incontinence b.Asymmetric muscle weakness c.Nasal vocal quality d.Fatigue e.Muscle weakness beginning in lower extremities

b, c, d Function of the anal and bladder sphincters usually remains intact with patients with ALS because the disease does not affect those nerves. Muscle weakness usually begins in the distal upper extremities. Fatigue, nasal vocal quality, and asymmetric muscle weakness are all signs of ALS

A patient with SLE is prescribed a corticosteroid. What side effects of this medication should the nurse review with the patient? (Select all that apply.) a. Tinnitus b. Facial hair c. Moon face d. Mood changes e. Increased weight f. Rash and pruritus

b, c, d, e Corticosteroids can cause weight gain, increased facial hair, acne, round moon face, mood changes, irritability, depression, increased appetite, increased weight, poor wound healing, headache, peptic ulcers, and osteoporosis. Tinnitus, rash, and pruritus are not adverse effects of corticosteroid therapy.

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to? (Select all that apply) a. avoiding the consumption of high-purine foods b. strategies for good dental hygiene and mouth care c. protecting the extremities from hot and cold temperatures d. maintaining joint function and preserving muscle strength e. performing mouth excursion (yawning) exercises on a daily basis

b, c, d, e Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. The nurse should include the following in the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and gingival problems); protection of hands and feet from cold exposure and possible burns or cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures (they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint movement occurs); use of assistive devices as appropriate and organization of activities to preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open mouth) (helps maintain temporomandibular joint function).

Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate four times daily. d. Increase dietary fiber intake.

b. Monitor stools for blood. Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

A terminally ill patient is receiving palliative care. How would the nurse explain the purpose of this type of care to the family? a. Palliative care reduces pain and prevents medical complications. b. Palliative care is designed to alleviate suffering and promote quality of life. c. Palliative cares purpose is to control the side effects of illness while postponing death. d. Palliative care involves withdrawing all medical care to allow natural death.

b. Palliative care is designed to alleviate suffering and promote quality of life. The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and promoting quality of life. Medical complications can be controlled by palliative care, but not prevented. Palliative care can also help control pain. The purpose of palliative care is not specifically to postpone death. Withdrawing all medical care would be inappropriate, as it would cause more suffering.

A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first? a.Client with intraocular pressure reading of 24 mm Hg b.Client who has had cataract surgery and has worsening vision c.Client whose red reflex is absent on ophthalmologic examination d.Client with a tearing, reddened eye with exudate

b.Client who has had cataract surgery and has worsening vision After cataract surgery, worsening vision indicates an infection or other complication. The nurse should see this client first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may have an infection.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? a.Client with a blood pressure of 180/98 mm Hg b.Client who reports shortness of breath c.Client who reports calf tenderness and swelling d.Client with a swollen and painful left great toe

b.Client who reports shortness of breath Clients with polycythemia vera often have clotting abnormalities due to the hyper-viscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder.

A client experiencing abdominal pain and diarrhea tells the nurse that he used to smoke. Which of the following gastrointestinal disturbances is this client most likely experiencing? a.Irritable bowel syndrome b.Crohn's disease c.Acute appendicitis d.Small bowel obstruction

b.Crohn's disease Current and former smokers appear to have a greater risk of developing Crohn's disease than nonsmokers. Not smoking will not cause irritable bowel syndrome, acute appendicitis, or small bowel obstruction.

