Exam 1
pseudomemebranous colitis
A client is in the acute care facility for the administration of intravenous (IV) antibiotics to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client has developed due to the antibiotic use?
24 hours
A client is ordered an intravenous (IV) solution of Ringer's lactate 1000 mL to infuse at 40 mL/hr. What is the maximum amount of time the nurse should allow this IV to hang?
Isotonic solutions maintain body fluid balance
A client is scheduled for a test that requires an NPO status and has been ordered 5% dextrose in water (D5W). The nurse understands which of the following to be the bestrationale for this action?
Respiratory rate of 24 breaths/minute Temperature of 102 °F Heart rate of 120 beats/minute
A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply. A. Respiratory rate of 24 breaths/minute B. Temperature of 102 °F C. Blood pressure of 120/80 mm Hg D. Heart rate of 120 beats/minute E. PaCO2 of 42 mm Hg
fungus
A client visits the clinic with the complaint of a circular rash on the upper right arm. The rash is diagnosed as tinea corporis. What type of infection does the nurse anticipate the client will be treated for?
Call for portable chest X-ray.
A central venous catheter has been inserted in the right subclavian vein of the client. Which of the following would be the priority nursing action before total parenteral nutrition (TPN) can be started?
direct contact
A client arrives at the clinic with the complaint that she is having a vaginal discharge after having sexual intercourse with her boyfriend 1 week ago. The client is diagnosed with gonorrhea and given a prescription for treatment. What type of infection transmission does the nurse understand occurred?
vehicle
A client arrives at the emergency department complaining of severe diarrhea and vomiting that began after ingesting a hot dog at the ball park 6 hours ago. How does the nurse understand that the contaminated food was transmitted to the client?
an abscess
A client comes to the clinic and informs the nurse that he has a "painful area under his armpit." The nurse observes a 2-cm raised area that is erythremic and has a white substance inside it. What does the nurse suspect the client may be experiencing?
The disease is spread by arthropods.
A client has received a diagnosis of Lyme disease. What does the nurse understand about the transmission of infection resulting in this disease?
prodromal stage
A client informs the nurse that he "thinks he is getting sick." Chief complaint of the client is low-grade fever, headache, and "has no energy." What stage of the infection does the nurse recognize the client is experiencing?
White blood cell (WBC) count of 22,000 cells/mm3
A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client's leukocytosis?
Client is experiencing a hemorrhagic stroke.
A client is brought to the emergency department with a diagnosis of possible cerebral vascular accident (CVA) and is being typed and crossmatched for fresh frozen plasma (FFP). Which is the best nursing understanding for this action?
Debridement
A client is hospitalized for an infected decubitus ulcer of the sacral area. The physician is planning to remove the dead and damaged tissue. What type of procedure will the nurse prepare the client for?
Monitor for fluid overload
A client with severe malnutrition is ordered intravenous (IV) albumin. Which is the primary assessment in providing nursing care for this client?
The invasive nature of the catheter provides a portal for infection.
A family member of a client in a long-term care facility asks the nurse why he cannot insert a catheter so the client will not develop skin breakdown from being wet. What should the explanation include when the nurse responds to the family member?
The family member was serving in the military in England in 1993 for 2 years.
A family member wants to donate blood for a client who needs a blood transfusion. What information from the family member would make them ineligible for donation?
An induration of 12 mm
A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?
3 to 6 inches, used for up to 4 weeks
A nurse is training other nurses at the hospital to insert midline catheters. What would the nurse teach the other nurses about how many inches of the catheter should be inserted into the required site and for how long can it be used?
Be tested for disease antibodies at appropriate intervals.
A nurse on the unit sustains a needlestick injury while caring for a client whose infection status is unknown. What would be the best course of action for the nurse to follow?
septic reaction
A postoperative total hip replacement client is to receive salvaged blood through the cell saver system. The nurse is most concerned about which possible transfusion reaction?
Prevents drug/solution incompatibilities
Before instilling any additives to a client's medication lock, normal saline is used to flush the device. Which of the following provides the best rationale for this action?
Do not use any solution that is leaking. Inspect IV solutions for transparency prior to administration. Do not use any solution that is expired.
In providing nursing care to a client, which actions should the nurse take to reduce the risk of administering a contaminated intravenous (IV) solution? Select all that apply. A. Use in-line filters on peripheral and central line IV solutions. B. Avoid reconstituting powder drugs when preparing the solution. C. Do not use any solution that is leaking. D. Inspect IV solutions for transparency prior to administration. E. Do not use any solution that is expired.
Reset the drip rate.
The client complains that the intravenous (IV) site is stinging. No signs of infiltration or inflammation are assessed, but the nurse notices the rate is running faster than ordered. Which action should the nurse take first?
