350 NCLEX Practice

In which order should the nurse explain the process of phagocytosis? 1. Attraction 2. Adherence 3. Recognition 4. Degradation 5. Cellular ingestion 6. Exposure/invasion 7. Phagosome formation

1. Exposure/invasion 2. Attraction 3. Adherence 4. Recognition 5. Phagosome form 6. Cellular ingestion 7. Degradation

Which diseases are caused by viruses? Select all that apply. 1 Mumps 2 Tetanus 3 Measles 4 Hepatitis B 5 Diphtheria

1. Mumps 3. Measles 4. Hepatitis B Mumps is a swelling of the parotid glands caused by a virus. Measles is a highly contagious viral disease characterized by rash and high fever. Hepatitis B (a serious liver infection) is caused by a virus. Tetanus is caused by Clostridium tetani and diphtheria is caused by Corynebacterium diphtheriae. Both are gram-positive bacilli bacterial strains.

While assessing a client with acquired immunodeficiency syndrome, the nurse suspects that the client has developed cryptosporidiosis. Which symptoms support the nurse's suspicion? Select all that apply. 1. Seizures 2. Diarrhea 3 Confusion 4 Weight Loss 5 Blurred Vission

2. Diarrhea 4. Weight loss Cryptosporidiosis is an intestinal infection caused by Cryptosporidium. The symptoms of cryptosporidiosis are diarrhea and weight loss. Seizures and confusion are the symptoms of toxoplasmosis encephalitis. Blurred vision is a symptom of cryptococcosis.

Which autoimmune disease affects the central nervous system? 1 Uveitis 2 Celiac disease 3 Multiple sclerosis 4 Goodpasture syndrome

3 Multiple sclerosis Multiple sclerosis is an autoimmune disease that affects the central nervous system. Uveitis is an autoimmune disease that affects the eyes. Celiac disease is an autoimmune disease that affects the gastrointestinal System. Goodpasture syndrome is an autoimmune disease that affects the kidneys.

A client develops acute appendicitis. Prior to arrival to the hospital, the client attempted self-care at home. Which self-care measures could potentially lead to rupture of the appendix? 1 Refusing food and liquids 2 Applying an ice pack to the abdomen 3 Taking a small volume enema 4 Taking acetaminophen (Tylenol) for pain

3 Taking a small volume enema Enemas can increase pressure in the intestines and cause rupture of an inflamed appendix. Fasting from food and liquids or applying an ice pack will not lead to rupture of the appendix. Taking acetaminophen will not increase the risk of rupture of the appendix.

Which diseases can be transmitted from client to client by droplet infection? Select all that apply. 1 Scabies 2 Shingles 3 Measles 4 Pertussis 5 Diphtheria

4 Pertussis 5 Diphtheria Pertussis and diphtheria are infectious diseases that are known to be transmitted by droplet infection. Shingles and measles are infectious diseases that are known to be transmitted by air. Scabies is an infectious disease that is transmitted by direct contact.

The emergency department nurse is assigned duty at a mass casualty situation. Which measures should the nurse take for personal preparedness? Select all that apply. 1 Carrying lip balm 2 Carrying sunglasses 3 Carrying ready to cook food 4 Carrying lists of credit card numbers 5 Carrying matchboxes in a plastic bag

1. Carrying lip balm 2. Carrying sunglasses 4. Carrying lists of credit card numbers A personal preparedness plan should be made by every nurse for disaster treatment. The nurse should carry toiletries such a lip balm as a personal preparedness measure for disaster treatment. The nurse should carry sunglasses as a protective measure for eyes. The nurse should carry lists of credit card numbers and back accounts while preparing for disaster treatment. The nurse should carry nonperishable items and food that does not require cooking. The nurse should carry matchboxes in a waterproof container instead of a plastic bag.

The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition? 1 Bacillus anthracis 2 Bordetella pertussis 3 Streptococcus pneumoniae 4 Mycobacterium tuberculosis

2 Bordetella pertussis This disease is caused by Bordetella pertusis. Pertussis is a respiratory tract infection that begins with the common cold and progresses to whooping cough. The client also develops coughing fits that last for several minutes. Inhalation anthrax is caused by Bacillus anthracis. Streptococcus pneumoniae may cause pneumonia. Mycobacterium tuberculosis infection leads to tuberculosis.

Which hypersensitivity reaction may occur in a newborn with hemolytic disease? 1 Type I 2 Type II 3 Type III 4 Type IV

2 Type II Hemolytic disease in a pregnant woman may result in erythroblastosis fetalis, a type II hypersensitivity reaction. Type I reactions involve immunoglobulin E (IgE)-mediated reactions such as anaphylaxis and wheal-and-flare reactions. Type III reactions are immune complex reactions such as rheumatoid arthritis or systemic lupus erythematosus. Type IV reactions are delayed hypersensitivity reactions such as contact dermatitis.

Which dietary changes does the nurse suggest for a client who has diarrhea associated with human immunodeficiency virus (HIV disease)? Select all that apply. 1 "Eat more fatty food." 2 "Eat much less roughage." 3 "Drink two cups of coffee daily." 4 "Eat more spicy and sweet food." 5 "Drink plenty of fluids between meals."

2 "Eat much less roughage." 5 "Drink plenty of fluids between meals." Clients infected with the HIV virus often suffer from diarrhea. Roughage should be limited in the diet of a client who has diarrhea associated with HIV disease, as it is not easy digestible. Drinking plenty of fluids helps to compensate for the fluid loss. Fatty foods are avoided as they alter the process of digestion. Coffee is avoided as it stimulates the gastrointestinal tract and leads to diarrhea. Spicy and sweet foods are avoided as they trigger the gastrointestinal tract and acidify the stomach contents that lead to diarrhea.

When donning sterile gloves, how should the second glove be handled? 1 Grasp by cuff and place on remaining hand. 2 Place sterile glove under cuff, and slide hand in glove. 3 Grasp inside second glove and place on nondominant hand. 4 Don glove on nondominant hand first, then hold below waist and slide on.

2 Place sterile glove under cuff, and slide hand in glove. Sterile gloves can only be handled by sterile equipment, or they are contaminated. The sterile glove that has been donned may touch under the cuff on the sterile surface as the nondominant hand is inserted. The sterile glove may not touch the inside of the glove. Donning a sterile glove and placing below the waist means contamination, as under the waist or in back is contaminated. Grasping by the cuff means the inside of the glove has been touched.

A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan? 1 1 week 2 4 months 3 2 to 6 weeks 4 48 to 72 hours

3. 2 to 6 weeks Although the usual incubation period of syphilis is about 3 weeks, clinical symptoms may appear as early as 9 days or as long as 3 months after exposure. The usual incubation period is 21 days.

after an above-the-knee amputation for bone cancer, an adolescent boy is returned to his room. He is monitored closely because of the potential for hemorrhage from the residual limb. What should the nurse plan to keep at the bedside? 1 Hemostat 2 Vitamin K 3 Pressure dressing 4 Protamine sulfate

3. Pressure dressing A pressure dressing will control hemorrhage until surgical intervention can be instituted. A hemostat is not practical because bleeding may be internal. Vitamin K is the antidote for warfarin (Coumadin). There is no indication that the client is taking Coumadin. Protamine sulfate is the antidote for an excessive amount of heparin; the client is not receiving heparin.

Which antitubercular medications may increase a client's risk for gout? Select all that apply. 1 Rifampin 2 Isoniazid 3 Bedaquiline 4 Ethambutol 5 Pyrazinamide

4 Ethambutol 5 Pyrazinamide

The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in what nutrient or nutrients? 1 Essential fatty acids 2 Dietary cellulose and fiber 3 Tryptophan, an amino acid 4 Vitamins A, C, E, and selenium

4 Vitamins A, C, E, and selenium Vitamins A, C, E, and selenium stimulate the immune system. The role of fatty acids in natural defense mechanisms is uncertain. Dietary cellulose and fiber have no known effect on natural defense mechanisms. Tryptophan has no known effect on natural defense mechanisms.

Which viral infection will cause the nurse to observe for warts? 1 Pox virus 2 Rhabdovirus 3 Epstein-Barr virus 4 Papillomavirus

4 Papillomavirus Warts are caused by papillomavirus. Pox viruses cause smallpox. Rhabdovirus causes rabies. Epstein-Barr causes mononucleosis and Burkitt's lymphoma.

Which disease is caused by Coronaviruses? 1 Pertussis 2 Inhalation anthrax 3 Coccidioidomycosis 4 Severe acute respiratory syndrome

4 Severe acute respiratory syndrome Severe acute respiratory syndrome is a respiratory infection caused by Coronaviruses. Pertussis is caused by the bacterium Bordetella pertussis. Inhalation anthrax is caused by Bacillus anthracis. Coccidioidomycosis is caused by Coccidioides.

After surgical implantation of radon seeds for oral cancer, what side effects of the radiation does the nurse observe in the client? 1 Nausea or vomiting 2 Hematuria or occult blood 3 Hypotension or bradycardia 4 Abdominal cramping or diarrhea

1 Nausea or vomiting The mucosa of the mouth and the vomiting center in the brainstem may be affected, producing nausea and vomiting. Hematuria or occult blood and hypotension or bradycardia are not side effects of radiation therapy to the oral cavity. Neither abdominal cramping nor diarrhea is an expected response because of the distance between the radon seeds and the intestines.

A client with tuberculosis asks the nurse about the communicability of the disease. Which is the best response by the nurse? 1 "Tuberculosis is not communicable at this time." 2 "Untreated active tuberculosis is communicable." 3 "Tuberculosis is communicable during the primary stage." 4 "With the newer long-term therapies, tuberculosis is not communicable."

2 "Untreated active tuberculosis is communicable." The statement that untreated active tuberculosis is communicable is an accurate statement; treatment is necessary to stop communicability. The statement that tuberculosis is not communicable at this time is false reassurance; untreated active tuberculosis is communicable. Tuberculosis is not communicable when there is no active infection; the primary complex refers to the presence of a primary (Ghon) tubercle and enlarged lymph nodes and is the initial response to exposure; active disease may or may not occur. Tuberculosis is a communicable disease; close contacts should be screened via a skin test.

Which school-age developmental characteristics increases the client's risk for poisoning? Select all that apply. 1 Trying new things 2 Adhering to group rules 3 Increasing independence 4 Being easily influenced by peers 5 Having a strong allegiance to friends

2 Adhering to group rules 4 Being easily influenced by peers 5 Having a strong allegiance to friends Developmental characteristics of the school-age client that increase the risk for poisoning include adhering to group rule, being easily influenced by peers, and having a strong allegiance to friends. Trying new things and increasing independence increase the risk for burn injury, not the risk for poisoning.

A client is admitted to the mental health unit of the hospital because of agitation and unprovoked hostile verbal attacks toward others in the workplace. What is the priority nursing intervention for this client? 1 Developing trust 2 Maintaining safety 3 Refocusing hostile energy 4 Preventing hostile outbursts

2 Maintaining safety The client is potentially harmful to others, as evidenced by previous episodes of hostile behavior. Developing trust is impossible until the client's anger and agitation begin to subside. Although refocusing hostile energy is important, it is not the priority. Preventing hostile outbursts may not always be possible.

A nurse teaches a couple about care of their newborn, who has been circumcised. The nurse concludes that the teaching is effective when the father says what? 1 "We shouldn't expect fussy behavior." 2 "We should leave the baby undiapered." 3 "We should apply petrolatum gauze to the penis." 4 "We should notify the clinic if we see a yellow discharge."

3 "We should apply petrolatum gauze to the penis." Petrolatum gauze helps control bleeding and prevents adherence to the diaper. Fussy behavior is expected for a few hours after the procedure. Leaving the baby undiapered is not practical with a male infant. Yellow exudate is expected; it is not a sign of an infectious process.

The survivors of an explosion develop heat stroke. Which intervention should be performed by the nurse on the disaster management team? 1 Start an intravenous infusion. 2 Assess the arterial blood gases. 3 Apply ice packs on the client's scalp. 4 Administer aspirin or any antipyretic drug.

3 Apply ice packs on the client's scalp. The immediate intervention in a client with heat stroke is to remove the client from the hot environment and apply ice packs on the scalp to cool the body's temperature. An intravenous infusion is started after the client is admitted to the hospital. Arterial blood gases should be assessed to evaluate the lungs. Administration of aspirin or antipyretic drugs should be avoided in the client with heat stroke to prevent its worsening.

What is important nursing care for pediatric clients with leukemia on chemotherapeutic protocols? 1 Preventing physical activity 2 Checking their vital signs every 2 hours 3 Having them avoid contact with infected persons 4 Reducing unnecessary stimuli in their environment

3 Having them avoid contact with infected persons Chemotherapy and acute lymphoblastic leukemia (ALL) cause immunosuppression (low white blood cells), thus increasing the risk for infection. Avoiding contact with infected persons is a necessary precaution. The client should maintain physical activity that can be tolerated. Although vital signs must be checked to assess for changes in pulse or blood pressure, unless there is clinical evidence of bleeding, it is not necessary to obtain vital signs every 2 hours. Children need stimulation that is appropriate for their developmental level except when acutely ill.

A registered nurse is teaching a nursing student about the various mechanisms that antiviral drugs use to control human immune deficiency (HIV) infections. Which statement made by the nursing student needs correction? 1 "Maraviroc blocks CCR5 receptors on CD4+ T-cells." 2 "Saquinavir blocks the fusion between HIV and the host cell." 3 "Zidovudine acts as a counterfeit base for reverse transcriptase." 4 "Nelfinavir prevents the breakup of viral protein strand into smaller fragments."

"Saquinavir blocks the fusion between HIV and the host cell." Saquinavir is a protease inhibitor that works by blocking the HIV enzyme protease; it is not a fusion inhibitor. Saquinavir prevents the viral protein strand from being lysed into active smaller fragments. Entry inhibitors such as maraviroc block CCR5 receptors on CD4+ T-cells. Zidovudine is a nucleoside reverse transcriptase inhibitor that acts as a counterfeit base for the HIV enzyme reverse transcriptase. Protease inhibitors such as nelfinavir prevent the breakup of viral protein strand into smaller active viral particles.

The nurse is teaching a client about automatic epinephrine injectors. Which statement made by the client indicates a need for additional education? 1 "I will keep the device in the refrigerator." 2 "I will keep the device away from light." 3 "If the cap is loose, I will obtain a replacement device." 4 "I will have at least two drug-filled devices on hand at all times."

1 "I will keep the device in the refrigerator." The device should be protected from extreme temperatures. Therefore the device should not be refrigerated. The device should be protected from light. If the cap is loose or comes off accidentally, the client should obtain a replacement device. The client should have at least two drug-filled devices on hand in case more than one dose is required.

Blackwater fever occurs in some clients with malaria. Which response should the nurse assess in this client? 1 Dark red urine 2 Low-grade fever 3 Clay-colored diarrhea 4 Coffee-ground emesis

1 Dark red urine Plasmodium falciparum in persons who have chronic malaria can cause hemoglobinuria (dark red urine), intravascular hemolysis, and renal failure as a result of destruction of red blood cells. Low-grade fever, clay-colored diarrhea, and coffee-ground emesis are unrelated to the development of blackwater fever.

What should an older client be instructed to do to ensure antibody-mediated immunity? Select all that apply. 1 Obtain a shingles vaccination 2 Receive a tetanus booster injection 3 Obtain the pneumococcal vaccination 4 Receive annual testing for tuberculosis 5 Receive an annual influenza vaccination

1 Obtain a shingles vaccination 2 Receive a tetanus booster injection 3 Obtain the pneumococcal vaccination 5 Receive an annual influenza vaccination Because older adults are less able to make new antibodies in response to the presence of new antigens, they should receive the shingles vaccination. Because older adults may not have sufficient antibodies present to provide protection when they are re-exposed to microorganisms they have already generated antibodies against, booster shots are encouraged. The pneumococcal and influenza vaccination help to create antibodies in response to new antigens. Testing for tuberculosis addresses cell-mediated immunity for the older client.

A client reports dry mouth, difficulty swallowing, vomiting, and blurred vision. During an assessment, the client reveals that he or she usually eats contaminated food. The nurse observes that the client has drooping eyelids. The client's laboratory reports indicate the presence of an infection. Which findings are expected in the client in the later stage of the disease indicated by these symptoms? Select all that apply. 1 Paralysis 2 Vesicular lesions 3 Bronchopneumonia 4 Painful lymphadenopathy 5 Bilateral cranial nerve impairment

1 Paralysis 5 Bilateral cranial nerve impairment Botulism is a disease caused by Clostridium botulinum, which usually spreads through contaminated food. The symptoms of botulism are dysphasia, dry mouth, drooping eyelids, and blurred or double vision. Paralysis and acute bilateral cranial nerve impairment follow in the later stage of the disease. Vesicular lesions are symptoms of anthrax. Bronchopneumonia is a symptom of pneumonic plague. Painful lymphadenopathy is a symptom of lymphatic plague.

Which are examples of actively acquired specific immunity? Select all that apply. 1 Recovery from measles 2 Recovery from chickenpox 3 Maternal immunoglobulin in the neonate 4 Immunization with live or killed vaccines 5 Injection of human gamma immunoglobulin

1 Recovery from measles 2 Recovery from chickenpox 4 Immunization with live or killed vaccines Naturally acquired active-type immunity is seen in a client who has recovered from measles or chickenpox or who has been immunized with a live- or killed-virus vaccine. Maternal immunoglobulin in a neonate and an injection of human gamma immunoglobulin into a client are examples of passively acquired specific immunity.

What assessment findings indicate that an older client is at risk for developing an infection? Select all that apply. 1 Thin skin 2 Weak cough 3 Sluggish bowel sounds 4 Male-pattern baldness 5 Indwelling urinary catheter

1 Thin skin 2 Weak cough 5 Indwelling urinary catheter Thin skin indicates a loss of protection by the integumentary system. A weak cough indicates a loss of protection by the respiratory system. Sluggish bowel sounds indicate a loss of protection by the gastrointestinal system. An indwelling urinary catheter is an invasive device which can introduce microorganisms into the client's system. Male-pattern baldness does not indicate a loss of protection by a body system.

