Adult Health exam 2
After teaching a client who has a stage 2 pressure injury, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching?
Chicken breast, broccoli, baked potato, ice water
A client with HIV-II is hospitalized for unrelated condition and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?
Consult with the pharmacy about drug interactions
A client is hospitalized on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?
Consult with the primary health care provider about obtaining stool cultures.
A client has been hospitalized with an opportunistic infection secondary to HIV-III. The client's partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best?
Contact the hospital social worker to assist the client with advanced directives
A 78 year old male with a past medical history of atrial fibrillation is admitted with a chronic leg would. Warfarin sodium sotalol. Negative pressure wound therapy to leg wound. Based on this information which action would the nurse take first?
Contact the primary health care provider to discuss the treatment
The nurse caring for clients admitted for infectious disease understands what information about emerging global diseases bioterrorism?
Many infections are or could be spread by international travel.
A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound?
Multi-fiber super absorbent dressing
The nurse understands that which type of immunity is the longest acting?
Natural active
A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority?
Never stop prednisone abruptly.
The nurse is caring for a client diagnosed with HIV-II. the clients CD4 cell count is 399 mm. What action by the nurse is best?
counsel the client on safer sex practices/ abstinence
A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?
"Antihistamines do not help poison ivy"
A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client's teaching?
"Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)."
A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond?
"A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."
A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information?
"If you leave work wearing your scrubs, go directly home and wash them right away"
An assistive personnel asks why brushing client's teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?
"It mechanically removes biofilm on teeth"
A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications?
"Maintain tight glycemic control and prevent hyperglycemia."
A nurse teaches a client with diabetes mellitus about sick-day management. Which statement would the nurse include in this client's teaching?
"Monitor your blood glucose levels at least every 4 hours while sick"
A client contacts the clinic to report a life long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate?
"Please make an appointment to be seen here as soon as possible"
When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How would the nurse respond?
"Tell me what it is about the injection that are concerning you"
After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?
"The lower abdomen is the best location because it is closest to the pancreas."
A new nurse reads a client has a wound "healing by second intention" and asks what that means. Which description by the charge nurse is most accurate?
"The wound is an open cavity that will fill in with granulation tissue"
A client with HIV-III asks the nurse why gabapentin is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best?
"This drug helps treat the pain from nerve irritation"
A client has been newly diagnosed with systemic lupus erthematosus and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material?
"Baby powder is good for the constant sweating"
The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type 2. Which statement will the nurse include in the teaching?
"Be sure to take the drug with each meal"
After teaching a young adult aclibenitrwbh.ocisonemwl/ytdeiasgntosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?
"Diabetes can cause blindness, so I should see the ophthalmologist yearly."
A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this client's teaching to prevent bloodborne infections?
"Do not share your monitoring equipment."
The nurse is planning teaching for a client who is starting exenatide extended release (ER) for diabetes mellitus type 2. Which statement will the nurse include in the teaching?
"Give your drug injection the same day every week."
A nurse cares for a patient who is prescribed pioglitazone. After 6 months of therapy, the client reports that he has a new onset of ankle edema. What assessment question would the nurse take?
"Have you gained unexpected weight this week?"
A nurse has educated a client on an epinephrine auto injector. What statement by the client indicates additional instruction is needed?
"I don't need to go to the hospital after nursing it"
A nurse is teaching a client who has itchy, raised red patches covered with a slivery white scale how to care for this disorder. What statement by the client shows a need for further information?
"I have to make sure I keep my lesions covered so I do not spread this to others"
A nurse is assessing a client who has a recent diagnosis of melanoma for underling of treatment choices. What statement by the client indicates good understanding of the information?
"I may need lymph node resection during Mohs surgery"
After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
"I should decrease my intake of protein and eliminate carbohydrates from my diet"
After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
"I should look into swimming or water aerobics to get my exercise."
A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information?
"I will be carful to keep my nails filed smoothly"
After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy?
"I will take this medicine immediately before I eat."
After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?
"If I develop an infection, I should stop taking my corticosteroid."
A nurse has presented an educational program to a community group on Lyme disease. What statement by a participant indicates the need to review the material?
"If Lyme disease is not treated successfully, it is usually fatal"
A nurse is teaching a client and family about self care at home for the client's wound infected with methicillin resistant staphylococcus aureus. What statement by the client indicates a need to review the information?
"If the dressing is dry, I canst or sleep anywhere in the house"
A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent injury?
"Use a bath thermometer to test the water temperature."
A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs?
"Walk at a moderate pace for 1 mile daily."
A nurse assesses a young female client who is prescribed tazarotene. Which question should the nurse ask prior to starting this therapy?
"Which method of contraception are you using"
The older client's adult child questions the nurse as to why the client is at higher risk for infection when the client's white blood cell count is within the normal range. What response by the nurse is best?
"White blood cells are less active in older people so they are not as efficient"
A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?" How would the nurse respond?
"Your brain needs a constant supply of glucose because it cannot store it."
A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How would the nurse respond?
"Your risk of diabetes is higher than the general population, but it may not occur."
The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 minutes of NPH insulin at 7:00 am. At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin?
4:00 p.m.(1600)
A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes mellitus type 2. Which A1C value would the nurse expect?
7.4%
A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk?
A 58-year-old American Indian
A nurse assesses clients on a medical-surgical unit. Which client is a greatest risk for a pressure injury development?
A 65 year old with hemiparesis and incontinence
The nurse is assessing a client for risk of developing metabolic syndrome. Which risk factor is associated with this health condition?
Abdominal obesity
A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's signs and symptoms have not changed. What action would the nurse take next?