Excess Fluid Volume
The client has been receiving intravenous (IV) fluids for the last 6 hours and now is demonstrating bounding pulse, crackles in the lungs, leg swelling, and a blood pressure more than 15 mm Hg higher than baseline. Which is the most likely nursing diagnosis for this client?
Y-administration tubing
The client has just had a transfusion ordered for severe anemia. The nurse is gathering the supplies that are needed in order to transfuse the client. What kind of tubing does the nurse know is needed to infuse blood or blood products?
Flush the lock with saline or heparinized saline.
The client is going out on pass for the afternoon with his family. The physician has ordered that his venipuncture device needs to be temporarily capped. How will the nurse ensure that the vein remains patent?
Hang dextrose 10%in water (D10W) until new container is ready.
The client is receiving total parenteral nutrition (TPN), and the solution bag is almost empty. The nurse discovers there are no containers prepared for use. The nurse contacts the health care provider. What order would the nurse expect from the health care provider?
Avoid visiting older adults.
The nurse is working on a gerontology unit. A family member calls and tells the nurse they want to bring the family in to see one of the clients on the unit. The family member is concerned because several of the family members have colds. What instructions should the nurse provide to someone with a respiratory infection?
prion
The intensive care unit nurse is caring for a client with a transmissible spongiform encephalopathy. The nurse knows that this type of encephalopathy is caused bywhat type of infectious agent?
every 72 hours
The nurse caring for a client with an intravenous infusion is looking up her institution's policy on changing IV equipment used in a venipuncture. When is most IV tubing changed?
Report the injury or exposure to the supervisor.
The nurse gave a client an injection and, when attempting to recap the needle, sustained a needlestick injury to the finger. What is the priority action by the nurse?
culture and sensitivity
The nurse has admitted a new client to the unit. This client has an open draining sore on his leg. What diagnostic test would the nurse anticipate being ordered?
opportunistic
The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed because of to the immunocompromised state of the client?
"Hespan can be used to treat hypovolemic shock." "Hespan is a solution used instead of a transfusion." "This solution pulls fluid into the vascular space." "This is a colloid solution used to replace blood."
The nurse is caring for a client who has an order to receive Hespan IV. The client asks the nurse what this solution is for. What would be the nurse's response? Select all that apply. A. "Hespan can be used to treat hypovolemic shock." B. "Hespan is an artificial blood replacement product." C. "Hespan is a solution used instead of a transfusion." D. "This solution pulls fluid into the vascular space." E. "This is a colloid solution used to replace blood."
The client's heart rate is greater than 90 beats/minute
The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately?
A culture
The nurse is caring for a client with an abscess on his back. The nurse observes purulent drainage coming from the abscess. What type of specimen does the nurse anticipate the physician will order to determine the type of bacteria present in the exudate?
Use standard precautions with all clients.
The nurse is caring for a group of five clients at the hospital. In order to control infections when caring for the group of clients, what intervention can the nurse perform?
An autoimmune response
The nurse is caring for an older adult client who develops a fever, rash over the trunk, and back and complains of feeling achy and very tired. What does the nurse suspect is occurring with this client?
"Make sure your family has all their childhood immunizations."
The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?
thorough handwashing
The nurse is teaching a health class in the local public health center. What instructions should the nurse provide as the single most important measure to prevent the spread of infection?
hypertonic solution
The nurse would expect to hang which of the following intravenous (IV) solution to a client with cerebral edema?
colloid solutions
The nursing instructor is discussing about the different types of IV fluids with the nursing students. What type of fluid would the instructor tell the students to be used to replace circulating blood?
tea and coffee
The nursing instructor is teaching beginning nursing students about infection. Toward the end of class, the instructor gives the students a scenario of a client with an infection who has developed fever and diarrhea. What should the student nurse instruct the client to avoid?
Phlebitis can develop.
The nursing instructor is teaching student nurses about venipuncture techniques and possible complications from the procedure. What can happen if the venipuncture device is left in the clients' vein too long?
Hang vented tubing
Thirty minutes after hanging a glass intravenous bottle of total parenteral nutrition (TPN), the nurse notices the solution has stopped dripping. Which is the besttroubleshooting action of the nurse?
Matching numbers on blood bag to client bracelet
To avoid complications of blood transfusion reaction, which nursing action is most important?
Injection of filgrastim (Neupogen)
Which is the best option for raising the white blood cell count in a cancer client who is at risk for congestive failure?
state licensing board
Which of the following provides the best practice for the graduate nurse in the administration and regulation of intravenous fluids to clients?
coughing
Which of the following would be considered a mechanical defense mechanism?