A client is admitted to the emergency department with allergic rhinitis and asthma. The laboratory report shows histamines and prostaglandins. Which type of hypersensitivity reaction may have occurred? 1 Type I 2 Type II 3 Type III 4 Type IV

1 Type I Type I hypersensitivity reactions (immediate hypersensitivity reactions) involve the immunoglobulin E (IgE)-mediated release of histamines and other mediators from mast cells and basophils. Allergic rhinitis and asthma may occur when mediators such as histamine and prostaglandins are involved as mediators of injury. Type II hypersensitivity reaction is cytotoxic mediated; it occurs in transfusion reactions. Type III reactions are immune complex-mediated hypersensitivity reactions such as rheumatoid arthritis. Type IV hypersensitivity reactions are delayed hypersensitivity reactions; an example is contact dermatitis.

A client with tuberculosis is prescribed rifampin. What does the nurse teach the client about this medication? Select all that apply. 1 "Avoid drinking alcohol while you are on this drug." 2 "Report immediately if you find a yellow appearance to the skin." 3 "Wear a protective clothing and sunscreen when going out in sunlight." 4 "Your soft contact lenses will become permanently stained with this drug." 5 "Immediately consult your physician if you find reddish orange tinge in your urine."

1 "Avoid drinking alcohol while you are on this drug." 2 "Report immediately if you find a yellow appearance to the skin." 4 "Your soft contact lenses will become permanently stained with this drug." Rifampin is an antitubercular drug that kills slow-growing organisms residing in the caseating granulomas. Rifampin may cause liver damage, so alcohol should be avoided as it potentiates liver damage. Yellow appearance to the skin is a sign of liver failure. Therefore, a client on rifampin therapy is taught to report the presence of any yellowing of the skin. Rifampin permanently stains soft contact lenses and therefore the client is made aware to avoid wearing them while on the medication. Pyrazinamide causes photosensitivity reactions and therefore a client on that drug therapy is advised to wear protective clothing and sunscreen when going outdoors. The nurse should inform the client that rifampin changes the color of body secretions, which is normal and harmless.

The nurse is teaching a client regarding the usage of antibiotics. Which statement made by the client indicates effective teaching? 1 "I should not take antibiotics to treat the flu." 2 "I should take an antibiotic to prevent illness." 3 "I should stop an antibiotic regimen when I am feeling better." 4 "I should borrow an antibiotic from a family member or friend in an emergency."

1 "I should not take antibiotics to treat the flu." Antibiotics are effective against bacterial infections; therefore the nurse instructs the client to avoid antibiotic use for viral infections such as flu and cold. Antibiotics should not be taken for preventing the disease as they may lead to resistance. The nurse should advise the client to not stop taking an antibiotic when feeling better as doing so may lead to the survival and multiplication of the hardiest bacteria, resulting in resistance. The client should not borrow an antibiotic as the antibiotic may not be appropriate in terms of dose, activity, and illness.

The primary healthcare provider has prescribed rifampin to a client with tuberculosis. Which instructions by the nurse will be beneficial to the client? Select all that apply. 1 "You should report any yellow tinge to your skin." 2 "Your soft contact lenses will be stained permanently." 3 "You should report any reddish orange tinge to your secretions." 4 "You need to drink at least 8 ounces of water with the medication." 5 "You should report any increased tendency to bruising or bleeding."

1 "You should report any yellow tinge to your skin." 2 "Your soft contact lenses will be stained permanently." 5 "You should report any increased tendency to bruising or bleeding." Rifampin is a first-line drug in the treatment of tuberculosis and clients should report any yellow tinge to the skin because this may be a sign of liver toxicity or failure. Staining of bodily fluids such as tears, urine, and sweat, is commonly associated with rifampin, so warning the client that contact lenses will be stained will be beneficial. The client should be instructed to immediately report any increased tendency to bruising or bleeding because this may indicate liver toxicity or damage. The need to drink at least 8 ounces of water with the medication is beneficial information for a client prescribed pyrazinamide. A reddish orange tinge to secretions is common with rifampin and not harmful, so it need not be reported.

A primary healthcare provider has prescribed isoniazid to a client with tuberculosis. Which instruction by the nurse will be most beneficial to the client? 1 "You should take the drug on an empty stomach." 2 "Your soft contact lenses will be stained permanently." 3 "You must use an additional method of contraception." 4 "You need to drink at least 8 ounces of water with the medication."

1 "You should take the drug on an empty stomach." Isoniazid is used as first-line drug therapy for tuberculosis. Absorption of the drug from the gastrointestinal tract can be prevented or slowed by the presence of food and antacids, so the client should be instructed to take the drug on an empty stomach. Staining of bodily fluids is commonly associated with rifampin. Rifampin reduces the effectiveness of oral contraceptives, so an additional method of contraception is required for any female client prescribed this drug who also uses birth control pills. The instruction to drink at least 8 ounces of water with the medication would be beneficial fora client who has been prescribed pyrazinamide.

What actions should the nurse take when a client develops an anaphylactic reaction? Select all that apply. 1 Apply oxygen at 90 to 100% 2 Call the Rapid Response Team 3 Elevate the head of the bed to 45 degrees 4 Assign a nursing assistant to stay with the client 5 Ensure emergency airway equipment is at the bedside

1 Apply oxygen at 90 to 100% 2 Call the Rapid Response Team 3 Elevate the head of the bed to 45 degrees 5 Ensure emergency airway equipment is at the bedside Emergency care of the client with anaphylaxis includes applying oxygen at 90 to 100%, calling the Rapid Response Team, elevating the head of the bed to 45 degrees, and ensuring that emergency airway equipment is at the bedside. The nurse should stay with the client because the client is acutely ill and may need immediate emergency interventions that are beyond the scope of a nursing assistant's practice.

Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. 1 Asthma 2 Hay fever 3 Sarcoidosis 4 Myasthenia gravis 5 Rheumatoid arthritis

1 Asthma 2 Hay fever Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions that are mediated by a reaction between IgE antibodies with antigens. It results in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis results from reactions between sensitized T cells with antigens. Myasthenia gravis results from a type II hypersensitivity reaction that occurs due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction that results from the formation of immune complexes between antigens and antibodies that results in inflammation.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection. Which clinical manifestations in the client should be immediately reported to the primary healthcare provider? 1 Blood in the urine 2 New or productive cough 3 Vomiting accompanied by fever 4 Burning, itching, and discharge from the eyes

1 Blood in the urine A client with HIV infection is at risk for multiple diseases. Therefore blood in the urine should be reported immediately to the primary healthcare provider as it maybe life threatening. New or productive cough is not a life-threatening symptom and can be reported within 24 hours. Vomiting accompanied by fever is not a life-threatening symptom and can be reported within 24 hours. Burning, itching, and discharge from the eyes are not life threatening and can be reported within 24 hours.

Which sexually transmitted infection is caused by Chlamydia trachomatis? 1 Cervicitis 2 Gonorrhea 3 Genital warts 4 Genital herpes

1 Cervicitis Cervicitis is caused by Chlamydia trachomatis. Gonorrhea is a sexually transmitted infection caused by Neisseria gonorrhoeae. Genital warts are caused by the Human papillomavirus. Genital herpes is caused by the Herpes simplex virus.

Which client most likely has type 1 mediated asthma A: IgE: +, IgG:-, IgM: - B: IgE: -, IgG:-, IgM: - C: IgE: -, IgG++, IgM: + D: IgE: -, IgG:+, IgM+

1 Client A Asthma is a type I or IgE-mediated hypersensitivity reaction. Therefore client A, with IgE antibodies in the blood, has type 1 mediated asthma. Client B, with no antibodies, may not have humoral allergy or may have a humoral deficiency. Client C and client D may have either type II or type III hypersensitivity reactions.

Client and Lymphocyte count A: 3000 cells/mm3 B: 5000 cells/mm3 C: 7000 cells/mm3 D: 9000 cells/mm3 The nurse is reviewing the laboratory report of four clients. Which does the nurse suspect to have acquired immunodeficiency syndrome (AIDS)? 1 Client A 2 Client B 3 Client C 4 Client D

1 Client A The normal lymphocyte count is between 5000 and 10,000 cells/mm3. A client with AIDS is leukopenic and has a lymphocyte count less than 3500 cells/mm3. Therefore, client A has AIDS. Clients B, C, and D have normal lymphocyte counts.

A nurse in a public health clinic is teaching clients how to prevent toxoplasmosis. What should the nurse instruct the clients to avoid? 1 Contact with cat feces 2 Exposure to heavy metals 3 Ingestion of freshwater fish 4 Excessive radiation exposure

1 Contact with cat feces Toxoplasma gondii, a protozoan, can be transmitted by exposure to infected cat feces or by ingestion of undercooked, contaminated meat. Toxoplasmosis is not related to heavy metals. T. gondii is a parasite of warm-blooded animals; fish are not considered the source of contamination. Toxoplasmosis is not related to radiation.

The laboratory results of a client with a pulmonary hemorrhage and glomerulonephritis reveal the presence of IgG antibodies. Which type of hypersensitivity reaction should a nurse suspect? 1 Cytotoxic reaction 2 Immediate reaction 3 Immune-complex reaction 4 Delayed hypersensitivity reaction

1 Cytotoxic reaction A client with a pulmonary hemorrhage and glomerulonephritis with deposits of IgG antibodies in the lungs and kidneys may have Goodpasture's syndrome. This reaction is a type 2 cytotoxic reaction that involves the lungs and kidneys. Immediate reactions are type 1 hypersensitivity reactions that include IgE antibody reactions. Immune-complex reactions such as systemic lupus erythematosus and rheumatoid arthritis are type 3 hypersensitivity reactions that include IgG and IgM antibodies. Delayed hypersensitivity reactions are type 4 reactions that involve cytokine and cytotoxic T-cell mediated immunity.

A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain 1 week later. What does the nurse identify as the cause of the posttherapeutic neuralgia? 1 Damage to the nerves 2 Untreated major depression 3 Scarring in the area of the rash 4 Continued presence of the skin rash

1 Damage to the nerves After the original infection has healed, the virus either remains quiescent or it may return. Posttherapeutic neuralgia, which occurs in some individuals, results from damage to the nerves caused by the varicella-zoster virus; the neuralgia may last for months. Untreated major depression and scarring in the area of the rash are unrelated to posttherapeutic neuralgia. The rash does not cause posttherapeutic neuralgia.

An older client reports severe muscle weakness and dysphagia. The primary healthcare provider also observes periorbital edema with a lilac eyelid rash in the client. Which autoimmune disease will the nurse most likely see documented in the client's electronic medical record? 1 Dermatomyositis 2 Reiter's syndrome 3 Ankylosing spondylitis 4 Systemic necrotizing vasculitis

1 Dermatomyositis In dermatomyositis, an older client may have severe muscle weakness, dysphagia, and periorbital edema. A skin rash is diagnostic for dermatomyositis. Joint pain and eye infection causing redness, pain, and drainage may be present in a client with Reiter's syndrome. Chronic back pain may be present in clients with ankylosing spondylitis. Peripheral artery disease causing severe pain and necrosis of toes or fingers may be present in a client with systemic necrotizing vasculitis.

Which bacteria colonies are commonly found in a client's large intestine? 1 Escherichia coli 2 Neisseria gonorrhoeae 3 Staphylococcus aureus 4 Haemophilus influenzae

1 Escherichia coli Escherichia coli are bacteria that are part of the normal flora in the large intestine. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease. Staphylococcus aureus secretes toxins that damage cells and causes skin infections, pneumonia, urinary tract infections, acute osteomyelitis, and toxic shock syndrome. Haemophilus influenzae causes nasopharyngitis, meningitis, and pneumonia.

A client has a body temperature of 102.8° F along with chills; dysuria; urethral discharge; and a boggy, tender prostate. Which organism is responsible for this condition? 1 Escherichia coli 2 Candida albicans 3 Trichomonas vaginalis 4 Condylomata acuminate

1 Escherichia coli A client with a body temperature of 102.8° F; chills; dysuria; urethral discharge; and a boggy, tender prostate may have bacterial prostatitis. Prostatitis is an inflammation of the prostate gland caused by Escherichia coli. Candida albicans may lead to candidiasis in the genitalia. Trichomonas vaginalis may lead to vulvovaginitis. Condylomata acuminate may result in vulva infections such as warts.

A client with acquired immunodeficiency syndrome (AIDS) is suspected to be infected with Cryptococcus neoforman. Which symptoms in the client support the nurse's suspicion? Select all that apply. 1 Fever 2 Seizures 3 Diarrhea 4 Confusion 5 Persistent dry cough

1 Fever 2 Seizures 4 Confusion Cryptococcosis is caused by Cryptococcus neoformans and is a debilitating meningitis. It can be a widely spread infection in a client with AIDS. The symptoms of cryptococcosis are fever, seizures, and confusion because the disease affects the brain. Cryptosporidium infection causes diarrhea. Pneumocystis jiroveci pneumonia causes persistent dry cough.

The nurse suspects the Jarisch-Herxheimer reaction in a client with syphilis who is on antibiotic therapy. Which symptoms in the client support the nurse's suspicion? Select all that apply. 1 Fever 2 Hypertension 3 Vasoconstriction 4 Generalized ache 5 Pain at the injection site

1 Fever 4 Generalized ach 5 Pain at the injection site Fever, generalized ache, and pain at the injection site are signs of the Jarisch-Herxheimer reaction in a client with syphilis receiving antibiotic therapy. This reaction is caused by the rapid release of products from the disruption of cells of the organism. Hypotension because of vasodilatation and declining peripheral resistance, not hypertension and vasoconstriction, are additional signs of Jarisch-Herxheimer reaction.

Which cytokine medication is administered to treat chemotherapy-induced neutropenia? 1 Filgrastim 2 Oprelvekin 3 Aldesleukin 4 Darbepoetin alfa

1 Filgrastim Colony-stimulating factors such as filgrastim are administered to treat chemotherapy-induced neutropenia. Oprelvekin is used to prevent thrombocytopenia. Aldesleukin is used to treat metastatic renal cell carcinoma. Darbepoetin alfa is administered to treat anemia related to chronic cancer and anemia related to chronic kidney disease.

A client with jaundice reports fatigue, abdominal pain, loss of appetite, dark urine, nausea, and vomiting. Which pathogen is most likely responsible for the client's condition? 1 Hepatitis C virus 2 Candida albicans 3 Varicella zoster virus 4 Cryptosporidium muris

1 Hepatitis C virus A client with jaundice, fatigue, abdominal pain, loss of appetite, dark urine, nausea, and vomiting may have hepatitis, caused by hepatitis C virus. Candida albicans is a fungus that causes oral thrush, esophagitis, and vaginitis. Varicella zoster virus causes shingles, an erythematous maculopapular rash along dermatomal planes, pain, pruritis, and progressive outer retinal necrosis. Cryptosporidium muris causes gastroenteritis, watery diarrhea, abdominal pain, and weight loss.

Which type of continuing care should a client expect if discharged home with an infusion device to continue treatment for a leg wound? 1 Home care 2 Rehabilitation 3 Skilled nursing care 4 Outpatient therapy

1 Home care Clients who are discharged with an infusion device to continue drug therapy at home should expect home care services to teach appropriate administration of drug therapy in the client's home. The client is being discharged to the home and not to rehabilitation or to a skilled nursing facility. Outpatient therapy is not identified as a method for continuing antibiotic therapy with an infusion device.

Which statements indicate a nurse has a correct understanding of interleukin-2? Select all that apply. 1 It enhances natural killer cells. 2 It produces an antiviral effect. 3 It is used to treat various malignancies. 4 It is used as an anti-inflammatory agent. 5 It stimulates differentiation of T-lymphocytes.

1 It enhances natural killer cells. 3 It is used to treat various malignancies. 5 It stimulates differentiation of T-lymphocytes. Interleukin-2 is used clinically to enhance natural killer cells, treat various malignancies, and stimulate differentiation of T-lymphocytes. Interleukin-1 is used as an anti-inflammatory agent. The antiviral effect is produced by interferons.

A client's diagnosis reports indicate the presence of syphilis, but the clinical manifestations of syphilis are absent in the client. Which stage of syphilis is the client in? 1 Latent 2 Tertiary 3 Primary 4 Secondary

1 Latent Syphilis is a sexually transmitted disease caused by Treponema pallidum. A client in the latent stage of syphilis shows a positive specific treponemal antibody test, but clinical manifestations are absent. Clinical manifestations in the tertiary stage of syphilis are presence of the gummas on the skin. Clinical manifestations in the primary stage of syphilis are chancres and genital ulcers. The clinical manifestations in the secondary stage of syphilis are malaise, fever, sore throat, headaches, and fatigue.

Which nursing actions should be effective for a client with rheumatoid arthritis who is receiving anakinra therapy? Select all that apply. 1 Monitoring the injection site 2 Monitoring the blood pressure 3 Teaching the client to report chest pain 4 Monitoring the while blood cell (WBC) count 5 Teaching the client to report difficulty in breathing

1 Monitoring the injection site 4 Monitoring the while blood cell (WBC) count 5 Teaching the client to report difficulty in breathing For the clients who are receiving anakinra therapy, the nurse should monitor the injection site as site reactions may occur. The nurse should also monitor the WBC count as the drug can cause a severe decrease in WBCs, which makes the client more susceptible to infection. The nurse should teach the client to report difficulty breathing as anakinra can cause serious respiratory infections and various types of cancer. The nurse should monitor the blood pressure in clients who are receiving infliximab therapy. The nurse should teach clients who are receiving infliximab therapy to report chest pain.

Which manifestations may indicate a client has systemic lupus erythematosus (SLE)? Select all that apply. 1 Pericarditis 2 Esophagitis 3 Fibrotic skin 4 Discoid lesions 5 Pleural effusions

1 Pericarditis 4 Discoid lesions 5 Pleural effusions SLE is a chronic, progressive inflammatory connective tissue disorder that can cause major organs and systems to fail. Pericarditis is a cardiovascular manifestation of SLE. Discoid lesion is a skin manifestation that is a key indicator of the presence of SLE. Pleural effusion, a pulmonary manifestation, is a key indicator of the presence of SLE. Esophagitis is one of the gastrointestinal manifestations of systemic sclerosis. Fibrotic skin is one of the skin manifestations of systemic sclerosis.

A client on immunosuppressive therapy is diagnosed with a peptic ulcer. Which medication might have led to this condition? 1 Prednisone 2 Azathioprine 3 Cyclosporine 4 Cyclophosphamide

1 Prednisone Prednisone is a corticosteroid that suppresses inflammatory responses. A side effect of prednisone is the development of peptic ulcers. Azathioprine is an immunosuppressant that may cause anemia. Cyclosporine is an immunosuppressant that may cause nephrotoxicity and hypertension. Cyclophosphamide is an immunosuppressant that may cause hemorrhagic cystitis.

