Exam 4
In which order will the nurse prioritize tasks in a managing a severe allergic reaction? 1 Maintain a patent airway 2 Recognize s/s of anaphylaxis 3 administer drugs 4 treat shock
2 Recognize s/s of anaphylaxis 1 Maintain a patent airway 3 administer drugs 4 treat shock
A patient with which occupation may have a higher risk for developing skin malignancies? SATA A. Baseball player B. Teacher C. Software engineer D. Farmer E. Construction worker
A, D, E
Which instruction about eliminating the risk of HIV transmission would the nurse provide? SATA A. Do not participate in sexual intercourse while under the influence of drugs B. Always use sterile equipment to inject drugs C. You may share thoroughly cleaned equipment to prepare the drugs D. Clean equipment used to inject drugs E. Wear gloves when self-injecting because of potential blood exposure
A,B,D
Which patient would benefit from education about HIV preexposure prophylaxis (PrEP)? A. A 52 year old recently single woman just diagnosed with chlamydia B. A 33 year old hospice worker who received a needle stick injury 3 hours ago C. A 23 year old woman living with HIV infection D. A 60 year old male in a monogamous relationship with an uninfected partner
A. A 52 year old recently single woman just diagnosed with chlamydia
A patient arrives in the ED with facial and chest burns caused by a house fire. Which action would the nurse take first? A. Auscultate for breath sounds B. Determine the extent and depth of the burns C. Infused the prescribed LR solution D. Give the prescribed Dilaudid
A. Auscultate for breath sounds
The nurse providing care for a patient with septic shock recalls that the RAAS system is activated during which stage? A. Compensatory B. Refractory C. Progressive D. Initial
A. Compensatory
Approximately 2 weeks after receiving a liver transplant, a patient develops a maculopapular rash on the soles of the feet and palms of the hands that quickly develop bullous formation. What does the nurse suspect this patient may be experiencing? A. Graft-versus host disease B. A local reaction to gloves C. A stress response D. An allergic reaction to the medications to avoid rejection
A. Graft-versus host disease
Which laboratory value would the nurse monitor to measure the by-product of anaerobic metabolism in a patient with sepsis? A. Lactic acid B. Arterial blood gas C. Blood culture D. Base deficit
A. Lactic Acid
During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluid? A. Measure hourly urine output B. Check skin turgor C. Monitor daily weight D. Assess mucous membranes
A. Measure hourly urine output
Which type of shock is associated with bradycardia? A. Neurogenic B. Hypovolemic C. Septic D. Cardiogenic
A. Neurogenic
Which nursing assessment finding is most concerning in a 65kg patient experiencing cardiogenic shock? A. PaO2 60mmHg B. HR of 96 beats/min C. BP 100/56 D. Urine output 260mL/ 8 hrs
A. PaO2 60mmHg
Which patient who has arrived at the HIV clinic would the nurse assess first? A. Patient who has had 10 liquid stools in the last 24 hours B. Patient whose rapid HIV antibody test is positive C. Patient who has nausea from prescribed antiretroviral drugs D. Patient whose latest CD4 count has dropped to 250
A. Patient who has had 10 liquid stools in the last 24 hours
Immediately after the nurse administers an intradermal injection of an allergen on the forearm, the patient reports itching. Which action should the nurse take first? A. Place a tourniquet above the site B. Reschedule the patient's other allergen tests C. Administer subcutaneous epinephrine D. Apply anti-inflammatory cream
A. Place a tourniquet above the site
The nurse designs a program to decrease the incidence of HIV infection in the adolescence would the nurse assign as the highest priority for these populations? A. Prevention of HIV transmission between sexual partners B. Ways to sterilize needles used by injectable drug users C. Means to prevent transmission through blood transfusions D. Methods to prevent perinatal HIV transmission
A. Prevention of HIV transmission between sexual partners
Which type of shock would the nurse infer if a patient with pneumonia develops hypotension, hypothermia, and leukocytosis? A. Septic B. Hypovolemic C. Cardiogenic D. Neurogenic
A. Septic
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? A. Stabilize the cervical spine B. Inspect the contact burns C. Check the blood pressure D. Assess alertness and orientation
A. Stabilize the cervical spine
Which method of transmission precaution would the nurse use when providing care in the hospital setting for a patient suspected with HIV? A. Standard B. Contact C. Airborne D. Droplet
A. Standard
