Unit 3 study guide
A nurse is teaching a client who has HIV about how the virus is transmitted which of the following statements should the nurse include in the teaching?
"HIV can be transmitted to anyone who has had contact with the infected blood."
Which precaution is MOST IMPORTANT for the nurse to teach a client, who is a secretary, and just had nasal tubes removed after a posterior nasal bleed? * Iggy SG
"If bleeding recurs, call 911 immediately."
A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching?
"Wash your genitalia using an antimicrobial soap"
A nurse is teaching a client who has HIV about the early manifestations of AIDS. Which of the following statements should the nurse include in the teaching?
"You can expect a persistent fever and swollen glands."
Which clients will the nurse recognize as at higher risk for having active TB in North America? SATA * Iggy SG
28 y.o. man with HIV-III (AIDS) 55 y.o. homeless man with alcoholism who stays weekly in a shelter 60. y.o. migrant farm worker from Mexico 68 y.o. man incarcerated for 20 years
With which client does the nurse anticipate possible complications from OSA? Iggy SG
28-y.o. who is 80 lbs (36.4 kg) overweight and has a short neck
With which clients will the nurse be alert for an increased risk of OSA? SATA. *Iggy SG
48 y.o. woman who has a short neck and a small chin 56 y.o. man who smokes two packs of cigarettes daily
Which clients will the nurse recognize to be at risk for developing pneumonia? SATA * Iggy SG
72- y.o with chronic confusion 66- y.o with influenza 49- y.o being mechanically ventilated and is orally colonized with Gram negative bacteria 28-y.o. who is extremely malnourished
Which client with asthma does the nurse consider to have the highest risk for a fatal outcome of an acute attack?
76-y.o. with HTN
A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for airway loss r/t aspirated oral and nasopharyngeal secretions? SATA * Test Bank
A 24 y.o. with a traumatic brain injury A 58 y.o. getting radiation therapy A 66 y.o. who is quadriplegic An 80-y.o. who is asphasic
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea OSA? * Test Bank
A 55-y.o. woman who is 50 lb (23kg) overweight
Which statements about OSA are true? SATA Iggy SG
A main feature is hypopnea Associated with frequent nightmares Causes fragmented nightmare sleep and daytime drowsiness
Which key elements will the nurse teach or reinforce to a client for self-management with a personal asthma action plan? Iggy SG
A schedule for prescribed daily controller drugs (s) and directions for prescribed reliever drug Client-specific daily asthma control assessment questions Directions for adjusting the daily controller drug schedule Emergency actions to take when asthma is not responding to controller and reliever drugs When to contact the primary health care provider (in addition to regularly scheduled visits )
Which factors or conditions that increase the risk for development of COPD will the nurse include in preparing client education materials? SATA
AAT deficiency Chronic exposure to inhalation irritants Cigarette smoking Hx of asthma
A client has been taking isoniazid for TB for 3 weeks. What lab results need to be reported to the primary HCP IMMEDIATELY? *Test Bank
ALT : 180 U/L
A nurse asks the supervisor why older adults are more prone to infection than other adults. What reasons does the supervisor give? (Select all that apply.) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective f. Higher rates of chronic illness
ANS: A, B, C, E, F Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, fewer lymphocytes and antibodies, and higher rates of chronic illness.
An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.
ANS: B In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30-pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions
ANS: B The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress.
A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings
ANS: B, D, E Disposing of dressings properly Performing proper hand hygiene Removing and replacing wet dressings Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to clients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds should always be covered.
A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? * Test Bank a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)
ANS: C First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine.
A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? * Test Bank a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule you for a computed tomography scan this week."
ANS: C This client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.
A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? *Test Bank a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.
ANS: D Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client should be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.
A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report
ANS: D Participating in hand-off report Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.
A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are BEST ? SATA *Test Bank
Administer oxygen and place client on an oximeter Administer prescribed albuterol inhaler Assess the client's lung sounds after administering the inhaler
The client dx with PCP is being admitted to the ICU. Which HCP's order should the nurse implement first?
Administer oxygen to the client via nasal cannula
The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement? * Med-Surg
Administer pain medication as soon as the time frame allows
Which HIV-positive client does the nurse expect will progress to HIV-III (AIDS) the most quickly? Iggy
Adult male who is transfused with HIV-contaminated blood
Which precautions (in addition to Standard Precautions) will the nurse initiate for the newly admitted client who has HIV-III and symptoms that include cough, dyspnea, chest pain, fever, chills, night sweats, weight loss, and anorexia? Iggy
Airborne Rationale: symptoms are related to TB
A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform FIRST?
Airway patency
The nurse is planning the care of a client Dx with pneumonia and writes a problem of "impaired gas exchange." Which is an expected outcome for this problem?
Alert and oriented to person, place, time, and events Rationale: impaired gas exchange leads to hypoxia and change in LOC
Which information will the nurse include when providing community education on prevention of seasonal influenza? SATA
All adults younger than 50 y..o. should received a quadrivalent immunization annually Sneeze into a disposable tissue or into your sleeve instead of your hand Wash your hands frequently and after blowing your nose, coughing, or sneezing
A nurse is assessing a client who is in the early stages of HepA. Which of the following manifestations should the nurse expect?
