Module 5 test CH
Discuss three ways to treat and/or manage Type 1 hypersensitivity.
Answer- 1. Immunotherapy- desensitizing or allergy shots where a dilute solutions of a known allergen is injected into patient. 2. Avoidance 3. Education to patient and family
Match the correct stages of wound healing with the terms of the left First intention requires gradual filling in of dead space with connective tissue Second intention delayed closure; high risk for infection with resulting scar Third intention edges brought together with skin lined up in correct anatomical position
Answer- First intention—edges brought together with skin lined up in correct anatomical position Second intention—requires gradual filling in of dead space with connective tissue Third intention—delayed closure; high risk for infection with resulting scar
When inspecting a skin lesion for a client with a concerning new area that has increased in size in the last 3 weeks, what are the ABCDE's of the assessment for this lesion?
Answer- A—asymmetry of shape, B—border irregularity C—color variation within one lesion D—diameter >6 mm E—evolving/changing features
Match the following assessments with the site of assessment for clients with dark skin. Pallor (darker than normal skin) Cyanosis (hard palate, conjunctivae, and sclera) Inflammation (mucous membranes) Jaundice (lips, tongue, conjunctivae, palms, soles) Skin bleeding (excessive warmth, changes in skin c consistency or texture)
Answer- Pallor (mucous membranes) Cyanosis (lips, tongue, conjunctivae, palms, soles) Inflammation (excessive warmth, changes in skin consistency or texture) Jaundice (hard palate, conjunctivae, and sclera) Skin bleeding (darker than normal skin)
Match the description with the thickness wounds the descriptions correlate to on the left. Partial-thickness wounds Damage extends into lower layers of dermis, underlying subcutaneous tissue Damage to epidermis, upper layers of dermis Must be filled with granulation tissue to heal Full-thickness wounds Heal by re-epithelialization within 5 to 7 days Contraction develops in healing process
Answer- Partial-thickness wounds 1. Damage to epidermis, upper layers of dermis 2.Heal by re-epithelialization within 5 to 7 days Full-thickness wounds 1. Damage extends into lower layers of dermis, underlying subcutaneous tissue 2. Must be filled with granulation tissue to heal 3. Contraction develops in healing process
A patient brought to the ER by ambulance has partial and full-thickness burns to the face, torso, left forearm, and anterior portions of both lower extremities from an incident involving deep frying a turkey at home. Calculate the burn percentage using the rule of nines for this patient.
Answer- 45% Rationale: Face= 4.5% L Forearm 4.5% Torso- 18% Anterior legs 9% each = 18%
What is the primary priority for the client that presents to the ER after being rescued from a fire. A. Inspection of mucous membranes for soot in the upper airway. B. Cutting off fabrics from the burns C. Calling next of kin D. Retrieving personal items from the patient to store in a safe place.
Answer- A Rationale: Airway is always a priority.
Type III Immune Complex Reactions result from excess antigens causing immune complexes to form in the blood. Which of the following is an example of this? A. Rheumatoid arthritis B. Asthma C. Celluitis D. Shock
Answer- A Rationale: Most auto-immune disorders are Type III immune complex reactions.
The nurse is caring for an 80-year old client with progressive fatigue, shortness of breath, and headaches. What assessment question will the nurse ask? Select all that apply. A. "Do you live with anyone?" B. "Have you been depressed lately?" C. "What medications do you routinely take?" D. "Could you tell me about your dietary habits?" E. "Do you have a history of cardiovascular disease?"
Answer- A Rationale: Older clients are likely to experience signs and symptoms of anemia (fatigue, shortness of breath, headaches) related to diet and chronically bleeding GI lesions (peptic ulcer disease). Therefore the nurse will ask questions related to diet, bleeding, and medications that could irritate the GI system. The nurse can ask social history questions and the question about cardiovascular disease (as medical history) afterward. Copyright © 2021, Elsevier Inc. All Rights Reserved.
The nurse is caring for a 25-year old client with a history of sickle cell disease (SCD). Today the client reports pain that is rated as a "9" on a 0-to-10 scale. Nursing assessment reveals grimacing, abdominal guarding, fever of 103.9º F, pale yellow hard palate, and several very small ulcers on the lower extremities. Which concern will the nurse address as the priority? A. Acute pain B. Hyperthermia C. Potential for infection D. Impaired tissue perfusion
Answer- A Rationale: Pain must be addressed first and foremost. All other assessment findings can be completed after pain medicine is administered.
The client with newly diagnosed HIV is preparing for discharge, which of the following statements made by the client indicates a need for further teaching? A. I should only seek help dealing with this diagnosis if I have suicidal ideations. B. I should continue to learn more about my condition and what symptoms to report. C. I may need homecare management for my condition. D. I should keep a list of resources and follow-up care.