What should the nurse identify as responses to the release of histamine during a type I rapid hypersensitivity reaction? Select all that apply. 1 Pruritus 2 Erythema 3 Fibrotic changes 4 Nasal mucus secretion 5 Conjunctival mucus secretion

1 Pruritus 2 Erythema 4 Nasal mucus secretion 5 Conjunctival mucus secretion

Which dietary modifications can help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? 1 Refraining from consuming fatty foods 2 Refraining from consuming frequent meals 3 Refraining from consuming high-calorie foods 4 Refraining from consuming high-protein foods

1 Refraining from consuming fatty foods Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. Therefore the client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutritional status. High-calorie and high-protein foods are beneficial to clients with AIDS because they provide energy and build immunity.

While assessing a client with acquired immunodeficiency syndrome (AIDS), the nurse suspects that the client has developed cryptococcosis. Which clinical manifestations support the nurse's suspicion of a cryptococcosis infection? Select all that apply. 1 Seizures 2 Dyspnea 3 Blurred vision 4 Neurologic deficits 5 Enlarged lymph nodes

1 Seizures 3 Blurred vision 4 Neurologic deficits Seizures, neurologic problems/deficits, and blurred vision are the manifestations of cryptococcosis. Cryptococcosis is a debilitating meningitis and can be a widely spread infection in clients who have AIDS. It is caused by Cryptococcus neoformans. Histoplasmosis is a respiratory infection caused by Histoplasma capsulatum, which progresses to widespread infection in a client with AIDS. The symptoms of histoplasmosis are dyspnea and enlarged lymph nodes.

Why would a primary healthcare provider recommend that a client with acquired immunodeficiency syndrome (AIDS) and Kaposi's sarcoma (KS) wear hats and long sleeves? 1 To maintain a normal appearance 2 To reduce pain 3 To promote healing 4 To prevent infection

1 To maintain a normal appearance Clients with KS lesions may be advised to wear hats, makeup, or long sleeves to maintain a normal appearance. Pain associated with KS lesions is treated with analgesics and comfort measures. Modified burrow's solution soaks may promote healing in some clients with KS. The cleaning and dressing of KS lesions will prevent infections.

A medical/surgical nurse is completing the admission assessment on a client diagnosed with a urinary tract infection. The client's admitting weight is 165 lb (74.8 kg). The vital signs are as follows: temperature 96° F (35.6° C), pulse 110, respirations 20, and blood pressure 88/56 mm Hg. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours is 20 mL via Foley catheter. Which intervention should the nurse recommend to the primary healthcare provider? 1 Transfer to a critical care unit 2 Discontinue the urinary catheter 3 Give 1 L of sodium chloride (making a total of 4 L) 4 Begin a dopamine hydrochloride drip at renal perfusion

1 Transfer to a critical care unit The client has a known infection, is exhibiting signs of sepsis, and is unresponsive to fluid therapy as evidenced by the low blood pressure. The client is showing signs of kidney failure. The client is manifesting probable signs of septic shock requiring a higher level of care. This question requires the medical/surgical nurse to synthesize the client's manifestations and make an evaluation of the need for more invasive care than is available on the admitting unit. Giving another fluid is plausible, but this client weighs 75 kg, requiring a maximum of 3 L of fluid to be given before a diagnosis of severe sepsis. The client requires more invasive monitoring than can be done on a medical/surgical unit to determine if more fluid or vasopressors are required. The urinary catheter is necessary to continue monitoring the urine output in this acute client.

During an assessment, a nurse suspects that a client is in the primary stage of syphilis. Which findings support the nurse's conclusion? Select all that apply. 1 Ulcers on the hands and lips 2 Patchy alopecia on the scalp 3 Headache and a sore throat 4 Firm and enlarged lymph nodes 5 Presence of gummas in the mouth

1 Ulcers on the hands and lips 4 Firm and enlarged lymph nodes The appearance of ulcers (called chancres) is the first sign of primary syphilis. These chancres commonly appear on the skin and mucous membranes such as the lips, hands, genitalia, nipples, mouth, anus, and rectum. Primary syphilis is a highly infectious stage that may be manifested by large, firm, and painless lymph nodes. The secondary stage of syphilis is characterized by patchy alopecia on the scalp and facial hair and is associated with a headache and sore throat. The presence of gummas on the mucous membranes such as the mouth is the manifestation of the tertiary stage of syphilis.

The nurse is caring for different clients who are affected in a disaster. What is the order of priority in which the nurse would provide care to the clients? 1. 70-year-old client with closed fractures 2. 40-year-old client with hemorrhagic shock 3. 35-year-old client with sprains and abrasions 4. 50-year-old client with open fractures and large wounds

1. 40-year-old client with hemorrhagic shock 2. 50-year-old client with open fractures and large wounds 3. 70-year-old client with closed fractures 4. 35-year-old client with sprains and abrasions The highest priority is given to a 40-year-old client with hemorrhagic shock, which is a life-threatening condition. Next level priority is given to a 50-year-old client with open fractures and large wounds. Then the next priority is given to a 70-year-old client with closed fractures, because the treatment can be delayed and may not be a threat to life. Least priority is given to the 35-year-old client with sprains and abrasions.

The nurse is reviewing the laboratory reports of four clients. Which client is in the third stage of human immune virus (HIV) disease? A: CD4+ t-cell count is 180/mm3 B: CD4+ T-cell count is 250 cells/mm3 C: CD4+ T-cell count is 380 cell/mm3 D: CD4+ T-cell count is 600 cells/mm3 1 Client A 2 Client B 3 Client C 4 Client D

1. Client A According to HIV disease classification, a client with HIV disease is in the third stage of the disease if the CD4+ T-cell count is less than 200 cells/mm3. Therefore, client A is in third stage of HIV disease. A client is in second stage of HIV disease if the CD4+ T-cell count is between 200 and 499 cells/mm3. Therefore, client B and client C are in the second stage of HIV disease. A client is in the first stage of HIV disease if the CD4+ T-cell count is greater than 500 cells/mm3. Therefore, client D is in first stage of HIV disease.

Arrange in order the steps involved in skin testing for an allergen causing a type I allergic reaction. 1. Use a skin testing needle to scratch the surface of the skin. 2. Apply topical steroid on the skin. 3. Observe for a wheal formation on the skin. 4. Discontinue corticosteroid medications. 5. Clean the inner side of the forearm with soap and water. 6. Place drops of sera containing the known allergen on skin.

1. Discontinue corticosteroid medication 2. Clean the inner side of the forearm with soap and water. 3. Place drops of sera containing the known allergen on skin. 4. Use a skin testing needle to scratch the surface of the skin. 5. Observe for a wheal formation on the skin. 6. Apply topical steroid on the skin The first step is to discontinue corticosteroid medications 2 weeks prior to the test to prevent a suppressed immune response. Then, on the day of testing, the test site (the inner side of the forearm) should be cleaned with soap and water to remove surface contaminants. Then drops of sera containing a known allergen should be placed on the skin. The skin is then scratched through the drop with the use of a skin testing needle. Control drops are also applied to compare reactions. Then positive signs for allergic reactions, such as erythema or wheal formation, should be observed. Finally the client should be discharged after a topical steroid is applied on the skin.

A client reports painful urination and profuse purulent urethral discharge. After assessment, the nurse finds that his testicles are swollen. The primary healthcare provider asks the client to undergo a nucleic acid amplification test. Which organism may be responsible for this condition in the client? 1 Treponema pallidum 2 Neisseria gonorrhoeae 3 Chlamydia trachomatis 4 Condylomata acuminata

2 Neisseria gonorrhoeae Neisseria gonorrhoeae causes gonorrhea. The symptoms of gonorrhea include dysuria, profuse purulent urethral discharge, and swollen testicles. The diagnostic test for gonorrhea is nucleic acid amplification test (NAAT). Treponema pallidum causes syphilis. The symptoms of syphilis include the presence of painless, indurated lesions on the penis, vulva, lips, mouth, vagina, and rectum. The diagnostic test for syphilis is direct fluorescent antibody test. Chlamydia trachomatis causes chlamydial infection, the symptoms of which are urethritis, rectal discharge, and pain during defecation. The diagnostic test for chlamydial infection is also NAAT, done by testing urine or collecting swab specimens from the urethra. Condylomata acuminata causes genital warts. Genital warts are small fleshy growths, bumps, or skin changes that appear near the genital or anal area. The diagnosis of genital warts is made based on the gross appearance of the lesions.

The blood report of a client with fungal infection reveals the presence of IgM and IgG antibodies. The skin test shows erythema and edema within 3 hours after injection. Which conditions does the nurse suspect in the client? Select all that apply. 1 Atopic dermatitis 2 Rheumatoid arthritis 3 Goodpasture syndrome 4 Acute glomerulonephritis 5 Systemic lupus erythematosus (SLE)

2 Rheumatoid arthritis 4 Acute glomerulonephritis 5 Systemic lupus erythematosus (SLE) A client with fungal infection, presence of IgM and IgG antibodies in the blood, and erythema and edema within 3 hours of skin test indicates type III hypersensitivity reactions. Type III mainly affects the kidneys, skin, joints, and lungs, which may lead to rheumatoid arthritis, acute glomerulonephritis, and SLE. Atopic dermatitis is a chronic, inherited skin disorder that results from type I anaphylactic reactions. Goodpasture syndrome is a disorder involving the lungs and kidneys and is an example of a type II hypersensitivity reaction.

The primary healthcare provider prescribes medication to prevent transplant rejection from increased concentration of interleukin-2. Which drugs could the nurse most likely administer? Select all that apply. 1 Sirolimus 2 Tacrolimus 3 Cyclosporine 4 Azathioprine 5 Mycophenolate

2 Tacrolimus 3 Cyclosporine Tacrolimus and cyclosporine are calcineurin inhibitors that stop the production and secretion of interleukin-2 and prevent the activation of lymphocytes involved in transplant rejection. Therefore tacrolimus and cyclosporine are most suitable for the client. Sirolimus, azathioprine, and mycophenolate are antiproliferative medications that inhibit something essential to DNA synthesis and prevent cell division in activated lymphocytes; thus they are effective for lessening transplant rejection involving DNA synthesis, not interleukin-2.

The nurse instructs a human immunodeficiency (HIV)-positive client about ways to prevent infections. During a follow-up visit, which statement made by the client indicates a need for more education? 1 "I reuse cups after washing them." 2 "I wash my hands with tap water after gardening." 3 "I rinse my toothbrush in liquid laundry bleach every week." 4 "I wash my armpits, groin, and genitals with antimicrobial soap twice a day."

2 "I wash my hands with tap water after gardening." An HIV-positive client should refrain from digging in soil and performing gardening activities. Soil contains several infectious microorganisms. In unavoidable circumstances, the client should wear gloves and wash hands thoroughly with antimicrobial soap after gardening. The client should refrain from reusing cups without washing them. Weekly rinsing of a toothbrush in liquid laundry bleach helps prevent infectious pathogens from accumulating on the brush. The armpits, groin, and genitals tend to house higher amounts of microorganisms and should be cleaned twice a day with antimicrobial soap.

A registered nurse is evaluating the statements of a nursing student providing instructions to the partner of a client with Ebola. Which instruction given by the nursing student needs correction? 1 "You should avoid direct contact with your partner's saliva." 2 "You should be careful because the Ebola virus spreads through the air." 3 "You should avoid having sex with your partner for 3 months even after the recovery of your partner." 4 "You should immediately report symptoms of fever, headache, and vomiting."

2 "You should be careful because the Ebola virus spreads through the air." Ebola disease is caused by the Ebola virus, which does not spread through the air, water, or food. Ebola spreads through bodily fluids. A client with Ebola may have the Ebola virus in the semen for 3 months even after recovery. Early symptoms of Ebola disease are fever, headache, and vomiting.

A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling? 1 20-year-old healthy woman 2 45-year-old woman with breast cancer 3 50-year-old man with diabetes mellitus 4 75-year-old man with Parkinson disease

2 45-year-old woman with breast cancer The smallpox vaccine should not be given to individuals who may be immunocompromised as a result of therapy for cancer. There is no contraindication to giving the smallpox vaccination to a healthy woman, a client with diabetes mellitus, or a client with Parkinson disease.

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F (39° C). The temperature was 99.2° F (37.3° C) when it was taken 6 hours ago. What is a priority nursing intervention in this case? 1 Assess the amount and color of urine; obtain a specimen for a urinalysis. 2 Administer the prescribed antipyretic and notify the primary health care provider. 3 Note the consistency of respiratory secretions and obtain a specimen for culture. 4 Obtain the respirations, pulse, and blood pressure; recheck the temperature in 1 hour.

2 Administer the prescribed antipyretic and notify the primary health care provider. Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia then can be initiated. More vigorous intervention than obtaining the respirations, pulse, and blood pressure is rechecking the temperature in 1 hour. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. Assessing the amount and color of urine and obtaining a specimen for a urinalysis is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also, the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. Noting the consistency of respiratory secretions and obtaining a specimen for culture is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma.

A client presents with sneezing; lacrimation; swelling with an airway obstruction; and pruritus around the eyes, nose, throat, and mouth. The nurse interprets these findings as a Type I hypersensitivity reaction. Which disease might have occurred in the client? 1 Angioedema 2 Allergic rhinitis 3 Contact dermatitis 4 Goodpasture syndrome

2 Allergic rhinitis Sneezing; lacrimation; swelling with an airway obstruction; and pruritus around the eyes, nose, throat, and mouth are symptoms of a hypersensitivity reaction resulting in allergic rhinitis. This reaction is a type I hypersensitivity reaction mediated by immunoglobulin E. Angioedema is a localized cutaneous lesion similar to urticaria, but it involves a deeper layer of the skin and the submucosa. Contact dermatitis is an example of a delayed hypersensitivity reaction. The skin lesions appear erythematous and are covered with papules, vesicles, and bullae.

A client presents with cutaneous lesions with swelling in the face, eyelids, and lips from dilation and engorgement of the capillaries. No welts or vesicles are observed. Which condition most likely has occurred in the client? 1 Urticaria 2 Angioedema 3 Atopic dermatitis 4 Systemic lupus erythematosus (SLE)

2 Angioedema Angioedemais a localized cutaneous lesion similar to urticaria but involving deeper layers of the skin and the submucosa. The principal areas of involvement include the eyelids, lips, tongue, and face. It occurs due to the dilation and engorgement of the capillaries. Urticaria is a cutaneous reaction against systemic allergens occurring in atopic people. It is characterized by transient wheals that may vary in size and shape and occur all over the body. Atopic dermatitis is a chronic, inherited skin disorder that is characterized by exacerbations and remissions. The skin lesions are more generalized and involve vasodilation of blood vessels, resulting in interstitial edema with vesicle formation. SLE is an autoimmune disease that is characterized by damage to multiple organs (kidneys, skin, joints, lungs).

Which type of immunity will clients acquire through immunizations with live or killed vaccines? 1 Natural active immunity 2 Artificial active immunity 3 Natural passive immunity 4 Artificial passive immunity

2 Artificial active immunity Artificial active immunity is acquired through immunization with live or killed vaccines. Natural active immunity is acquired when there is natural contact with antigens through a clinical infection. Natural passive immunity is acquired through the transfer of colostrums from mother to child. Artificial passive immunity is acquired by injecting serum from an immune human.

A client's laboratory report shows elevated IgE levels and positive skin tests. The nurse suspects an allergic reaction. Upon assessment the nurse discovers skin lesions (vesicles), which are widespread. Which condition will the nurse most likely observe written in the client's medical record? 1 Allergic rhinitis 2 Atopic dermatitis 3 Contact dermatitis 4 Goodpasture syndrome

2 Atopic dermatitis Elevated IgE levels and positive skin tests occur in individuals with atopic dermatitis. The skin is characterized by the presence of lesions that spread widely over the skin, unlike in contact dermatitis where they occur locally. Contact dermatitis is a red itchy rash that involves mediators such as cytokines, resulting in a delayed hypersensitivity reaction. Allergic rhinitis may occur yearly or seasonally and involves mediators such as histamine and mast cells that result in an IgE-mediated hypersensitivity reaction. Goodpasture syndrome is an autoimmune disorder involving lungs and kidneys, and does not cause edematous papules or lesions; it involves mediators such as complement lysis and tissue macrophages that cause type II cytotoxic hypersensitivity reaction.

In clients with Goodpasture syndrome, what is the pathophysiology of this syndrome? 1 Antigen-specific IgE binds to the surface of basophils and mast cells 2 Auto-antibodies attack the glomerular basement membrane and neutrophils 3 Rapid and systemic reactions of the organs within seconds after exposure to an allergen 4 Autoimmune destruction of the lacrimal and salivary mucus-producing glands

2 Auto-antibodies attack the glomerular basement membrane and neutrophils Goodpasture syndrome is an autoimmune disorder in which auto-antibodies attack the glomerular basement membrane and neutrophils, especially in the lungs and kidneys. A client may have allergies when an antigen-specific IgE binds to the surface of basophils and mast cells, which stimulates the production of vasoactive amines. Rapid and systemic reactions of the organs within seconds after exposure to an allergen may lead to anaphylactic shock. A client with Sjögren's syndrome may have the autoimmune destruction of the lacrimal and salivary mucus/moisture-producing glands.

A client has undergone scratch testing but the causative allergen is yet to be identified. What would be the next step to confirm a strongly suspected allergen? 1 Administer allergy shots 2 Begin intradermal testing 3 Request that a client take an oral food challenge 4 Begin radioallergosorbent testing

2 Begin intradermal testing An intradermal test is administered when a strongly suspected allergen tests negative with the scratch test. A testing dose of sera is injected intradermally into the arm and any signs of allergy are observed to confirm the allergen. Allergy shots are a therapeutic method of reducing sensitivity to a known allergen when exposure cannot be avoided. An oral food challenge is done to confirm an ingested allergen if skin testing completely fails. Radioallergosorbent testing is useful to measure immunoglobulin E levels to ascertain the presence of an allergic reaction.

Which client may have a type II hypersensitivity reaction? A: Allergic rhinitis B: Goodpastures syndrome C:Rheumatoid arthritis D:Contact dermatitis due to poison ivy exposure

2 Client B - Goodpastures syndrome Goodpasture's syndrome is a disorder involving the lungs and kidneys; this syndrome is a type II hypersensitivity reaction. Client A has a type I hypersensitivity reaction. Client C has a type III hypersensitivity reaction. Client D has a type IV hypersensitivity reaction.

