Exam 3 Adult Health I (Sensory, Tissue Integrity, Immunity)

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.) A. More difficulty seeing due to a greater sensitivity to glare B. Decreased cough reflex C. Decreased bladder capacity D. Decreased systolic blood pressure E. Dehydration of intervertebral disc

ANS: A, B, C, E Rationale: Expected physiologic changes of aging include more difficulty seeing due to greater sensitivity to glare, decreased cough reflex, decreased bladder capacity, dehydration of intervertebral disc.

A nurse is providing discharge teaching to a client who has HIV. Which of the instructions about infection prevention should the nurse include? (Select all that apply.) A. Avoid large gatherings of people B. Clean toothbrush by running through the dishwasher C. Change pet litter boxes with disposable gloves D. Consume fresh fruit and raw vegetables E. Avoid digging in the garden

ANS: A, B, E Rationale: The nurse should instruct the client to avoid large crowds or gatherings of people, especially if individuals have been ill or exposed to illness; this can place clients who have HIV at risk of infection. The client should clean the toothbrush by running it through the dishwasher. If the client does not have a dishwasher, rinsing the toothbrush with bleach followed by hot water is also effective at destroying bacteria on the toothbrush. The client should avoid digging in the garden because exposure to the dirt, which contains bacteria and organisms, places the client at risk of infection. (pg. 342)

What information should be included in an informational program to be presented on burn prevention to a senior citizens group? (Select all that apply.) A. Do not smoke in bed or when sleepy B. Wear well-fitted clothing when cooking or when grilling outdoors C. Establish a meeting place for all family members outside of the home in case of a fire D. Establish a plan for exiting each room of your home in the case of a fire E. Have a fire extinguisher readily available in the kitchen

ANS: A, B, E prevention of Burns includes not smoking in bed or when sleepy, not wearing loose-fitting clothing (e.g., bathrobes, nightgowns, pajamas) when cooking or around an open heat source and installing a portable hand fire extinguisher in the kitchen. The remaining options are related to safely evacuating a home in case of a fire.

Which opportunistic infections can be observed in AIDS (Select all that apply) A. Toxoplasmosis B. Gastroenteritis C. TB D. Candidiasis E. Cytomegalovirus

ANS: A, C, D, E

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Limit visitors in the client's room B. Encourage fresh vegetables in the diet C. Increase protein intake D. Instruct the client to consume 2,000 calories/day E. Restrict fresh flowers in the room

ANS: A, C, E Rationale: Limit visitors and ensure ill individuals do not visit the client, to decrease the risk of infection. Some facilities restrict consumption of fresh vegetables due to the presence of bacteria on the surface and the increased risk for infection. The client should increase protein consumption, which promotes wound healing and prevents tissue breakdown. The client should consume up to 5,000 calories/day because caloric needs double or triple beginning 4-12 days following the burn. Flowers should not be in the client's room due to the bacteria they carry, which increases the risk for infection (pg. 507 CMS book)

A nurse is assessing a client for HIV. Which of the following are risk factors associated with this virus? (Select all that apply.) A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult woman E. Occupational exposure

ANS: A, D, E Rationale: Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take cautionary measures to prevent HIV exposure. Being an older adult woman is a risk factor associated with HIV virus due to vaginal dryness and thinning of the vaginal wall. Occupational exposure, such as being a health care worker, is a risk factor associated with the HIV virus.

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I will clean the hearing aids with alcohol wipes." B. "I will not use hairspray if I am wearing the hearing aids." C. "I will change the batteries once a week." D. "I will expect the hearing aids to whistle when I cup my hand over them.

ANS: A. "I will clean the hearing aids with alcohol wipes." Rationale: Alcohol use can break down the mechanism of the hearing aids. The client should follow the manufacturer's instructions, which usually include using a soft cloth to remove cerumen and other debris and never immersing them in water.

A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching? A. "Pressure injury documentation includes the location, stage, measurement, and condition of the wound bed and any drainage present." B. "Drainage from a pressure injury only needs to be documented if a foul odor is present." C. "If the pressure injury is healing as expected, documentation can be completed with every other dressing change." D. "Pressure injuries found on the mucous membranes should be documented as stage 1 pressure injuries."

