AH1 Final Exam 2022
buck's traction
(weights) knee immobility:widely used in the lower limb for femoral fractures, lower backache, acetabular and hip fractures.
urse is reviewing a medical record of a client with a peptic ulcer. Which f the following findings should the nurse recognize as a risk factor for this condition?
- History of NSAID use
A nurse on a tele unit is caring for a client who has Crohn's disease and a calcium level of 8mg. Which of the following changes on the client ECG will the nurse expect to see? SATA
- prolonged ST segment -Prolonged QT interval
Chron's disease
A chronic inflammatory bowel disease that affects the lining of the digestive tract.
The nurse is planning the care of a client with sickle cell disease who has been admitted for the treatment of an acute Vaso occlusive crisis. What nursing diagnosis should the nurse prioritize in the clients plan of care?
Ineffective thermoregulation related to hypothalamic dysfunction
A client has been newly diagnosed with a wound infection; he questions the nurse how to immune system functions. The nurse discuss that the immune system is activated after the failure of which body defense?
Integumentary system
A nurse is caring for a client that PCP suspects may have pernicious anemia. The nurse should expect PCP to prescribe which of the following diagnostic tests?
Intrinsic factor blocking antibodies
Neutropenic precautions
Isolation procedures to protect an immunocompromised patient from infections
ORIF
Open Reduction and Internal Fixation (orthopedic surgery)
Thrombocytopenia
a condition in which there is an abnormally small number of platelets circulating in the blood
sickle cell anemia
a genetic disorder that causes abnormal hemoglobin, resulting in some red blood cells assuming an abnormal sickle shape
A nurse is creating a structure plan for a client with thrombocytopenia. Which of the following instructions should the nurse include? SATA
a. Lubricate the lips with water-soluble ointment. b. Brush teeth with a soft toothbrush. c. Blow nose gently.
An 89 year old client is admitted wit a diagnosis of acute pulmonary edema and complains of fatigue and dyspnea. The client has a history of anemia, HTN, cardiomegaly and osteoporosis. Cardiac catheterization reveals injection fraction of 35%. Based on this information which nursing diagnosis is the most appropriate?
altered peripheral tissue perfusion
A client has been diagnosed with ulcerative colitis and the nurse is preparing for a discharge client education. What should be included in the client education plan regarding diet?
avoid food that are high in fat residue
The medical nurse is aware that a client with sickle cell anemia benefits from understanding what situation can precipitate sickle cell crisis. When teaching a client with sickle cell anemia about the strategies to prevent crisis what measures should the nurse recommend?
avoiding cold temperatures and ensuring sufficient hydration
wound evisceration
internal tissues and organs protruding from open wound
wound dehiscence
separation of the layers of a surgical wound; may be partial, or superficial only, or complete, with disruption of all layers
A nurse is caring for a client that is HIV positive and is 1 day post op following appendectomy. The nurse should wear a gown as a PPE when taking which of the following actions?
- completing a dressing change
A nurse is caring for a client with a diagnosis of malnutrition and is started on TPN. The nurse should monitor the client for which of the following complications? SATA
- electrolyte imbalances - infection at central line insertion site - fluid imbalances- nausea and vomiting - high blood glucose level
A nurse is caring for a client with multiple lacerations. Which of the following factors are likely to delay wound healing?
- low serum albumin - smoking and obesity
A nurse is preparing to administer Benadryl 30mg IM STAT to a client with allergic reaction. Available is Benadryl 50mg in 1mL. How many mL should the nurse administer?
0.6mL
A nurse is planning nutritious instructions for a client experiencing fatigue due to iron deficiency anemia. Which of the following food should the nurse recommend to the client?
1 cup of canned black beans
A nurse is administering RBC's 350mL/ 3 hour to a client with anemia. The nurse should set the IV pump to deliver how many mL per hour?
117
A nurse is preparing to administer Narcan 1mg IV push. Available is Narcan 0.4mg/mL. How many mL should the nurse administer?
2.5mL
) A nurse on a cancer unit is caring for a client who has breast cancer. The nurse would consider implementing neutropenic precautions when the client's WBC count is
2000
A nurse is preparing to instill 840mL of internal nutrition via client G tube over 24 hours using an infusion pump. The nurse should set up the infusion pump to deliver how many mL per hour?
35
Peptic Ulcer Disease
A break or ulceration in the protective mucosal lining of the lower esophagus, stomach, or duodenum
A nurse is providing care for 4 clients at med surg unit. Which of the following clients should the nurse identify as being at risk for development of pressure ulcer? SATA
A client who has protein calorie malnutrition A client who has right sided heart failure A client who has postoperative delirium
compartment syndrome
A painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues. (can require fasciotomy)
A group of nurses is discussing risk factors for transmission of HIV for clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?