Anorexia
The emergency department (ED) manager is reviewing client charts to determine how well the staff perform when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? *Test Bank
Antibiotics started before admission
What is the priority action for the nurse to take first to prevent harm for a client whose tissue flap over the carotid artery after Head & Neck surgery is spurting bright red blood ? * Iggy SG
Apply immediate, direct pressure to the site
What is the nurse's best first action to prevent harm for a client with COPD who is 1 dat post-op and now has an SpO2 of 83 %? * Iggy SG
Apply oxygen Rationale: COPD pt , must have SpO2 of at least 88%
What is the nurse's best FIRST action for a client who is 6 hours Post-op from abdominal surgery and now has profuse bleeding from the incision? * Iggy SG
Apply pressure to the wound dressing
Which assessment findings will the nurse expect in a client with late-stage l9ver cirrhosis whose total serum albumin level is low? SATA *Iggy SG
Ascites Hypotension Hyponatremia Dependent edema
A nurse cares for a client with arthritis who reports frequent asthma attacks. What action would the nurse take first ?* Test Bank
Ask about medications the client is currently taking
The nurse is caring for a client who just returned from an extended trip overseas. The client has severe HA, muscle aches, fever, fatigue, sore throat and cough with acute respiratory distress. Which nursing action is appropriate? SATA * Iggy SG
Ask the client about exposure to anyone who was ill Explain that visitors will not be allowed into the care unit Obtain ABGs
A nurse plans care for a client who has COPD and thick, tenacious secretions. Which interventions would the nurse include in the client's plan of care ? SATA. *Test Bank
Ask the client to drink 2 L of fluids daily Add humidity to the prescribed oxygen Use a vibrating chest physiotherapy device Administer the ordered mucolytic agent
The nurse is completing a Preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? Med-Surg
Ask the client to hay happens when he takes the de codeine
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take First? * Test Bank
Assess the client's airway
The client is complaining of left shoulder pain. Which interventions should the nurse implement first? * Med-Surg
Assess the neurovascular status of the left hand
What is the nurse's PRIORITY action when a client with ascites reports increased abdominal pain and chills? *Iggy SG
Assessing for abdominal rigidity and taking the client's temperature
What is the PRIORITY ACTION for nurse to take it PREVENT HARM when caring for a client with fresh packing in place for a posterior nosebleed? Iggy SG
Assessing the airway
The client dx with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? * Med-surg
Assist the client into a sitting position at 90 degrees
A nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery?
Assist the client to choose a communication method
A client has been dx with an empyema. What would the nurse anticipate providing to this client? SATA *Test Bank
Assisting with chest tube insertion Performing frequent respiratory assessment Facilitating pleural fluid sampling Providing antipyretics as needed
Which neuromuscular assessment change indicates to the nurse that a client who has late-stage liver cirrhosis now has encephalopathy? Iggy SG
Asterisk
What is the PRIORITY ACTION for a nurse to take to prevent harm when a client who is talking and laughing while eating begins to choke on a piece of meal ? Iggy SG
Attempt to remove the obstruction with oral suction
What is the priority action for a nurse to take to prevent harm when a client who is talking and laughing while eating begins to choke on a piece of meat ? Iggy SG
Attempt to remove the obstruction with oral suction
Which assessment findings does the nurse expect to see in a client having an acute asthma attack? SATA. * Iggy SG
Audible wheezing Breathlessness while speaking Cyanosis of the nail beds Sternal retractions
Which discharge precautions will the nurse teach a client and family after extensive surgery for OSA? SATA
Avoid aspirin or aspirin-containing products Drink cool liquids and eat soft. foods for a week or two Examine your mouth and throat daily for any thick drainage and pus or a beefy red color
Which interventions are most appropriate for the nurse to teach a client with a nasal fracture to reduce bleeding from the injury? SATA
Avoid blowing or picking the nose Use acetaminophen for pain rather than aspirin or other NSAIDS
A nurse teaches a client who has COPD. Which assessments r/t nutrition would the nurse include in this client's teaching? SATA. *Test Bank
Avoid drinking fluids just before and during meals Rest before meals if you have dyspnea Have about six small meals a day Use pursed-lip breathing during meals Choose soft, high-calorie, high-protein foods
Which precautions is MOST IMPORTANT for the nurse to instruct with cirrhosis and his or her family about continuing care in the home?
Avoid taking acetaminophen or drinking alcohol
A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? * Test Bank a. "I need to take extra vitamin C while on INH." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."
C INH needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin (Rifadin).
What is the nurse's FIRST action when a client develops an abdominal wound evisceration after a hard sneeze? *Iggy SG
Call for help and stay with the client
A nurse is assessing a toddler who has AIDS. Which of the following findings is an indication of an opportunistic infection?
Candidiasis
A client with an infection has a fever. What actions by the nurse help increase the client's comfort? SATA
Change the client's gown and linens when damp Offer cool fluids to the client frequently Sponging the client with tepid water
A nurse working in the preoperative Holding area performs which functions to ensure client safety? SATA *Iggy
Check that consent is on the chart Ensure that the client has an armband on Have the client help mark the surgical site Allow the client to use the toilet before giving sedation Assess the client for fall risks
Which client assessment findings alert the nurse to the possibility of uncomplicated community-acquired pneumonia (CAP)? SATA. *Iggy SG
Chest discomfort Dyspnea Increased sputum production Fever
Which clinical manifestation should the nurse expect to assess in the client recently dx with COPD? Med-surg
Chronic sputum production Rationale: early sign of COPD
Which assessment finding on a client with pneumonia who is receiving IV antibiotics and oxygen by nasal cannula indicates to the nurse that initial goals for this client have been met ? Iggy *SG
Client is alert and oriented to person , place , and time
A nurse is participating in an ethics committee meeting about a cowboy has a hx of alcohol use disorder and needs a liver trans7. Which of the fo7actions should the committee take first? * ATI
Collect information r/t the issue
The client is in the preicteric phase of hepatitis.which s/s should the nurse expect the client to exhibit during this phase? *Med-surg
Complaints of fatigue and diarrhea
Which interventions is an important psychosocial consideration for the client dx with AIDS?
