Exam 2 Study Questions
Which patient does the nurse recognize as being most likely to be affected by sickle cell disease?
A 14-year-old African American boy
A nurse is completing a nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
Body mass index Weight history Blood urea nitrogen (BUN) level Serum albumin level
The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth?
Dilute liquid preparations of iron with juice and drink with a straw
A client with leukemia is being discharged from the hospital to hospice care. Which statement by the client indicates the client is not appropriately dealing with spiritual distress?
I don't understand why this happened to me
An office worker takes a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity?
Anaphylactic (type 1)
A client has been diagnosed with pernicious anemia. During client education, the nurse emphasizes the importance of lifelong intramuscular administration of:
B12
For a client diagnosed with pernicious anemia, the nurse emphasizes the importance of lifelong administration of
B12
A client has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The health care provider's choice of antibiotics would be primarily based on what diagnostic test?
Blood cultures
The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply.
Antiretroviral therapy targets different stages of the HIV life cycle. The CD4 count is the major indicator of immune function and guides therapy.
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia?
Apply prolonged pressure to needle sites or other sources of bleeding
A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse?
"It is important that you continue to take your medication to avoid an acute exacerbation.
A client with Hodgkin lymphoma is receiving information from the oncology nurse. The client asks the nurse why it is necessary to stop drinking and smoking and stay out of the sun. What would be the nurse's best response?
"It's important to reduce other factors that increase the risk of second cancers."
A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply.
A chest radiograph Drug susceptibility testing Complete history and physical examination
A nursing student is preparing a teaching plan for a client with an immunodeficiency disorder. The student is going to include the cardinal symptoms in teaching. Which of the following would the student include? Choose all that apply.
Chronic or recurrent severe infections Chronic diarrhea Poor response to treatment of infections
A nurse is documenting the results of assessment of a client with bronchiectasis. What would the nurse most likely include in documentation?
Clubbing of the fingers
The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors should the nurse list that can be controlled or modified?
Cholesterol levels, hypertension, and smoking
A nurse is admitting a client with emphysema. What are presenting findings the nurse should assess? Select all that apply.
Chronic cough Dyspnea Wheezing
The nurse is caring for a client in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The client has become hypotensive. What is the cause of this complication to the ARDS treatment?
Hypovolemia secondary to leakage of fluid into the interstitial spaces
Which of the following are risk factors for the development of chronic obstructive pulmonary disease (COPD)? Select all that apply.
Infection Occupational dust Second-hand smoke Tobacco smoke Air pollution
Scleroderma typically begins with the involvement of which system?
Integumentary
The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?
Monitor weight daily
An adult client is admitted to the ED with chest pain. The client states that he had unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?
Morphine sulphate, oxygen, and bed rest
A nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy the nurse will teach the about for osteoarthritis?
NSAIDs
The nurse is assessing a client with leukemia. How would the nurse assess for enlargement and tenderness over the liver and spleen?
by palpating the abdomen
Which assessment parameter is important for the client diagnosed with congestive heart failure?
distended veins
A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess?
diuretics
A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:
empyema
A client with leukemia has developed a cough and increased fatigue. What is the primary nursing intervention?
evaluate for potential infection
Which particular area(s) should be examined to assess peripheral edema?
feet, ankles
For a client with Hodgkin lymphoma, who is at a risk for ineffective airway clearance and impaired gas exchange, the nurse places the client in a high Fowler's position to
increase lung expansion
The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client?
promote safety
A nurse is caring for a client with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this client, the nurse should assign the highest priority to which nursing diagnosis?
risk for infection
What intervention is appropriate before the client begins taking efavirenz therapy?
testing for stevens-johnson syndrome
The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
The nurse is caring for a client with a history of endocarditis. What topic should the nurse prioritize during health promotion education?
Oral hygiene
The nurse is preparing a client for cardiac surgery. During the procedure, the client's heart will be removed and a donor heart implanted at the vena cava and pulmonary veins. What procedure will this client undergo?
Orthotropic transplant
The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?