ANS: A. "Pressure injury documentation includes the location, stage, measurement, and condition of the wound bed and any drainage present."

A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? A. "Wash your genitalia using an antimicrobial soap." B. "Rinse your dishes with cold water." C. "Clean your toothbrush once per month." D. "Incorporate raw fruits and vegetables into your diet."

ANS: A. "Wash your genitalia using an antimicrobial soap." Rationale: The nurse should instruct the client to bathe daily using an antimicrobial soap to prevent the spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap is recommended. (pg. 342)

A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching? A. "You can expect a persistent fever and swollen glands." B. "You can expect an elevated white blood cell count." C. "You can expect increased blood pressure and edema." D. "You can expect weight gain."

ANS: A. "You can expect a persistent fever and swollen glands." Rationale: Clients who have AIDS can have a persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of AIDS. (pg. 331)

The client who tripped while carrying an open kettle of hot water received scald burns to the entire chest, the entire anterior section of the right arm, the right half of the abdomen, and the anterior portion of the right leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines? A. 22%-23% B. 30%-31% C. 39%-40% D. 48%-49%

ANS: A. 22%-23% Rationale: The anterior thorax, which includes the chest and abdomen, is 18% of the total body surface area. Therefore, the entire chest and half of the abdomen would be 13.5%. The anterior right area adds another 4.5%, bringing the total to 18%. The anterior section of the right thigh adds another 4.5%, bringing the total body surface area involved in this injury to approximately 22% to 23%. (pg. 523, Physiological Integrity)

A 58-year-old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 63% B. 81% C. 72% D. 54%

ANS: A. 63% Rationale: Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? A. A client who is incontinent and is taking a prescribed diuretic B. A client who has a lower extremity fracture and uses the overhead bed trapeze to move C. A client who is NPO for surgery and receiving IV fluids D. A client who has lung cancer and will be receiving their first radiation treatment

ANS: A. A client who is incontinent and is taking a prescribed diuretic

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A. Apply a moisture barrier ointment to the client's skin. B. Clean the client's skin and perineum with hot water after each episode of incontinence. C. Check the client's skin every 8 hr for signs of breakdown. D. Request a prescription for the insertion of an indwelling urinary catheter.

ANS: A. Apply a moisture barrier ointment to the client's skin. Rationale: Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.

A nurse is teaching a client who has extensive deep partial- and full-thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes? A. Bacterial growth B. Scarring C. Skin graft size D. Pain

ANS: A. Bacterial growth Rationale: Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help prevent bacteria from entering the body when a client has an impairment of the protective covering of the skin, as with burns. It and the dressing create a protective barrier between bacteria and the exposed body tissues. This therapy helps prevent infection.

A patient with AIDS states that several purple and white "spots" have appeared on the arm and the chest; they are not painful and are nonpruritic. Several days after the appearance of these spots, the patient believes there is also some blood in the stool. What might be the cause of the skin lesions and the blood in the stool? A. Kaposi sarcoma B. Herpes simplex C. Herpes zoster D. Basal cell carcinoma

ANS: A. Kaposi sarcoma

The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the 5th cardinal sign of inflammation? A. Loss of function B. Altered level of consciousness C. Sepsis D. Fever

ANS: A. Loss of function Rationale: The classic description of inflammation has been handed down through the ages. In the 1st century AD, the Roman physician Celsus described the local reaction of injury in terms now known as the cardinal signs of inflammation. These signs are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). In the 2nd century AD, the Greek physician Galen added a fifth cardinal sign, function laesa (loss of function). Altered level of consciousness is not a cardinal sign of inflammation. Sepsis and fever are systemic signs of infection.

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and PRN. Which of the following objects should the nurse use to reduce skin irritation around the incision area? A. Montgomery straps B. Enzymes C. Alcohol swabs D. A transparent dressing

ANS: A. Montgomery straps Rationale: Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips.

A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy? A. Quantitative RNA assay B. Platelet count C. Enzyme immunoassay (EIA) test D. Western blot

ANS: A. Quantitative RNA assay Rationale: A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness

The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? A. Replace fluids and electrolytes. B. Prevent contractures of extremities. C. Monitor urine output hourly. D. Prepare to assist with an escharotomy.

