Final 260
19. What is a humoral immune response against invading antigens?
B cells and their effector products make up adaptive immunity known as humoral immunity. The humoral immune response begins with the recognition of antigens. B cells label specific cells for destruction. B Cells> The Humoral Immune Response. Antibodies secreted by B cells label invading microbes for destruction. Antibodies> Genetic recombination generates millions of B cells, each specialized to produce a particular antibody. Antibodies react against certain blood types and pregnancy hormones.
. a nasogastric (NG) buckube to wall suction. For a bowel obstruction what are the nursing interventions for postoperative plan of care?
(Chapter 47/Pg. 531 ATI Med Surg Book) o Assess and maintain proper function of the NG tube and suction equipment. o Maintain accurate I & O o Assess bowel sounds and abdominal girth; return of flatus o Monitor tube for displacement (decrease in drainage, increased nausea, vomiting, distention). o Instruct client to maintain NPO status.
110. A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHAapprovedN95 respirator mask when caring for a client with which of the following infectious diseases?
C. Tuberculosis
86. A nurse is considering the risk factors for a client who has a surgical wound. Which of the following factors place the client at risk for dehiscence?
poor nutritional state - obesity - wound infection
26. What instructions about heat therapy to assist in the treatment of cellulitis is ture.
Warm compress promotes comfort /done 4x a day for 15-30 minutes
39. A nurse is caring for a client who is a triathlete and is scheduled for knee arthroscopy due to knee pain. Would this client be able to do this procedure?
(Chapter 68 Pg. 751 ATI Med Surg) YES o Arthroscopy is done to visualize the internal structures of a joint, most commonly the knee or the shoulder joints. o Number and placement of incisions depend on the area of the joint needing to be visualized and the extent of the needed repair. o Arthroscopy cannot be done if infection is present in the joint or if the client is unable to bend the joint at least 40 degrees o Indications: -Potential diagnoses: A client who has sustained injuries to his joints may undergo arthroscopy to ascertain the extent of damage, during which time repair may also be done using the arthroscope (torn ligament, meniscus, or synovial biopsy). -Client presentation: joint swelling, pain, and crepitus, joint instability
A nurse is caring for a client following arthroscopic knee surgery. What would you teach to prevent postoperative complications
(Chapter 68/Pg. 752 ATI Med Surg Book) o Infection may occur as with any procedure that disrupts the integrity of the skin o Client education: Notify provider immediately of swelling, redness, or fever
36. What is the nurse priority focus of care for A nurse in an emergency department preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash.
(Found on quizlet) Airway protection (airway, breathing, circulation)
94. A client who is postoperative returns to the unit in skeletal traction. When assessing the client, the nurse should expect which of the following findings?
-Slight pain at the insertion site -serous drainage on the dressing -minimal edema around the traction ropes
87. A nurse is caring for a client who has herpes zoster (shingles). Which of the following is an expected finding?
-clustered skin vesicles **From quizlet** It's a reoccurrence of Chicken Pox, and is very painful Symptoms - painful rash on one side of the face or body; forms blisters that scab over in 7-10 days and clears up within 2-4 weeks; fever, headache, chills, upset stomach Complications - postherpetic neuralgia- pain continues long after blisters have cleared, nerve damage; vision loss; neurological problems; skin infections
65. A nurse is in-servicing a group of clients in the community on early detection for colorectal cancer. The nurse knows that the American Cancer Society recommends that men and women beginning at age 50 are at average risk and should have flexible sigmoidoscopy every
5 years.
85. A nurse is caring for a client with suspected malignant melanoma. Which of the following is an expected Finding when assessing the lesion?
? an irregular shaped lesion A - Asymmetry: one side does not match the other B - Borders: Ragged, notched, irregular, or blurred edges C - Color: Lack of uniformity in pigmentation (shades of tan, brown, or black) D - Diameter: Width greater than 6mm, or about the size of a pencil eraser E - Evolving: Or change in appearance (shape, size, color, height, texture) or condition (bleeding, itching)
. which is an expected finding? For a client who has a delayed hypersensitivity reaction.
A delayed hemolytic reaction can develop 2 to 14 days following transfusion as a result of antibody response to non ABO donor antigens that weren't detected during crossmatch. Symptoms include fever of unknown origin, and unexplained decrease in hemoglobin or hematocrit levels, an increase in serum bilirubin levels, and the appearance of jaundice. Graft vs. Host Disease: Symptoms develop days, weeks following the infusion and include skin rash, fever, jaundice due to liver dysfunction, and bone marrow suppression. Post transfusion purpura can develop 7 to 10 days post infusion.
21. A middle-aged client tells the nurse that she tested positive for a mutant BRCA-1 gene. What is the client?
A person that tests positive for BRCA-1 gene is 3 to 7 times more likely to develop breast cancer. This person is also more likely to develop other cancers. Middle-aged woman whose mother died at age 48 of breast cancer
67. A nurse is caring for a client who has a long history of peptic ulcers and is admitted for treatment of pyloric obstruction. The nurse is preparing to insert a nasogastric tube. Which of the following options is
Gastric decompression
120. A nurse is caring for a client who is postoperative from a total hip arthroplasty. The nurse assists the client into a supine position. Which intervention would prevent adduction which can lead to possible dislocation.
A= Maintain foam wedge between legs
48. A nurse is providing teaching for a client who is preparing for a below the knee amputation. Regarding the postoperative placement of prosthesis? What teaching ?