The nurse is preparing a teaching plan for clients receiving antitubercular medications. Which teaching plan needs correction? 1 Clients taking ethambutol should drink plenty of fluids. 2 Clients taking Isoniazid should take the drug with food. 3 Clients taking pyrazinamide should wear a hat while going out in the sun. 4 Clients taking rifampin should use other contraceptive methods even after stopping the medication.

2 Clients taking Isoniazid should take the drug with food. Taking isoniazid with food should be corrected. The presence of food may slow or even prevent the absorption of isoniazid from the stomach. Therefore the client should take the medication on an empty stomach, either 1 hour before or 2 hours after eating. Ethambutol may increase uric acid formation. The client should drink plenty of water to reduce uric acid precipitation and kidney problems. Pyrazinamide is a photosensitive medication that may increase the risk of sunburn. Therefore the client should wear a hat and protect himself or herself from sun exposure. Rifampin may decrease the efficiency of oral contraceptives. Therefore the nurse should instruct the client to use an additional method of contraception even after stopping the medication.

What is the primary focus of nursing care for a client admitted with tetanus caused by a puncture wound? 1 Monitoring urinary output 2 Decreasing external stimuli 3 Maintaining body alignment 4 Encouraging high intake of fluid

2 Decreasing external stimuli The slightest stimulation can set off a wave of severe, painful muscle spasms involving the whole body. Nerve impulses cross the myoneural junction and stimulate muscle contractions caused by exotoxins produced by Clostridium tetani. Monitoring urinary output is not a major nursing concern for clients with tetanus. Body alignment is not an important consideration for clients with tetanus. Oral intake of fluids may not be possible because of excessive secretions and laryngospasms.

A client with radiation therapy for neck cancer reports, "I feel a lump while swallowing and foods get stuck." What does the nurse document in the client's medical history? 1 Dysgeusia 2 Dysphagia 3 Xerostomia 4 Odynophagia

2 Dysphagia Dysphagia is having difficulty while swallowing. This characterizes pharyngeal and esophageal involvement, which further impedes eating. In this condition, the client may report a feeling of having a "lump" when swallowing and feeling that "foods get stuck." Dysgeusia is the loss of taste; clients will report that all food has lost its flavor. While xerostomia may contribute to difficulty swallowing, it is not the term used; xerostomia is used to indicate dry mouth. Odynophagia is painful swallowing; clients will report severe pain while swallowing.

Which medications prescribed to a client after a kidney transplant surgery may require the client to visit a dentist? Select all that apply. 1 Sirolimus 2 Everolimus 3 Prednisone 4 Cyclosporine 5 Prednisolone

2 Everolimus 4 Cyclosporine Everolimus is an antiproliferative drug that inhibits cell division in activated lymphocytes. Everolimus could cause gingival hyperplasia as a side effect. Cyclosporine may also cause gingival hyperplasia. Therefore the client may have to visit a dentist because of these medications. Sirolimus may cause leukopenia and thrombocytopenia. Prednisone and prednisolone may cause hypertension and hyperglycemia.

Which medication should the nurse anticipate being prescribed for a client with C. difficile-associated disease (CDAD)? Select all that apply. 1 Penicillin 2 Fidaxomicin Ciprofloxacin 3 Ciprofloxacin 4 Metronidazole 5 Vancomycin

2 Fidaxomicin Ciprofloxacin 4 Metronidazole 5 Vancomycin A new oral antibacterial drug available specifically for managing C. difficile is fidaxomicin. Oral metronidazole and vancomycin have been the drugs of choice to treat CDAD. Ciprofloxacin has contributed to the development of a new more virulent strain of this pathogen. Penicillin is used to treat bacterial infections and not CDAD.

A mother with the diagnosis of acquired immunodeficiency syndrome (AIDS) states that she has been caring for her baby even though she has not been feeling well. What important information should the nurse determine? 1 If she has kissed the baby 2 If the baby is breast-feeding 3 When the baby last received antibiotics 4 How long she has been caring for the baby

2 If the baby is breast-feeding Epidemiologic evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn.

A laboratory report shows that a client tested positive for human epidermal growth factor (HER), and a medical report reveals the presence of advanced breast cancer. Which medication would be used to treat this condition? 1 Erlotinib 2 Lapatinib 3 Rituximab 4 Tositumomab

2 Lapatinib HER-2 is overexpressed in clients with advanced breast cancer. Lapatinib inhibits epidermal growth factor-r (EGFR)-tyrosine kinase (TK) and binds HER-2. Erlotinib is an EFGR-TK inhibitor prescribed to treat non-small cell lung cancer and advanced pancreatic cancer. Rituximab and tositumomab are administered to treat non-Hodgkin's lymphoma.

Which test result should a nurse review to determine if the antibiotic prescribed for the client will be effective? 1 Serologic test 2 Sensitivity test 3 Serum osmolality 4 Sedimentation rate

2 Sensitivity test Infected body fluids are tested to determine the antibiotics to which the organism is particularly sensitive or resistant (sensitivity). The serologic test checks for antibody content. The serum osmolality test provides data about fluid and electrolyte balance. The erythrocyte sedimentation rate (ESR) is a nonspecific test for the presence of inflammation.

A client with acquired immunodeficiency syndrome (AIDS) reports speech, gait, and vision difficulty. The nurse observes the client is confused and lethargic. Which microorganism is most likely responsible for this condition? 1 Candida albicans 2 Toxoplasma gondii 3 Pneumocystis jiroveci 4 Mycobacterium tuberculosis

2 Toxoplasma gondii Toxoplasmosis encephalitis is an opportunistic infection caused by Toxoplasma gondii. The symptoms of toxoplasmosis encephalitis are speech, gait, and vision difficulty along with confusion and lethargy. An overgrowth of Candida albicans causes mouth pain and difficulty swallowing. Pneumocystis jiroveci causes pneumonia in a client with acquired immunodeficiency syndrome (AIDS). Mycobacterium tuberculosis causes tuberculosis in a client with AIDS.

A client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client? 1 Type I 2 Type II 3 Type III 4 Type IV

2 Type II A classic type II reaction occurs when a recipient receives ABO-incompatible blood from a donor. Naturally acquired antibodies to antigens of the ABO blood group are in the recipient's serum but are not present on the erythrocyte membranes. Anaphylactic reactions are type I reactions that occur only in susceptible people who are highly sensitized to specific allergens. Tissue damage in immune-complex reactions, which are type III reactions, occur secondary to antigen-antibody complexes. Although cell-mediated responses are usually protective mechanisms, tissue damage occurs in delayed hypersensitivity reactions. The tissue damage in a type IV reaction does not occur in the presence of antibodies or complement.

A client who works manufacturing latex gloves presents with dryness, pruritus, fissuring, and cracking of the skin followed by redness and inflammation about 24 hours after contact. The nurse identifies it as an allergic reaction. Which condition most likely has occurred? 1 Type I allergic reaction 2 Type IV contact dermatitis reaction 3 Immune complex reaction 4 Cytotoxic hypersensitivity reaction

2 Type IV contact dermatitis reaction Type IV contact dermatitis is caused by the chemicals used in the manufacturing process of latex gloves. It is characterized by dryness, pruritus, fissuring, and cracking of the skin and occurs within 6 to 48 hours of contact. Type I allergic reaction is a response to the natural rubber latex proteins and occurs within minutes of contact with the proteins; skin redness, urticaria, rhinitis, and conjunctivitis are the clinical manifestations. Immune-complex reaction is a type III hypersensitivity. The kidneys, skin, joints, blood vessels and lungs are common sites for deposit. Cytotoxic hypersensitivity reactions involve the direct binding of IgG or IgM antibodies to an antigen on the cell surface and is a type II hypersensitivity.

The nurse is assessing four clients with infections in the mouth. Which client can be treated by nystatin as an oral suspension? A: trench mouth B: Moniliasis C: Cold sores D: Parotitis

2. Client B Moniliasis is a fungal infection caused by Candida albicans. Nystatin is an antifungal medication used to treat fungal infections. Therefore client B can be treated with nystatin. Client A, with trench mouth, can be treated by a topical application of antibacterial and mouth irrigations with chlorhexidine. Client C, with cold sores, can be treated with antiviral medications. Client D, with parotitis, can be treated with adequate fluid intake and antibacterial medication.

A client who is on monoclonal antibody medication reports rigors, headache, myalgia, and gastrointestinal disturbances. The medical history shows that the client is on muromonab-CD3. Which medications could be beneficial for the reported symptoms? Select all that apply. 1 Sirolimus 2 Cyclosporine 3 Acetaminophen 4 Diphenhydramine 5 Methylprednisolone

3 Acetaminophen 4 Diphenhydramine 5 Methylprednisolone Acetaminophen, diphenhydramine, and methylprednisolone are administered to reduce the adverse effects associated with muromonab-CD3 use. When monoclonal antibodies are administered, a flulike syndrome occurs during the first few days of treatment because of cytokine release. Rigors, headache, myalgia, and gastrointestinal disturbances are the adverse effects of monoclonal antibodies. Sirolimus and cyclosporine are used in combination to reduce the graft loss that occurs in transplant recipients.

A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics (Canada: Canadian Pediatric Society)? 1 One dose of diphtheria toxoid, oral poliomyelitis, live measles, live rubella, and mumps vaccines 2 Two doses of diphtheria toxoid and; oral poliomyelitis vaccine and one dose of live measles, live rubella, and mumps vaccine 3 Three doses of diphtheria toxoid and oral poliomyelitis vaccine and one dose of live measles, live rubella, and mumps vaccine 4 Three doses of diphtheria toxoid vaccine; two doses of oral poliomyelitis vaccine; and one dose of live measles, live rubella, and mumps vaccine

3 Three doses of diphtheria toxoid and oral poliomyelitis vaccine and one dose of live measles, live rubella, and mumps vaccine Three doses of diphtheria toxoid and oral poliomyelitis vaccine and one dose of live measles, live rubella, and mumps vaccine is the schedule for active immunization as recommended by the American Academy of Pediatrics (Canada: Canadian Pediatric Society). One dose of diphtheria toxoid, oral poliomyelitis, live measles, live rubella, and mumps vaccines does not follow the schedule for active immunization as recommended by the American Academy of Pediatrics (Canada: Canadian Pediatrics Society). Two doses of diphtheria toxoid and oral poliomyelitis vaccine and one dose of live measles, live rubella, and mumps vaccine does not follow the schedule for active immunization as recommended by the American Academy of Pediatrics (Canada: Canadian Pediatrics Society). Three doses of diphtheria toxoid vaccine; two doses of oral poliomyelitis vaccine; and one dose of live measles, live rubella, and mumps vaccine does not follow the schedule for active immunization as recommended by the American Academy of Pediatrics (Canada: Canadian Pediatrics Society).

A registered nurse is teaching a student nurse regarding the precautions to be followed while caring for a client infected with Ebola virus. Which statement by the student nurse indicates the need for further teaching? 1 "I will isolate the infected client in a private room." 2 "I will use standard, contact, and droplet precautions." 3 "I will not touch the prepared food for the infected client." 4 "I will avoid direct contact with body fluids of the infected client."

3 "I will not touch the prepared food for the infected client." The Ebola virus is not spread via air, water, or food. Therefore avoiding the touching of prepared food for the infected client may not help in preventing Ebola. The nurse should correct this misconception. All the other statements are correct. Clients with Ebola should be isolated in a single room to prevent the spread of infection. While caring for a client with Ebola, the nurse should use standard, contact, and droplet precautions to prevent Ebola infection. The nurse should avoid direct contact with body fluids of the infected client to prevent the spread of Ebola infection.

A female client is upset with her diagnosis of gonorrhea and asks the nurse, "What can I do to prevent getting another infection in the future?" Which is the most practical response the nurse can give to someone who plans to be sexually active? 1 "Douche after every intercourse." 2 "Avoid engaging in sexual behavior." 3 "Insist that your partner use a condom." 4 "Use a spermicidal cream with intercourse."

3 "Insist that your partner use a condom." Once people become sexually active, they usually remain sexually active; a condom, although not 100% effective, is the best protection against gonorrhea in a sexually active person. The response "Douche after every intercourse" has no proven protective effect against sexually transmitted infections; excessive douching can alter the vaginal environment and may promote an ascending infection. The response "Avoid engaging in sexual behavior" is not a realistic response to a sexually active person. Spermicidal cream has no protective effect against sexually transmitted infections.

A nurse is educating a client with human immunodeficiency virus (HIV) about self-management. Which suggestion by the nurse benefits the client? 1 "Limit your daily fluid intake." 2 "Eat more roughage." 3 "Rinse your mouth with normal saline after every meal." 4 "Maintain a 4-to-5-hour gap in between meals."

3 "Rinse your mouth with normal saline after every meal." A client infected with HIV should maintain proper oral care to improve his or her appetite. The client should rinse his or her mouth with sterile water or normal saline several times a day, especially after meals, to maintain proper oral hygiene. The client should drink plenty of fluids to maintain proper body fluid balance. Roughage should be limited in a client's diet because it is not easily digestible and may lead to severe diarrhea and contains microorganisms that can lead to infection. The client should consume small, frequent meals to maintain adequate caloric intake.

A client receiving cisplatin therapy has developed tumor lysis syndrome (TLS). Which medication should the nurse administer to treat the TLS? 1 Mesna 2 Flavoxate 3 Allopurinol 4 Aprepitant

3 Allopurinol Allopurinol should be administered to this client to promote purine excretion. Cisplatin is a nephrotoxic agent that is used in clients with cancer. TLS is the precipitation of metabolites (purine and potassium) of cell breakdown. Mesna and flavoxate are used to treat hemorrhagic cystitis in clients on chemotherapy; mesna is a protectant while flavoxate manages symptoms. Aprepitant is used to prevent nausea and vomiting in a client on the day of chemotherapy.

Which immunomodulatory is beneficial for the treatment of clients with multiple sclerosis? 1 Interleukin 2 2 Interleukin 11 3 Beta interferon 4 Alpha interferon

3 Beta interferon Beta interferon is an immunomodulator that is administered in the treatment of multiple sclerosis. Interleukin 11 is used in the prevention of thrombocytopenia after chemotherapy. Interleukin 2 is used for the treatment of metastatic renal cell carcinoma and metastatic melanoma. Alpha interferon is administered for the treatment of hairy cell leukemia, chronic myelogenous leukemia, and malignant melanoma.

A client in the emergency department states, "I was bitten by a raccoon while I was fixing a water pipe in the crawl space of my basement." Which is the most effective first-aid treatment for the nurse to use for this client? 1 Administering an antivenin 2 Maintaining a pressure dressing 3 Cleansing the wound with soap and water 4 Applying a tourniquet proximal to the wound

3 Cleansing the wound with soap and water Infection is caused by viral contact with the dermal layer of skin; cleansing the wound with soap and water helps remove superficial contaminants. Antivenins are not effective against microbiologic stresses. A pressure dressing will not prevent infection. Application of a tourniquet may impair circulation and will not prevent infection.

The nurse is reviewing the medication charts of four clients prescribed with cytokines. Which client's medication chart indicates the nurse needs to intervene? A: Condition: rheumatoid arthritis Prescribed cytokine : Etanercept B: Condition Chemotherapy induced thrombocytopenia Prescribed Cytokine: Oprelvekin C: Condition: Chemotherapy-induced neutropenia Presribed cytokine: Anakinra D: Metastic Melanoma, Prescribed Cytokine: Aldesleukin 1 Client A 2 Client B 3 Client C 4 Client D

3 Client C The nurse should intervene in the client taking anakinra. Colony-stimulating factors such as filgrastim and pegfilgrastim are effective in treating chemotherapy-induced neutropenia in client C. Anakinra is used to treat rheumatoid arthritis. All the rest are correct treatments. Cytokines are the soluble factors secreted by white blood cells that act as messengers between the cell types. Cytokines instruct cells to alter their proliferation, differentiation, secretion, and activity from immunomodulatory effects. Etanercept is used in the treatment of rheumatoid arthritis in client A and should not be questioned. Interleukin 11 (platelet growth factor) such as oprelvekin helps to prevent chemotherapy-induced thrombocytopenia in client B and should not be questioned. Aldesleukin is interleukin-2 that reduces metastatic melanoma in client D and metastatic renal cell carcinoma and should not require follow up.

The nurse is caring for four clients in the medical unit. Which nursing instruction indicates a need for correction? A: Condition : Abnormal vaginal bleeding Instruction: Avoid super absorbent tampons B: Condition : Diarrhea Instruction: Wash hands frequently C: Condition : Acquired immunodeficiency syndrome (AIDS) Instruction: Never share your eating utensils D: Condition : Tuberculosis Instruction: Wear a mask during transport to other areas

3 Client C Human immunodeficiency virus leads to acquired immunodeficiency syndrome. The virus in client C cannot be transmitted through sharing eating utensils, hugging, dry kissing, shaking hands, and using toilet seats. The nurse should advise client A to use sanitary pads rather than superabsorbent tampons to prevent toxic shock syndrome (TSS) due to Staphylococcus aureus infection. Client B with diarrhea should wash hands frequently to reduce the transmission of the disease. The nurse should advise client D with tuberculosis to wear a mask to prevent the transmission of Mycobacterium tuberculosis from small droplets when being transported.

Which process does the IgD immunoglobulin support? 1 Manifestation of allergic reactions 2 Protection of the body's mucous surfaces 3 Differentiation of the B-lymphocytes 4 Provision of the primary immune response

3 Differentiation of the B-lymphocytes IgD is present on the lymphocyte surface; this immunoglobulin differentiates B-lymphocytes. IgE causes symptoms of allergic reactions by adhering to mast cells and basophils. IgE also helps to defend the body against parasitic infections. IgA lines the mucous membranes and protects the body surfaces. IgM provides the primary immune response.

When assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies areas of white plaque on the client's tongue and palate. What is the nurse's initial response? 1 Instruct the client to perform meticulous oral hygiene at least once daily. 2 Scrape an area of one of the lesions and send the specimen for a biopsy. 3 Document the presence of the lesions, describing their size, location, and color. 4 Consider that these lesions are universally found in clients with AIDS and require no treatment.

3 Document the presence of the lesions, describing their size, location, and color. Documentation of nursing findings during assessment is a nursing function; this facilitates early treatment. Scraping an area of one of the lesions and sending the specimen for a biopsy medical intervention is beyond the scope of nursing practice. Inadequate oral hygiene has not been identified as a cause of plaques; once-daily treatment is insufficient for anyone. Candida is a frequent secondary infection in clients with AIDS; it is treated when present.