A pregnant woman with a history of early chronic HIV infection is seen at the clinic. Which information will the nurse include when teaching the patient? a.The antiretroviral medications used to treat HIV infection are teratogenic. b.Most infants born to HIV-positive mothers are not infected with the virus. c.Since she is at an early stage of HIV infection, the infant will not contract HIV. d.It is likely that her newborn will become infected with HIV unless she uses antiretroviral drug therapy (ART).

b.Most infants born to HIV-positive mothers are not infected with the virus. Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a.Auscultate the patient's bowel sounds. b.Notify the patient's health care provider. c.Administer the prescribed PRN antiemetic drug. d.Give the scheduled dose of prednisone (Deltasone).

b.Notify the patient's health care provider. The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a.Monitor intake and output. b.Provide a low-sodium diet. c.Increase oral fluid intake. d.Weigh the client daily.

b.Provide a low-sodium diet. A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

The nurse is caring for a patient who has been diagnosed with Crohn's disease. When providing education concerning dietary recommendations, which statement by the patient indicates an understanding of the teaching? a.I should try to eat as much fiber daily as I can. b.Reducing dietary fat and fiber will be helpful in managing my condition. c.I should not have lactose-containing products. d.Eating a larger breakfast and smaller lunch and dinner portions is recommended.

b.Reducing dietary fat and fiber will be helpful in managing my condition. A diet of low-fat, low-fiber foods that have a high protein and caloric content is instituted. Small frequent feedings are best. Lactose avoidance helps some patients but is not a global recommendation.

A client complains of acute gastrointestinal distress. While obtaining a health history, the nurse asks about the family history. Which disorder has a familial basis? a.Hepatitis b.Ulcerative colitis c.Appendicitis d.Bowel obstructions

b.Ulcerative colitis Genetic factors have been identified as susceptibility factors for the development of ulcerative colitis. None of the other choices have a genetic predisposition for developing the disorder.

Amlodipine (Norvasc) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will a.reduce the fight or flight response. b.decrease spasm of the coronary arteries. c.increase the force of myocardial contraction d.help prevent clotting in the coronary arteries.

b.decrease spasm of the coronary arteries. Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., amlodipine, nifedipine [Procardia]) are a first-line therapy for this type of angina. Platelet inhibitors, such as aspirin, help prevent coronary artery thrombosis, and b-blockers decrease sympathetic stimulation of the heart. Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand.

A patient is admitted to the hospital with a sickle cell crisis. While caring for the patient during the crisis, it is important for the nurse to a.limit the patient's intake of oral and IV fluids. b.evaluate the effectiveness of opioid analgesics. c.encourage the patient to ambulate as much as tolerated. d.teach the patient about high-protein, high-calorie foods.

b.evaluate the effectiveness of opioid analgesics. Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

To assess the patency of a newly placed AV graft for dialysis, the nurse should (select all that apply) a.Monitor the BP in the affected arm b.Irrigate the graft daily with low dose heparin c.Palpate the area of the graft to feel a normal thrill d.Listen with a stethoscope over the graft to detect a bruit e.Frequently monitor the pulses and neurovascular status distal to the graft

c, d, e A thrill can be felt on palpation of the area of anastomosis of the arteriovenous graft, and a bruit can be heard with a stethoscope. The bruit and thrill are created by arterial blood rushing into the vein. The BP should not be taken in the arm with the AV graft.

While preparing for the discharge of an elderly, terminally ill patient, the family asks for information concerning the most appropriate time to become involved with a hospice agency. Which action by the nurse is most appropriate? a. Encourage the family to hold off making the contact until death is very close. b. Estimate the patient's life expectancy to gauge when contact with hospice should be made. c. Assist the family in making contact with a hospice agency at this time. d. Determine what expectations the family has of the hospice agency.

c. Assist the family in making contact with a hospice agency at this time. Hospice agencies provide vital services to patients who are facing death and to their families. Referrals should be prompt. Even though a hospice is generally considered appropriate in the last 6 months of life, it is not appropriate for the nurse to make that determination. Waiting until the time of death is at hand does not leave much time for the hospice agency to assist the family. Determining the family's expectations is an action more appropriate for the hospice intake nurse.