A= Wrap the stump with an elastic bandage in a figure eight configuration
11. in a discharge teaching for a client who has (SLE). Which of the following instructions should the nurse include?
ATI Med-surge Pg. 967 ATI - Client Education ■ Avoid UV and sun exposure. Use sunscreen when outside and exposed to sunlight. ■ Use mild protein shampoo and avoid harsh hair treatments. ■ Use steroid creams for skin rash. ■ Report peripheral and periorbital edema promptly. ■ Report evidence of infection related to immunosuppression. ■ Avoid crowds and individuals who are sick, because illness can precipitate an exacerbation. ■ Educate client of childbearing age regarding risks of pregnancy with lupus and treatment medications. Quizlet The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? 1. "Exposure to sunlight will help control skin rashes." 2. "There are no activity limitations between flare-ups." 3. "Monitor your body temperature." 4. "Corticosteroids may be stopped when symptoms are relieved." Correct answer #3. "Monitor your body temperature." Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation
17. A nurse is caring for a client who is positive for human immunodeficiency virus (HIV) the nurse anticipates what plans to discuss for the progression the disease with the provider.
Anti-retroviral therapy HAART, Fuzeon (infusion inhibitors). Teach the client the signs and symptoms that need to be reported immediately. Follow up and monitoring of CD4+ counts.
81. A nurse is preparing an educational program regarding basal cell carcinoma. Which of the following should be included in the presentation?
Basal cell are small, waxy NODULE with superficial blood vessels, well-defined borders. • Invades local structures (nerves, bone, cartilage, lymphatic and vascular tissue) • Rarely metastatic but high rate of recurrence • Topical chemotherapy with fluorouracil cream for treatment of widespread superficial basal cell carcinoma
. What is included in the postoperative teaching to prevent pulmonary complications?
Deep breathing exercises/splinting/use of incentive spirometer/pursed lip breathing
93. A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins promote wound healing and should be included in the teaching?
From Pearson Slides: o Encourage an intake of 2,000 to 3,000 mL of fluid/day, from food and beverage sources if not contraindicated (heart and renal failure). o Provide education about good sources of protein (meat, fish, poultry, eggs, dairy products, beans, nuts, whole grains). o Note if serum albumin levels are low (below 3.5 g/dL), because a lack of protein increases the risk for a delay in wound healing and infection. o Provide nutritional support (vitamin and mineral supplements, nutritional supplements, and enteral and parenteral nutrition). Most adult clients need at least 1,500 kcal/day for nutritional support.
63. A nurse is caring for a client who has received radiation therapy. The client reports dryness, redness, and scaling within the designated radiation treatment markings. Which of the following should actions should the nurse take?
External Radiation: Wash area with plain water; no soap, deodorant, lotions, medications, perfumes, or talcum powder to site. Don't wash off markings. Use electric razor if necessary. No heat or cold. Protect from sun exposure.
124. A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and has skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications? Fat embolism
Fat embolism
7. Which of the following foods contains the most iron? Nutrition ATI page 10
Food sources include organ meats, egg yolks, whole grains, and green leafy vegetables. Quizlet. The richest sources of iron in the diet are: fruits and vegetables. nuts and seeds. meats and seafood. breads and pastries.
1A nurse in a clinic is assessing a client who, has a significantly decreased CD4 cell count, the client is likely to have which of the following condition?
HIV Pg. 953 NOTES: HIV targets CD4+ lymphocytes, also known as T-cells or T-lymphocytes. Normal Adult CD4 is between 500 - 1200 cells/mm3 Stage 1: CD4+ T-LYMPHOCYTE COUNT = 500 cells/mm3 or more (29% or more) Stage 2: CD4+ T-LYMPHOCYTE COUNT = 200 to 499 cells/mm3 (14 to 28%) Stage 3 (Aids): CD4+ T-LYMPHOCYTE COUNT = Less than 200 cells/mm3 (< 14%)
13. Describe the initial symptoms experienced with HIV and AIDS infection
HIV symptoms are similar to influenza (chills, nausea, weight loss, night sweats) headache, weakness and fatigue and can include a rash and a sore throat. (Manifestations occur within 2 to 4 weeks of infection). • AIDS is characterized by life-threatening opportunistic infections. Kaposi's sarcoma, recurrent pneumonia. Candidiasis of the esophagus, TB, wasting syndrome. Burkitt's lymphoma. Less than 200 cells/mm CD4+ count.
. A nurse is caring for a client who has a peptic ulcer. Which of the following findings is a risk factor for this condition?
Helicobacter pylori (H. pylori) infection • NSAID and corticosteroid use • Severe stress • Hypersecretory states • Type O blood • Excess alcohol ingestion • Chronic pulmonary or kidney disease • Zollinger-Ellison syndrome (combo of PUUD, hypersecretion of gastric acid, and gastrin secreting tumors).
62. A nurse is preparing a client for a radiation treatment. Which of the following should the nurse inform the client to expect?
Radiation given in addition to excision of tumors to ensure all cancer gone. May be only treatment or just palliative to shrink tumor size. Typically 3-5x/week for 5-8 weeks. 15-30 minute sessions. External (see below) Internal radiation - low risk of exposure to others. Even so, small children and pregnant women should avoid. Visitors should limit time of interaction and remain 6 feet away.