ANS: A. Replace fluids and electrolytes. Rationale: After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding? A. Report of exposure to a skin irritant B. Denial of pruritus C. Systemic symptoms including elevated temperature D. Report of generalized joint discomfort

ANS: A. Report of exposure to a skin irritant Rationale: The most common cause of contact dermatitis is exposure to a topical irritant therefore identifying this irritant is a component of treatment.

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? A. Transparent dressing B. Wet-to-dry gauze dressing C. Hydrogel dressing D. Alginate dressing

ANS: A. Transparent dressing Rationale: A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area.

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage the skin over the client's bony prominences. D. Elevate the head of the bed no more than 45°.

ANS: A. Use a transfer device to lift the client up in bed. Rationale: Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's lab values? A. WBC 17,000/mm3 B. Neutrophils 3,000/mm3 C. RBC 4.2 million/mm3 D. Lymphocytes 3,000/mm3

ANS: A. WBC 17,000/mm3 Rationale: The expected reference range for a WBC count for a child is 5,000 to 10,000/mm3. A WBC count of 17,000/mm3 is elevated. The nurse should expect to see an elevated WBC count because appendicitis is an acute bacterial infection.

A nurse is caring for a client who is HIV-Positive who is teaching the client about the earliest manifestations of AIDS. Then the nurse explains that they include which of the following? A. persistent fever, swollen glands, diarrhea, weight loss and fatigue b. elevated WBC count C. increased BP, tachycardia, dyspnea and edema D. influenza like symptoms: fatigue, sore throat, muscle pain, headache, swollen glands

ANS: A. persistent fever, swollen glands, diarrhea, weight loss and fatigue Rationale: influenza like symptoms is for HIV

A child's arm is burned from accidentally spilling boiling water on it and the parent calls the clinic. The nearest ED is an hour away. Which instructions would be appropriate to give the parent? (Select all that apply) A. Apply antibiotic ointment to any open skin B. Briefly soak the arm with cool water C. Cover the area with a clean dry cloth D. Place ice on the arm to relieve pain E. Remove clothing if not stuck to skin around the burn

ANS: B, C, E

How is HIV transmitted? (Select all that apply) A. Saliva B. Breast milk C. Semen D. Urine E. Blood F. Vaginal fluids G. Sweat

ANS: B, C, E, F

A nurse is assessing a client who has DM and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (SATA) A. Bradycardia B. An increase in neutrophils C. An increase in RBCs D. An increase in platelets E. Localized edema

ANS: B, E Rationale: Tachycardia is also an indicator of infection

A nurse is teaching a client who has human immunodeficiency virus (HIV) about how the virus is transmitted. Which of the following statements should the nurse include the teaching? A. "HIV can be transmitted as soon as a person develops manifestations." B. "HIV can be transmitted to anyone who has had contact with infected blood." C. "HIV is transmitted through the respiratory route via droplets." D. "HIV is transmitted only during the active phase of the virus."

ANS: B. "HIV can be transmitted to anyone who has had contact with infected blood." Rationale: The concentration of the virus is highest in blood but also has been isolated in other body fluids, including sputum, saliva, cerebrospinal fluid, urine, and semen. Clients who have HIV are cautioned to practice safe sex, avoid donating blood, and abstain from sharing needles with others. (pg. 327)

A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome (AIDS). Which of the following statements by the client's partner indicates a need for further teaching? A. "I will dispose of soiled tissues in separate plastic bags." B. "I'll clean up blood spills immediately with hot water." C. "I know that handwashing is an important preventive measure." D. "I will wash soiled clothes in hot water."

ANS: B. "I'll clean up blood spills immediately with hot water." Rationale: The client's partner should clean blood or potentially contaminated body substances with a bleach solution and wear gloves when coming into contact with blood products. (pg. 341 Infection Control for Home Care chart)

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? A. 18% B. 22.5% C. 27% D. 36%

ANS: B. 22.5% Rationale: Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18% or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

A nurse is performing a physical assessment of a client who has lupus. Which of the following findings should the nurse expect? A. A grey colored, non-purpuric papular rash. B. A dry, red rash across the bridge of the nose and on the cheeks. C. Pitting edema of the hands and fingers. D. Subcutaneous nodules on the ulnar side of the arm.