Administer another half-cup (120 mL) of orange juice
A client is to receive a fecal microbiota translation tomorrow. What action by the nurse is best?
Administer bowel cleansing as prescribed.
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?
Administration of intravenous insulin
A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6 degrees f. What response by the nurse is best?
Asses the client for more specific signs
A client with HIV-II has had a sudden decline in status with a large increase in viral load. What action would the nurse take first?
Assess the client for adherence to the drug regimen
A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What intervention by the nurse is best?
Assess the client for support systems
A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best?
Assess the client's airway
A nurse is talking with a client about a negative enzyme linked immunosorbent assay test for HIV. The test is negative and the client states "Whew! I was really worried about that result" What action by the nurse is most important?
Assess the client's sexual activity and patterns
A nurse is caring for a client who has a non healing pressure injury on the right ankle. Which action would the nurse take first?
Assess the right leg for pulses, skin color, and temperature
A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?
Auditing staff members hand hygiene practices
A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection?
Boggy feel to granulation tissue
A nurse learning about antibody mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?
Bone marrow
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?
Correctly identifying the client prior to a blood transfusion
A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as show: What action by the nurse takes is most appropriate?
Ensure a patient airway while calling in the rapid response team
A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?
Ensure that the radiology department is aware of the Isolation Precautions
The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time?
Establish intravenous access to provide fluids
A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care?
Everything between the entry and exit wounds can be damaged
A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first?
Examine the client's feet for signs of injury
A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dl Postprandial blood glucose: 200 mg/dl Hemoglobin A1c level 5.5% How would the nurse interpret these laboratory findings?
Good control of blood glucose
A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem?
Has a weight gain of 2 lb
The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dl a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dl. What diabetic complication does the nurse suspect?
Hyperglycemic-hyperosmolar state (HHS)
A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: BP: 90/62 pulse: 120 beats/min RR: 28 breaths/min Urine output: 20 mL/hr K: 2.6 Potassim chloride 40 mEq/L IV bolus STAT increase IV fluid to 100 mL/hr
Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription.
The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition?
Increased rate and depth of respiration
A client with HIV-III is admitted to the hospital with toxoplasma gondii infection. Which action by the nurse is most appropriate?
Initiate protective precautions
A nurse assess a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. What action would the nurse take?
Instruct the client to rotate sites for insulin injection
A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first?
Irregular mole with multiple colors on the leg
A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shift to the left" on the white blood cell count. What action by the nurse is most important?
Notify the primary health care provider and request antibiotics
A client is admitted with possible sepsis. Which action will the nurse perform first?
Obtain specified cultures
A nurse is observing an assistive personnel perform hygiene and provides comfort measures to a client with an infection. What action by the AP requires intervention by the nurse?
Ordering an oscillating fan for the client
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from urine. What action by the nurse is most appropriate?
Prepare to administer vancomycin
A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the nurse to decreased kidney function in this client?
Presence of protein in urine
A nurse develops a dietary plan for a client with diabetes mellitus and new-onset mircoalbuminuria. Which component of the client's diet would the nurse decrease?
Proteins
The nurse learns that the most important function of inflammation and immunity is which purpose?
Providing maximum protection against infection
A client has a leg wound is in stage II of the inflammatory response. For what sign or symptom does the nurse assess?
Purulent drainage
A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence based knowledge?
Raises the head of the bed no more than 45 degrees
A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers an don the wrists. What action would the nurse take?
Request a prescription for permethrin
A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately?
Serum potassium level of 2.5 mEq/L
A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best?
Show the family how to avoid spreading the disease
The nurse learning about infection discovers that which factor is the best and most important barrier to infection?
Skin and mucous membranes
A nurse assessing clients with pressure injuries. Which wound description is correctly matched to its description?
Suspected deep tissue injury: nonblanchable deep purple or maroon
A client with HIV-III is hospitalized and has weeping Kaposi and sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important for the nurse's safety?
adhering to standard precautions
A primary health care provider notifies the nurse that a client has "bandemia" What action does the nurse anticipate?
administer antibiotics
The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest?
anal intercourse
A client with HIV-III has been hospitalized with suspected cryptoporidiosis. What physical assessment would be the most important with this condition?
assessing mucous membranes
A clinic nurse is working with an older client. What action is most important for preventing infections in this client?
assessing vaccination records for booster shot needs
A nurse is caring for a client with HIV-III who was admitted with HAND. What sign or storm would be most important for the nurse to report to the primary health care provider?
change in pupil size
The nurse is providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?
consistent use of standard precautions
An HIV-negative client who has an HIV positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug?
does not reduce the need for safe sex practices
A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client?
pH 7.28 HCO3 18 mEq/L PCO2 28 mm Hg PO2 98 mm Hg
A client is hospitalized with pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?
pace activities, allowing for adequate rest
A client with known HIV-II is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4 cell count of 180 and a negative tuberculosis skin test 4 days ago. What action would the nurse take first?
place the client under airborne precautions
The nurse working with clients who have autoimmune diseases understands that what component of cell mediated immunity is the problem?
regulator T cells
A 66 year old male with a health history of a cerebral vascular accident and left side paralysis. WBC: 8000 Prealbumin 15.2 Albumin 4.2 Lymphocyte count: 2000 sacral ulcer 4x2x1.5 cm Based on this information which action would the nurse take?
request a dietary consult
A nurse assesses a client who has psoriasis. Which action would the nurse take first?
shake the clients hand and introduce self
What does the nurse learn about the function of colony-stimulating factor?
triggers the bone marrow to shorten the time needed to produce mature WBC