75. A nurse in a clinic is teaching a client how to do fecal occult blood testing. Which of the following statements
Instruct the client about proper collection technique. The client may also need to be instructed about dietary and medication restrictions to follow prior to obtaining samples (red meat, anticoagulants). Obtain specimens from three different stools. Avoid Poultry a few days before A stool sample is collected and tested for blood, ova and parasites (Giardia lamblia), and bacteria (Clostridium difficile). Stool also may be collected to assess for DNA changes in the vimentin gene Client Presentation ■Gastrointestinal bleeding ■Unexplained diarrhea Nursing Actions ■Occult blood - Provide the client with cards impregnated with guaiac that can be mailed to provider or with a specimen collection cup. If the cards are used, three samples are usually required. ■Stool for ova and parasites and bacteria - Provide the client with a specimen collection cup. ◯Client Education ■Occult blood - Instruct the client about proper collection technique. The client may also need to be instructed about dietary and medication restrictions to follow prior to obtaining samples (red meat, anticoagulants). ■Stool for ova and parasites and bacteria - Instruct the client about proper collection technique (time frame for submission to laboratory, need for refrigeration)
. What home instructions are okay for a client who has an immunodeficiency?
Instruct the client to avoid crowded areas or traveling to countries with poor sanitation. • Encourage the client to avoid raw foods such as vegetables and meats. Instruct the client to avoid cleaning pet litter boxes to reduce the risk of toxoplasmosis. • Practice good hand hygiene and frequent hand hygiene to reduce risk of infection.
94. A client who is postoperative returns to the unit in skeletal traction. When assessing the client, the nurse should expect which of the following findings?
Slight pain at the insertion site -serous drainage on the dressing -minimal edema around the traction ropes
18 Which of following should the nurse include in a discussion about the medication ( Methotrexate) in relationship to pregnancy
Methotrexate (Rheumatrex) is a DMARD with serious side effects: hepatoxicity (liver damage), ulcerative stomatitis, low WBC count which makes a person more susceptible to infection. Methotrexate is harmful to fetus PREGNANCY CATEGORY X, hence not used in pregnancy
70. A nurse is caring for a client who just had an upper gastrointestinal endoscopic procedure. Which of the following is the assessment priority for this client?
Perforation/bleeding.
30 The nurse notes decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely due to what
Pna Bed rest. Not expanding lungs Atelectasis
What laboratory tests would the nurse anticipates form a provider regarding a human immunodeficiency reaction.
Positive result from an HIV antibody screening test (ELISA) enzyme linked immunosorbent assay would be followed up with a Western Blot test. Then a viral load test can report quantity.
What factor that may exacerbate SLE?
Pregnancy, infection, sunlight NOTES: See question 11
. A nurse is caring for a client who sustained a large contusion on the head and a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following observations indicates to the nurse that the client could be developing a serious complication?
Pulmonary complications and CNS changes
69. A nurse is caring for a client who has cirrhosis. When delivering the clients lunch tray, which of the following items requires intervention?
Restrict sodium intake 2g/day. Fluid restricted as necessary for ascites/edema (1500mL/day). Adequate calories and protein recommended unless serum ammonia levels high. Plant protein preferred over animal protein.
90. A nurse working in a dermatologist's office is planning an educational session regarding skin cancer. When discussing risk factors the nurse should include which of the following?
Risk Factors o Immunosuppression therapy o Exposure to ultraviolet light (natural light or indoor tanning) over long periods of time o Chronic skin inflammation, burns, or scars o Fair complexion (blonde or red hair, fair skin, freckles, blue eyes) with a tendency to burn easily o Presence of several large or many small moles o Family or personal history of melanoma o Residing in higher elevations or in close proximity to equator (thinner layer of ozone) o Age over 50 years
Appropriate response by the nurse who is caring for a client who has a new diagnosis of (SLE) and asks where this disease originates within the body.
SLE is classified as either discoid or systemic. Discoid primarily affects the skin. It is characterized by an erythematosus butterfly over the nose and cheeks and is generally self-limiting. Systemic SLE affects the connective tissues of multiple organ systems and can lead to major organ failure. Medication induced SLE can be caused by medications (procainamide, hydralazine, isoniazid). Findings resolve when the medication is discontinued, and it does not cause renal or neurologic disease.
. During a routine physical examination, a nurse observes a 1-cm lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should realize that this observation is suggestive of which of the following types of skin cancer?
Squamous cell (rough, scaly lesion with central ulceration and crusting).
61. A nurse is assessing a client's immune function by reviewing the laboratory report of the cellular response of the T cells. Which of the following conditions should the nurse know that are affected by the T cells?
T cells mature in Thymus gland. Control of viral infections and destruction of cancer cells. Involved in hypersensitivity reactions and graft tissue rejection (type IV, delayed). impair cellular immunity
22. What is the effective way to teach deep breathing exercises and cough effectively after surgery?
Teach client exercises before surgery. Assist client with incentive spirometer at least every 2 hours to encourage expansion of the lungs and prevent atelectasis. Also, provide the client with a pillow or folded blanket so the client can splint as necessary for abdominal incision.
23. A client scheduled for a transurethral resection of the prostate what Preoperative nursing care would the nurse include
There will be an indwelling urinary catheter and a continuous bladder irrigation in place From quizlet: "an indwelling urinary catheter is required for at least a day."