Answer- A Rationale: The client should begin dealing with psychosocial effects of the disease immediately.
Which lab values would the nurse alert the provider for in a patient receiving Thiazide diuretics and Lactated Ringers? A. Calcium of 11.5 B. WBC of 9.8 C. Platelets of 425,000 D. Total protein of 8
Answer- A Rationale: Thiazides and Lactated Ringers contain calcium.
Which of the following regarding WBC with differential is accurate? A. Lymphocyte account for 20-40 % B. Segmented neutrophils account for 40-60% C. Band neutrophils account for 5% D. Reticulocytes account for 1% E. Basophils account for 1%
Answer- A, B, C, E Rationale: Reticulocytes are not included in a WBC with diff.
Which of the following are changes seen with burn patients? Select All That Apply. A. Functional B. Anatomical C. Psychosocial D. Cancer E. Psoriasis
Answer- A, B, C, Rationale: Cancer and psoriasis are not listed as changes that are noted in these patients.
Sepsis, MODS (Multi-Organ Dysfunction Syndrome), and Death are all complications of Sickle Cell Disease, which interventions are key in preventing a crisis? Select All That Apply. A. Ensure adequate oxygen and perfusion. B. Increased sodium and potassium in diet. C. Adequate hydration. D. Drug therapy. E. Transfusion. F. Know early detection symptoms.
Answer- A,C,D,E,F Rationale: Increasing sodium and potassium is not one of the key interventions in managing Sickle Cell Disease.
A nurse is assessing a client with a genetic history of cancer. Which assessment finding requires immediate nursing intervention? A. Blood pressure 140/90 B. Nagging cough with hoarseness C. Nasal congestion for several days D. Muscle tension in the cervical spine
Answer- B Rationale: A nagging cough with hoarseness is one of the seven warning signs of cancer. Given the genetic predisposition combined with the assessment data, there is cause for concern so the nurse must intervene here first. Other findings can be subsequently addressed.
A 72 year old male with a history of GI bleed, presents to the ED with pallor, breathlessness on exertion, with decreased oxygenation levels with complaints of fatigue and decreased energy levels. Which laboratory value would the nurse expect to find. A. WBC of 7.8 B. Hemoglobin of 8.2 C. Hematocrit of 35% D. Albumin of 4.2
Answer- B Rationale: All other levels are WNL and patient presents with symptoms of Anemia.
A 33-year-old client with a history of sickle cell disease had an emergent open reduction and internal fixation of the right femur after a car crash. Which nursing intervention is the priority following surgery? A. Treating pain B. Ensuring adequate IV hydration C. Titrating oxygen to SPO2 > 95% D. Examining the surgical incision for infection
Answer- B Rationale: Anesthesia and stress can precipitate a sickle cell crisis. Adequate hydration is a postoperative priority to support vital signs, as well as treat sickle cell symptoms and sickle cell-associated pain. Effective hydration will augment additional pain management strategies necessary for treating sickle cell pain and postoperative pain. Ensuring adequate oxygenation is also important because hypoxemia initiates or worsens the sickling of cells. Examination of the surgical site can continue after hydration is ensured.
When implementing plan of care for patient with leukemia, all of the following except which action would be included. A. Preventing infection. B. Frequent transfusions. C. Minimizing injury. D. Prevention of infection.
Answer- B Rationale: Frequent transfusions are not indicated in the planning and implementation of care for patients with leukemia.
When caring for a client with MRSA, which precaution will the nurse institute? A. Droplet B. Contact C. Airborne D. Neutropenic
Answer- B Rationale: MRSA is spread by contact; therefore, the nurse will institute contact precautions.
Laboratory results for your patient with sickle cell disease have been completed. When reviewing the report, which result does the nurse anticipate? A. Hct 40% B. HbS 90% C. WBC 8000/mm3 D. Total bilirubin 0.5 mg/dL
Answer- B Rationale: The HbS is reflective of a client with sickle cell disease (SCD). Clients with SCD usually have low Hct, high WBC, and high total bilirubin. The other values shown here are within normal limits.
Which of the following is not a burn injury phase? A. Acute B. Latent C. Rehabilitative D. Emergent
Answer- B Rationale: This not one of the phases of burn injury discussed.