The nurse suspects that a client with inhalation anthrax is in the prodromal stage of disease. Which symptoms support the nurse's conclusion? Select all that apply. 1 Hypoxia 2 Cyanosis 3 Dry cough 4 Hypotension 5 Mild chest pain

3 Dry cough 5 Mild chest pain

A client undergoing tuberculosis therapy reports eye pain that worsens when moving the eyes with decreased color vision. Which medication most likely is responsible for the client's condition? 1 Rifampin 2 Isoniazid 3 Ethambutol 4 Pyrazinamide

3 Ethambutol Eye pain that is worsened when the eyes are moved with decreased color vision may be indicative of optic neuritis. Ethambutol, especially at high dosages, can cause optic neuritis, a condition that can result in blindness. Rifampin reduces the effectiveness of oral contraceptives, increasing the risk of an unplanned pregnancy, and can change bodily fluid orange. Isoniazid can deplete the body of the B-complex vitamins. Pyrazinamide increases uric acid formation and worsens gout.

The primary health care provider prescribes contact precautions for a client with hepatitis A. What nursing interventions are required for contact precautions? 1 Private room with the door closed 2 Gown, mask, and gloves for all persons entering the room 3 Gown and gloves when handling articles contaminated by urine or feces 4 Gowns and gloves only when handling the client's soiled linen, dishes, or utensils

3 Gown and gloves when handling articles contaminated by urine or feces Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal or urine contamination. Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. Hepatitis A is not transmitted via the airborne route and therefore a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. Wearing gowns and gloves only when handling the client's soiled linen, dishes, or utensils is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer.

Which organism causes Hansen's disease? 1 Clostridium tetani 2 Haemophilus pertusis 3 Mycobacterium leprae 4 Legionella pneumophila

3 Mycobacterium leprae Mycobacterium leprae causes Hansen's disease (leprosy). Clostridium tetani causes tetanus (lockjaw). Haemophilus pertusis causes pertussis (whooping cough) and Legionella pneumophila causes pneumonia (Legionnaires' disease).

The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority? 1 Assisting the client in eating and drinking 2 Maintaining fluid balance in the client 3 Providing adequate oxygenation for the client 4 Encouraging the client to perform breathing exercise

3 Providing adequate oxygenation for the client Pneumocystis jiroveci pneumonia may cause difficulty in breathing; therefore the client should be provided adequate oxygenation. A client with human immunodeficiency virus (HIV) and mouth lesions may need assistance in eating and drinking. An important nursing concern in a client with dehydration is maintaining fluid balance. Encouraging regular breathing exercises may be incorporated when the client is stable and is not the priority.

A client has been admitted to the hospital with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The client has a urinary catheter in place. No private rooms are available. Which room assignment would be most appropriate for this client? 1 Roommate has a urinary catheter. 2 Roommate is bedridden and uses a bedpan for urination. 3 Roommate has MRSA in the urine. The roommate is ambulatory, but confused. 4 Roommate is alert and oriented with a diagnosis of pneumonia but practices good hygiene when using the bathroom.

3 Roommate has MRSA in the urine. The roommate is ambulatory, but confused. If a private room is not available, the client may be placed in a room with another client who has the same active infection with the same microorganism if no other infection is present. The roommate with a urinary catheter, who is bedridden, or who has pneumonia does not indicate MRSA in the urine. Topics

A client is diagnosed with herpes genitalis. What should the nurse do to prevent cross-contamination? 1 Institute droplet precautions. 2 Arrange transfer to a private room. 3 Wear a gown and gloves when giving direct care. 4 Close the door and wear a mask when in the room.

3 Wear a gown and gloves when giving direct care. The exudate from herpes virus type 2 is highly contagious; gown and gloves should be worn. A face shield should be worn if there is a potential for splashing of body fluids. The organism is not in respiratory tract secretions; the organism is present in the exudate from active lesions. Arranging transfer to a private room is unnecessary. Closing the door and wearing a mask when in the room is not necessary because herpes genitalis is not an airborne infectious disease.

A nurse is caring for a 26-year-old client recently diagnosed with human immunodeficiency virus (HIV) and has a CD4 count of 150. The client needs an update on immunizations and asks which ones are needed. Which vaccines are required to comply with the recommended immunization schedule for a client with HIV? 1 Influenza; measles, mumps, rubella (MMR); varicella; and hepatitis A vaccines 2 Pneumococcal, MMR, influenza, and varicella vaccines 3 Diphtheria, tetanus, hepatitis A, and hepatitis C vaccines 4 Tetanus, hepatitis B, influenza, and pneumococcal vaccines

4 Tetanus, hepatitis B, influenza, and pneumococcal vaccines According to recent recommendations, adults with HIV should receive tetanus, influenza, hepatitis B, and pneumococcal vaccines. Live pathogen vaccines (MMR, varicella) are contraindicated for individuals who are immunosuppressed. Currently there is no immunization for hepatitis C, and the diphtheria vaccine is not recommended.

A nurse is counseling a client with tuberculosis regarding isoniazid (INH) therapy. Which statement made by the client indicates the nurse needs to follow up? 1 "I should take a multivitamin supplement daily." 2 "I should take the medication 1 hour before eating." 3 "I should immediately report to the primary healthcare provide if my skin and eyes appear yellow." 4 "I should apply sunscreen and wear sun-protective clothing while going outside."

4 "I should apply sunscreen and wear sun-protective clothing while going outside." Applying sunscreen needs to be followed up since this is a misconception and needs to be corrected. INH is a first-line medication used in the treatment of tuberculosis. This medication is not a photosensitive medication. All the rest are correct statements and require no follow up. Clients taking INH may have low levels of vitamin B complex; therefore, the client should take a daily supplement to prevent peripheral neuropathy. The client should take the medication 1 hour before meals because the presence of food may prevent the absorption of the medication from the gastrointestinal tract. Yellow discoloration of the skin and eyes should be immediately reported because it may indicate medication-induced liver toxicity or failure.

A tuberculin skin test with purified protein derivative (PPD) tuberculin is performed as part of a routine physical examination. When does the nurse instruct the client to make an appointment so the test can be read? 1 1 week 2 12 hours 3 24 to 48 hours 4 48 to 72 hours

4 48 to 72 hours It takes 48 to 72 hours for antibodies to respond to the antigen and form an indurated area. The results of tuberculosis skin tests that are not read within this timeframe will not be accurate.

A pregnant woman presents with a body temperature of 103 °F, cough, headache, muscle aches, chest pain, severe joint pain and night sweats and is diagnosed with coccidioidomycosis. Which medication will the nurse most likely observe prescribed on the medication administration record? 1 Doxycycline 2 Ciprofloxacin 3 Pyrazinamide 4 Amphotericin B

4 Amphotericin B An elevated body temperature of 103 °F, cough, headache, muscle aches, chest pain, severe joint pain and night sweats are symptoms of coccidioidomycosis, a fungal infection. Pregnant women can safely take amphotericin B because the drug will not affect the fetus. Doxycycline is a tetracycline that may lead to discoloration of the teeth in the newborn. Ciprofloxacin is a broad-spectrum antibiotic used to treat various bacterial infections and is ineffective with a fungal infection. Pyrazinamide is one of the first-line treatments for tuberculosis.

While caring for a client with an intravenous cannula, the nurse assesses the site and finds that it red, swollen, and warm with purulent drainage near the insertion site. Which nursing intervention provides client comfort? 1 Slowing the infusion rate temporarily 2 Elevating the extremity slightly above level 3 Applying cold and warm compresses frequently 4 Cleaning the site with alcohol by expressing the drainage

4 Cleaning the site with alcohol by expressing the drainage A client with redness, swelling, and warmth with purulent drainage at the insertion site may have an infection. The nurse should clean the site immediately with alcohol and express any drainage to minimize infection. Slowing the infusion is not recommended because it may lead to a systemic spread of the infection. Elevating the extremity may help in phlebitis, with thrombosis, or with ecchymosis and hematoma. Application of cold and warm compresses may reduce the pain in a client with thrombophlebitis.

A client presents to the emergency department with shortness of breath, bloody sputum, weight gain, generalized edema, and a blood pressure of 150/110. The nurse reviews the client's laboratory results and determines that the client has impaired renal function. Which diagnosis will the nurse most likely observe written in the client's electronic medical record? 1 Crohn's disease 2 Myasthenia gravis 3 Sjögren's syndrome 4 Goodpasture syndrome

4 Goodpasture syndrome Goodpasture syndrome is an autoimmune disorder that may lead kidney problems such as glomerulonephritis. A client with Goodpasture syndrome and subsequent glomerulonephritis may have shortness of breath, hemoptysis, generalized edema, hypertension, decreased urine output, weight gain, and tachycardia. Crohn's disease is an autoimmune disease that affects the gastrointestinal tract, producing diarrhea, low-grade fever, weight loss, and abdominal pain. Myasthenia gravis is a rare chronic autoimmune disease that leads to neuromuscular disease, producing progressive muscle weakness, diplopia, fatigue, and difficulty chewing. Sjögren's syndrome is associated with dry eyes and dry mucous membranes of the nose, mouth and vagina.

Which cytokine increases growth and maturation of myeloid stem cells? 1 Interleukin-2 2 Thrombopoietin 3 Granulocyte colony-stimulating factor 4 Granulocyte-macrophage colony-stimulating factor

4 Granulocyte-macrophage colony-stimulating factor Granulocyte-macrophage colony-stimulating factor is a cytokine that increases growth and maturation of myeloid stem cells. Interleukin-2 is a cytokine that increases growth and differentiation of T-lymphocytes. Thrombopoietin is a cytokine that increases growth and differentiation of platelets. Granulocyte colony-stimulating factor is a cytokine that increases numbers and maturity of neutrophils.

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. What does the nurse explain to the client regarding the diagnostic criterion for acquired immunodeficiency syndrome (AIDS)? 1 Contracts HIV-specific antibodies 2 Develops an acute retroviral syndrome 3 Is capable of transmitting the virus to others 4 Has a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%)

4 Has a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%) AIDS is diagnosed when an individual with human immunodeficiency virus (HIV) develops one of the following: a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%), wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flulike syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain) 1 to 3 weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.

A construction worker sustains a puncture from a rusty nail. It is unknown when the worker had the last immunization for tetanus, and the primary health care provider prescribes tetanus immune globulin. What protection does this type of immunization offer? 1 Lifelong passive immunity 2 Long-lasting active protection 3 Stimulation of antibody production 4 Immediate passive short-term immunity

4 Immediate passive short-term immunity Tetanus immune globulin contains ready-made antibodies and confers short-term passive immunity. Passive immunity lasts a short time, not throughout life. Immune globulins confer passive artificial immunity, not long-lasting active immunity. Immune globulins are antibodies; they do not stimulate the production of antibodies.

A client's laboratory report reveals an antigen-immunoglobulin (IgE) reaction. The nurse suspects the presence of allergic rhinitis. Which type of medication would treat this condition? 1 Antipruritic 2 Decongestant 3 Sympathomimetic 4 Mast cell stabilizing

4 Mast cell stabilizing An antigen-immunoglobulin (IgE) interaction may result in allergic rhinitis. Mast cell stabilizing drugs inhibit the release of histamines, leukotrienes, and other agents from the mast cell after antigen-IgE interactions. Antipruritic drugs are administered to protect the skin and provide relief from itching. Decongestant medications and sympathomimetics are used to treat anaphylactic reactions and act by stabilizing mast cells from further degranulation.

A client with mild diarrhea is diagnosed with a Clostridium difficile infection. Which is the first-line drug that would be used to treat this condition? 1 Rifaximin 2 Fidaxomicin 3 Vancomycin 4 Metronidazole

4 Metronidazole Metronidazole is the first line of treatment prescribed to clients with a Clostridium difficile infection. Rifaximin is used to treat traveler's diarrhea caused by Escherichia coli. Fidaxomicin is reserved for clients who are at risk for the relapse of or have recurrent Clostridium difficile infections. Vancomycin is preferred for serious Clostridium difficile infections.

A client's laboratory report shows severe neutropenia and thrombocytopenia. Which medication may have caused this condition? 1 Daclizumab 2 Cyclosporine 3 Methylprednisolone 4 Mycophenolate mofetil

4 Mycophenolate mofetil Mycophenolate mofetil is a cytotoxic drug that may cause neutropenia and thrombocytopenia. Daclizumab may cause hypersensitivity reaction and anaphylaxis. Cyclosporine may cause neurotoxicity, nephrotoxicity, and hypertension. Methylprednisolone may cause peptic ulcers, osteoporosis, and hyperglycemia.

Which parameter should the nurse consider while assessing the psychologic status of a client with acquired immune deficiency syndrome (AIDS)? 1 Sleep pattern 2 Severity of pain 3 Cognitive changes 4 Presence of anxiety

4 Presence of anxiety Presence of anxiety should be considered while assessing the psychologic status of a client with AIDS. Sleep patterns and severity of pain are related to the assessment of activity and rest, a physical status. Cognitive changes are related to the assessment of neurologic status.

A client reports hair loss, joint pain, and a facial rash. The nurse documents the presence of a butterfly rash on the face in the client's medical record. Which disorder does the nurse suspect? 1 Scleroderma 2 Angioedema 3 Rheumatoid arthritis 4 Systemic lupus erythematosus

4 Systemic lupus erythematosus Systemic lupus erythematosus is an autoimmune connective tissue disorder characterized by joint pain, alopecia, and rashes on the face. A characteristic butterfly rash is a major skin manifestation of systemic lupus erythematosus. Scleroderma is a chronic, inflammatory, autoimmune connective tissue disease characterized by hardening of the skin. Angioedema is the diffuse swelling of the eyes and lips. Rheumatoid arthritis is an inflammatory autoimmune disease process that affects primarily the synovial joints. The primary symptom of rheumatoid arthritis is painful swollen joints.

A client in the gynecology unit has edema and a sore throat. Upon assessment, a nurse finds that the client has a body temperature of 101° F and a blood pressure reading of 80/60 mmHg. Which condition would the nurse suspect? 1 Cervicitis 2 Vulvovaginitis 3 Genital herpes 4 Toxic shock syndrome (TSS)

4 Toxic shock syndrome (TSS) TSS is an infection caused by Staphylococcus aureus and Streptococcus pyogenes. Signs include high body temperature, rash, myalgia, sore throat, edema, and hypotension. Cervicitis is a complication caused by the Herpes simplex virus, Neisseria gonorrhoeae, and Chlamydia trachomatis. Vulvovaginitis is an inflammation of the lower genital tract due to a hormonal imbalance and changes in the vagina and vulva flora. Genital herpes is an acute, recurring, incurable viral disease that occurs due to the herpes simplex virus. Signs of this disease include a tingling sensation in the skin and the appearance of vesicles in the genital area.

The nurse is advising a client with acquired immunodeficiency syndrome (AIDS) to avoid the consumption of undercooked meat. Which infection can be prevented in the client by following this measure? 1 Tuberculosis 2 Cryptococcosis 3 Cryptosporidiosis 4 Toxoplasmosis encephalitis

4 Toxoplasmosis encephalitis Toxoplasmosis encephalitis is caused by Toxoplasma gondii, which may occur due to the ingestion of infected undercooked meat or by contact with contaminated cat feces. Tuberculosis is caused by Mycobacterium tuberculosis and is spread by airborne routes. Cryptococcosis is caused by Cryptococcus neoformans, which is a debilitating meningitis and can be a widely spread infection in AIDS. Cryptosporidiosis is an intestinal infection caused by Cryptosporidium organisms.

What is the most effective strategy for preventing the transmission of infection? 1 Wearing gloves and a gown 2 Applying face mask and a gown 3 Applying a face mask and gloves 4 Wearing gloves and hand hygiene

4 Wearing gloves and hand hygiene The combination of hand hygiene and wearing gloves is the most effective strategy for preventing infection transmission. A gown and face mask are considered personal protective equipment; however, they are not considered the most effective strategy to prevent the transmission of infection.

Place the pathophysiologic process of tuberculosis infection in its correct order. 1. Necrotic areas calcify or liquefy. 2. Caseation necrosis occurs in the center of the lesion. 3. Areas of caseation undergo resorption, degeneration, and fibrosis. 4. Granulomatous inflammation is created by tuberculosis bacillus in lungs. 5. Granulomatous inflammation becomes surrounded by collagen, fibroblasts, and lymphocytes.

Granulomatous inflammation is created by tuberculosis bacillus in lungs Granulomatous inflammation becomes surrounded by collagen, fibroblasts, and lymphocytes. Caseation necrosis occurs in the center of the lesion. Areas of caseation undergo resorption, degeneration, and fibrosis. Necrotic areas calcify or liquefy. Tuberculosis is a highly communicable disease caused by Mycobacterium tuberculosis. The process of infection in tuberculosis starts by formation of granulomatous inflammation by tuberculosis bacillus in lungs. This granulomatous inflammation then becomes surrounded by collagen, fibroblasts, and lymphocytes. The necrotic tissue then turns into a granular mass, called a caseation necrosis, which occurs in the center of the lesion. Then the areas of caseation undergo resorption, degeneration, and fibrosis. Finally, the necrotic areas undergo calcification or liquefaction.

A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teaching? 1 "I'll have to be careful not to cut my baby's nails short." 2 "I gave all of my baby's woolen blankets to my nephew." 3 "The baby can't have foods made with whole milk anymore." 4 "I'll need to buy a whole new wardrobe of cotton clothing for the baby."

1 "I'll have to be careful not to cut my baby's nails short." The baby's nails should be cut very short to minimize injury from scratching. Woolen and synthetic fabrics tend to further irritate the eczematous rash. Nonhuman milk can exacerbate eczema. Cotton clothing seems to be tolerated the best by infants with eczema.