Complete an advance directive
The nurse is preparing a client for surgery. Which interventions should the nurse implement first? Med-Surg
Complete the Preoperative checklist
Which assessment finding indicates to the nurse that a client who sustained laryngeal trauma and is being treat with humidified oxygen that further action is needed urgently? Iggy SG
Confused and disoriented, difficulty producing sounds, pulse oximetry 80%
Which specific s/s does the nurse expect to see in an 80y.o. client admitted with bacterial pneumonia? SATA * SG
Confusion Decreased oxygen saturation Weakness and fatigue
The nurse is assessing a 79 y.o client Dx with pneumonia. Which signs and symptoms should the nurse expect to assess in the client? Med-Surg
Confusion and lethargy
Which side effect does the nurse assess for in a client who has been using an opioid analgesic for the past 5 days? Iggy SG
Constipation Rationale: constipation is a side effect of opioid
While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take FIRST? * Test Bank
Contact the primary health care provider and prepare for intubation
Which factors increase the efficacy of infection by the HIV? Iggy
Contains the enzyme reverse transcriptase
Which observation of a client's chest tube setup indicates to the nurse a leak is present in the system? Iggy SG
Continuous bubbling in the water-seal chamber
While assessing a client who is 12 hours post-op after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is best ? *Test Bank
Cover the insertion site with sterile gauze
Which type of respiratory support does the nurse prepare for a client with severe angioedema and tongue swelling from exposure to seafood who has stridor and an oxygen saturation of 70 %? Iggy SG
Cricothyroidotomy
Which type of respiratory support does the nurse prepare for a client with severe angioedema and tongue swelling from exposure to seafood who has stridor and an oxygen saturation of 70%? Iggy SG
Cricothyroidotomy
Which factor does the nurse consider most likely to be responsible for promoting infection development in an older adult client after an HIV exposure? Iggyv
Decline in the overall efficiency of the immune system
Which symptoms in a client with cirrhosis and encephalopathy indicate to the nurse that the prescribed lactulose therapy is effective? SATA *Iggy SG
Decrease confusion Two or three soft stools daily Lower serum ammonia levels
A nurse learns older adults are at higher risk for complications after surgery. What reasons for this does the nurse understand? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes f. Slower reaction times
Decreased cardiac output Decreased oxygenation Frequent nocturia Mobility alterations Slower reaction times
For which possible long-term health changes will the nurse assess a client who has moderate OSA? SATA
Decreased cognition Diabetes mellitus Resistant HTN Stroke
Which s/s in a client with long-standing chronic COPD indicate to the nurse the possibility of cor polmonale ? SATA. * Iggy
Dependent edema Distended neck vein Swallow liver
Which s/s in client with long-standing COPD indicate to nurse the possibility of cor pulmonale? (SATA)
Dependent edema Distended neck veins Swollen liver
Which additional assessment finding in a client who has a severe sore throat with pain that radiates behind the ear and difficulty swallowing supports the nurse's suspicion that the client may have a peritonsillar abscess? * Iggy SG
Deviated uvula
Which physiologic responses indicate to the nurse that the client is experiencing acute pain? SATA
Diaphoresis Tachycardia Dilated pupils
The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? SATA. * Med-Surg
Discuss how to cough and deep breathe effectively Teach ways to manage post-op pain Discuss events which occur in the post-anesthesia care unit (PACU)
Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain? * Med-Surg
Discuss the pain with the client
Which action to prevent harm is most important for a nurse to include when teaching a client with TB about the prescribed first-line drug therapy? *Iggy SG
Do not drink alcohol in any quantity while taking these drugs
The circulating nurse observed the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement?
Do nothing because this is the correct procedure
A nurse cares for a client with COPD who appears thin and disheveled. Which questions would the nurse ask FIRST? SATA * Test Bank
Do you experience shortness of breath (SOB) with basic activities?
A nurse assesses a client with COPD. Which questions would the nurse ask to determine the client's activity tolerance? SATA * Test Bank
Do you have any difficulty sleeping? How long does it take to perform your morning routine? Have you lost any weight lately? How does your activity compare to this time last year ?
What is the nurse's best response to a client with COPD who is prescribed an inhaled long-acting beta 2 agonist and asks why the drug can't be taking as a pill ? SATA * Iggy SG
Drugs taken by mouth have systemic side effects and taken are harder to control
For which side effects will the nurse prepare the client who is to receive 6 weeks of external beam radiation therapy for throat cancer? SATA
Dry mouth Taste changes Increased fatigue Dry, red, and peeling skin Difficulty swallowing Numbness and tingling
Which subjective assessment findings will the nurse expect in a client who has just been dx with early-stage pulmonary arterial hypertension (PAH)?
Dyspnea and fatigue
A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse include in this client's teaching?
Eat a well-balanced, nutritious diet
Which activities are MOST important for the nurse to teach a client with esophageal varices to prevent harm from bleeding or hemorrhage? SATA *Iggy SG
Eat soft foods and cool liquids. Do not engage in strenuous exercise or heavy lifting.
A client with a broken arm had ice placed on it for 20 mins. A short time after the ice was removed, the client reports that the effect has worn off and requests pain meds, which cannot be given yet. Which actions by the nurse are most appropriate? SATA
Educate the client on cold therapy Repeat the ice application Teach the client relaxation techniques
A client has been diagnosed with TB. What action by the nurse takes highest priority? *Test Bank
Educating the client on adherence to the treatment regimen
The nurse in a long-term care facility is planning the care for a client with PEG feeding tube. Which intervention should the nurse include in the plan of care ?
Elevate the HOB after feeding the client
A home health nurse evaluates a client who has COPD. Which assessments would the nurse include in this client's evaluation? SATA. *Test Bank
Examination of mucous membranes and nail beds Measurement of rate, depth, and rhythm of respirations Determine the client's need and use of oxygen Ability to perform activities of daily living
What is the nurse's best first action when a post-op client with a rhinoplasty repeatedly swallows? Iggy SG
Examine the throat for bleeding
Which subjective symptoms will the nurse expect a client with OSA to report or describe? SATA * Iggy SG
Excessive daytime sleepiness Decreased ability to concentrate Irritability Heavy snoring
A nurse cares for a client after radiation for neck cancer. The client reports extreme dry mouth. What action by the nurse is MOST appropriate? SATA. * Test Bank
Explain that xerostomia may be a permanent side effect
Which pain scale will the nurse use to most accurately assess the pain level of an adult client who has either a language barrier or reading problems?