Which finding about a patient who is receiving vasopresson to treat septic shock indicates an immediate need for the nurse to intervene? A. The patient reports diffuse chest pressure B. The patient's urine output is 18 mL/hr C. The patient's peripheral pulses are weak D. The patient's heart rate is 110 beats. minute
A. The patient reports diffuse chest pressure
The nurse is caring for a patient who is living with HIV and taking antiretroviral therapy. Which should the nurse address when planning care? A. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy) B. The patient is unable to explain the effects of atorvastatin C. The patient reports having no side effects from the medications D. The patient reports feeling "constantly tired"
A. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy)
The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient indicates a need for further teaching? A. "The drugs are combined to inhibit different ways the kidney can be rejected" B. "After a couple of years, I will be able to stop taking immunosuppressants" C. "If I develop an acute rejection episode, I will need additional types of drugs" D. "I need to be monitored closely for development of cancer"
B. "After a couple of years, I will be able to stop taking immunosuppressants"
A patient in the emergency room is anxious and reports difficulty breathing after being stung by a wasp. Which action is priority? A. Administer antihistamines B. Assess the patient's airway C. Provide high-flow oxygen D. Remove the stinger from the site
B. Assess the patient's airway
When caring for a patient in acute septic shock, which intervention would the nurse expect to incorporate into the plan of care? A. Administering osmotic diuretics B. Infusing large amounts of IV fluid C. Administering IV diphenhydramine D. Assisting with the insertion of a ventricular assist device
B. Infusing large amounts of IV fluid
Which information would the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma? A. Low-dose systemic chemotherapy is used to treat BCC B. Minimizing sun exposure reduces risk for future BCC C. Screening for metastasis will be important D. Treatment plans include watchful waiting
B. Minimizing sun exposure reduces risk for future BCC
Which type of shock would the nurse monitor for in a patient with a tension pnemothorax? A. Hypovolemic B. Obstructive C. Septic D. Anaphylactic
B. Obstructive
A patient who has HIV has a CD4 count of 400. Which factor is important of ART for this patient? A. CD4 count B. Patient's ability to follow a complex medication regimen C. How the patient obtained HIV D. Patient's tolerance for potential medication side effects
B. Patient's ability to follow a complex medication regimen
The nurse provides care for a patient experiencing shock. Assessment findings are indicative of decreasing cardiac output and identifies the patient is in which stage of shock? A. Refractory B. Progressive C. Compensatory D. Initial
B. Progressive
The nurse is caring for a patient with superficial partial thickness burns of the face sustained within the last 12 hours. Which is a manifestation? A. Blisters B. Reddening of the skin C. Damage to sweat glands D. Destruction of all skin layers
B. Reddening of the skin
The nurse is reviewing laboratory results for a patient who had a large burn 48 hours ago. Which result requires priority action? A. BUN of 37 B. Serum potassium of 6.1 C. Serum sodium of 147 D. Hematocrit of 53%
B. Serum potassium of 6.1
A 3 year old child is admitted to the burn unit with partial and full thickness burn over 30% of the body. Which complication should the nurse assess for? A. Hypertension B. Shock C. Pneumonia D. Contractures
B. Shock
Which type of diagnostic testing would identify a patient's specific allergy who has recurrent symptoms of hives and rashes? A. Enzyme-linked immunosorbent assay B. Skin testing C. Testing bronchial secretions D. CBC
B. Skin testing
Which type of hypersensitivity would the nurse document whne a patient reports experiencing a runny nose and sneezing? A. Type II B. Type III C. Type I D. Type IV
C Type I
The nurse is reviewing the fluid and electrolyte shifts that occur during burn injury. Which of these occur during the emergent stage of a burn injury? Select all that apply A. Movement of potassium into the cells B. Adherence of albumin to vascular walls C. Edema in nonburned areas D. Elevated hematocrit E. Movement of water and sodium to the interstitial fluid
C, D, E
A patient who has severe refractory psoriasis on the face, neck, and extremities reports being socially withdrawn because of the lesions A. Discuss the possibility of taking part in an online support group B. Suggest that the patient use cosmetics to cover the psoriatic lesion C. Ask the patient to describe the impact of psoriasis on quality of life D. Encourage the patient to volunteer to work on community projects