Which parental occupations would require the nurse to closely monitor a toddler-age client for lead toxicity? Select all that apply. 1 Ceramics work 2 Radiator repair 3 Healthcare work 4 Bridge repair work 5 Brass foundry work

1 Ceramics work 2 Radiator repair 4 Bridge repair work 5 Brass foundry work Parental occupations that may place a toddler-age client at risk for lead toxicity include ceramics work, radiator repair, bridge repair work, and brass foundry work. Healthcare work does not lead to an increased risk for lead toxicity. Full list of sources of lead: lead based paint in deteriorating condition, lead solder, lead crystal, battery casings, lead fishing sinkers, lead curtain weights, lead bullets Some of these may contain lead: ceramic ware, water, pottery, pewter, dyes, industrial factories, vinyl mini-blinds, playground equipment, collectible toys, some imported toys or children's metal jewelry, artists paints, pool cue chalk Occupations and hobbies involving lead: battery and aircraft manufacturing, lead smelting, brass foundry work, radiator repair, construction, furniture refinishing, bridge repair work, paint contracting, mining, ceramics, stained glass, jewelry making

A team is sent to care for earthquake victims. Which basic professional certification is most desirable in the nurse to become the member of this team? 1 Certification in Emergency Care 2 Certification in Basic Life Support 3 Certification in Advanced Cardiac Life Support 4 Certification in Pediatric Advanced Life Support

1 Certification in Emergency Care A Certified Emergency Nurse possesses a certification in core emergency nursing knowledge, which is useful at an emergency disaster site. To perform cardiopulmonary resuscitation in clients with cardiac arrest, the nurse should possess a Certification in Basic Life Support. If the nurse has to perform any invasive airway management, pharmacology, or electrical therapies, an Advanced Cardiac Life Support certification is desired. If the nurse has to perform any neonatal and pediatric resuscitation, the nurse should possess a Pediatric Advanced Life Support certification.

Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? 1 Covering the nose 2 Protecting the eyes 3 Decontaminating the skin 4 Administering prophylactic antibiotics

1 Covering the nose Radiologic dispersal devices (RDDs), also known as "dirty bombs," consist of a mix of explosives and radioactive material (e.g., pellets).The priority nursing action to protect against the radioactive dust and smoke that can cause illness from an RDD is covering the nose and the mouth to decrease the risk for inhalation. Protecting the eyes is the priority if present during the explosion, but not necessarily when exposed to the subsequent dust and smoke. Decontaminating the skin is important but not the priority. Administering prophylactic antibiotics will not be effective to prevent illness related to an RDD.

A client with multiple injuries due to an accident is admitted into the emergency department. Which is the priority nursing intervention in this situation? 1 Establishing a patent airway in the client 2 Cleaning injuries with an antiseptic solution 3 Administering blood of appropriate blood type 4 Administering intravenous fluids and electrolytes

1 Establishing a patent airway in the client A client that could have a brain injury can progress rapidly to anoxic brain death without an adequate oxygen supply. The priority nursing intervention in a client in the emergency department is to establish a patent airway to ensure adequate oxygen supply. The nurse can clean the injuries with an antiseptic solution after establishing a patent airway. The nurse can administer blood and intravenous fluids and electrolytes to the client after establishing a patent airway.

A client who attempted suicide by slashing the wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implemented when the client arrives on the unit? Select all that apply. 1 Obtaining vital signs 2 Assessing for suicidal thoughts 3 Instituting continuous monitoring 4 Initiating a therapeutic relationship 5 Inspecting the bandages for bleeding 6 Tell the patient, "You have so much to live for. Your life isn't that bad."

1 Obtaining vital signs 2 Assessing for suicidal thoughts 3 Instituting continuous monitoring 4 Initiating a therapeutic relationship 5 Inspecting the bandages for bleeding Obtaining vital signs and inspecting the bandages for bleeding are interventions that must be performed in this situation; physiologic stability must be maintained. Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress. A therapeutic relationship must be developed so the client can trust the nurse to provide a safe environment and aid emotional recovery. Telling the patient that their life isn't that bad and that they have much to live for does not promote therapeutic communication and is not appropriate.

What is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs)? 1 Removing the catheter 2 Keeping the drainage bag off of the floor 3 Washing hands before and after assessing the catheter 4 Cleansing the urinary meatus with soap and water daily

1 Removing the catheter Research demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs). Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs.

How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction? 1 Replace the top linen and only the necessary bottom linen. 2 Lift the client from side to side while changing the bed linen. 3 Change the linen from top to bottom without lowering the head of the bed. 4 Slide the client onto a stretcher to remake the bed and then slide the client back to the bed.

1 Replace the top linen and only the necessary bottom linen. Until a client's condition has reached some degree of stability after a myocardial infarction, routine activities such as changing sheets are avoided so that the client's movements will be minimized and the cardiac workload reduced. Lifting the client from side to side while changing the bed linen is contraindicated because it increases oxygen consumption and cardiac workload; also, it may strain the health team members who are lifting the client. Changing all the linen causes unnecessary movement, which increases oxygen demand and makes the heart work harder. Any activity is counterproductive to rest; rest must take precedence so that the cardiac workload is reduced.

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's hierarchy of needs does this nursing action address? 1 Safety 2 Self-esteem 3 Physiological 4 Interpersonal

1 Safety A call bell system enables the client to communicate with the staff and supports safety and security, which is a second-level need. Self-esteem involves intrapersonal needs, the fourth level of basic needs. Physiological needs include air, food, and water and represent the first level of needs. Interpersonal needs involve love and belonging, which are third-level needs.

Which should the nurse include in the plan of care to decrease the risk for injury related to motor vehicle accidents for a school-age client? 1 Securing seat belts properly 2 Using a low heat setting when cooking 3 Recommending enrollment in swimming lessons 4 Making sure smoke detectors are installed in the home

1 Securing seat belts properly Properly securing seat belts is appropriate for the nurse to include in the plan of care to decrease the risk for injury related to motor vehicle accidents for school-age clients. Using a low heat setting when cooking decreases the risk for burn injury. Recommending enrollment in swimming lessons decreases the risk for drown injury. Making sure smoke detectors are installed in the home is appropriate to decrease the risk for burn injury.

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan? 1 "Wash used dishes in hot, soapy water." 2 "Let dishes soak in hot water for 24 hours before washing." 3 "You should boil the client's dishes for 30 minutes after use." 4 "Have the client eat from paper plates so they can be discarded."

1. "Wash used dishes in hot, soapy water." A person cannot contract human immunodeficiency virus (HIV) by eating from dishes previously used by an individual with AIDS; routine care is adequate. Washing used dishes in hot, soapy water is sufficient care for dishes used by the AIDS client. Dishes do not need to soak for 24 hours before being washed. The client's dishes do not need to be boiled for 30 minutes after use. Paper plates are fine to use but are not indicated to prevent the spread of AIDS.

What would help facilitate communication and coordination during a mass casualty event in a hospital using the hospital incident command system? Select all that apply. 1 Activate communication equipment 2 Establish a command center in a designated location 3 Provide key personnel with distinctive clothing identifying their role 4 Ensure key personnel are properly immunized and have a personal emergency plan 5 Distribute job action sheets identifying reporting relationships, tasks, and responsibilities

1. Activate communication equipment 2. Establish a command center in a designated location 3. Provide key personnel with distinctive clothing identifying their role 5.Distribute job action sheets identifying reporting relationships, tasks, and responsibilities To facilitate communication and coordination during a mass casualty event in a hospital using the hospital incidence command system, communication equipment needs to be activated. In addition, a command center needs to be created in a designated location. Key personnel need to be easily identified, which can be done by providing distinctive clothing which identifies their role. Jobs action sheets that identify reporting relationships, tasks, and responsibilities will also help facilitate communication and coordination at this time. Key personnel do not need to be immunized or have a personal emergency plan when handling a disaster within an organization.

A healthcare provider writes prescriptions for a young child with a tentative diagnosis of Wilms tumor. Which prescription should the nurse question? 1 Renal biopsy 2 Abdominal ultrasound 3 Computed tomography scan 4 Magnetic resonance imaging

1. Renal biopsy A renal biopsy is an invasive procedure. In the early stages, Wilms tumor is encapsulated. Any disruption of the tumor capsule may precipitate metastasis. Magnetic resonance imaging, computed tomography, and abdominal ultrasound are all helpful in making the diagnosis.

The nurse notes that a client is not adhering to prescribed antibiotic therapy. Which reason should the nurse document? 1 "I skipped some doses because I don't like to take pills." 2 "I left my pills in the bedroom and I forgot to take them with breakfast." 3 "I saw on television what the side effects are and decided to not take the pills." 4 "I had to choose between getting my prescription filled and paying the heating bill."

2 "I left my pills in the bedroom and I forgot to take them with breakfast." Nonadherence is accidental failure to take a medication. Noncompliance is deliberately failing to take a medication as might be done when skipping doses because of not liking to take pills, choosing to not take a medication because of information seen on television, and not being able to afford medication.

A registered nurse is evaluating the statements of a client after teaching the client measures to decrease the risk for antibiotic-resistant infections. Which statements made by the client indicate a need for more education? Select all that apply. 1 "I should wash my hands frequently." 2 "I should skip doses when I am completely well." 3 "I should avoid taking antibiotics to treat the common cold." 4 "I should save unfinished antibiotics for later emergency use." 5 "I should avoid taking antibiotics without asking the physician."

2 "I should skip doses when I am completely well." 4. "I should save unfinished antibiotics for later emergency use." Antibiotics should not be stopped even if the client is feeling better. Skipping doses may allow antibiotic-resistant bacteria to develop. Antibiotics should not be saved for later emergency use because old antibiotics can lose their effectiveness and in some cases can even be fatal if taken. Hand washing is necessary to prevent infections. Antibiotics are effective against bacterial infections but not viruses, which cause the common cold. Antibiotics should be taken only after asking the physician.

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? 1 A statement that the nursing staff was not at fault because the client initiated the accident 2 A listing of facts related to the incident as witnessed by the nurse 3 The name of the nurse who was responsible for implementing the restraints 4 The potential reasons why the restraints were not in place at the time of the fall

2 A listing of facts related to the incident as witnessed by the nurse The nurse filling out an incident or variance report needs to state only the objective facts surrounding the incident, no opinion or speculation. In an incident report, fault or blame is subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to include in an incident or variance report.

The nurse is caring for a hospitalized immunosuppressed client. Which interventions will be beneficial for safe and effective care of this client? Select all that apply. 1 Advise the client to eat raw fruits daily 2 Avoid using supplies from common areas 3 Encourage activity at an appropriate level 4 Use alcohol-based hand rubs before touching the client 5 Change gauze-containing wound dressing on alternative days

2 Avoid using supplies from common areas 3 Encourage activity at an appropriate level 4 Use alcohol-based hand rubs before touching the client Supplies from common areas should not be used for neutropenic clients to prevent contracting infection. Physical activity at a level appropriate for client's condition should be encouraged to promote health. Alcohol-based hand rubs should be used before touching the client to decrease the risk of infection. Immunosuppressed clients should avoid eating raw fruits and vegetables; they should eat a low-bacteria diet. Gauze-containing wound dressings should be changed on a daily basis, not on alternative days, to prevent infection.

Client, vital signs, respirations, heart rate A: 15 min prior / current, (14, 19), (70,80) B: 15 min prior / current, (17,10), (72,120) C: 15 min prior / current, (16,14), (80,85) D: 15 min prior / current, (13,15), (82, 85) The nurse is assessing the vital signs of four clients and comparing them with their previous vital signs measurements. Which client should be treated first to ensure safety? 1 A 2 B 3 C 4 D

2 B According to a three-tiered triage system, the client with unstable vital signs is categorized under the emergent tier level. Normal respiratory rates and heart rates are in the range of 12 to 20 breaths per minute and 70 to 100 beats per minute, respectively. Client B first has normal values for respiratory rate and heart rate and then shows markedly elevated values for respiratory and heart rates. Therefore client B should be treated first. Clients A, C, and D do not have any fluctuations from normal values for respiratory and heart rates. Therefore clients A, C, D can be treated after treating client B.

Which nursing interventions require a nurse to wear gloves? Select all that apply. 1 Giving a back rub 2 Cleaning a newborn immediately after delivery 3 Emptying a portable wound drainage system 4 Interviewing a client in the emergency department 5 Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

2 Cleaning a newborn immediately after delivery 3 Emptying a portable wound drainage system Personal protective equipment (PPE) should be used because the newborn is covered with amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub; there is no indication that the nurse is in contact with bodily secretions. PPE is not necessary when conducting an interview because it is unlikely that the nurse will come into contact with the client's body fluids. PPE is not necessary when obtaining the blood pressure of a client, even if the client is HIV positive.

What is the mechanism of action of penicillin? 1 Prevents reproduction of the pathogen 2 Inhibits cell wall synthesis of the pathogen 3 Inhibits nucleic acid synthesis of the pathogen 4 Injures the cytoplasmic membrane of the pathogen

2 Inhibits cell wall synthesis of the pathogen Penicillin is an antimicrobial medication that inhibits cell wall synthesis of the susceptible pathogen. Gentamicin is an antimicrobial medication that prevents the reproduction of the susceptible pathogen. Actinomycin is an antimicrobial medication that inhibits nucleic acid synthesis of the susceptible pathogen. Antifungal agents injure the cytoplasmic membrane of the susceptible pathogen.

A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs? 1 Level 1 2 Level 2 3 Level 3 4 Level 4

2 Level 2 A nurse who assists an older client in getting to the washroom is fulfilling the safety and security need, which is the second level of need according to Maslow's hierarchy of needs. The first level involves physiological needs such as air, water, and food. Belonging needs such as friendship, social relationships, and sexual love fall under the third level of need. The fourth level of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth and achievement.

Which should the nurse include information for at each health maintenance visit for the parents of a toddler-age client? 1 Iron 2 Plants 3 Aspirin 4 Corrosives

2 Plants Plants are the number one cause of accidental poisonings for the toddler-age client; therefore, the nurse should provide education related to this type of accidental poisoning at each health maintenance visit. Iron, aspirin, and corrosives also lead to accidental poisoning; however, these are not as common as plant poisoning.

A client is admitted in active labor at 39 weeks' gestation. During the initial examination the nurse identifies multiple red blisterlike lesions on the edges of the client's vaginal orifice. Once the nurse has spoken to the primary healthcare provider and received prescriptions, what is the priority nursing action? 1 Beginning the intravenous (IV) antibiotic 2 Preparing for a cesarean birth 3 Taking a smear of the lesions for testing 4 Documenting the need for double gloving

2 Preparing for a cesarean birth The lesions are probably a herpes infection, which can be fatal to the newborn if it is transmitted during a vaginal birth. Herpes is a viral infection that does not respond to antibiotics. A client in active labor will give birth vaginally, before the test results of the smear become available. Standard precautions should be used; double gloving is unnecessary.

Which is the priority topic when teaching the parents of a toddler-age client regarding the selection of toys? 1 Cost 2 Safety 3 Creativity 4 Appropriateness

2 Safety While all of these considerations are factors when choosing an age-appropriate toy for a toddler-age client, the priority is safety, especially in regards to size and sturdiness. Cost, creativity, and appropriateness are also factors; however, these are not the priority when using Maslow's Hierarchy of Needs to plan client care.

A school nurse is planning to teach the importance of hand washing to the children in first grade. What is the most effective approach for this age group? 1 Showing a video of the correct hand washing technique 2 Demonstrating hand washing and asking for return demonstrations 3 Involving them in a discussion about the importance of hand washing 4 Describing how germs cause illness and how hand washing prevents disease

2. Demonstrating hand washing and asking for return demonstrations Six-year-old children are still in the perceptual phase of cognitive development. They base judgments on what they see rather than on what they reason; reasoning begins around age 7. These children are at the developmental stage when they want to show off their accomplishments; just watching the technique without feedback is not sufficient at this age. These children are too young to understand the abstract concepts involved in a discussion of the cause and effect regarding pathogens or to understand why hand washing is so important in preventing illness.

The parents inform the nurse that their school-age child frequently plays in hazardous places. However, the parents find it difficult to restrain the child from engaging in such activities. Which instruction is a priority in this case? 1 "Always accompany the child everywhere." 2 "Avoid giving any sports equipment to the child." 3 "Ensure the child has eye, ear, or mouth protection." 4 "Avoid outdoor games and invite the child's friends to your home."

3 "Ensure the child has eye, ear, or mouth protection." School-age children have well-developed motor functions, so they engage in hazardous activities. Therefore it is important to ensure that the child has eye, ear, or mouth protection to prevent injuries and accidents. It may not be feasible to accompany the child everywhere. The child is not at risk for injury from sports equipment alone, but also from reckless physical activities like running or jumping. Avoiding outdoor games is restricting the child's developmental needs.

While assessing an older adult with decreased perception of touch, the nurse provides instructions to the client to reduce the risk associated with falling. Which statements made by the nurse are beneficial to the client? Select all that apply. 1 "Move slowly when changing positions." 2 "Hold on to handrails while ambulating." 3 "Look where your feet are placed while walking." 4 "Wear shoes that give good support while walking." 5 "If you are unable to change your position frequently request assistance."

3 "Look where your feet are placed while walking." 4 "Wear shoes that give good support while walking." 5 "If you are unable to change your position frequently request assistance." Decreased perception of touch is a physiological change of the nervous system associated with aging. The client may experience decreased sensory perception that may cause the client to fall. The client should be instructed to look carefully where feet are placed while walking to prevent falling. Good support from wearing shoes while walking may reduce the risk of falling in clients with decreased perception of touch. If the client is unable, the caretaker should change the position of the client frequently (every hour) while the client is in bed or in a chair. Physiological changes, such as altered balance and decreased coordination, may lead to a fall if the client is moving quickly. The client with this neurological change should move slowly when changing positions and hold on to handrails while walking to prevent falls.

What action describes artificial active immunity? 1 Antibodies are passed from one person to another 2 Antibodies against an antigen are made naturally in the body 3 Antibodies are made after an antigen is injected into the body 4 Antibodies are transferred into the body after being made in another body or animal

3 Antibodies are made after an antigen is injected into the body Artificial active immunity is the protection developed by vaccination or immunization, and the immune system responds by making antibodies. Natural passive immunity occurs when antibodies are passed from one person to another, such as in the case of a mother to the fetus. Natural active immunity occurs when the body responds naturally by making antibodies against an antigen. Passive immunity occurs when the antibodies against an antigen are transferred to a person's body after first being made in the body of another person or animal.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1 Place the client in a left side-lying position. 2 Apply oxygen via nonrebreather mask. 3 Apply a petroleum gauze dressing over the site. 4 Prepare to reinsert a new chest tube.

3 Apply a petroleum gauze dressing over the site. A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress. Preparing to reinsert a new chest tube is not a priority of the nurse at this moment.

A nurse is providing preoperative teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is what? 1 Viral 2 Fungal Correct 3 Bacterial 4 Rickettsial

3 Bacterial Haemophilus influenzae and Streptococcus pneumoniae, both bacteria, are the most frequent causes of otitis media. If an ear infection develops, the parents should contact their healthcare provider immediately so an antibiotic may be prescribed. Otitis media is not caused by viral, fungal, or rickettsial organisms.