FACES (smile to frown )
A nurse is assessing pain on a confused older client who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? *Iggy SG
FACES Pain Scale-Revised
Which assessment findings for a community dwelling client who reports "not feeling well" for about 2 months indicate to the nurse the possibility of active TB? SATA * Iggy SG
Fatigue Night sweats Persistent cough Low-grade fever SOB Blood-streaked sputum
Which symptoms in a client with COPD does the nurse associate directly with chronic hypoxemia? Iggy SG
Finger clubbing
Which symptoms in a client with chronic COPD does the nurse associate directly with chronic hypoxemia?
Finger clubbing
Which action will the nurse perform FIRST for a client with an active nosebleed (epistaxis)? Iggy SG
Have the client sit upright with the head forward
The nurse is conducting an interview with a 75-y.o. client admitted with acute pain. Which question would have priority when assisting with pain management? * Med-Surg
Have you ever had difficulty getting your pain controlled?
For clients with which types of hepatitis will the nurse teach about prevention of infection s[read through the oral-fecal contamination route? SATA *Iggy SG
HepA (HAV) HepE (HEV) Rationale: contaminated food and water sources
A nurse is reviewing the lab results of a client who is taking a medication and notes that the client's blood test show an elevated level of the enzymes aspartate sminotransferase (AST) and ALT. The nurse should recognize that these findings are potential indications of which of the following conditions?v* ATI
Hepatic toxicity
The 56 y.o client Dx with TB is being discharged. Which statement made by the client indicates an understanding of the discharge instructions?
I must stay on the medication for months if I am to get well
Which statement indicates the client dx with asthma needs more teaching concerning the medication regimen?
I need to take oral glucocorticoids every day to prevent my asthma attacks
The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed? Med-Surg
I will be glad when this is over so I can go home today
After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates that the client comprehends the teaching? *Test Bank
I will take this medication every morning to help prevent an acute attack
After teaching a client who is prescribed salmeterol, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? * Test Bank
I will use the drug when I have an asthma attack
Which client problems are appropriate for the nurse to include in the plan of care for the client dx with COPD? SATA. * Med-surg
Impaired gas exchange Inability to tolerate temperature extremes Activity intolerance Inability to cope with change in roles Alteration in nutrition
Which change in a client's WBC differential does the nurse interpret as associated with a severe or prolonged bacterial infection? SATA *Iggy SG
Increased immature neutrophils
What will the nurse recognize as the cause of splenomegaly in a client who has cirrhosis? Iggy SG.
Increased pressure in the portal vein causing backflow of blood into the spleen
After collaboration with the registered dietitian nutritionist, the nurse expects to reinforce which nutritional changes to the client with chronic obstructive pulmonary disease (COPD)? Select all that apply. A. Increasing protein intake B. Avoiding dry or crumbly food C. Eating all fruit and vegetables raw D. Eating six smaller meals instead of three larger ones daily E. Drinking as much fluid as possible during meals to reduce coughing F. Greatly increasing the percentage of carbohydrates consumed daily
Increasing protein intake Avoid dry or crumbly food Eating six smaller meals instead of three larger ones daily
Which common factors will the nurse recognize as contributing to or worsening of hepatic encephalopathy in clients with liver cirrhosis? SATA * Iggy SG
Infection Opioids GI bleeding High-protein diet
Which instructions will the nurse give to a client after rhinoplasty to prevent harm from bleeding? SATA * Iggy SG
Limit or avoid straining during bowel movements (e.g. Valsalva maneuver) Do not sniff upwards or blow your nose Avoid aspirin-containing products or NSAIDS Use a humidifier to prevent mucosal drying
Which client symptoms suggests the possibility of sinus cancer to the nurse ? Iggy SG
Long-term bloody nasal discharge
Which changes does the nurse teach adults to be aware of as warning signs of Head & Neck cancer? SATA. Iggy SG
Lump in mouth, neck, or throat Change in fit of dentures Difficulty swallowing Numbness in the mouth, lips, or face
Which change in lab immune indicators does the nurse expect to find in a client whose HIV disease is at stage HIV-III (AIDS)? Iggy
Lymphocytopenia
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching? * Test Bank
Make sure you clean the humidifier to prevent infection
Which actions are appropriate for the nurse to perform to prevent harm in a client with cirrhosis and ascites who has just undergone an EGD? SATA *Iggy SG
Measuring oxygen saturation Assessing for return of the gag reflex Monitoring heart rate and blood pressure
A nurse plans care for a client who is at risk for infection. Which interventions will the nurse implement to prevent infection? SATA * Test Bank
Monitor WBCs and differential Screen all visitors for infections Promote sufficient nutritional intake
Which actions will the nurse take to prevent hypoxemia in the Post-op client? SATA
Monitor the client's oxygen saturation Encourage the client to cough and breathe deeply Ambulated the client as early as the surgeon permits Remind the client to use incentive spirometry every hour while awake
Which activities are the circulating nurse's responsibilities in the OR?
Monitor the position of the client, prepare the surgical site ., and ensure the client's safety
A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which statements indicate that the client CORRECTLY understood the teaching? SATA * Test Bank
Nasal saline sprays will help to prevent rebleeding I will wait at least 1 month before resuming weight lifting I will apply a small amount of petroleum jelly to my nares
Which findings would the nurse expect when assessing a client with HIV disease at HIV-I classification? SATA Iggy
No indications of an AIDS-defining illness CD4+ T-cell count of greater than 500 cells/mm3
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client's bed. The client's blood pressure changes from 122/78 mm Hg 30 mins ago and is now 138/60 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Notify the primary health care provider d. Nothing; this is expected.
Notify the primary HCP
What is the nurse's BEST FIRST action when a client who just had a liver transplant develops oozing around two IV sites as well as has some new bruising?
Notifying the surgeon immediately
A nurse assesses a client who is 6 hours post surgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? SATA * Test Bank
Observe for clear drainage Assess for signs of bleeding Watch client for frequent swallowing Ask the client to open his or her mouth
The client Dx with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?