31. When administering narcotic analgesic to the client frequently for pain immediately postoperative following thoracic surgery. What should the nurse recognize as the primary reason for this action?
Unable to take deep breath/lack of oxygenation due to pain/narcotic can cause respiratory depression "It facilitates the client's deep breathing"
. To prevent aspiration a nurse in a postanesthesia recovery unit is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse take
Withhold fluids until the client demonstrates a gag reflex"
. A client with a fractured mandible. And has had intermaxillary fixation to repair what would he nurse. What position immediately post op would the nurse put them in:
lateral Most important goal post op: prevent aspiration
.what is the appropriate precautions for A nurse to implement when creating the plan of care for a client who is immunosuppressed.
• Monitor temperature and WBC count • Take temp daily, report elevated temps to the provider • Avoid food sources that contain bacteria • Signs and symptoms of infection need to be reported immediately to provider. Also, monitor skin and mucous membranes for signs of infection. • Wash toothbrush daily • Avoid gardening, yardwork • If patients WBC drops below 1,000, place the patient in a private room and initiate neutropenic precautions. Neutropenia is a neutrophil count of less than 2,000/mm3 • Instruct clients to avoid crowded places. • Teach client importance of a well-balanced diet. • Don't share personal care items (toiletry) with others.
. A nurse is teaching a client about skin cancer. Which of the following client statements indicates a need for further teaching?
"I will limit sun exposure to 1 hour daily." (really broad - this is what I found online) • I will avoid sun exposure after 3 pm (rationale - patient SHOULD avoid sun exposure between 10 am - 3 pm. • I will remove the dressing when I get home and cleanse the site with tape water (rationale - after a skin biopsy to diagnose skin cancer, the patient must keep the dressing dry for 8 hours and then remove the dressing and cleanse it with tape water daily to remove dry blood and crust. The MD is notified if there is drainage or continued bleeding. Suture is removed in 7-10 days after biopsy.) From Quizlet: • A nurse is teaching a client about the risk for cancer. Which of the following client statements indicates the need for further teaching? A. "I see a dermatologist regularly for the mole on my thigh." B. "I take Milk of Magnesia for occasional constipation." C. "I tan using an indoor tanning lotion instead of laying out in the sun." D. "I used to smoke but switched to chewing tobacco 3 years ago."
The nurse should instruct the client that this medication (Rifadin might do which of the following?
Quizlet: turn body secretions to a red-orange color
25. A nurse is caring for a client who has cellulitis of the leg. what interventions should be included in the nurse's care plan for the client?
Quizlet: warm compresses to the affected area"
79. A nurse is performing discharge teaching for a client who is postoperative for a simple mastectomy.
The client is to begin outpatient radiation therapy tomorrow. Which of the following instructions about maintaining skin integrity is appropriate? • Gently wash the skin over the irradiated area with mild soap and water. Dry the area thoroughly using patting motions • Do not remove or wash off radiation "tattoos" (markings) that are used to guide therapy. • Do not apply powders, ointments, lotions, deodorants, or perfumes to the irradiated skin • Wear soft clothing and avoid tight/constricting clothes • Do not expose the irradiated skin to sun or a heat source • Inspect skin for evidence of damage and report to the provider
35. A nurse is caring for a patient who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. What would alert the nurse that's a problem that requires intervention?
(Chapter 18/Pg.193-194 ATI Med Surg Book) Chest tubes are inserted into the pleural space to drain fluid, blood, or air; reestablish a negative pressure; facilitate lung expansion; and restore normal intrapleural pressure Complications: o Air leaks can result if connection is not taped securely Nursing Actions: o Monitor the water seal chamber for continuous bubbling (air leak finding). If observed, locate source of air leak, and intervene accordingly (tighten the connection, replace drainage system). o Check all of the connections o Notify to provider if an air leak is noted, and if prescribed, gently apply a padded clamp to determine the location of air leak. Remove the clamp immediately following assessment. Accidental disconnection, system breakage, or removal complications can occur at any time Nursing Actions: o If tubing separates, the client is instructed to exhale as much as possible and to cough to remove as much air as possible from the pleural space. The nurse cleanses the tips and reconnects the tubing. o If the chest tube drainage system is compromised, the nurse immerses the end of the tube in sterile water to restore the water seal. o If chest tube is accidentally removed, an occlusive dressing taped on only three sides should be immediately place over the insertion site. This allows air to escape and reduces risk for development of a tension pneumothorax. Tension pneumothorax: o Sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause a tension pneumothorax o Assessment findings include tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, asymmetry of the chest, and cyanosis.
44.Care of a client placed into Skeletal traction.
(Chapter 72 Pg.792-793) o Skeletal: The pulling force is applied directly to the bone by weights attached by rope directly to a rod/screw placed through the bone to promote bone alignment. Weights can be applied as needed. o Nursing actions: Assess neurovascular status, maintain body alignment/realign, avoid lifting or removing weights, ensure weights hang freely, if weights are displaced-replace weights, ensure pulley ropes are free of knots, fraying, or loosening every 8 -12 hrs., notify provider if client experiences severe pain from muscle spasms, monitor skin integrity and document, heat/massage for muscle spasms, therapeutic touch/relaxation techniques o Pin site care: -Monitor infection including drainage and redness (color, amount, and odor). -Loosening of pins -Tenting of skin at pin site (skin rising up pin) -Pin care protocols (chlorhexidine)/based on provider preference and facility policy, 1 cotton swab for each pin, done once a shift 1 -2 times a day, crusting at site should be removed
45. A nurse is assessing a client who reports numbness and pain in his right palm and index and middle fingers. nurse should ask the client to do which of the following?