Which nursing action helps reduce the development of healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA)? 1 Applying triple antibiotic ointment to puncture sites 2 Bathing clients every other day with soap and tepid water 3 Bathing clients with chlorhexidine gluconate (CHG) solution 4 Performing hand hygiene with soap and water after removing gloves

3 Bathing clients with chlorhexidine gluconate (CHG) solution Current evidence shows that bathing hospitalized clients with pre-moistened cloths or warm water containing chlorhexidine gluconate (CHG) solution can significantly reduce HA-MRSA infection by 23% to 32%. Topical antibiotic ointment, every other day bathing, and washing hands with soap and water after removing gloves are not identified as reducing HA-MRSA.

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? 1 Airborne precautions 2 Droplet precautions 3 Contact precautions 4 Protective environment

3 Contact precautions Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms (MDRO) such as methicillin-resistant Staphylococcus aureus (MRSA), stool infected with Clostridium difficile, draining wounds where secretions are not contained, or scabies. Airborne precautions are used for infected droplets smaller than 5 mcg, such as measles, chickenpox (varicella), or pulmonary tuberculosis (TB). Droplet precautions are used for droplets larger than 5 mcg and when within 3 feet (0.9 m) of the client, such as streptococcal pharyngitis, mumps, and influenza. Protective environment focuses on clients with a compromised immune system to protect them from incoming pathogens.

A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the primary healthcare provider. What should the nurse do to help prevent the client from developing a urinary tract infection? 1 Assess urine specific gravity. 2 Collect a weekly urine specimen. 3 Maintain the prescribed hydration. 4 Empty the drainage bag once a day.

3 Maintain the prescribed hydration. Promoting hydration maintains urine production that flushes the bladder, thereby preventing urinary stasis and possible infection. Although assessing urine specific gravity may help identify a urinary tract infection, it will not prevent it. Although collecting a weekly urine specimen for culture and sensitivity may help identify a urinary tract infection, it will not prevent it. The collection bag is emptied once every shift unless the bag is full and needs to be emptied sooner. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse take to decrease the risk of transmission to others? 1 Insert a urinary catheter. 2 Initiate droplet precautions. 3 Move the client to a private room. 4 Use a high-efficiency particulate air (HEPA) respirator during care.

3 Move the client to a private room. Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter as this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods.

Several nurses from Pennsylvania who are members of a disaster medical assistance team (DMAT) are being sent to South Carolina to provide healthcare to hurricane victims. What action is required prior to these nurses providing care? 1 Applying for licensure in South Carolina 2 Showing Pennsylvania state nursing license 3 None since the nurses are acting as federal employees 4 Calling the National Council for the State Boards of Nursing and request licensure

3 None since the nurses are acting as federal employees Because licensed healthcare providers such as nurses act as federal employees when they are deployed, their professional licenses are recognized and valid in all states. There is no need for the nurses to apply for licensure in South Carolina, show Pennsylvania license, or call the National Council for the State Board of Nursing to request licensure.

A nurse manager is evaluating the effectiveness of a disaster drill during which nurses were sent from their usual assignments to the emergency department. Which criterion should be used for the nurse manager to evaluate care during the disaster drill? 1 Number of fatalities 2 Cost of nurse overtime 3 Nurse-to-client ratio on units 4 Completion of critical pathways

3 Nurse-to-client ratio on units During a disaster, nursing coverage on all units should remain appropriate for client safety. Disaster nursing is concerned with providing care for clients in imminent danger and requires mobilization of people and resources from other areas. Number of fatalities is not the basis for evaluating the effectiveness of care; during a disaster, many clients may be dead on arrival. Cost is not the concern during a disaster. Completion of critical pathways is not the basis for evaluation of care during a disaster.

For which care activities should the nurse apply a mask, eye protection (goggles), or a face shield? Select all that apply. 1 Changing an infusion bag 2 Preparing an enteral feeding 3 Suctioning a nasotracheal tube 4 Irrigating an abdominal wound 5 Inserting an intravenous catheter

3 Suctioning a nasotracheal tube 4 Irrigating an abdominal wound The nurse should apply a mask, eye protection, or a face shield when conducting procedures and client-care activities that are likely to generate splashes or sprays of blood, body fluids, or secretions such as suctioning a nasotracheal tube or irrigating an abdominal wound. The nurse is not likely to be splashed with blood, body fluids, or secretions when changing an infusion bag, preparing an enteral feeding, or when inserting an intravenous catheter.

A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The healthcare provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation 3 Surgical asepsis 4 Medical asepsis

3 Surgical asepsis Catheter insertion requires the procedure to be performed under sterile technique. Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.

A girl comes to the physician's office for her 14-year-old check-up. What is the most important anticipatory guidance that can be offered to the client? 1 Abstinence 2 Healthy diet 3 Ways to prevent accidents 4 Correct handwashing technique

3 Ways to prevent accidents The biggest health risk for adolescents is accidents—they are the number-one cause of death in this age group—so anticipatory guidance during interactions with adolescents should be directed at accident prevention. Adolescents have a thought process that allows them to participate in risky behaviors because they feel as though nothing bad will ever happen to them. All adolescents are at risk for accidents, but not all 14-year-olds are sexually active. Although dietary issues and hygiene issues are important, they are not as important as accident prevention.

The nurse assists with a client's yearly physical examination. After the examination is completed, the client is diagnosed with tuberculosis. Which action best reflects appropriate epidemiological follow-up? 1 Obtaining a list of people the client has had contact with over the past year 2 Suggesting that the client notify acquaintances that the disease has developed 3 Requiring employees at the client's work site to have chest x-rays as soon as possible 4 Encouraging close family members, friends, and coworkers of the client to have a skin test

4 Encouraging close family members, friends, and coworkers of the client to have a skin test People exposed to the client need screening, and it is appropriate to start with a skin test; those with positive reactions should be tested further. Making a list of all the people the client has had contact with over the past year is not necessary and is impractical; only recent close contacts need to be identified. Only close friends and contacts need to be notified. Only employees in proximity to the client need be screened, and a chest x-ray film is not the best initial screening method.

A client has a tonic-clonic seizure. Which is the priority nursing intervention during the tonic-clonic stage of the seizure? 1 Go for additional help 2 Establish a patent airway 3 Turn the client on the side 4 Protect the client from injury

4 Protect the client from injury Protecting the client from injury, together with observation and documentation of the seizure activity, is the primary nursing care for a client with a tonic-clonic seizure. The client should not be left unattended. Establishing a patent airway is done after the seizure; the mouth should not be pried open to insert an airway during a seizure because injury may occur. Turning the client on the side will assist with establishing an airway after the seizure, but it is an unsafe action during a seizure.

A school-aged child is undergoing chemotherapy. How can the nurse best manage a common side effect of chemotherapy? 1 Restricting fluid intake 2 Instituting contact precautions 3 Keeping the hair closely cropped 4 Providing meticulous oral hygiene

4 Providing meticulous oral hygiene Children undergoing chemotherapy are prone to mucosal cell damage that can produce ulcers throughout the gastrointestinal tract; oral ulcers are a common side effect and can cause extreme discomfort. Increased fluid intake is encouraged to enhance the excretion of uric acid crystals. Chemotherapy acts as an immunosuppressant. Contact precautions protect the care provider; it is the child who needs to be protected. Keeping the hair short will not prevent it from falling out while the child is undergoing chemotherapy.

A client is admitted to an emergency unit after a factory explosion. The nurse is obtaining the client's family history and checking for a medical alert bracelet. Which safety consideration is the nurse following? 1 Patient identification 2 Injury prevention for staff 3 Injury prevention for clients 4 Risk for errors and adverse events

4 Risk for errors and adverse events Risk for errors and an adverse event is a safety consideration applied by nurses to identify any possible risks to a client's health. It involves obtaining the client's family history and checking the client for a medical alert bracelet. Patient identification involves providing an identification (ID) bracelet for each client and using two unique identifiers. Injury prevention for staff is a safety consideration that involves use of standard precautions at all times to prevent any violence involving clients. Injury prevention for clients is a safety consideration that involves keeping rails on the stretcher or placing it in a lower position.

A woman arrives at the women's health clinic complaining of frequency and burning pain when voiding. The diagnosis is a urinary tract infection. What is important for the nurse to encourage the client to do? 1 Void every 2 hours. 2 Record fluid intake and urinary output. 3 Pour warm water over the vulva after voiding. 4 Wash the hands thoroughly after urinating and defecating.

4 Wash the hands thoroughly after urinating and defecating. Hand washing is a medical aseptic technique and should limit the spread of microorganisms and help prevent future urinary tract infections if incorporated into the client's health practices. Voiding every 2 hours is unnecessary, but the client should be encouraged to void when the urge occurs. Intake and output need not be measured. Pouring warm water over the vulva after voiding is unnecessary for cystitis; it may be used as a part of perineal care for other problems.

An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. What should the nurse tell the girl that may help her wear the bracelet consistently? 1 Hide the bracelet under long-sleeved clothes. 2 Wear the bracelet when engaging in contact sports. 3 Ask her friends to wear bracelets that look like hers. 4 Select a bracelet similar to bracelets worn by her peers.

4. Select a bracelet similar to bracelets worn by her peers. Because adolescents have a developmental need to conform to their peers, the teenager should be able to select a bracelet of a design similar to that of those worn by her peers. Hiding the bracelet under long-sleeved clothes might be acceptable in cool weather, but not when it is warm and friends are wearing T-shirts. The bracelet should be worn at all times when the girl is not with responsible family members. Asking friends to wear a similar bracelet may be difficult, especially if the girl does not wish to tell her friends why she needs the bracelet.

A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care? 1 Place in a warm, dry environment. 2 Maintain standard and contact precautions. 3 Administer prescribed antibiotic immediately. 4 Allow parents and siblings to room in with the infant.

2. Maintain standard and contact precautions. RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mask or in a croup tent. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant. Antibiotics are not effective against RSV, and their use is contraindicated.

The client's laboratory report shows deposits of immunoglobulin G (IgG) along the basement membranes of the lungs. The primary healthcare provider interprets this finding as a sign of Goodpasture's syndrome. What would be the reason for this condition? 1 Goodpasture's syndrome develops rapidly after exposure to allergens. 2 Goodpasture's syndrome is caused by dilation and engorgement of the capillaries. 3 Goodpasture's syndrome occurs when circulating antibodies combine with tissue antigens. 4 Goodpasture's syndrome is caused by exposure of the skin to substances that combine with epidermal proteins.

3.

Which emergency response team is involved in emotional recovery of victims after a disaster? A American Red Cross B Disaster Medical Assistance Team C community emergency response team D Federal Emergency Management Agency

A. American Red Cross The American Red Cross has a critical incident stress management unit. This unit arranges group discussions to allow participants to share and validate their feelings and emotions about the experience. DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours and they are part of the National Disaster Medical System (NDMS) in the United States. A community emergency response team and the Federal Emergency Management Agency train citizens to understand their personal responsibility in preparing for a natural or man-made disaster.

The laboratory report of a client reveals the presence of 350 cells/mm3 (350 cells/uL) of CD4+ T-cell count. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

Stage 2 According to the CDC, human immunodeficiency disease is divided into four stages. A client with a CD4+ T-cell count between 200 and 499 cells/mm3 (499 cells/uL) is in the second stage of HIV disease. A client with a CD4+ T-cell count of greater than 500 cells/mm3 (500 cells/uL) is in the first stage of HIV disease. A client with a CD4+ T-cell count of less than 200 cells/mm3 (200 cells/uL) is in the third stage of HIV disease. The fourth stage of HIV disease indicates confirmed HIV infection with no information regarding CD4+ T-cell counts.

The nurse finds that some clients have extensive full-thickness body burns and severe head trauma after an apartment building fire. The nurse also finds that these clients require mechanical ventilator for survival. Which disaster triage tag does the nurse applies to this group of clients? A Red B Black C Green D Yellow

B Black Clients with extensive full-thickness body burns, severe head trauma, and high cervical spinal cord injury requiring mechanical ventilation are given black tags as they are expected to die. Clients with airway obstruction or shock are given red tags as they require immediate attention. Clients with open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours are given yellow tags. Green tags are issued to clients with minor injuries.

Which clients belong to class I according to the disaster triage tag system? A Clients who can wait a short time for treatment B Clients who are dead or expected to die C Clients who need emergency treatment D Clients who have no urgent need for treatment

C.Clients who need emergency treatment Emergent clients are identified with red tags and belong to class I according to the disaster triage tag system. Clients who can wait a short time for treatment are identified by yellow tags and belong to class II according to the disaster triage tag system. Clients who are expected to die or are dead are given a black tag and belong to class IV in the disaster triage tag system. Clients who have no urgency for treatment are issued green tags and belong to class III.

A client with a diagnosis of severe preeclampsia is admitted to the hospital from the emergency department. Which precaution should the nurse institute? 1 Padding the side rails on the bed 2 Placing the call button next to the client 3 Having oxygen and a facemask available 4 Assigning a nursing assistant to stay with the client

1. Padding the side rails on teh bed. Padded side rails help prevent injury during the clonic-tonic phase of a seizure. The client must be protected from injury if there is a seizure. Although some clients experience an aura before a seizure, there is not enough time to use a call button and wait for help. Oxygen is useless during a seizure when the client is not breathing or is thrashing about. Assigning a staff member to stay with the client in anticipation of a seizure is impractical and unproductive.

The mother of a preschooler reports to a nurse that her child has reverted back to bed wetting. Which questions asked by the nurse are appropriate? Select all that apply. 1 "Does your child have an illness?" 2 "Is there a new sibling in the family?" 3 "Did you recently move in to a new home?" 4 "Does your child regularly visit a house that was built before 1950?" 5 "Does your child live in a house built before 1978 with ongoing renovations?"

1 "Does your child have an illness?" 2 "Is there a new sibling in the family?" 3 "Did you recently move in to a new home?" Stress can cause preschoolers to revert to bed wetting. Sources of stress for preschoolers may include illness, the birth of a sibling, and relocation to a new home. Regular visits to a house that was built before 1950 or living in a house built before 1978 with ongoing renovations may result in lead poisoning.

The nurse is teaching the parents of a toddler-age client about food safety related to choking. Which parental statement indicates the need for further education? 1 "Hot dogs are safe and do not present a choking hazard for my child." 2 "Ice cream is safe and does not present a choking hazard for my child." 3 "Chicken nuggets are safe and do not present a choking hazard for my child." 4 "Mashed potatoes are safe and do not present a choking hazard for my child."

1 "Hot dogs are safe and do not present a choking hazard for my child." Large round foods, such as hot dogs, should be avoided until the toddler is able to chew effectively due to the risk for choking. Ice cream, chicken nuggets, and mashed potatoes are not identified as choking hazards for the toddler-age client.

Clients A: Severe respiratory distress B: Chest pain resulting from trauma C: Hip fracture in older client D: Cystitis The nurse is caring for the victims of a hurricane. Which client should be triaged first?

1 A Severe respiratory distress Client A with severe respiratory distress is triaged under emergency severity index 1 (ESI-1) and should be seen immediately because his or her condition is most severe. Client B with chest pain resulting from trauma is triaged under ESI-2 and is seen within 1 hour. Client C with a hip fracture could be delayed treatment because the condition is less severe and is prioritized as ESI-3. Client D with cystitis is triaged as ESI-4, and the client could receive delayed treatment.

Community members have received mailed notices asking them to come to different healthcare agencies within the community at the same time on the upcoming Saturday afternoon. What is the purpose of asking community members to perform this task? 1 Test the emergency preparedness plan 2 Determine if community members can read 3 Measure the effectiveness of mailed communication 4 Identify community members who do not work weekends

1 Test the emergency preparedness plan The Joint Commission mandates that hospitals have an emergency preparedness plan that is tested through drills. One of the drills or events must involve communitywide resources and an influx of actual or simulated clients to assess the ability of collaborative efforts and command structures. Asking community members to come to healthcare agencies in the community at the same time is testing the emergency preparedness plan through simulating a disastrous event. The mailed notice was not sent to determine if community members can read, measure the effectiveness of mailed communication, or to identify community members who do not work weekends.

A. Displaced or multiple fractures B. Skin rash C. Strains and sprains D Simple fracture The nurse is using a three tier triage system to treat four clients who sustained injuries after a bus accident. Which condition is triaged as urgent among these client conditions? 1 A 2 B 3 C 4 D

1. A Client A with displaced or multiple fractures does not have an immediately life-threatening condition, but needs immediate treatment when compared to other clients, so is considered urgent and triaged under as urgent. Client B with a skin rash, client C with strains and sprains, and client D with a simple fracture could wait several hours and are triaged as nonurgent.

The mother of a 5-year-old girl child reports to a nurse that her daughter has a genital discharge and recurrent urinary tract infections. What should the nurse suspect from the mother's statement? 1 The child may be a victim of sexual abuse. 2 The child may be a victim of physical abuse. 3 The child may be a victim of physical neglect. 4 The child may be a victim of emotional neglect.

1. The child may be a victim of sexual abuse. Genital discharge and recurrent urinary tract infections are signs of sexual abuse. Bruises, burns, fractures, or dislocation may indicate physical abuse. Malnutrition and poor hygiene may indicate physical neglect. Enuresis and sleep disorders may indicate emotional neglect.

A nurse is changing the dressing of a sixth-grader with severe burns. What basic principles of surgical asepsis must the nurse consider? Select all that apply. 1 A paper field must remain dry to be considered sterile. 2 Sterile items held below the waist are considered sterile. 3 A 1-inch (2.5 centimeter) border around a sterile field is considered contaminated. 4 Sterile objects in contact with clean objects are considered contaminated. 5 A fenestrated drape is not considered sterile.

1A paper field must remain dry to be considered sterile. 3A 1-inch (2.5 centimeter) border around a sterile field is considered contaminated. 4Sterile objects in contact with clean objects are considered contaminated. Once a sterile paper field becomes wet it allows microorganisms on the surface of the table to contaminate the field. A 1-inch (2.5 centimeter) border around the outer edge of a sterile field is considered contaminated because the edges touch the table. Once a sterile object comes into contact with any object that is not sterile, it is no longer considered sterile. Sterile objects below the waist are considered contaminated. A fenestrated drape may be considered sterile as long as it has not been contaminated.

An older resident in a nursing home who has a diagnosis of dementia hoards leftover food from the meal tray and other seemingly valueless articles and stuffs them into pockets "so the others won't steal them." What should the nurse plan to do? 1 Remove the resident's unsafe and soiled articles during the night. 2 Give the resident a small bag in which to place selected personal articles and food. 3 Explain to the resident why the nursing home's policy for cleanliness and safety must be followed. 4 Explain to the resident that the staff is required to keep harmful objects out of reach in the resident's closet.