Obtain a sputum specimen for culture and sensitivity
A client is admitted with possible sepsis. Which action will the nurse perform FIRST? Test Bank
Obtain specific cultures
A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection would the nurse provide for this client?* Test Bank
Omelet, soft whole-wheat bread
Which discharge care issues are a priority for the nurse to teach a client with facial trauma who has undergone surgical intervention to wire the jaw shut? SATA * Iggy SG
Oral care Use of wire cutters Aspiration prevention Dental liquid diet
A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse assess for? SATA. *Test Bank
Oral mucosa is gray or dark brown Pain when drinking grapefruit juice Oral lesions that are over 2 weeks old Changes in the pt's voice quality
The nurse is assessing the client dx with COPD Which data require immediate intervention by the nurse?
Oxygen flowmeter set on eight (8) liters
How will. The nurse determine whether a client who suffered severe laryngeal trauma has subcutaneous emphysema? Iggy SG
Palpating for air under the skin
Which routes are the most common means of HIV transmission? SATA Iggy
Parenteral Perinatal Sexual
Which clients will the nurse suggest to be immunized against HepB (HBV) ? SATA
People who have unprotected sex with more than one partner Men who have sex with men Firefighters Health care providers Clients prescribed immunosuppressant drugs
Which symptoms reported by a client who had HIV-III (AIDS) indicates to the nurse possible infection with Pneumocystis jiroveci? Iggy
Persistent cough and breathlessness
The nurse is caring for the client Dx with pneumonia. Which information should the nurse include in the teaching plan? SATA
Place the client on oxygen delivered by nasal cannula Plan for periods of rest during activities of daily living Monitor the client's pulse oximetry readings every four (4) hours
The client has had a liver biopsy. Which post-op interventions should the nurse implement? *Med-drug
Place the client on the right side
The client is admitted to a medical unit with a Dx of pneumonia. Which signs and symptoms should the nurse assess in the client?
Pleuritic chest discomfort and anxiety
For which serious complications of the infection will the nurse caring for a client who has seasonal influenza continuously monitor? Iggy SG * SATA
Pneumonia Sepsis
Which problem should the nurse identify as priority for client who is one day Post-op? * Med-Surg
Potential for hemorrhaging
Which additional condition(s) or factor (s) will the nurse recognize as increasing the risk for ventilator-associated pneumonia (VAP)? SATA *Iggy SG
Presence of feeding tube Tooth loss and mouth sores Bacterial colonization of the airway
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following lab findings should the nurse monitor prior to the procedure? * ATI
Prothrombin time
A charge nurse is rounding on several older clients on ventilators in the ICU whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)? *Test Bank
Provide oral care every 4 hours
Which signs and symptoms will the nurse expect to find on assessment of a client with chronic liver disease who has an elevated serum bilirubin level? SATA * Iggy SG
Pruritus Icterus Jaundice pale, clay colored stools Dark, coffee-colored urine
Which Pos-opt interventions would the Pre-op nurse typically teach a client to prevent complications following surgery? SATA
ROM Incision splinting Deep breathing exercises Use of Incentive Spirometry
The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first ? Med-Surg
Re-count all sponges
A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect?
Reddish-purple skin lesions
Which changes in s/s in a client with bacterial pneumonia does the nurse report to the primary HCP as indicators of possible empyema? SATA *Iggy SG
Reduced chest wall motion on one side Decreased breath sounds Flat percussion Persistent fever
Which nonverbal manifestations in an older adult client indicate to the nurse that the client is likely having acute pain? SATA
Restlessness Profuse sweating Confusion Increased BP
Which drugs and side effects will the nurse plan to teach a client with non-drug-resistant TB who is bring discharged on first-line therapy? SATA *Iggy SG
Rifampin; contact lenses can become stained orange Isoniazid; report yellowing of the skin or darkened urine Ethambutol; report any changes in vision
The client on a medical floor is dx with HIV encephalopathy. Which client problem is priority?
Risk for injury
Which items will the nurse tell family members living with s client who is HIV positive to avoid sharing to prevent the spread of HIV? SATA Iggy
Safety razor Toothbrushes
Which asthma drugs or drugs categories have the primary purpose of asthma relief (rescue) rather than asthma control ? SATA * Iggy SG
Short-acting beta agonists Rationale: only SABA
Which assessment finding does the nurse expect for a client who has had a neck dissection with removal of muscle tissue, lymph nodes, and the 11th cranial nerve ?