C. Ask the patient to describe the impact of psoriasis on quality of life
A patient with O-positive blood is transfused with AB-positive blood. Which hypersensitivity reaction does the nurse anticipate the patient will experience? A. IgE-mediated reaction B. Immune-complex reaction C. Cytotoxic reaction D. Delayed hypersensitivity reaction
C. Cytotoxic reaction
Which assessment has the highest priority when providing care for a client witha burn in the emergent stage? A. Type of first aid provided B. Location of the burn C. Extent of the burn D. Cause of the burn
C. Extent of the burn
When teaching a group of adults about immunoglobulins, which function would the nurse present for IgG? A. Causes an allergic response B. Responsible for primary immune response C. Responsible for secondary immune response D. Lines mucous membranes
C. Responsible for secondary immune response
A patient who is receiving immunotherapy has just received an allergen injection. Which finding is the most important to communicate to the provider? A. The patient's symptoms did not improve in 2 months B. There is redness and swelling at the injection site C. There is a 2 cm wheal at the site of the injection D. The patient's IgG level is increased
C. There is a 2 cm wheal at the site of the injection
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? a. Nystatin tablet b. Oral acyclovir (Zovirax) c. Oral saquinavir (Invirase) d. Aerosolized pentamidine (NebuPent)
C.Oral saquinavir (Invirase)
Which patient may have the highest risk for developing malignant melanoma? A. A patient who required phototherapy as an infant to treat hyperbilirubinemia B. A black patient with a family history of cancer C. A Hispanic male with a history of psoriasis who responded poorly to treatment D. A fair-skinned woman who uses a tanning booth regularly
D. A fair-skinned woman who uses a tanning booth regularly
Which patient would the nurse assess first? A. A patient with partial thickness burns who is receiving IV fluids at 500mL/hr B. A patient with burns who reports level 8 pain C. A patient with full-thickness leg burns who is scheduled for a dressing change D. A patient with smoke inhalation who has wheezes and confusion
D. A patient with smoke inhalation who has wheezes and confusion
Several interventions are prescribed by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which should the nurse complete first? A. give diphenhydramine B. start continuous ECG monitoring C. Draw blood for CBC D. Administer epinephrine
D. Administer epinephrine
A patient who uses injectable illegal drugs asks the nurse how to prevent AIDS. Which is used to prevent HIV? A. Clean your drug injection equipment before each use B. Avoid sexual intercourse when using injectable drugs C. Ask those who share equipment to be tested for HIV D. Consider a needle and syringe exchange program
D. Consider a needle and syringe exchange program
Which type of shock would the nurse suspect when the client is admitted to the ED after a motor vehicle accident? A. Neurogenic B. Septic C. Cardiogenic D. Hemorrhagic
D. Hemorrhagic
A client in shock develops a MAP of 60 mmHg. Which prescribed medication would the nurse implement? A. Continue to monitor B. Obtain ABG C. Increase the rate of O2 D. Increase the rate of IV fluid
D. Increase the rate of IV fluid
Which complication is the client at high risk for when sepsis has developed after severe burn injuries? A. Constipation B. Malabsorption syndrome C. Diarrhea D. Paralytic ileus
D. Paralytic ileus
A patient with extensive electrical burn injuries is admitted to the ED. Which prescribed intervention should the nurse perform? A. check potassium level B. Assess pain level C. Assess oral temperature D. Place on heart monitor
D. Place on heart monitor
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the provider? A. O2 saturation of 93% on room air B. Heart rate of 118 beats/min C. Blood pressure of 92/56 mm Hg D. Skin cool and clammy
D. Skin cool and clammy
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted. Which action should the nurse take first? A. Assess orientation and LOC B. Administer the ordered morphine sulfate IV C. Stay at the bedside and reassure the patient D. Use pulse oximetry to check the oxygen saturation
D. Use pulse oximetry to check the oxygen saturation
A client sustains full-thickness and deep partial-thickness burns. The client asks, "What is the difference between my full-thickness and deep partial-thickness burns?" Which information will the nurse share with the client? Sorry guys I can't find the options online and the video is cut off
Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis.