(Chapter 89 ATI Med Surg) o Rheumatoid Arthritis is a chronic, progressive inflammatory disease that can affect tissues and organs, but principally attacks the joints producing an inflammatory synovitis. It involves joints bilaterally and symmetrically, and it typically affects several joints at one time. RA typically affects upper joints first. o Nursing Care: Apply heat for pain in hands/fingers (heated paraffin)
43. A client is admitted to the rehabilitation unit following a spinal cord injury that resulted in paraplegia. Client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. What action should you take?
(Found online from Spinal Cord Injury Care Plans) ________________________________________ Nursing Diagnosis: • Anticipatory Grieving May be related to • Perceived/actual loss of physio psychosocial well-being Possibly evidenced by • Altered communication patterns • Expression of distress, choked feelings, e.g., denial, guilt, fear, sadness; altered affect • Alterations in sleep patterns Desired Outcomes • Express feelings • Begin to progress through recognized stages of grief, focusing on 1 day at a time. Nursing Interventions Rationale Identify signs of grieving (shock, denial, anger, depression). Patient experiences many emotional reactions to the injury and its actual or potential impact on life. These stages are not static, and the rate at which patient progresses through them is variable. Shock Note lack of communication or emotional response, absence of questions. Shock is the initial reaction associated with overwhelming injury. Primary concern is to maintain life, and patient may be too ill to express feelings. Provide simple, accurate information to patient and SO (Significant other) regarding diagnosis and care. Be honest; do not give false reassurance while providing emotional support. Patient's awareness of surroundings and activity may be blocked initially, and attention span may be limited. Little is actually known about the final outcome of patient's injuries during acute phase, and lack of knowledge may add to frustration and grief of family. Therefore, early focus of emotional support may be directed toward SO. Encourage expressions of sadness, grief, guilt, and fear among patient, SO and friends. Knowledge that these are appropriate feelings that should be expressed may be very supportive to patient and SO. Incorporate SO into problem solving and planning for patient's care. Assists in establishing therapeutic relationships. Provides some sense of control of situation of many losses and forced changes, and promotes well-being of patient. Denial Assist patient and SO to verbalize feelings about situation, avoiding judgment about what is expressed. Important beginning step to deal with what has happened. Helpful in identifying patient's coping mechanisms. Note comments indicating that patient expects to walk shortly and is making a bargain with God. Do not confront these comments in early phases of rehabilitation. Patient may not deny entire disability but may deny its permanency. Situation is compounded by actual uncertainty of outcome, and denial may be useful for coping at this time. Focus on present needs (ROM exercises, skin care). Attention on "here and now" reduces frustration and hopelessness of uncertain future and may make dealing with today's problems more manageable. Anger Identify use of manipulative behavior and reactions to caregivers. Patient may express anger verbally or physically (spitting, biting). Patient may say that nothing is done right by caregivers and SO or may pit one caregiver against another. Encourage patient to take control when possible (establishing care routines, dietary choices, diversional activities). Helps reduce anger associated with powerlessness, and provides patient with some sense of control and expectation of responsibility for own behavior. Accept expressions of anger and hopelessness. Avoid arguing. Show concern for patient. Patient is acknowledged as a worthwhile individual, and nonjudgmental care is provided. Set limits on acting out and unacceptable behavior when necessary (abusive language, sexually aggressive or suggestive behavior). Although it is important to express negative feelings, patient and staff need to be protected from violence and embarrassment. This phase is traumatic for all involved, and support of family is essential. Depression Note loss of interest in living, sleep disturbance, suicidal thoughts, and hopelessness. Listen to but do not confront these expressions. Let patient know nurse is available for support. Phase may last weeks, months, or even years. Acceptance of these feelings and consistent support during this phase are important to a satisfactory resolution. Arrange visit by individual similarly affected, as appropriate. Talking with another person who has shared similar feelings and fears and survived may help patient reach acceptance of reality of condition and deal with perceived and actual losses. Consult with and refer to psychiatric nurse, social worker, psychiatrist, pastor. Patient and SO need assistance to work through feelings of alienation, guilt, and resentment concerning lifestyle and role changes. The family (required to make adaptive changes to a member who may be permanently "different") benefit from supportive, long-term assistance and counseling in coping with these changes and the future. Patient and SO may suffer great spiritual distress, including feelings of guilt, deprivation of peace, and anger at God, which may interfere with progression through and resolution of grief process.
A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide (Tebrazid). What do you teach the client to tests regularly for the duration of this medication therapy?
(Found this online) A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide (Tebrazid). The nurse should explain that the client needs which of the following tests regularly for the duration of this medication therapy? A. Liver function tests B. Gallbladder studies. C. Thyroid function studies D. Blood glucose levels A is correct answer Rationale: Pyrazinamide can cause hepatotoxicity, thus the provider will monitor liver function regularly. B is incorrect
. A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHAapproved N95 respirator mask when caring for a client with which of the following infectious diseases?