ANS: B. A dry, red rash across the bridge of the nose and on the cheeks.

The nurse is most concerned by observing when assisting with an older client's bath: A. A firm, irregularly shaped, pink-colored nodule B. A slightly raised multicolor lesion with an asymmetrical, irregular border C. A pearly papule with prominent blood vessels D. Rough, scaly, sandpaper-like patches that are slightly tender

ANS: B. A slightly raised multicolor lesion with an asymmetrical, irregular border Rationale: A slightly raised multicolor lesion with an asymmetrical irregular border is characteristic of melanoma that accounts for less than 5% of skin cancer cases, but it causes most skin cancer deaths. A firm, irregularly-shaped, pink-colored nodule or persistent red lesion is characteristic of squamous cell carcinoma. A pearly papule with prominent blood vessels is a characteristic of a basal cell carcinoma. A tender, rough, scaly, sandpaper-like patch is a characteristic of actinic keratoses (a precancerous lesion).

A nurse is caring for a client who has a superficial partial thickness burn. Which of the following is an appropriate action for the nurse to take? A. Administer an IV infusion of 0.9% sodium chloride. B. Apply cool, wet compresses to the affected area. C. Clean the affected area using a soft-bristle brush. D. Administer morphine sulfate.

ANS: B. Apply cool, wet compresses to the affected area.

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output

ANS: B. Characteristics of the cough and sputum Rationale: The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse's priority assessment is the client's cough characteristics. A client who has burns to the face is at risk for pulmonary injury, and the development of a brassy cough can indicate an impending loss of airway.

The patient is diagnosed with vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions should the nurse use to best prevent transmission of the infection to others? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions

ANS: B. Contact precautions

The nurse is caring for a patient who is admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? A. Assess and treat pain. B. Evaluate airway and circulation. C. Place two IV catheters and initiate fluid resuscitation. D. Use the rule of nines to estimate percent of body surface area burned.

ANS: B. Evaluate airway and circulation.

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms? A. Pneumocystis lung infection B. Flu-like symptoms and night sweats C. Fungal and bacterial infections D. Kaposi's sarcoma

ANS: B. Flu-like symptoms and night sweats Rationale: The nurse should explain that the initial symptoms may include flu-like symptoms and night sweats in category A of HIV infection.

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions? A. Dehydration B. Fungal infection C. Compartment syndrome D. Pleural effusion

ANS: B. Fungal infection Rationale: The nurse should monitor the client for fungal infections due to the impairment of the phagocytic cells. Fungal and bacterial infections are the primary results of the dysfunction.

The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? A. Apply an ice pack to the right hand. B. Place the hand in cool water. C. Be sure to rupture any blister formation. D. Go immediately to the doctor's office

ANS: B. Place the hand in cool water. Rationale: Cool water gives immediate and striking relief from pain and limits local tissue edema and damage.

A client with bacterial pneumonia is to be started on IV antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins? A. Urinalysis B. Sputum culture C. Chest radiograph D. Red blood cell count

ANS: B. Sputum culture

The nurse is using Montgomery straps on a client following abdominal surgery. What is the rationale for using Montgomery straps for the client? A. To support the abdominal muscles B. To enable frequent dressing changes C. To exert pressure over a bleeding point D. To ensure adequate return circulation to the heart

ANS: B. To enable frequent dressing changes

A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following pieces of information should the nurse include in the teaching? A. "PCP is sexually transmitted from person to person." B. "You were most likely exposed to a contaminated surface such as a drinking glass." C. "PCP results from an impaired immune system." D. "You might have contracted PCP from a family pet."

ANS: C. "PCP results from an impaired immune system." Rationale: The organism that causes PCP exists as part of the normal flora of the lungs and develops into a fungus. It becomes an aggressive pathogen when the immune system is compromised, causing infection. (pg. 332 & 339)

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns? A. 9% B. 18% C. 27% D. 36%

ANS: C. 27% Rationale: According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.