A terminal patient with a fulminating leg wound needs surgery, yet it is unlikely the patient will survive the procedure. The nurse could ethically support which action by the health care team? a. Explaining that the surgery is needed, and every effort will be done to keep the patient alive b. Telling the patient that offering surgery was an error and that treatment will be done with medications and therapy c. Deciding not to conduct the surgery and determining if there are other treatment approaches d. Conducting the surgery without telling the patient that survival is unlikely.

c. Deciding not to conduct the surgery and determining if there are other treatment approaches The surgery should not be done with the promise of keeping the patient alive. If the patient is likely to die, this violates the ethical principle of veracity. Surgical intervention is stressful and painful. If the patient is not likely to survive the surgery, it should not be performed. The ethical action is to determine if other treatment approaches exist. Lying to the patient is not ethical and should not be supported by the nurse. This is unethical conduct. The patient should be taken to surgery only if informed consent is valid.

Which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. I will switch from whole milk to 1% or nonfat milk. b. I like fresh salmon and I will plan to eat it more often. c. I will miss being able to eat peanut butter sandwiches. d. I can have a cup of coffee with breakfast if I want one.

c. I will miss being able to eat peanut butter sandwiches. Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

The nurse is reinforcing teaching provided to a patient with gout. Which food should the patient state will be avoided that indicates teaching has been effective? a. Rice b. Beets c. Liver d. Bananas

c. Liver The patient should be instructed to avoid high-purine (protein) foods such as organ meats, shellfish, and oily fish. Rice, beets, and bananas do not need to be avoided.

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. Benign tumors do not cause damage to other tissues. b. Benign tumors are likely to recur in the same location. c. Malignant tumors may spread to other tissues or organs. d. Malignant cells reproduce more rapidly than normal cells.

c. Malignant tumors may spread to other tissues or organs. The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

c. Oatmeal with cream During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient about the medications available for treatment. b. Inform the patient how to protect sexual and needle-sharing partners. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to notify individuals who have had risky contact with the patient.

c. Remind the patient about the need to return for retesting to verify the results. After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.

Which instructions will the nurse include in discharge teaching for a patient who has had a hemorrhoidectomy at an outpatient surgical center? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before a bowel movement is expected. d. Delay having a bowel movement for several days until healing has occurred.

c. Take prescribed pain medications before a bowel movement is expected. Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. Delay of bowel movements is likely to lead to constipation. A high-residue diet will increase stool bulk and prevent constipation. Sitz baths are used to relieve pain and keep the surgical area clean.

A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from knowing the seriousness of the illness. The nurse should provide which explanation? a. This attitude is helpful to give parents time to cope. b. This will help the child cope effectively by denial. c. Terminally ill children know when they are seriously ill. d. Terminally ill children usually choose not to discuss the seriousness of their illness.

c. Terminally ill children know when they are seriously ill. The child needs honest and accurate information about the illness, treatments, and prognosis. Because of the increased attention of health professionals, children, even at a young age, realize that something is seriously wrong and that it involves them. Thus, denial is ineffective as a coping mechanism. The nurse should help parents understand the importance of honesty. Parents may need professional support and guidance from a nurse or social worker in this process. Children will usually tell others how much information they want about their condition.

The sibling of a 4-year-old girl dies from sudden infant death syndrome. The parents are concerned because the 4-year-old girl showed more outward grief when her cat died than now. How should the nurse explain this reaction to the parents? a. The child is not old enough to have a concept of death. b. This suggests maladaptive coping, and referral is needed for counseling. c. The death may be so painful and threatening that the child must deny it for now. d. The child is not old enough to have formed a significant attachment to her sibling.

c. The death may be so painful and threatening that the child must deny it for now. Children of this age believe that their thoughts can cause death. The child may feel guilty and responsible. The loss may be so deep, painful, and threatening that the child needs to deny it for a time. Denial is within the range of a normal response to the death of a sibling. Counseling is not indicated at this time. Denial is also characteristic of the child's developmental level. These children do have a concept of death, seeing it as a separation. The child also would have formed an attachment to the sibling, who was in the house and sharing the parents time and attention.