A client reports having unprotected intercourse and is concerned about exposure to HIV. The nurse will assess whether the client has which initial symptom? A. Lymphocytopenia B. Flu-like symptoms C. Opportunistic infection D. Reduced numbers of CD4+ T-cells
Answer- B Rationale: When a person is infected with HIV, the first manifestations are flu-like symptoms including fever, night sweats, chills, headache, and muscle aches. As time passes, CD4+ T-cells are infected and taken out of service. This cell count drops to below-normal levels, and those that remain may not function normally. Lymphocytopenia (decreased lymphocyte counts) occurs as a result. Also, as the CD4+ T-cell level drops, the client is at risk for bacterial, fungal, and viral infections, as well as some opportunistic cancers.
What lab values would the nurse treating a burn victim be most concerned with? Select all that apply. A. Digoxin level B. Pre albumin C. Albumin D.Total protein E. Estrogen level
Answer- B, C, D
When providing care to a client on contact isolation, what special precautions does the nurse implement based on the client's diagnosis? (Select all that apply.) A. Keep the door closed at all times. B. Wear gloves when entering the room. C. Wear a mask when working within 3 feet of the client. D. Wear a gown to prevent contact with contaminated items. E. Dedicated equipment should be used for this client alone.
Answer- B, D, E Rationale: Health care personnel and visitors should wear gloves upon entering the room to prevent contact with the client, contaminated items, or uncontrolled body fluids. There should also be dedicated equipment for this client to prevent the spread of infection. A mask should be worn with Airborne and Droplet Precautions. The door should be kept closed with Airborne Precautions, not Contact Precautions.
Which of the following is a treatment for C-Diff? A. Depends B. Laxatives C. Fecal Microbiota Transplantation D. Tums
Answer- C
Which client does the nurse identify whose immune function is most efficient? A. 12 month old infant B. 18 year old adolescent C. 32 year old adult D. 49 year old adult
Answer- C Rationale: Immune function is most efficient when people are in their 20s and 30s and slowly declines with increasing age. The immune system is developing and changing during infancy and teen years.
The nurse is preparing to administer the client's with an MRSA infection's medications. Which drug was likely ordered by the health care provider to address MRSA? A. Amoxicillin B. Ciprofloxacin C. Vancomycin D. Erythromycin
Answer- C Rationale: MRSA is susceptible to only a few antibiotics such as vancomycin (Vancocin) and linezolid (Zyvox), as well as ceftarolinefosamil.
Which of the following would the nurse not to expect on the care plan for the patient with HIV? A. Potential for poor gas exchange. B. Potential for impaired skin integrity. C. Potential for increased immunity. D. Potential for infection.
Answer- C Rationale: Patients with HIV have impaired immunity.
A patient with lymphoma receiving monoclonal antibody therapy presents to the ED, with an serum potassium of 6 and a calcium of 12, What does the nurse predict is the diagnosis of this patient? A. SVC syndrome B. HIT C. Tumor Lysis Syndrome D. Gout
Answer- C Rationale: The key information is that TLS is common in lymphoma patients with monoclonal antibody therapy, pertinent lab results are high potassium and calcium.
An increase in immature neutrophils circulating in the blood in response to an infection is known as what? A. This is normal. B. Downward shift C. Shift to the right D. Shift to the left
Answer- D
Which of the following lab values would you expect for your patient with Heparin Induced Thrombocytopenia? A. WBC- 6,000 B. Hemoglobin-13 C. Hematocrit - 35% D. Platelets- 190,000
Answer- D Rationale: All other lab values are within normal limits.
Five minutes later, the client with the peanut allergy continues to experience some shortness of breath, and reports tongue swelling and anxiety. What is the priority nursing intervention? A. Assess lung sounds B. Provide reassurance C. Notify the health care provider D. Contact the Rapid Response Team
Answer- D Rationale: The client has tongue swelling, indicating angioedema. She is still short of breath and may have abnormal breath sounds such as crackles and wheezes. Respiratory failure due to swelling of the tongue and larynx may soon follow. Emergency respiratory management is critical during an anaphylactic reaction because severity increases with time. This is the time to call the Rapid Response Team so they will be on the way; all other actions can immediately follow their notification.
The nurse is caring for a client with bleeding gums that reports increased fever, fatigue, malaise, and "chills." What is the priority nursing intervention? A.Notify the health care provider. B.Document assessment findings. C.Administer antipyretic drugs as prescribed. D.Review laboratory data and prepare to obtain blood cultures. Copyright © 2021, Elsevier Inc. All Rights Reserved.
Answer- D Rationale: The nurse should initially review the client's laboratory analysis for signs of pancytopenia related to the client's report and assessment findings of fatigue (anemia), bleeding gums (thrombocytopenia), and chills (neutropenia). Laboratory data are needed before informing the heath-care provider and deciding whether to administer medication. Obtaining blood cultures prior to antibiotic administration is an important intervention. Antipyretic medications may be prescribed to treat the fever. Copyright © 2021, Elsevier Inc. All Rights Reserved.