A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV? A. An occupational therapist who works with a client who has HIV B. A personal trainer who works with a client who has HIV C. A phlebotomist who collects blood from clients who have HIV D. A nurse who works for an insurance company and collects urine samples from clients who have HIV

ANS: C. A phlebotomist who collects blood from clients who have HIV Rationale: The greatest risk for exposure to HIV is from a needle stick; therefore, the phlebotomist who is collecting blood is at greatest risk.

A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include? A. Bathe daily with moisturizing soap. B. Apply antibacterial topical medication to the crusted exudate. C. Apply warm compresses to the affected area. D. Cover the affected area with snug-fitting clothing.

ANS: C. Apply warm compresses to the affected area. Rationale: The client should apply warm compresses to the affected area to promote comfort.

A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan? A. Enforce strict bedrest for 3 days. B. Apply fresh ice packs every 4 hr. C. Elevate the affected leg on two pillows. D. Apply antibiotic ointment to the wound with dressing changes.

ANS: C. Elevate the affected leg on two pillows. Rationale: Cellulitis is an acute inflammation of the deep connective tissue of the skin, caused by infection. The edema of the inflammatory response puts the client at risk for skin breakdown. Elevation of the affected area and frequent repositioning reduces dependent edema and assists in the healing process.

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound? A. Hydrofiber B. Alginate C. Hydrogel D. Transparent film

ANS: C. Hydrogel

What is the leading cause of death in people with AIDS? A. Kaposi Sarcoma B. Malnutrition C. Infection D. Encephalopathy

ANS: C. Infection

A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is the top priority? A. Monitor intake and output. B. Administer antibiotics. C. Monitor respiratory status. D. Encourage fluid and food intake.

ANS: C. Monitor respiratory status. Rationale: The priority action for the nurse when using the airway, breathing, and circulation (ABC) approach to client care is to monitor the client's respiratory status closely. Smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from the inflammatory response to heat can obstruct the airway. Endotracheal intubation may become necessary to maintain a patent airway. (pg. 464)

A nurse is caring for a client who requires frequent dressing changes for an abdominal wound. Which binder is preferable in this case? A. Abdominal binder B. Tape binder C. Montgomery strap D.T-binder

ANS: C. Montgomery strap

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II? A. Massage the reddened areas. B. Pad the ulcer. C. Promote mobility and/or frequent repositioning. D. Suggest an egg crate mattress.

ANS: C. Promote mobility and/or frequent repositioning. Rationale: Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer.Reddened areas should never be massaged. Padding the ulcer may not be appropriate. An egg crate mattress may be suggested but is not the best option.

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan? A. Massage the client's red bony prominences. B. Assess the client's skin for increased coolness. C. Reposition the client every 2 hr. D. Keep the client's skin moist.

ANS: C. Reposition the client every 2 hr. Rationale: The nurse should change the client's position every 2 hr to stimulate circulation and prevent pressure ulcers.

A nurse is caring for client who has human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? A. Protective isolation B. Droplet precautions C. Standard precautions D. Airborne precautions

ANS: C. Standard precautions Rationale: Standard precautions should be implemented with every client to prevent the spread of infection transmitted by direct or indirect contact with infectious blood or body fluids. Because HIV is spread through blood and bodily fluids, standard precautions are appropriate. (pg. 330 Recommendations for Preventing HIV transmission by Health Care Workers Box)

A nurse is assessing a client who has an exacerbation of herpes zoster. the nurse should observe the client's skin for which of the following? A. Confluent, honey-colored, crusted lesions B. Papules, vesicles, pustules and crusts C. Unilateral, localized, nodular skin lesions D. Fluid-filled vesicular rash in the genital region

ANS: C. Unilateral, localized, nodular skin lesions

A nurse is assessing a client who is 48 hr post-op following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Blood pressure 102/66 mm Hg B. Straw-colored urine from an indwelling urinary catheter C. Yellow-green drainage on the surgical incision D. Respiratory rate 18/min

ANS: C. Yellow-green drainage on the surgical incision Rationale: Thick yellow-green drainage is indicative of an infection and should be reported immediately.