Shoulder drop with limitation of movement
Which actions will the nurse take to prevent disease transmission when caring for a client who has an infection with multidrug resistant organism? SATA *Iggy SG
Showering as soon as reaching home after work Keep work clothes separate from personal clothes Wearing scrubs and changing clothes before leaving work
A Post-op nurse is caring for a client who received a neuromuscular blocking agent during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next? *Iggy SG
Signs of oxygenation
Which actions will the nurse suggest to a client to help improve mild obstructive sleep apnea to report or describe? SATA * Iggy SG
Sleeping on the side rather than in a supine position Losing weight to come within 20 % of his or her ideal weight Using an oral position-fixing device to prevent tongue subluxation
Which actions will the nurse suggest to a client to help improve mild OSA? SATA *Iggy SG
Sleeping on the side rather than in s supine position Losing weight to come within 20% of his or her ideal weight Using an oral position-fixing device to prevent tongue subluxation Rationale: use a CPAP machine
What is the nurse's best response to a client with COPD who states that there is no reason to quit cigarette smoking now that the disease has already been dx ? SATA Iggy SG
Smoking cessation can slow the rate of your disease progression
What is the nurse's BEST response when a 62-y.o. client whose brother was just dx with Head & Neck cancer asks what he could do to reduce his risk for also developing this cancer? Iggy SG
Stop smoking and dunk alcohol only in moderation
A nurse is providing teaching for a client who has received a liver transplant and has a prescription to transition from cycloporine to tacrolimus. Which of the following should the nurse include in the teaching? * ATI
Stop taking the cyclosporine for 24 hours and then begin taking the tacrolimus
A nurse assesses a client who has facial trauma. Which assessment findings require IMMEDIATE intervention? SATA * Test Bank
Stridor Ecchymosis behind the ear Rationale: ecchymosis behind the ear is called " battle sign "
For which symptoms does the nurse teach the client who is going home with a peritonsillar abscess to go to the emergency department immediately? *Iggy SG
Stridor or excessive drooling
Which teaching point is MOST appropriate for the client with a peritonsillar abscess? * Test Bank A. Gargle with warm salt water B. Take all antibiotics as directed C. Let us know if you want liquid medications D. Wash hands frequently
Take all antibiotics as directed
The nurse is caring for a client with right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? * Med-Surg
Tape a petroleum jelly occlusive dressing in three (3) sides to the insertion site
Which PRIORITY action will the nurse take to help prevent the complication of pneumonia for a client who is post-op from extensive abdominal surgery? *Iggy SG
Teaching coughing, deep-breathing exercises, and use of incentive spirometry
The nurse must obtain surgical consent form for the scheduled surgery. Which client would not be able to consent legally to surgery? Med-Surg
The 16- y.o. client who has a fractured ankle
The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further Preoperative teaching? * Med-Surg
The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed
The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? SATA. * Med-Surg
The client has loose, decayed teeth The client smokes 2 packs of cigarettes a day The client reports using herbs
The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome? Med/Surg
The client has no I juries from the OR equipment
The nurse on a medical floor is caring for clients dx with AIDS. Which client should be seen first?
The client who has flushed, warm skin with tented turgor
Which statement would be an expected outcome for the postop client who had general anesthesia? * Med-Surg
The client will have a pulse of reading of 97% on room air
Which statement should the nurse identify as the expected outcome for a client experiencing acute pain? *Med-Surg
The client will participate in self-care activities
The nurse is caring for a client dx with end-stage COPD. Which data warrant immediate intervention by the nurse? Med-surg
The client's sputum is rusty colored
The client dx with liver problems ask the nurse, "why are my stools clay-colored?" On which scientific rationale should the nurse base the response? * Med-surg
The liver is unable to excrete bilirubin
Which statement BEST describes the Interprofessional collaborative roles of the nurse and surgeon when obtaining informed consent? * Iggy SG
The nurse may serve as a witness that the client has been informed by the surgeon before surgery is performed
A post-op client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problem r/t the drain are being met? *Iggy SG
There is no redness, warmth, or drainage at the insertion site
Which statement indicates to the nurse the client dx with asthma understands the teaching regarding mast cell stabilizer medications? Med-Surg
These drugs are not good at the time of an attack Rationale: Mast cell drugs = maintenance meds , fo not treat an attack
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client stares that all food tastes bland. How would the nurse respond? * Test Bank
This is normal after surgery. What types of food do you like to eat?
Which procedure will the nurse prepare to assist with for a client who arrives in the emergency department with a severe crush injury to face with blood gurgling from the mouth and nose and obvious respiratory distress? SATA Iggy SG
Tracheostomy
Which action will the nurse recommend for the client who suffers from chronic xerostomia induced by radiation treatment for Head & Neck cancer ? * Iggy SG
Try using moisturizing mouth spray
The nurse is feeding a client Dx with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
Turn the client to the side
How will the nurse categorize the level of asthma control for a client who reports usually waking at night with wheezing at least three times weekly and needing to use the prescribed reliever inhaler to stop the episodes?
Uncontrolled Rationale: uncontrolled asthma
Which assessment findings in a client who is HIV positive and has new-onset acute confusion will the nurse report immediately to the immunity HCP? SATA. Iggy
Unequal pupils Reduced grip strength
Which action will the nurse take to prevent infection when a 95 y.o. nursing home resident has a productive cough, fever, chills, and a hx of night sweats but the client's Mantoux test for TB is negative? *Iggy SG
Use Airborne Precautions until a chest x-ray shows the client not to have active TB
The client is dx with mild intermittent asthma. Which medication should the nurse discuss with the client? * Med-Surg
Use of a "rescue inhaler"
A preop nurse is assessing a client prior to surgery. Which information would be the most important for the nurse to relay to the surgical team? *Iggy SG
Use of multiple herbs and supplements
A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? SATA. *Test Bank
Use your abdominal muscles to squeeze air out of your lungs Breathe out slowly w/o puffing your cheeks Exhale at least twice the amount of time it took to breathe in
Which suggestions will the nurse make to a client with asthma who is a runner to prevent an exercise-induced attack? SATA
Use your reliever inhaler before starting your run Run on an indoor track during cold weather
Which factor will the nurse recognize as increasing a client's risk for developing community-acquired pneumonia (CAP)? * Iggy SG
Using tobacco and alcohol often and regularly
A client is being discharged on long-term therapy for TB. What referral by the nurse is MOST appropriate? *Test Bank
Visiting nurses for directly observed therapy
Which essential nutrient will the nurse expect to be deficient in a client who has liver cirrhosis and ascites? *Iggy SG
Vitamin K
Which actions are most effective for nurses and other health care workers to prevent occupational transmission of viral hepatitis? SATA* Iggy SG
Washing hands before and after contact with all clients Using needleless systems for parenteral therapy Using STANDARD PRECAUTIONS with all clients regardless of age or sexual orientation Obtaining an immunoglobulin injection after exposure to hepatitis A Being fully vaccinated with the hepatitis B vaccine
A nurse cares for several clients on an inpatient unit. Which infection control measures will the nurse implement? SATA *Test Bank
Wear a gown when contact of clothing with body fluids is anticipated Teach clients and visitors respiratory hygiene techniques Disinfect frequently touched surfaces in client-care areas
Which assessment technique will the nurse use to most accurately determine increasing ascites in a client with advanced liver cirrhosis and portal HTN?