Your patient's lab work comes back and reveal the following, what would the nurse suspect is the patient's diagnosis? WBC- 22,000 RBC- 3million/mm3 Hemoglobin- 7.6 Hematocrit- 25% Platelets- 40,000/mm3
Answer- Sickle Cell Crisis Rationale: in sickle cell the WBC and platelets will be increased while the RBC, Hgl and HCt will be decreased.
The nurse is preparing to admit a client who is 80 years old from a long-term care facility. The client has end-stage COPD, is on oxygen, is unable to ambulate, and is incontinent of bowel and bladder. The nurse finds an area to the coccyx that is intact with a localized area of non-blanchable erythema. Color changes are not purple or maroon. What would the nurse stage this as?
Answer- Stage 1
What is the best intervention to prevent transmission of HIV?
Answer- Standard precautions and good hand hygiene.
Two hours later, the client Breast Cancer receiving chemotherapy and radiation reports difficulty swallowing because of sores in her mouth. What does the nurse anticipate is the problem with the client's mouth? What nursing interventions will be implemented?
Answer- The client is most likely experiencing mucositis (sores in mucous membranes). With chemotherapy, mucous membrane cells are killed more rapidly than they are replaced, resulting in the formation of mouth sores. Mouth sores are painful and interfere with eating. Examine the mouth and between the teeth every 4 hour for fissures, blisters, lesions, or drainage. Document the findings. Provide frequent good mouth care. Encourage the client to avoid mouthwashes that contain alcohol. For mouth care, use a soft-bristled toothbrush or disposable mouth sponges. Do not use dental floss or pressure gum cleaners. Rinse the mouth with ½ peroxide and ½ normal saline every 8 hour. Normally the client should drink at least 2 L of fluids, but due to the client's nausea and vomiting, this is not possible. Continue to monitor IV fluid replacement.
A 51-year-old client is in the emergency department with cellulitis of the right leg. Laboratory results from a culture taken earlier in the week by the primary health care provider indicate that the wound is positive for MRSA. Based on the information provided from the ED during the SBAR report, what type of isolation room should the medical-surgical nurse prepare for the client?
Answer- The client should be admitted to a private room under Contact Isolation precautions.
The nurse is preparing to admit a client who is 80 years old from a long-term care facility. The client has end-stage COPD, is on oxygen, is unable to ambulate, and is incontinent of bowel and bladder. What could have precipitated this pressure injury?
Answer- The client's bowel and bladder incontinence is a likely cause.
The nurse is preparing to admit a client who is 80 years old from a long-term care facility. The client has end-stage COPD, is on oxygen, is unable to ambulate, and is incontinent of bowel and bladder. What interventions should be started to prevent further deterioration of the client's skin in a pressure ulcer?
Answer- The nurse and staff should check the client for any moisture during hourly rounds. The nurse may ask the provider about pressure relief devices, as well as a topical protective barrier to coat the skin. The client is probably in a high-Fowler's position most of the time due to COPD, which puts pressure on the sacral and coccyx areas, so the nurse should assess the skin carefully and often. Ensure adequate fluid, protein, and caloric intake for the client.
Based on the client's history of new onset of shortness of breath and edema of the eyes and lips, what does the nurse suspect is the problem? What questions are appropriate to ask this client?
Answer- The nurse anticipates that the client may be having an anaphylactic reaction. The client stated a peanut allergy. These have been linked to contact with latex. Because the client had been working prior to presenting to the ED, the nurse should inquire about use of latex gloves at work. Anaphylaxis is the most dramatic and life-threatening example of type I hypersensitivity reaction; it occurs rapidly and systemically.
What are the five cardinal signs of inflammation?
Answer- Warmth, Redness, Swelling, Pain and Decreased function.
When do pressure ulcers occur?
Answer- When skin and underlying soft tissue are compressed between a bony prominence and external surface.
Which of the following are health promotion and maintenance considerations to decrease likelihood of burn injuries? Select All That Apply. A. Prevention. B. Use home smoke and carbon monoxide detectors. C. Set the water heater temperature below 140F. D. Plan escape routes in homes in case of a fire, ensure there is only one exit route. E. Never smoke when using oxygen.
Answer: A, B, E Rationale: There should always be more than one exit route if possible and water temperatures should be set to below 120F.