The nurse has completed discharge teaching for a client who is being discharged to home after treatment for cellulitis. Which statement by the client during evaluation of the response to teaching would the nurse need to​ clarify? A. "Before doing wound​ care, I need to scrub my hands with soap and water for at least 20​ seconds." B. "I should wash the wound at least once daily with soap and​ water." C. ​"After cleaning the​ wound, I need to apply antibiotic ointment and a clean​ bandage." ​D. "I need to carefully monitor the size of the wound to make sure it is not​ increasing."

ANS: C. ​"After cleaning the​ wound, I need to apply antibiotic ointment and a clean​ bandage."

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? Characteristics of the cough and sputum

ANS: Characteristics of the cough and sputum

Nurse Kaye is carrying out her operative teachings for an older client who will have cataract surgery on the right eye. The nurse concludes that the client needs further understanding about the teachings if he says: A. "I will sleep on my left side after surgery." B. "I will wipe my nose gently if it is congested after surgery." C. "I will call my physician if I have sharp and sudden pain or a fever after surgery." D. "I will bend below my waist frequently to increase circulation after surgery."

ANS: D. "I will bend below my waist frequently to increase circulation after surgery." Rationale: Immediately after the procedure, the client should avoid bending over, to prevent putting extra pressure on the eye.

A nurse is providing teaching to a client who has a prescription for heat therapy for Tx of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching? A. "I will sit on the side of the tub and soak my right leg two times every day." B. "I'll keep a heating pad on the calf of my right leg when I am lying down." C. "I'll place my leg under a heat lamp every 3 hours." D. "I'll wrap a warm, wet towel around my right calf every 4 hours."

ANS: D. "I'll wrap a warm, wet towel around my right calf every 4 hours." Rationale: Moist heat is more effective than dry heat in treating cellulitis. Moist heat relieves the manifestations of inflammation by increasing blood flow to the affected area. The nurse should instruct the client to elevate the right leg 8 to 15 cm (3 to 6 in) above the level of the heart and apply warm, moist heat to the site every 2 to 4 hr.

An adult client was burned in a car fire. The client sustained a circumferential burn to the right arm, the anterior torso, and half of the anterior face. What percent of the body was burned using the rule of nines? A. 15.75% B. 27% C. 29.25% D. 31.5%

ANS: D. 31.5% Rationale: R arm = 4.5%(anterior) + 4.5%(posterior) = 9% whole arm. Anterior Torso = 18. Anterior Face: 4.5%. To get the answer: 9+18+4.5 = 31.5%

A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse further checks for which of the following that is also indicative of the presence of SLE? A. Emboli B. Ascites C. Two hemoglobin S genes D. Butterfly rash on cheeks and bridge of nose

ANS: D. Butterfly rash on cheeks and bridge of nose Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many conditions but are not associated with SLE.

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? A. Speak using his usual tone of voice. B. Stand directly in front of the client. C. Rephrase statements the client does not hear. D. Determine if the client uses hearing aids.

ANS: D. Determine if the client uses hearing aids. Rationale: The first action the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning.

A 52-year-old female patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? A. Cough, diarrhea, headaches, blurred vision, muscle fatigue B. Night sweats, fatigue, fever, and persistent generalized lymphadenopathy C. Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes D. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea

ANS: D. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea Rationale: Clinical manifestations of an acute infection with HIV include flu-like symptoms between 2 to 4 weeks after exposure. Early chronic HIV infection clinical manifestations are either asymptomatic or include fatigue, headache, low-grade fever, night sweats, and persistent generalized lympadenopathy. Intermediate chronic HIV infection clinical manifestations include candidal infections, shingles, oral or genital herpes, bacterial infections, Kaposi sarcoma, or oral hairy leukoplakia. Late chronic HIV infection or acquired immunodeficiency syndrome (AIDS) includes opportunistic diseases (infections and cancer)

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision C. Onset of progressive dementia D. Reddish-purple skin lesions

ANS: D. Reddish-purple skin lesions Rationale: Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are treated with radiation and/or chemotherapy. (pg. 333 txtbk)

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision C. Onset of progressive dementia D. Reddish-purple skin lesions

ANS: D. Reddish-purple skin lesions Rationale: Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are treated with radiation and/or chemotherapy. (pg. 333)

A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following? A. Serous B. Purulent C. Sanguineous D. Serosanguineous

ANS: D. Serosanguineous Rationale: Watery red drainage should be documented as serosanguineous.