(Found this online) A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA approved N95 respirator mask when caring for a client with which of the following infectious diseases? A. Pertussis B. Mycoplasmal pneumonia C. Tuberculosis D. Respiratory syncytial virus A is incorrect Rationale: Pertussis is transmitted by large droplets and does not require the use of an individually fitted N95 respirator mask. The nurse should wear a fluid resistant surgical mask when caring for a client who has Pertussis. B is incorrect Rationale: Mycoplasmal pneumonia is transmitted by large droplets and does not require the use of an N95 respirator mask. The nurse should wear a fluid resistant surgical mask when caring for a client who has mycoplasmal pneumonia. C is correct answer Rationale: Tuberculosis is transmitted by small droplets and requires the nurse to wear an individually fitted N95 respirator mask when caring for clients who have this disease. D is incorrect Rationale: Respiratory syncytial virus is transmitted by large droplets and does not require the use of an N95 respirator mask. The nurse should wear a fluid resistant surgical mask when caring for a client who is infected with the respiratory syncytial virus.
59. A nurse is caring for a client who has systemic lupus erythematosus and is about to start taking hydroxychloroquine (Plaquenil) to reduce skin inflammation. The nurse should instruct the client to report which of the following as an indication of a toxic reaction to this medication?
A) Muscle Cramps B) Antimalarial drug - Retinal toxicity and possible irreversible blindness are primary concerns. Ophthalmological exam every 6 months.
46. A nurse is caring for an older adult client who has rheumatoid arthritis and is taking aspirin (Bufferin) 650 mg every 4 hours. What lab should be ordered to evaluate the effectiveness of the above medication
A= bleeding (aspirin may cause bleeding, tiniitus, gastric ulceration, nausea, heartburn
40. What is the nurse's priority regarding a fiberglass cast for a fractured tibia
A= checking capillary refill (My Pearson Online Assignment 13.3 Fractures) o Neurovascular status: Assess 5 P's every 1-2 hours (Pain, Pulses, Pallor, Paresthesia, Paralysis) -Capillary refill -Monitor extremity for edema and swelling -Assess for deep, throbbing, and unrelenting pain -Monitor tightness of the cast -Elevate the injured extremity above the level of the heart o Pain management: Assess pain from 0 to 10, administer pain meds as prescribed, move client gently and slowly o Prevent infection: Sterile techniques for dressing changes, assess wound for size, color, or presence of drainage o Mobility: Support the injured extremity above and below the fracture site when moving and positioning the client, turn/reposition the client on bed rest every 2 hrs., support ambulation when able
121. A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is appropriate regarding the postoperative placement of a prosthesis? The prosthesis will be in place immediately following surgery to?
A= improve your ability to ambulate sooner
113. A nurse is caring for an adolescent who has a newly applied fiberglass cast for a fractured tibia. Immediately following application of a fiberglass cast, the nurse should recognize that the priority nursing action is to
A= report any worsening or unrelieved painfe
104. A nurse in a postanesthesia recovery unit is admitting a client who is postoperative following a tonsillectomy.Which of the following actions should the nurse take to prevent aspiration?
A= withhold fluids until the client demonstrates a gag reflex
A nurse is caring for a client who had abdominal surgery two days ago. Which of the following findings by the nurse requires immediate attention?
A= wound has thick yellow-green drainage • Nausea/Vomiting • Abdominal Distension • Postoperative Ileus • Delayed gastric emptying • Hiccups • Evisceration/Dehiscence
8 A nurse is assessing an older client who has received radiation therapy to treat lung cancer. Based on an understanding of the effects of radiation therapy, the nurse should focus the assessment on what?
ATI Med surge pgs. 1004 & 1005, describes radiation therapy for internal and external please be sure to review these pages. Below are nursing action and teaching for EXTERNAL radiation treatment only! ATI - Nursing Actions (External Radiation) External radiation or teletherapy is delivered over the course of several weeks and aimed at the body from an external source. ■ The client's skin over the targeted area is marked with "tattoos" that guide the positioning of the external radiation source. ■ Provide a well-balanced diet that does not contain red meat. Radiation can cause dysgeusia, making foods such as red meat unpalatable. ■ Help the client manage fatigue by scheduling activities with rest periods in between and using energy-saving measures (sitting during showers and ADLs). ■ Monitor for radiation injury to skin and mucous membranes and implement a skin care regimen. ☐ Skin - blanching, erythema, desquamation, sloughing, hemorrhage ☐ Mouth - mucositis, xerostomia (dry mouth) ☐ Neck - difficulty swallowing ☐ Abdomen - gastroenteritis ■ Monitor CBC (possible decreased platelets and WBCs). ATI - Client Education ■ Review nutrition considerations related to mucositis (avoid spicy, salty, acidic foods; hot foods may not be tolerated). ■ Gently wash the skin over the irradiated area with mild soap and water. Dry the area thoroughly using patting motions. ■ Do not remove or wash off radiation "tattoos" (markings) that are used to guide therapy. Do not apply powders, ointments, lotions, deodorants, or perfumes to the irradiated skin. ■ Wear soft clothing and avoid tight or constricting clothes. ■ Do not expose the irradiated skin to sun or a heat source. ■ Inspect skin for evidence of damage and report to the provider. Quizlet 1 Physical assessment of the Radiation Therapist includes daily assessment of patients: 1) Skin - erythema, dry and moist desquamation 2) Fatigue/sleep patterns 3) NVD - nausea, vomiting, diarrhea 4) Mouth/throat changes 5) Pain 6) Alopecia 7) Weight loss 8) Refer to nurse or doctor if conditions worsen. Quizlet 2 What nursing implementation is there for radiation therapy? Interventions to reduce side effects of radiation therapy. Dry mouth is most common. Pilocarpine hydrochloride (Salagen) is often effective and should be started before and continue for 90 days. Increase fluids, chew sugarless gum or sugarless candy, use nonalcoholic mouth rinses and artificial saliva. Carry water. Take frequent rests, regular exercise. Eat soft bland food if irritation occurs. Do not use lotions 2 hours before treatment. Avoid all exposure to sun.