"Are you only able to breathe when you are sitting upright?"
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?
"Experiences exertional dyspnea when walking 3 feet; states, I cannot catch my breath."
The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective?
"I should avoid prolonged sun exposure."
A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse?
"I'll see a genetic counselor before starting a family."
A client with early stage rheumatoid arthritis asks the nurse what to do to help ease the symptoms of the disease. What would be the best response by the nurse?
"The health care provider could prescribe anti-inflammatory drugs.
The nurse is educating an 80-year-old client diagnosed with heart failure about his medication regimen. What should the nurse to teach this client about the use of oral diuretics?
Take the diuretic in the morning to avoid interfering with sleep.
A client's current antiretroviral regimen includes enfuvirtide (T-20). What dietary counseling will the nurse provide based on the client's medication regimen?
Take this med without regard to meals
The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has?
A general reduction in all white blood cells
A client with pericarditis has just been admitted to the CCU. The nurse planning the client's care should prioritize what nursing diagnosis?
Acute pain related to pericarditis
A client is being treated in the ED for respiratory distress coupled with bacterial pneumonia. The client has no medical history. However, the client works in a coal mine and smokes 10 cigarettes a day. The nurse anticipates which order based on the client's immediate needs?
Administration of antibiotics
The nurse is educating a patient with allergic rhinitis about how the condition is induced. What should the nurse include in the education on this topic?
Airborne pollens or molds
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?
Airway Obstruction
A client with asthma has developed obstruction of the airway. Which of the following does the nurse understand as having potentially contributed to this problem? Choose all that apply.
Airway remodeling Swelling of bronchial membranes Thick mucus
A nurse is teaching a client about bronchodilators. What bronchodilator actions that relieve bronchospasm should the nurse include in the client teaching? Select all that apply.
Alter smooth muscle tone Reduce airway obstruction Increase oxygen distribution
The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension?
Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.
A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times?
An EpiPen
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia?
Applying prolonged pressure to needle sites or other sources of external bleeding
A client with advanced leukemia is responding poorly to treatment. The nurse finds the client tearful and trying to express feelings, but he is clearly having difficulty. What is the nurse's most appropriate action?
Ask if the client would like the nurse to sit with him while he collects thoughts.
After receiving a diagnosis of acute lymphocytic leukemia, a client is visibly distraught, stating, "I have no idea where to go from here." How should the nurse prepare to meet this client's psychosocial needs?
Assess the client's specific needs for education and support.
A client with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the client to exhibit what heart rhythm?
Atrial Fibrillation
A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure?
B-type natriuretic peptide (BNP)
A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern?
Butterfly rash
A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to
Combat inflammation
Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process?
Consolidation
A client presents to the clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause?
Coronary arteriosclerosis
A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following?
Dental procedures
The nurse is reviewing the echocardiography results of a client who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure is this client experiencing?
Dilated ventricles without hypertrophy of the ventricles
The nurse is admitting a client with reports of dyspnea on exertion and fatigue. The client's ECG shows dysrhythmias that are sometimes associated with left ventricular hypertrophy. What diagnostic tool would be most helpful in diagnosing cardiomyopathy
Echocardiogram
A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?
Elevated uric acid levels
The critical care nurse is caring for a client who is receiving cyclosporine postoperative heart transplant. What outcome represents a therapeutic outcome of this pharmacologic treatment?
The client does not experience organ rejection.
The nurse is administering injected allergens for "hyposensitization," which may produce harmful systemic reactions. Prior to administering these allergens, what medication should the nurse have at the bedside?
Epinephrine
A client with end-stage renal disease has a decreased red blood cell production. What medication can the nurse administer with physician's order that will increase the production of erythrocytes?
Epoetin Alpha
Which of the following is a common irritant that acts as a trigger of asthma?
Esophageal reflux
The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?
Has a weight gain of 5 pounds
Which is a primary chemical mediator of hypersensitivity?
Histamine
The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs?
The client experiences chest pain, palpitations, or dyspnea.