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)

ANS: D. Temperature of 39.1°C (102.4°F) Rationale: An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms.

A charge nurse is teaching a group of health care workers about hand hygiene. A. Keep artificial nails trimmed B. Use alcohol-based hand rubs before administering eye drops C. Wash hands with alcohol-based hand rubs when the client has C. Diff D. Use chlorhexidine to wash hands if the client is immunosuppressed

ANS: D. Use chlorhexidine to wash hands if the client is immunosuppressed Rationale: The CDC recommends health care workers use chlorhexidine for hand washing when providing care to a client who is immunosuppressed.

In addition to hand washing, what important precautions must the nurse take when changing the dressing of an AIDs patient? A. Wearing a mask B. Strict isolation C. Wearing gloves D. Wearing gown and gloves

ANS: D. Wearing gown and gloves

Mary had an accidental needlestick one night during her shift as an emergency medical technician. Initially, she tested positive for HIV by the ELISA test. Which test would be done next to confirm an HIV infection? A. Immunoelectrophoresis B. Ouchterlony C. Complement fixation D. Western blot

ANS: D. Western blot

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: A. Prevent hypothermia B. Assess the blood pressure C. Assess the airway D. Prevent infection

ANS: C. Assess the airway Rationale: Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A. Check the client's vital signs. B. Assess the client's pain level. C. Cover the wound with a moist, sterile gauze dressing. D. Obtain a culture and sensitivity of the wound drainage.

ANS: C. Cover the wound with a moist, sterile gauze dressing. Rationale: The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

Hematocrit

Male: 42-52 Women: 36-46

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the Rule of Nines (NGN Question?) 22.5%

ANS: 22.5%

The client has sustained severe burns on both the anterior right and left leg and the anterior chest and abdomen. According to the rule of nines, what percentage of the body has been burned? _____

ANS: 36% Each leg is 18%, with the anterior surface (front) being 9%. Because the anterior of both legs is burned (9% each), that would be 18%. That 18% plus the anterior surface of the trunk, which is 18%, totals 36% of the total body surface burned.

A nurse is caring for a client who is suspected of having HIV. The nurse should identify which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply). A. Western Blot B. Indirect immunofluorescence assay (ELISA) C. CD4+ T-lymphocytes count D. HIV RNA quantification test E. Cerebrospinal fluid (CSF) analysis

ANS: A, B Rationale: Positive results of a Western blot test confirm the presence of HIV infection. Positive results of an indirect immunofluorescence assay confirm the presence of HIV infection (CMS pg. 575).

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) A. Administer analgesics. B. Prevent wound infections. C. Provide fluid replacement. D. Decrease core temperature. E. Initiate physical therapy.

ANS: A, B, C Rationale: Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

Which of the following are subscales on the Braden Scale for predicting pressure ulcers? (Select all that apply.) A. Nutrition B. Moisture C. Mobility D. Age E. BMI

ANS: A, B, C Rationale: The six subscales of the Braden Scale are sensory perception, activity, mobility, moisture, friction and shear, and nutrition.

For many women, one of the first symptoms of HIV infection is: A. Vaginal candidiasis B. Burning on urination C. Menstrual irregularities D. Hemorrhoids

ANS: A. Vaginal candidiasis

A nurse is caring for an adolescent who has superficial partial-thickness burn to the thigh. Which of the following actions should the nurse take? A. Prepare the adolescent for transport to burn facility B. Cleanse the affected area with tepid water C. Scrub the affected area using a soft-bristle brush D. Administer morphine sulfate

ANS: B. Cleanse the affected area with tepid water

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions? A. Halitosis B. Gingivitis C. Xerostomia D. Candidiasis

ANS: D. Candidiasis

Hemoglobin

Men: 14-17 Women: 12.5-15

RBCs

Men: 4.7-7 Women: 3.7-5.2

INR

Normal: 0.8-1.1 Therapeutic: 2-3 Critical: >5.5

PT

Normal: 11-12.5 Therapeutic: 1.2-2x

aPPT

Normal: 30-40 Therapeutic: 1.5-2.5x Critical: >70