Weighing the client daily at the same time of the day
Which nonpulmonary change in a client with chronic obstructive pulmonary disease (COPD) indicates to the nurse that the disorder may becoming more serious? A. Abdominal muscles contract on exhalation B. Increased urinary output at night C. Morning sputum production D. Weight loss of 11 lb (5 kg)
Weight loss of 11 lb (5kg)
A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is MOST important?
What is your occupation?
Which questions is most important to ask a client who may have an endemic respiratory infection with fever, cough, HA, muscle aches, chest pain, and night sweats , and tests negative to the common forms of influenza? SATA * Iggy SG
What meds do you take daily ? Do you have a chronic illness of any kind ? Where have you traveled in the past 2 to 4 weeks
The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? Med-surg
Willingness to modify lifestyle
What is the BEST explanation a nurse will provide a client whose skin test result for TB is positive? SATA. *Iggy SG
You have been infected, but this does not mean active disease is present
A community health nurse is caring for a client who was exposed to HIV 2 days ago. The client asks the nurse what she should do. Which of the following responses should the nurse provide?
You will need to take prophylactic medications for 4 weeks
A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action would the nurse take ? * Test Bank
a. Encourage oral rinsing after fluticasone administration.
A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) *Iggy SG a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client
b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs.
The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? * Med-surg
gastrointestinal bleeding
A nurse is monitoring the lab results of a client who has end-stage liver failure. Which of the following results should the nurse expect? *ATI
increased PTT ( Prothrombin Time)
Which problem has the highest priority for the nurse to help the wife of a client with late-stage small cell lung cancer to provide symptom management in the home ? Iggy SG
severe pain
A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching?
"You can suck on popsicles to numb your mouth." The nurse should instruct the client to suck on popsicles or ice chips, which can numb the mouth.
A client is being admitted with suspected tTB. What actions by the nurse are BEST?
Admit the client to a negative-airflow room Obtain specialized respirators for caregivers
A nurse is assessing a client who is in the early stages of HepA. Which of the following manifestations should the nurse expect? * ATI
Anorexia
The nurse is teaching assistive personnel (AP) about the care of who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? SATA Test Bank
Apply lotion to the client's dry skin areas For the patient's oral care, use a soft toothbrush Provide clippers so the patient can trim the fingernails
Which assessment is a PRIORITY for the nurse caring for a client with HIV-III (AIDS) who has an exacerbation of crytosporidiosis? SATA Iggy
Assess for signs of dehydration and electrolyte imbalance
The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take?
Assist the client to void before the procedure Rationale: void before paracentesis to prevent bladder damage
A nurse is providing discharge teaching to a client who has HIV. Which of the instructions about infection prevention should the nurse include? SATA
Avoid large gatherings of people Clean toothbrush by running through the dishwasher Avoid digging in the garden
The client in end-stage failure has vitamin K deficiency. Which interventions should the nurse implement? SATA
Avoid rectal temperature Use only a soft toothbrush Monitor the platelet count Use small-gauge needles
A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care?
Avoid salty foods
With which activities does the nurse teach unlicensed assistive personnel (UAP) and nursing students caring for a client who is HIV positive to wear gloves to prevent disease transmission? Select all that apply. Iggy A. Applying lotion during a back rub B. Brushing the client's teeth C. Emptying a Foley catheter reservoir D. Feeding the client E. Filing the client's fingernails F. Providing perineal care
B. Brushing the client's teeth C. Emptying a Foley catheter reservoir F. Providing perineal care
The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-Systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? Test Bank
Cardiovascular assessment Rationale: complication of TIPS procedure is right-sided HF
Which conditions, all present in a female client, alert the nurse to the possibility of HIV infection? SATA Iggy
Chronic vaginal candidiasis Pelvic Inflammatory Disease (PID) Genital herpes
A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? Test Bank
Consult with the provider about obtaining stool cultures.
A nurse is assessing a client who has AIDS and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider?
Decreased hemoglobin
A nurse is caring for a client who has HIV. Which of the following lab findings should suggest to the nurse that medication therapy is effective?
Decreased viral load
A nurse is teaching a client who has cirrhosis of the liver and a hx of alcohol consumption . The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions?
Destroying liver cells that are later replaced with scar tissue
A nurse is teaching a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include as the purpose of bile? * ATI
Digesting fats
The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? SATA * Med-surg
Do not share needles or equipment Use barrier protection during sex Get the HepB vaccine
Which client conditions experienced over the past year indicates to the nurse that the client's HIV status may have progressed to HIV-III (AIDS)? SATA Iggy
Dx with invasive cervical cancer Had two episodes of bacterial pneumonia in the past year
A nurse assesses a client who has cirrhosis of the liver. Which lab findings would the nurse expect in client's with this disorder ? SATA Test Bank
Elevated INR Elevated serum ammonia Elevated prothrombin time (PT)
A nurse is reviewing the lab report for a client with suspected HELLP syndrome. Which of the following findings should the nurse report to the provider as an indication of this disorder? ATI
Elevated liver enzymes
A nurse is providing discharge teachings to the partner of a client who has a new diagnosis of HepA. Which of the following instructions should the nurse include in the teaching?
Encourage her to eat foods that are high in carbs
Which interventions should the nurse discuss with the client who is in the interic phase of hepatitis C? * Med-surg
Encourage rest periods
Which non infection related health promotion behavior is a priority for the nurse to teach a client with HIV disease at state II?
Exercise regularly and maintain a healthy weight
A nurse is caring for a client with a hx of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following lab tests to determine the possibility of recent excessive alcohol use?