Which exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Bite to the arm that does not result in open skin. b. Splash into the eyes while emptying a bedpan containing stool. c. Needle stick with a needle and syringe used for a venipuncture. d. Contamination of open skin lesions with patient vaginal secretions.
c. Needle stick with a needle and syringe used for a venipuncture.
After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment• Petechiae noted on chest and legs• Crackles heard bilaterally in lung bases• No redness or swelling at central line IV site Laboratory Data• Blood urea nitrogen (BUN) 34 mg/Dl• Hematocrit 30%• Platelets 50,000/µLVital Signs• Temperature 100°F (37.8°C)• Pulse 102/min• Respirations 26/min• BP 110/60 mm Hg• O2 saturation 93% on 2L O2 via nasal cannula a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate.
c. Platelet count and presence of petechiae
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Initiate continuous electrocardiogram (ECG) monitoring. c. Provide oxygen at 100% per non-rebreather mask. d. Draw blood to type and crossmatch for transfusions.
c. Provide oxygen at 100% per non-rebreather mask.
A patient informed of a positive rapid screening test for HIV is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Inform the patient about the available treatments. b. Teach the patient how to manage a possible drug regimen. c. Remind the patient to return for retesting to verify the results. d. Ask the patient to identify those persons who had intimate contact.
c. Remind the patient to return for retesting to verify the results.
A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.
c. The patient's IV infusion site is cool and pale.
A patient is admitted with severe burns over the front lower extremities, abdomen, chest, and both sides of the arms. What is the percentage of burn?
54%
A patient has just arrived in the ED after an electrical burn from exposure to a high-voltage current. Which is priority? A. Peripheral pulses B. Extremity movement C. Pupil reaction to light D. Oral temperature
B. Extremity movement
Which fluid increases osmotic pressure to provide rapid volume expansion for a patient experiencing hypovolemic shock? A. 3% sodium chloride B. Human serum albumin C. 0.9% sodium chloride D. Lactated Ringers
B. Human serum albumin
Which clinical manifestation indicates that the patient is undergoing plasmapheresis is experiencing citrate toxicity? A. Hypertension B. Conjunctivitis C. Sneezing D. Headache
D. Headache
Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? A. There are no signs of hemorrhage B. Hemoglobin is within normal limits C. MAP is 72 mm Hg D. Urine output 65 mL over the past hour
D. Urine output 65 mL over the past hour
A 73-year-old male was taken to the Emergency Department by ambulance because his wife found him sitting up in his recliner, awake but not responsive. He takes sitagliptin daily for type 2 diabetes mellitus and a daily multivitamin. 1) The nurse recognizes that based on the patient's history and diagnosis, he is currently at risk for complications, especially __________, __________, and __________. In two or more sentences, explain what lab results lead you to conclude these risks. Options: Septic shock Fluid overload Respiratory failure Hypertensive crisis Coronary vessel occlusion Acute kidney injury
Respiratory failure, AKI, Septic shock
A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.
a. Give normal saline IV at 500 mL/hr.
During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Heart rate 112 beats/minute c. Decreased bowel sounds d. Pale, cool, and dry extremities
a. New onset of confusion
After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles inthe lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rateof 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg
b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics
Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.
b. Urine output of 41 mL over past 2 hours
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hour
c. 938 mL/hour
Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation
d. Oxygen saturation
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask
d. Place the patient on 100% oxygen using a non-rebreather mask