10. A nurse is preparing for the hospital admission of client who is suspected to have active tuberculosis (TB).How?
ATI Med-surge Pg. 251 ATI - Prevent infection transmission. ■ Wear an N95 or HEPA respirator when caring for clients who are hospitalized with TB. ■ Place the client in a negative airflow room, and implement airborne precautions. ■ Use barrier protection when the risk of hand or clothing contamination exists. ■ Have the client wear an N95 or HEPA respirator if transportation to another department is necessary. The client should be transported using the shortest and least busy route. ■ Teach the client to cough and expectorate sputum into tissues that are disposed of by the client into provided sacks.
9. The nurse should explain to the client that, after the laboratory has the enzyme immunoassay (EIA) results to whom?
ATI Med-surge Pg. 713 (EIA is mainly used to test for HIV, but this enzyme is also present with Hepatitis C. If there is no HIV option go with Hep C. Aight!) ATI Human Immune Deficiency Virus (HIV) The enzyme immunoassay (EIA) test and Western blot assay are used to detect the presence of HIV Interpretation of Findings - The enzyme immunoassay (EIA) test, formerly the enzyme-linked immunosorbent assay (ELISA) is an antibody test used to measure the client's response to HIV. The test is typically positive 3 weeks to 3 months after the infection occurs, but it can be delayed for as long as 36 months. False positive results can occur; therefore further testing is needed. If the EIA is positive, the Western blot assay is used to confirm the diagnosis of HIV. Quizlet HIV A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient? a. "The EIA test will need to be repeated to verify the results." ANS: A After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not usually part of HIV testing. It is not appropriate for the nurse to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not AIDS. ATI HEPATITIS C Med Surge Pg. 624 A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following is an expected laboratory finding? A. Presence of immunoglobin G antibodies (IgG) B. Presence of enzyme immunoassay (EIA) CORRECT: The presence of enzyme immunoassay is an expected laboratory finding in a client who has a new diagnosis of hepatitis C. C. Aspartate aminotransferase (AST) 35 units/L D. Alanine aminotransferase (ALT) 15 IU/L
The nurse should know that which of the following is a diagnostic tool used to screen for TB? A chest x-ray may be ordered to detect active lesions in the lungs.
Acid-fast bacilli smear and culture - A positive acid-fast test suggests an active infection. The diagnosis is confirmed by a positive culture for Mycobacterium tuberculosis. Sputum culture - Mycobacterium tuberculosis (Same as above?) NOTES: • Sputum tests Sputum smear for acid-fast bacilli Sputum culture • 4-8 weeks before detected Sensitivity testing Polymerase chain reaction detects DNA from M. tuberculosis Chest x-ray
68. A nurse is instructing a client how to decrease nausea secondary to chemotherapy and radiation. The nurse understands that the client needs more teaching if the client states, "I will try
Administer anti-emetics, Serotonin Receptor Agonists (Zofran). Drink fluids, but avoid with meals. Eat small meals throughout day. Dry foods, like cereal, toast, or crackers first thing in morning. Avoid greasy, high fat meals right before chemo. Avoid strong odors. Don't lay flat for at least 2 hours after eating. Fresh air and loose clothing.
92. A nurse is developing a plan of care to prevent skin break down for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
Air mattress and turning client every 2 hours
5 A client who is receiving cisplatin (Platinol) for treatment of ovarian cancer the client's most recent complete blood count (CBC) decrease. It is important for the nurse to consider which of the following for the client?
Cisplatin may increase myelosuppression. Use with caution and monitor CBC. Monitor for bleeding (bruising) or infection (fever, sore throat). NOTES: Platinum compounds › Select Prototype Medication: cisplatin (Platinol) - › Kills rapid growing cells by interrupting DNA and RNA synthesis › Cell cycle phase nonspecific. › Includes bladder, testicular, and ovarian cancers Give antiemetic for nausea and vomiting. ● Advise clients to perform good oral hygiene and avoid mouthwash with alcohol. ● Advise female clients to use birth control during treatment. Medication is nephron and ototoxic ***Nephrotoxicity (kidney damage), peripheral neuropathy, ototoxicity (tinnitus and hearing loss) are major dose limiting effects of these drugs (like Cisplatin).
29. What is the most important goal in the immediate postoperative period is to do which of the following.
From ati book: maintaining airway patency and ventilation and monitoring circulatory status are the priorities for care
74. A nurse is planning a menu for a client who has folic acid deficiency anemia and is selecting food high in folic acid. Which of the following should the nurse include?