GGT = Gamma-glutamyl transferase
Which PPE does the nurse assemble for use when giving oral and parenteral drugs care to an HIV-positive client who has amoebic diarrhea? SATA
Gloves Gown
A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following PPE items should the nurse don prior to providing client care? SATA
Gown Gloves Rationale: Nurse requires standard precautions when caring for a client who has AIDS
The public health nurse is teaching day-care workers . Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? * Med-surg
Hepatitis A
The nurse is caring for a client with hepatitis C. The client's brother states, "O do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? Test Bank
Hepatitis C is not spread through casual contact
Which factors or problems in an HIV-positive client does the nurse know increases the risk for HIV transmission? SATA Iggy
High viral load Chronic confusion Non adherence to the drug regimen
The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease are contracted? SATA. *Test Bank
How old are you? Do you work in health care ? Are you receiving hemodialysis? Do you use IV drugs? Did you receive blood before 1992? Have you even been in prison or jail?
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a NEED FOR FURTHER TEACHING ? Test Bank
I need to avoid protein in my diet Rationale: protein may need to be decreased NOT eliminated
A nurse is providing discharge teaching to a client who has HIV. Which of the following statements by the client indicates an understanding of the teaching?
I should discard open beverages that have been unrefrigerated for 1 hr
A nurse is providing discharge teaching to the partner of a client who has AIDS. Which of the following statements by the client's partner indicates a need for further teaching?
I'll clean up blood spills immediately with hot water
A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information? Test Bank
If you leave work wearing your scrubs, go directly home and wash them right away
What is the nurse's BEST response to a client considering pre-exposure prophylaxis who asks why HIV testing must be performed every 3 months while on this therapy?
If you should become HIV positive while taking this therapy, your disease may become drug resistant
The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess ? SATA Test Bank
Infection GI bleeding Constipation Hypovolemia
A nurse is caring for a client who has immunodeficiency virus (HIV). The client asks the nurse, "Should I tell my partner that I am HIV positive? Which of the following statements should the nurse provide?
It sounds like you are unsure what to say to your partner
The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? SATA *Test Bank
Jaundice Clay-colored stools Icterus Ascites Petechiae Dark urine
The nurse is caring for a client with hepatic portal-Systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses that the patient is receiving little dietary protein. How would the nurse respond? Test Bank
Less protein in the diet will help the liver rest and will restore liver function Rationale: low protein is prescribed when serum ammonia levels increase and/or the client shows signs of PSE
A nurse is providing teaching to a newly licensed nurse about caring for a client who has a prescription for gemfibrozil. The nurse should instruct the new,y licensed nurse to monitor which of the following lab tests? *ATI
Liver function
A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse an7gir this client? * ATI
Liver transplant Rationale: Fulminant hepatic failure = caused by viral hepatitis * liver transplant is treatment of choice
A nurse receives report from the lab on a client who was admitted for fever. The lab technician states that the client has "a shift to the left" on the WBC. What action by the nurse is most important? Test bank
Notify the HCP and request antibiotics
The client dx with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement?
Notify the HCP for an order for an antifungal swish-and-swallow medication
A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? SATA *ATI
Obtain the client's PT and INR measurements Administer lactulose 30 mL PO 4 times daily Obtain daily weight and abdominal girth measurements Administer a daily multivitamin
A nurse who is HIV positive and is now a client on a surgical unit the day after abdominal surgery asks a nurse colleague to keep her HIV status from the rest of the nursing staff. What is the unit nurse's BEST response? Iggy
Of course, there is no need for anyone else here to know
The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? SATA *Test Bank
Oxygen therapy Feet elevated on pillows Daily weights Respiratory therapy
A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following pieces of information should the nurse include in the teaching?
PCP results from an impaired immune system
The nurse is assessing a client who has HepC. What extrahepatic complications would the nurse anticipate? SATA * Test Bank
Polyarthritis Heart disease Myalgia
The client dx with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restrictions should be implemented by the nurse to address this complication? *Med-drug
Reduce protein intake to 60 to 80 g/day
A nurse is providing teaching to a c,isn't who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects? *ATI
Reduces ammonia levels
A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS?
Small, purple-colored skin lesions
A nurse is caring for a client who has immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV?
Standard precautions
Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? *Med-surg
Standard precautions
The client dx with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen NGT. Which nursing interventions should the nurse implement for this treatment?*. Med-surg
Stay with the client at all times
A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention? *ATI
Take serial measurements of the abdomen with a tape measure
The client dx with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? *. Med-surg
Tell the client vital signs will be taken frequently after the procedure
The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach?
The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in
The client dx with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the UAP warrants intervention by the nurse? * Med-surg
The UA{ is assisting the client to take a hot soapy shower
The nurse identifies the client problem "excess fluid volume " for the client in liver failure. Which short-term goal would be most appropriate for this problem? *Med-surg
The client will have no increase in abdominal girth
An 18-month old infant has Pneumonia. Results of enzyme-linked immunosorbent assay ELISA testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors?
The infant's mother is likely HIV positive
A nurse is conducting dietary teaching for a client who has AIDS. Which of the following instructions should the nurse include in the teaching?
Use a separate cutting board for poultry
Which statements are true regarding Standard Precautions? SATA *Test Bank
Use personal protective equipment as needed for client care Wear gloves when touching client excretions or secretions
Based on the concept of "Treatment as Prevention, " which outcome statement indicates to the nurse that the howl of combination antiretroviral therapy for an HIV-positive client is being met? Iggy
Viral load is at an undetectable level
Which actions does the nurse recommend for a night shift co-worker, who just experienced a sharps injury from a known HIV positive source client to take immediately? SATA Iggy *Only one answer is correct from SATA
Wash the injured area immediately for at least 1 minute with soap and water
Which assessment questions is priority for the nurse to ask the client dx with end-stage liver failure secondary to alcoholic cirrhosis? * Med-surg
When did you have your last alcoholic drink
A nurse is providing teaching about antiretroviral therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching?
You should take antiretroviral medications on a routine schedule
which gastrointestinal assessment data should the nurse expect to find when assessing the client in end stage liver failure? 1. hypoalbuminemia and muscle wasting 2. oligomenorrhea and decreased body hair 3. clay colored stools and hemorrhoids 4. dyspnea and caput medusae
clay colored stools and hemorrhoids: Rationale: clay colored stools and hemorrhoids are gastrointestinal effects of liver failure