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. The patient meets the criteria for a diagnosis of an acute HIV infection. b. The patient will be diagnosed with asymptomatic chronic HIV infection. c. The patient has developed acquired immunodeficiency syndrome (AIDS). d. The patient will develop symptomatic chronic HIV infection in less than a year.

c. The patient has developed acquired immunodeficiency syndrome (AIDS). Development of PCP meets the diagnostic criterion for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.

When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which instruction will the nurse include? a.Limit fluids to 2 to 3 quarts a day. b.Take a daily multivitamin with iron. c.Avoid exposure to crowds as much as possible. d.Drink only one or two caffeinated beverages daily.

c.Avoid exposure to crowds as much as possible. Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

Client education should include minimizing client discomfort due to hemorrhoids. Nursing management should include: a.Advise to wear silk undergarments b.Suggest eating a low roughage diet c.Avoid straining during defecation d.Use of a Sitz bath for 30 minutes

c.Avoid straining during defecation Straining can increase intra-abdominal pressure. Teaching should also include suggest eating a high roughage diet, wearing of cotton undergarments and to use a Sitz bath for only 15 minutes.

When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications? a.Adalimumab (Humira) b.Prednisone (Deltasone) c.Capsaicin cream (Zostrix) d.Sulfasalazine (Azulfidine)

c.Capsaicin cream (Zostrix) Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.

The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? a.Patient admitted with a large acute myocardial infarction b.Patient being discharged after an exacerbation of heart failure c.Patient who had mitral valve replacement with a mechanical valve d.Patient being treated for rheumatic fever after a streptococcal infection

c.Patient who had mitral valve replacement with a mechanical valve Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a.Initiate Droplet Precautions for the client. b.Notify the provider about the CD4+ results. c.Place the client under Airborne Precautions. d.Use Standard Precautions to provide care.

c.Place the client under Airborne Precautions. Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alternative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

When prioritizing care, which of the following patients should the nurse see first? a.The 52-year-old patient who is admitted for a relapse of MS day three whose being treated effectively with Solu-Medrol b.The patient who has been put on seizure precautions 24 hours ago c.The 32-year-old female with a recent diagnosis of Guillain-Barre syndrome d.The 65-year-old man who has just been diagnosed with early stage Parkinson's disease

c.The 32-year-old female with a recent diagnosis of Guillain-Barre syndrome Guillain Barre syndrome is a medical emergency due to its high potential for respiratory failure and autonomic dysfunction. Although B has been recently put on seizure precautions, there is no evidence that he is currently having a seizure. All other patients are in more stable conditions

Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses

The nurse is reviewing the immune system with a patient newly diagnosed with an autoimmune disorder. What should the nurse explain as the purpose of antibodies? a. They destroy foreign antigens. b. Work on many different antigens c. Are specific according to blood type d. Attach to antigens to label them for destruction

d. Attach to antigens to label them for destruction Antibodies are also called immunoglobulins (Ig) or gamma globulins and are glycoproteins produced by plasma cells in response to foreign antigens. Antibodies attach to antigens to label them for destruction. They do not themselves destroy foreign antigens. Each antibody is specific for only one antigen. There are five classes of human antibodies, designated by letter names: IgG, IgA, IgM, IgD, and IgE. They are not specific according to blood type.

When interviewing a patient with abdominal pain and possible irritable bowel syndrome, which question will be most important for the nurse to ask? a. Have you been passing a lot of gas? b. What foods affect your bowel patterns? c. Do you have any abdominal distention? d. How long have you had abdominal pain?

d. How long have you had abdominal pain? One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance also are associated with IBS, but are not diagnostic criteria.