A phlebotomist that collects blood from clients with HIV
The nurse is providing care for a client whose IBD has necessitated hospital treatment. Which of the following will most likely be included in the patient's medication regimen?
Anti-choleretic medications 30 minutes before a meal
A nurse is providing instructions to a client with a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the instructions?
Aplastic anemia results from decreased bone marrow production of RBCs.
A client has an ileostomy created for his history of IBD, but the client is now preparing for discharge. What should the client be taught about changing this device in a home setting?
Apply a skin barrier to the parastomal skin pouch prior to applying the pouch
After receiving a diagnosis of acute lymphocytic leukemia, the client is visibly distraught stating "I have no idea where to go from here". How should the nurse prepare to meet this clients' psychosocial needs?
Assess the patients specific needs for education and support
The client nurse educator is presenting health promotion education to a client who will be treated for non-Hodgkin's lymphoma on an out-client basis. The nurse should recommend which of the following actions?
Avoiding highly crowded public places
A nurse is caring for a client with HIV. Which of the following lab values should the nurse report to the PCP?
CD4 T Cell count of 180 cells
A nurse is preparing to perform a blood transfusion for a client. Which of the following actions should the nurse take? SATA
Check vital signs before transfusion. Check the expiration date of the blood product with a second nurse.
A nurse is instructing a client with a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of anemia?
Chronic blood loss
Ulcertive Colitis
Chronic inflammation of the rectum and large intestines
The nurse is caring for a client who is two days post op following abdominal surgery. The nurse notices that the clients wound has eviscerated. After calling for help, what should the nurse do next?
Cover the area with a sterile dressing moistened with 0.9% sodium chloride
The nurse is completing dietary instructions on consuming a low fiber diet for a client with ulcerative colitis, which of the following foods should be eliminated in the client's diet?
Dry Apricots or cooked cabbage
A client with poorly controlled diabetes has developed end stage renal failure and consequent anemia. When reviewing this client's treatment plan the nurse should anticipate the use of which drug?
Epoetin alfa
A nurse is assessing a client with a puncture wound on the right foot. Which of the following findings is a manifestation of acute osteomyelitis?
Localized erythema
Imbalanced nutrition can be characterized by excessive or deficient food intake. What potential effect of imbalanced nutrition should be noted?
Prolonging confinement to bed
Which lab test would the nurse consider most important in planning care for a client with Chron's disease who exhibits severe weight loss, dry skin, and muscle wasting?
Serum sodium
hemolytic reaction
The destruction of a patient's erythrocytes that occurs when receiving a transfusion of an incompatible blood type. Also called a transfusion reaction.
A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the disease. What should the nurse explain to this client?
There could be decrease production of platelets
A nurse is planning care for a client with pernicious anemia. Which of the following interventions should the nurse care to implement?
Vitamin B 12 injections
megaloblastic anemia
a blood disorder characterized by anemia in which the red blood cells are larger than normal
A woman who is in her third trimester of pregnancy is experiencing an exacerbation of iron deficiency anemia in recent weeks. When providing the client with nutritional guideline as a meal suggestion what food would be most likely to increase the woman iron stores?
beef liver accompanied by OJ
aplastic anemia
characterized by an absence of all formed blood elements caused by the failure of blood cell production in the bone marrow
A nurse is providing instruction to a client with GERD about ways to manage this condition. Which of the following instructions should the nurse include
eat 4 small meals each day
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates allergic transfusion reaction?
generalized urticaria
A young adult client has received a news that her treatment for Hodgkins lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the client receives regular health assessment in the future due to risk of what complication?
hematologic cancer
pernicious anemia
lack of intrinsic factor for B12 absorption
A nurse is admitting a client who is exhibiting signs and symptoms of nutritious deficit. An inadequate intake of what intake increases the client susceptibility of infection?
protein
A nurse is providing patient education to a client with RA about increasing physical rest as part of the treatment plan.Which of the following outcomes of this intervention should the nurse document as a goal for this client?
reduced joint stress
A nurse is assessing a client that is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction?
report of low back pain
. A nurse is reviewing the primary health care providers prescriptions for a client experiencing paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take?
start an NG tube
The nurse is caring for a client who needs a daily increase of calcium intake to reduce the risk of osteoporosis. Choose the food that would be the best for a vegetarian client?
steamed broccoli
A Nurse is monitoring a client with peptic ulcer disease. Which of the following findings is an indication of perforation?
sudden abdominal pain
A client admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?
tofu
A nurse is assessing a client's immune function by reviewing laboratory value of the cellular response of the T cells. The nurse should recognize which of the following condition is affected by T cells?
transplant rejection