Green leafy vegetables • Dried peas and beans • Seeds • Orange juice (citrus fruits) • Breads, cereals, and other grains fortified with folic acid • Liver
2. Which of the following goals should the nurse included for a client who is receiving combination chemotherapy for breast cancer? With decreased CBC
Neutropenic precautions, bleeding precautions and injury due to anemia/weakness. NOTES: Chemotherapy can lower your blood counts. A CBC will reveal such blood conditions as neutropenia, anemia, or thrombocytopenia. All of these conditions can be treated
. A nurse is planning care for a client who has metastatic breast cancer and is being treated with chemotherapy and radiation. Client has neutropenia. What's the client's plan of care?
Implement neutropenic precautions. Med Surge ATI Pg. 1001 Have the client remain in his room unless he needs to leave for a diagnostic procedure or therapy. In this case, place a mask on him during transport. X Protect the client from possible sources of infection (plants, change water in equipment daily). X Have client, staff, and visitors perform frequent hand hygiene. Restrict visitors who are ill. X Avoid invasive procedures that could cause a break in tissue unless necessary (rectal temperatures, injections). X Keep dedicated equipment in the client's room (blood pressure machine, thermometer, and stethoscope). X Administer colony-stimulating factors filgrastim (Neupogen, Neulasta) as prescribed to stimulate WBC production. QUIZLET 1. Visitors should wear mask over mouth 2. No sick visitors 3. No flowers or plants, or certain foods 4. Daily Bath 5. Must wash hands after touching things. 6. Should do oral hygiene 7. Cannot eat fresh fruits/vegetables, must be fully cooked
64. A nurse is evaluating a series of lab tests. The nurse recognizes that an increase in the client's prostate specific antigen (PSA) laboratory value is indicative with which of the following diagnosis?
Levels are used to diagnose and stage prostate cancer and to monitor treatment.
84. A nurse is providing teaching for a client who has a superficial lesion. The biopsy indicates malignant Melanoma. Which of the following should the nurse discuss as the treatment of choice
Malignant melanoma are new moles or change in existing moles. • Surgical excision is the treatment of choice for small superficial lesions. Deeper lesions require wide local excision, after which skin grafting may be needed. • Interferon for postoperative treatment of stage III or greater melanomas o Nursing actions Report and provide relief for adverse or toxic effects of chemotherapy Encourage adequate nutrition and fluid intake ** Vague question, all depends on progression. However, I believe the MOST COMMON is surgical Excision ** From ATI • Therapeutic Procedures o Cryosurgery to freeze and destroy isolated lesions by applying liquid nitrogen (-200° C). Skin becomes edematous and tender. Client Education - Teach the client to cleanse with hydrogen peroxide and apply a topical antimicrobial until healed. o Topical chemotherapy with 5-fluorouracil cream for treatment of actinic keratoses or for widespread superficial basal cell carcinoma. Client Education • Prepare the client for extended treatment that will cause the lesion to weep, crust, and erode. • Reassure the client that the appearance of the lesion will improve after treatment. o Interferon for postoperative treatment of stage III or greater melanomas Nursing Actions • Report and provide relief for adverse or toxic effects of chemotherapy. • Encourage adequate nutrition and fluid intake. o Surgical Interventions Excision • The incision will be closed with sutures if possible. A skin graft may be necessary for large areas. • Client Education - Advise the client about postoperative wound care and care of the skin graft if used. o Complications - skin abscess and cellulitis
24. What should the nurse include in prevention of the postoperative complications teaching for a client who is to undergo a gastrectomy.
Quizlet: "apply a sequential compression device"
77. A nurse is assisting a group of clients in an outpatient clinic. For which of the following clients should the nurse anticipate scheduling a colonoscopy?
Patients who has GI issues such as chronic IBD (crohn's disease, ulcerative colitis) • Used to visualize lesions in patients who have risk for colorectal cancer. • Adults aged 50-75 years old for visualization of polyps or lesions (every 10 years)
66. A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following is an appropriate nursing response?
Pretest Explain procedure - Sim's or left lateral position, lubricated colonoscope inserted. Air insufflated for better visualization, photos taken of polyps or abnormal tissue. Record baseline vitals and pertinent labs. Report anxiety and fears to physician. Client Teaching: To bring a driver. To breathe deeply and slowly through mouth during insertion. Takes 15 min - 1 hour. Post Test: Monitor vitals and report abnormal changes. Assess for anal bleeding, abdominal distention, sever pain, severe abdominal cramps, and fever, and report immediately
60. A nurse is planning care for a female client who has a history of a T4 spinal cord injury and is at risk for infection. Which of the following nursing actions is appropriate for helping to decrease the client's risk of a urinary tract infection (UTI) while hospitalized?
Proper hand hygiene. In-line stabilization when moving patient. Pressure ulcer risk - special bedding, even distribution of weight
73. A nurse who is planning care for a client who has ulcerative colitis is teaching about the common link with Crohn's disease. Which of the following conditions should the nurse include in the client education?
• Patients who have ulcerative colitis will have insufficient production of intrinsic factor (glycoprotein produced by the parietal cell of the stomach) and those with Crohn's disease will have poor absorption which will cause insufficient absorption of Vitamin B12. Both will then have pernicious anemia. They both may require supplemental B12 injections. o B12 is necessary to convert folic acid from its inactive form to its active form. Folic acid is necessary for the production of new RBCs o Diet needs to be low fiber, high protein & calories o Avoid caffeine and alcohol. o Take MVI with iron o Small frequent meals may reduce the occurrence of the manifestation o Smoking cessation for Crohn's disease