A nurse is caring for a client with COPD. The client's medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. Therapeutic effects of this medication would include which of the following? Select all that apply.
Increased expiratory flow rate Relief of dyspnea
A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?
Iron will cause the stools to darken in color.
The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation, the educator describes what consequence of this disorder ?
Left ventricular hypertrophy
A protease inhibitor, an antiretroviral agent that can be taken without regard to meals is:
Lexiva
The nurse is caring for a client who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?
Lipids and fibrous tissue
A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
Low serum potassium
The nurse is caring for a client with a T-cell disorder. What clinical manifestation does the nurse determine will be present?
Lymphopenia is usually present. Chronic mucocutaneous candidiasis is an associated disorder.
An older adult client has been diagnosed with COPD. What characteristic of the client's current health status would rule out the safe and effective use of a metered-dose inhaler (MDI)?
The client has severe arthritis in her hands.
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?
Observe stools for blood.
While assessing a client, the nurse will recognize what as the most obvious sign of anemia?
Pallor
A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level?
Petechiae
The client is prescribed albuterol 2 puffs as a metered-dose inhaler. Which action by the client demonstrates understanding of administration for this medication?
Positions the inhaler 2 finger widths away from the lips
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?
Potassium
A nurse assesses a client with pneumonia. Which assessments are diagnostic for pneumonia? Select all that apply.
Presence of crackles Egophony Wheezes Whispered pectoriloquy Percussion dullness
A hospitalized client with heart failure puts on the call light and states, "I've become very short of breath, and I've been coughing up this pink frothy sputum." The nurse immediately suspects which of the following complications?
Pulmonary edema
Primary gout is often caused by an inherited disorder in which type of metabolism?
Purine
A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease?
Recognizing and promptly treating streptococcal infections
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Record the observation
A client with cardiovascular disease is being treated with amlodipine, which is intended to cause what therapeutic effect?
Reducing the heart's workload by decreasing heart rate and myocardial contraction
The nurse is caring for a client with mitral stenosis who is scheduled for a balloon valvuloplasty. The client tells the nurse that he is unsure why the surgeon did not opt to replace his damaged valve rather than repair it. What is an advantage of valvuloplasty that the nurse should cite?
Repaired valves tend to function longer than replaced valves.
A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects?
Throbbing headache or dizziness
A nursing student assists a registered nurse to admit a client with a primary immunodeficiency. The nurse explains to the student that primary immunodeficiencies predispose people to three conditions. Which of the following three are those conditions?
Severe infections Cancer Autoimmunity
Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?
Spironolactone
An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care?
Suction the client's airway secretions.
Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?
The symptoms indicate an acute coronary episode and should be treated as such.
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse informs the client that she should self-administer epinephrine in what site?
Thigh
A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?
Tracheostomy
A client with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin. The nurse should recognize the possible need for what antidote?
Vitamin K
A client who has recently started working in a coal mine is concerned the effects on long-term health. How does the nurse advise the client to prevent occupational lung disease? Select all that apply.
Wear appropriate protective equipment when around airborne irritants and dusts. Do not smoke, or quit smoking if currently smoking.
Which of the following would the nurse expect to assess as the most common finding associated with fibromyalgia?
Widespread chronic pain
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?
Withhold the medication and notify the physician of the heart rate.
The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium?
You Selected: It may have developed an increased area of infarction during the time without treatment.
A client is receiving immunotherapy as part of the treatment plan for an allergic disorder. After administering the therapy, the client states, "I guess I can go home now." Which response by the nurse would be most appropriate?
You need to stay another half hour
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
apply and allergy bracelet and flag the chart
A patient with acute myeloid leukemia (AML) has a neutrophil count that persists at less than 100/mm3. What should the nurse cautiously monitor this patient for?
infection
A client seen in the outpatient clinic has common variable immunodeficiency. It is important for the nurse to teach the client about the need for more frequent screening for which complication?
malignancy
A nurse should advise a client with gout to avoid which foods?
organ meats and scallops
Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply.
p24 antigen test polymerase chain reaction