2 Give the resident a small bag in which to place selected personal articles and food. Giving the resident a small bag in which to place selected personal articles and food allows the client to exercise the right to decide which articles to keep and helps ensure safety and cleanliness. Removing the resident's unsafe and soiled articles during the night deceives the client and will create mistrust toward the staff. Because of the client's decreased attention span and memory, explanations alone will not help ensure safety or meet this client's needs. Telling the resident that the staff is required to keep harmful objects out of reach in the resident's closet does not address the client's needs; no data indicate that the resident is hoarding harmful objects.

A 2-year-old child with previously diagnosed hemophilia is admitted to the pediatric unit for observation after a motor vehicle collision. The toddler has several bruises but no other apparent injuries. What is the nurse's specific concern regarding this child? 1 Risk for falls 2 Undetected injury 3 Deficient fluid volume 4 Development of infection

2 Undetected injury Although the child has no apparent injuries, internal bleeding may have occurred. The child should be monitored for internal bleeding in case there is an undetected injury. Although all 2-year-olds are at risk for falls, falls are not the greatest danger for this child at this time. Although all toddlers are at risk for fluid imbalances because of their larger percentage of body fluid to body mass, this is not a priority at this time. A child with hemophilia is at no greater risk for infection than any other child; the skin is intact, so this is not a priority.

Oxygen therapy is prescribed for a client being cared for in the coronary care unit. The nurse implements safety precautions. Which information should the nurse consider when planning care for this client? 1 Oxygen is flammable. 2 Oxygen supports combustion. 3 Oxygen has unstable properties. 4 Oxygen converts to an alternate form of matter.

2. Oxygen supports combustion. Oxygen is necessary for the production of fire. Oxygen does not burn; it supports combustion. Flammability, unstable properties, and conversion to an alternate form of matter are irrelevant regarding the need for safety precautions.

A hospitalized client is on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). Which statement by an unlicensed assistive personnel (UAP) (Canada: continuing care assistant, CCA) indicates a need for further teaching? 1 "I will put on gloves and a gown before entering the room." 2 "I will wash my hands before entering and leaving the room." 3 "I will remove the gown, then the gloves, before washing my hands." 4 "I will leave a thermometer, blood pressure cuff, and stethoscope in the room for use for this client only."

3 "I will remove the gown, then the gloves, before washing my hands."

What would the nurse describe as the uses of automated tracking systems with infrared and radiofrequency technology (RFT) in emergency departments? Select all that apply. 1 To identify clients 2 To categorize triage priority 3 To track client's triage priority upon arrival 4 To track interaction of clients with caregivers 5 To portray the overall census and acuity of clients

3 To track client's triage priority upon arrival 4 To track interaction of clients with caregivers 5 To portray the overall census and acuity of clients Emergency departments use automated tracking systems with infrared and RFT for disaster treatment. These systems track client's triage priority upon arrival, track interaction of clients with caregivers, and portray the overall census and acuity of clients. Identification of clients is done using a special bracelet with a disaster number. Categorizing triage priority is done using a disaster triage tag system.

The nurse is performing resuscitation interventions for airway, breathing, and circulation as part of a primary survey in a client. Which order of actions should the nurse follow for this client? 1. Use direct pressure for external bleeding. 2. Prepare for chest decompression if needed. 3. Assess breath sounds and respiratory effort. 4. Establish airway by positioning, suctioning, and oxygen as needed. 5. Maintain vascular access using a large-bore catheter.

3,1,4,5,2 The primary survey includes assessment of airway/cervical spine, breathing, circulation, disability, and exposure. First, the nurse should establish airway patency by positioning, suctioning, and providing oxygen as needed. Assess breath sounds and respiratory effort and provide chest decompression if needed in order to assess breathing. Maintain vascular access using a large-bore catheter and use direct pressure for any external bleeding.

Which action should the nurse take when caring for a client who is suspected as having the Ebola virus? 1 Consider cohorting the client 2 Wear a face mask and gown at all times 3 Follow standard and droplet precautions 4 Avoid contact with all body fluids and discharges

3. Follow standard and droplet precautions Because the Ebola virus is highly contagious and transmitted through all body fluids and discharges the nurse should avoid coming in contact with any fluids or discharges from the client. The client should be isolated in a private room and not cohorted. Personal protective equipment when caring for a client with the Ebola virus includes gown, gloves, mask, and goggles. Standard, droplet, and airborne precautions should be followed when caring for this client.

A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection. What is the rationale for the nurse's comment? 1 Poor personal hygiene is the cause. 2 Inadequate dietary intake is the cause. 3 The client's developmental level is the cause. 4 A procedure performed at the hospital is the cause.

4 A procedure performed at the hospital is the cause. An iatrogenic infection is one caused by healthcare providers or therapy. Poor personal hygiene, inadequate dietary intake, and the client's developmental level are not the causes of an iatrogenic infection.

A client who had a brain attack (cerebrovascular accident, CVA) has left-sided hemiparesis but is able to ambulate with assistance. When getting up from a lying position, the client reports feeling lightheaded and dizzy. The nurse explains that these clinical manifestations are a result of which condition? 1 Inflamed peripheral nerves 2 Loss of blood and blood volume 3 Demyelination of peripheral nerves 4 Blood pooling in the lower extremities

4 Blood pooling in the lower extremities Dilation of blood vessels causes dependent pooling when the client moves to an upright position, resulting in orthostatic (postural) hypotension. The client can limit feelings of lightheadedness and dizziness by moving gradually when changing positions. Inflammation of peripheral nerves is not the cause of the clinical manifestations. Inflamed peripheral nerves can cause neuropathies. Loss of blood and blood volume causes hypovolemia, leading to shock. Demyelination of peripheral nerves leads to multiple sclerosis.

A nurse is teaching breast-feeding to a newly delivered client. Which statement by the client indicates the need for further instruction? 1 "I'll try to empty my breasts at each feeding." 2 "I'll alternate between breasts to start feedings." 3 "I need to wash my breasts with soapy water before I breast-feed." 4 "I need to stroke my baby's cheek gently when I'm ready to breast-feed."

3. "I need to wash my breasts with soapy water before I breast-feed." Soap irritates, cracks, and dries breasts and nipples, making it painful for the mother when the baby sucks; it also increases the risk for mastitis. The client should empty the breasts at each feeding to keep milk flowing. Alternating between breasts to start feedings is a permissible and often-used technique of breast-feeding. Gently stroking the baby's cheek elicits the rooting reflex; the infant's head turns toward and touches the mother's breast.

A nurse is preparing a teaching plan for a client with syphilis. In which stage is syphilis not considered contagious? 1 Tertiary stage 2 Primary stage 3 Secondary stage 4 Incubation stage

1 Tertiary stage The tertiary stage is noncontagious; tertiary lesions contain only small numbers of treponemes. The primary stage lasts 8 to 12 weeks; the chancre is teeming with spirochetes, and the individual is contagious. The duration of the secondary stage is variable (about 5 years); skin and mucosal lesions contain spirochetes, and the individual is highly contagious. The incubation stage lasts 2 to 6 weeks; spirochetes proliferate at the entry site, and the individual is contagious.

A woman in active labor arrives at the birthing unit. She tells the nurse that she was told that she had a chlamydial infection the last time she visited the clinic; however, she stopped taking the antibiotic after 3 days because she "felt better." In light of this history what would the nurse anticipate as part of the plan of care? 1 Administration of antibiotics before delivery 2 Oxytocin infusion to augment labor 3 Epidural anesthesia to relieve difficult labor discomfort 4 Magnesium sulfate infusion to prevent a precipitous birth

1 Administration of antibiotics before delivery A maternal chlamydia infection is transmitted to the newborn during passage through the birth canal; therefore administration of antibiotics before delivery is necessary. If birth is imminent, the safest method of delivery is cesarean birth. There is no reason to accelerate labor. Time is needed to prepare for a cesarean birth. A difficult labor is not related to a maternal chlamydial infection. A precipitous birth is not related to a maternal chlamydial infection.

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next? 1 Bending and then straightening their knees 2 Bending at the waist and then straightening the back 3 Placing one foot in front of the other and then leaning back 4 Placing pressure against the client's axillae and then raising their arms

1 Bending and then straightening their knees The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs, the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomic structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client? 1 Use standard precautions. 2 Employ airborne precautions. 3 Plan interventions to limit direct contact. 4 Discourage long visits from family members.

1 Use standard precautions. The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact and discouraging long visits from family members will unnecessarily isolate the client.

Which suggestion of the nurse would help the client prevent respiratory problems? 1 "You should start painting your house." 2 "You should engage in heavy physical activity." 3 "You should wear a mask while working in certain industries." 4 "You should move from a rural to an urban area."

3 "You should wear a mask while working in certain industries." Wearing a mask can protect the client from any harmful dust that may lead to respiratory problems. Paints may contain harmful chemicals; avoiding painting may be helpful in preventing respiratory problems. Clients performing heavy physical activities are at a higher risk of suffering from respiratory problems. Urban areas have more air pollution than rural areas.

Which personnel should the nurse state are responsible for deciding the number, acuity, and resources needed for clients during a disaster? 1 Triage officer 2 Community relations officer 3 Medical command physician 4 Hospital incident commander

3 Medical command physician Medical command physicians have the authority to decide the number, acuity, and resources needed for clients during a disaster. Triage officers are the physicians or nurses who are responsible for evaluating the clients rapidly and determining the priority of treatment. The community relations officer serves as a liaison between the healthcare facility and the media. Hospital incident commanders act as leaders and are responsible for implementing the emergency plan.

Which statement of the nurse is true regarding disasters? 1 "Multi-casualty and mass casualty disaster events are same." 2 "An internal disaster creates a need for evacuation or relocation." 3 "External disasters, rather than internal disasters, result in death." 4 "Multi-casualty events require the collaboration of multiple agencies."

2 "An internal disaster creates a need for evacuation or relocation." An internal disaster is an event that occurs inside a healthcare facility and endangers the safety of staff or clients. It creates a need for evacuation or relocation. Multi-casualty and mass casualty disaster events are not the same. Both external and internal disasters may result in deaths. Multi-casualty events are managed by a hospital using local resources.

A father calls the clinic because he wants information about how to care for his child's severe diaper rash. The nurse asks the father what he has been doing so far and determines that the father needs further teaching when he says what? 1 "I expose the buttocks to the air." 2 "I direct a heat lamp at the buttocks." 3 "I don't use soap to clean the diaper area." 4 "I apply a medicated ointment to the diaper area."

2 "I direct a heat lamp at the buttocks." Heat lamps are not used because of the potential for burns. Exposing the diaper area will promote drying and healing. Soap may irritate excoriated skin. Ointment protects the buttocks from the irritating contents of stool.

What causes medications used to treat AIDS to become ineffective? 1 Taking the medications 90% of the time 2 Missing doses of the prescribed medications 3 Taking medications from different classifications 4 Developing immune reconstitution inflammatory syndrome (IRIS)

2 Missing doses of the prescribed medications The most important reason for the development of drug resistance in the treatment of AIDS is missing doses of drugs. When doses are missed, the blood drug concentrations become lower than what is needed to inhibit viral replication. The virus replicates and produces new particles that are resistant to the drugs. Taking the medications 90% of the time prevents medications from becoming ineffective. Taking medications from different classes prevents the drugs from becoming ineffective. Immune reconstitution inflammatory syndrome (IRIS) occurs when T-cells rebound with medication therapy and become aware of opportunistic infections.

After a fire in the hospital, a client is found to have dyspnea and gasping breathing. The client also has neck trauma and is unable to speak. Which nursing interventions are most appropriate? Select all that apply. 1 Placing a nasogastric tube 2 Performing jaw-thrust maneuver 3 Prepare assist in performing endotracheal intubation 4 Monitoring respiratory rate and oxygen saturation 5 Monitoring the heart rate and rhythm continuously

2. Performing jaw-thrust maneuver 3. Prepare assist in performing endotracheal intubation The jaw-thrust maneuver may help in opening a client's airway. Endotracheal intubation may assist the client in obtaining proper breathing. A nasogastric tube should not be placed in the client with neck trauma because it could enter the brain. Monitoring the respiratory rate and oxygen saturation is required after performing the jaw-thrust maneuver and endotracheal intubation may be required in this situation. Heart rate and rhythm should be monitored continuously in an emergency condition to assess the condition after the client has stabilized breathing.

A registered nurse is teaching a student nurse about the functions and utilization of trauma centers. Which statement of the student nurse indicates effective learning? 1 "Clients requiring advanced life support should be sent to a level II trauma center." 2 "Most injured clients requiring urgent treatment should be sent to a level I trauma center." 3 "Clients requiring stabilization with major injuries should be sent to a level III trauma center." 4 "Clients requiring full continuum of trauma services should be sent to a level IV trauma center."

3 "Clients requiring stabilization with major injuries should be sent to a level III trauma center." A trauma center is a specialty care facility that provides competent and timely trauma services to clients, depending on its designated level of capability. A level III trauma center is usually located in community hospitals. It stabilizes clients with major injuries. A level II trauma center is also located in community hospitals and provides care to most injured clients. A level I trauma center is in a large teaching hospital in a densely populated area. It provides a full continuum of trauma services for all clients. A level IV trauma center is located in rural and remote areas. It provides basic trauma client stabilization and advanced life support within its resource capabilities.

The disaster management team is evaluating the damage that can happen due to a disaster. They also attempt to limit the influence of the disaster on the health community's function. Which phases of disaster management would the nurse state represents these actions? Select all that apply. 1 Recovery 2 Response 3 Mitigation 4 Evaluation 5 Preparedness

3 Mitigation 5 Preparedness The attempt to minimize the influence of the disaster on the human health and community function refers to the mitigation phase of disaster management. Identification of potential risks and evaluating the potential damage before the disaster event indicates the first phase of disaster management, which is preparedness. Recovery is the process of assisting affected clients in regaining a normal level of functioning following a disaster. Response is a process of combating a disaster event and providing assistance to clients affected by the disaster. Evaluation is the process of assessing the response effort to prepare for the future.

Which color should the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station? 1 Red 2 Black 3 Green 4 Yellow

3. Green An emergency triage system uses colored tags to designate both the seriousness of the injury and the likelihood of survival. Green would be used for minor injuries such as the victim who is able to ambulate independently. Red indicates life-threatening injuries requiring immediate attention. Black indicates that the victim is expected to die. Yellow indicates urgent but not life-threatening injuries.

What is a manifestation of tertiary syphilis? 1 Chancre 2 Alopecia 3 Gummas 4 Condylomata lata

3. Gummas Gummas which are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.

While performing a secondary emergency assessment survey, the nurse uses the mnemonic AMPLE to determine the client's condition after a natural disaster. Which type of assessment is performed in this scenario? 1 Give comfort measures 2 Inspect posterior surfaces 3 Facilitate family presence 4 History and head-to-toe assessment

4 History and head-to-toe assessment History and head-to-toe assessment involves use of the mnemonic AMPLE that includes Allergies, Medication history, Past health history, Last meal, and Events preceding illness/injury to determine the history of the client. Giving comfort measures is an emergency assessment that is used to assess, treat, and reassess for pain and anxiety. Posterior surfaces are inspected to determine bleeding, bruises, and lacerations. Facilitating family presence includes determining the caregiver's desire to be present during invasive procedures.

A nurse counsels the mother of an 8-month-old infant to be sure that the floors are free of small objects when her child is crawling. What is the rationale for this instruction? 1 Sharp objects can injure the fragile skin of an infant. 2 Eight-month-old infants hide small objects, making them difficult to locate. 3 Floors may cause infections in infants when they pick up and mouth objects. 4 Eight-month-old infants pick up small objects and place them in their mouths.

4. Eight-month-old infants pick up small objects and place them in their mouths. Eight-month-old infants have the ability to use their fingers and thumbs in opposition (pincer grasp); this enables them to pick up small objects and put them in their mouths, where they may be aspirated. Although an infant's skin is fragile, damage to the skin is not the major concern. The danger is not that the items may be hidden but that they may be put into the mouth. The floor is not an infectious health hazard if it is clean.

Which is the first antibody formed after exposure to an antigen? 1 IgA 2 IgE 3 IgG 4 IgM

4. IgM IgM (immunoglobulin M) is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.

A primary healthcare provider prescribes an antihypertensive medication. Which over-the-counter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive? 1 Omeprazole 2 Acetaminophen 3 Docusate sodium 4 Pseudoephedrine

4. Pseudoephedrine Pseudoephedrine has a pressor effect that may counteract antihypertensive medications, causing an increase in blood pressure. Omeprazole does not interact with antihypertensives. However, it can increase the action of phenytoin, digoxin, clopidogrel, and cyclosporine. Acetaminophen does not have to be avoided when receiving an antihypertensive. Docusate sodium does not have to be avoided when receiving an antihypertensive.

A group of 100 bomb blast victims were admitted to the hospital within an hour of the event. How should the hospital management use this information? A Arrange surgery facilities for 50 victims. B Arrange beds for at least 20 more victims. C Prepare staff to treat 100 more clients. D Shift the 100 existing clients to other hospitals.

C Prepare staff to treat 100 more clients. Hospital management can anticipate the total number of victims of a disaster by doubling the number of victims who arrive in the first hour. Therefore they should prepare staff to treat 100 additional clients. Generally half of the victims require surgery within 8 hours; therefore the hospital management should arrange surgery facilities for at least 100 victims. Generally, 30% of total victims require admission to the hospital; therefore the hospital staff should arrange extra beds for 60 victims(30/200 × 100= 60). Shifting the 100 existing clients is not appropriate, as other hospitals may also be taking in of victims.

The nurse is planning a protocol for providing care to earthquake victims found with severe injuries. Which order of care should the nurse include in the protocol? 1. To assess the breath sounds 2. To infuse intravenous fluids 3. To maintain the cervical spine alignment 4. To stop bleeding by applying external pressure

To maintain the cervical spine alignment To assess the breath sounds To stop bleeding by applying external pressure To infuse intravenous fluids According to priorities of the primary survey in emergency care, the nurse should first stabilize the cervical spine to reduce the risk of spinal injury. Secondly, the nurse should assess the breath sounds by auscultation to evaluate the chest expansion or any evidence of chest wall trauma. After ensuring effective ventilation, the third step is to apply direct pressure in order to stop external bleeding. Lastly, restore circulation by providing intravenous vascular access with fluids and blood as needed.