Which statement by a patient indicates good understanding of the nurses teaching about prevention of sickle cell crisis? a. Home oxygen therapy is frequently used to decrease sickling. b. There are no effective medications that can help prevent sickling. c. Routine continuous dosage narcotics are prescribed to prevent a crisis. d. Risk for a crisis is decreased by having an annual influenza vaccination.

d. Risk for a crisis is decreased by having an annual influenza vaccination. Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

The nurse is providing discharge instructions to a client diagnosed with systemic lupus erythematosus (SLE). Which of the following would not be including in these instructions? a. Activity will need to be decreased during an exacerbation. b. Body temperature should be monitored. c. Corticosteroid treatment must be slowly tapered off. d. Sunbathing decreases symptoms.

d. Sunbathing decreases symptoms. Exposure to sunlight exacerbates the disease process. Body temperature should be monitored for increases and possible infection. Corticosteroid treatment cannot be abruptly stopped. Activity with rest periods should be encouraged.

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. oral ferrous sulfate tablets. b. regular blood transfusions. c. iron dextran (Imferon) infusions. d. cobalamin (B12) spray or injections.

d. cobalamin (B12) spray or injections. Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

The nurse reviewing laboratory reports on kidney function identifies a result that suggests decreased renal function, which is: a.BUN 10.5 mg/dL b.Creatinine 0.6 mg/dL c.BUN 15 mg/dL d.Creatinine 2.0 mg/dL

d.Creatinine 2.0 mg/dL The normal for BUN is 10 to 20 mg/dL. The normal for creatinine is 0.6 to 1.2 mg/dL. The creatinine is elevated.

A patient with hemophilia calls the nurse in the hemophilia clinic to discuss all these problems. Which problem is most important to communicate to the physician? a.Skin abrasions b.Bleeding gums c.Multiple bruises d.Dark tarry stools

d.Dark tarry stools Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.

Which information will the nurse include when teaching a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a.Peppermint tea may be helpful in reducing your symptoms. b.You should avoid eating between meals to reduce acid secretion. c.Vigorous physical activities may increase the incidence of reflux. d.It will be helpful to keep the head of your bed elevated on blocks.

d.It will be helpful to keep the head of your bed elevated on blocks. Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a.Nausea and vomiting b.Frontal headache c.Vertigo and syncope d.Mid-sternal chest pain

d.Mid-sternal chest pain Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.

Antiretroviral therapy (ART) is being considered for an HIV-infected patient who has a CD4+ cell count of 400/l. Which factor is most important to consider when determining whether ART will be started for this patient? a.Patient social support system b.HIV genotype and phenotype c.Potential medication side effects d.Patient ability to comply with ART schedule

d.Patient ability to comply with ART schedule Drug resistance develops quickly unless the patient takes ART medications on a stringent schedule, and this endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.

Which position would be ideal for the client in the early postoperative period after hemorrhoidectomy? a.High Fowler's b.Trendelenburg's c.Supine d.Side - lying

d.Side - lying Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side lying positions are ideal from a comfort perspective. A high Fowler's or supine position will place pressure on the operative site and is not recommended. There is no need for Trendelenburg's position.

A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first? a.Document the findings in the chart. b.Notify the surgeon immediately. c.Reassess the drainage in 1 hour. d.Take a full set of vital signs.

d.Take a full set of vital signs. The drainage in the NG tube should initially be brown with old blood. The presence of bright red blood indicates bleeding. The nurse should take a set of vital signs to assess for shock and then notify the surgeon. Documentation should occur but is not the first thing the nurse should do. The nurse should not wait an additional hour to reassess.

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a.The patient has relapsing-remitting MS. b.The patient walks a mile a day for exercise. c.The patient complains of pain with neck flexion. d.The patient has an increased serum creatinine level.

d.The patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

A client has a history of being treated for ulcerative colitis. The nurse realizes that a life-threatening complication of this disorder is: a.Crohn's disease. b.small bowel obstruction. c.peptic ulcer disease. d.toxic megacolon.

d.toxic megacolon. Toxic megacolon is a life-threatening complication of ulcerative colitis, and it requires immediate surgical intervention. Crohn's disease, small bowel obstruction, and peptic ulcer disease are not life-threatening complications of ulcerative colitis.