Match the corresponding precaution with the method of transmission. Contact suspended in air-TB Droplet Indirect and direct gown, dedicated equipment Airborne 3 feet distance-Influenza
Answer- Contact -indirect and direct-gown , dedicated equipment Droplet-3 feet distance-Influenza Airborne-suspended in air-TB
The nurse is preparing to admit a client who is 80 years old from a long-term care facility. The client has end-stage COPD, is on oxygen, is unable to ambulate, and is incontinent of bowel and bladder. Which additional interventions should be implemented at this time for the patient with a newly developed stage 2 ulcer? A. Application of a transparent film dressing B. Application of a dry cotton gauze dressing C. Surgical débridement of the pressure injury D. Administration of IV antibiotics every 8 hours
Answer- A Rationale: An adhesive clear film dressing provides protection for partial-thickness lesions such as stage II pressure injuries.
The client asks how MRSA was contracted. What is the appropriate nursing response? A. "MRSA is spread by direct contact in the hospital and community settings." B. "People who travel to third-world countries always return with MRSA." C. "MRSA is transmitted through the air like TB." D. "The most common way to get MRSA is when someone coughs on you."
Answer- A Rationale: MRSA is spread by direct contact, such as with indwelling catheters, vascular access devices, and endotracheal tubes, in the hospital and community settings.
A client who has been hiking in the woods comes to the ED with urticaria. After administering an antihistamine as prescribed, what teaching does the nurse provide? A. Avoid outdoor activity. B. Use a sauna to relieve pain. C. Apply tea bags to the lesions. D. Consume 1 to 2 alcoholic beverages.
Answer- A Rationale: Management of urticaria (hives) focuses on removing the triggering substance and relieving symptoms. The client should stay indoors at this time, as something in the woods likely triggered the reaction. Because the skin reaction is caused by histamine release, topical and/or oral antihistamines such as diphenhydramine (Benadryl) are helpful. Teach the client to avoid overexertion, alcohol consumption, and warm environments such as warm or hot showers, which contribute to blood vessel dilation and make the symptoms worse. Nothing further needs to be applied to the lesions at this time.
A client with polycythemia vera is admitted with shortness of breath, hypertension, and loss of pulses in the right foot. Which nursing intervention is the priority? A. Assess hydration status B. Evaluate for hypertensive crisis C. Elevate lower extremities on pillows D. Use soft-bristle toothbrush to prevent bleeding
Answer- A Rationale: Polycythemia vera, a form of malignant RBC hyperproduction and clotting factor dysfunction, requires evaluation of intravascular hydration, preparation of laboratory tests for possible therapeutic phlebotomy, and anticoagulant therapy to decrease clots. clients with this disease are at risk of hypertension and experience poor tissue oxygenation as well, requiring assessment. Raising lower extremities may assist with perfusion and symptoms but would not be a priority in this scenario. Using a soft-bristle toothbrush is helpful to prevent bleeding, yet hydration is still the priority.
For which side effect does the nurse assess in a client undergoing radiation for breast cancer? A. Fatigue B. Hair loss C. Mucositis D. Nausea and vomiting
Answer- A Rationale: Radiation-induced fatigue can be debilitating and may last for weeks to months. Mucositis, alopecia, and nausea and vomiting are side effects associated more frequently with chemotherapy.
The UAP reports that the client who just ambulated to the toilet, stubbed their toe and limped back to bed. When assessing the client you note redness, warmth and tenderness to palpation in the clients great toe, Which stage of inflammation would this bed categorized as? A. Stage 1 B. Stage 2 C. Stage 3 D. There is indication of an acute inflammatory response.
Answer- A Rationale: Redness, warmth and pain are all signs of inflammation. Stage 2 results in puss formations and exudate. Stage 3 results in new tissue formation and scar tissue.
The nurse has educated a client with a shellfish allergy about angioedema. Which client statement requires further nursing teaching? A. "Shrimp is OK to eat because it is not a shellfish." B. "I keep an epinephrine injector in my backpack." C. "Angioedema includes swelling of eyes, lips, and tongue." D. "When I see a new provider, I will disclose my shellfish allergy."
Answer- A Rationale: Shrimp is a shellfish, and should not be consumed by clients with shellfish allergies. This statement therefore requires further teaching by the nurse. The client should carry an epinephrine injector at all times. Symptoms of angioedema include swelling of eyes, lips, and tongue. clients should report all allergies to health care providers.
A client has been admitted to the ED with bilateral eyelid swelling and subsequent difficulty seeing. What is the priority nursing assessment? A. Airway B. Nasal cavity C. Visual disturbance D. Drugs taken consistently
Answer- A Rationale: The client likely has angioedema that has caused the swelling. This can progress very quickly to affect the airway. Interventions focus on stopping the reaction and ensuring an adequate airway. While swelling can invade the nasal cavity, the priority is on securing and maintaining the airway. The visual disturbance will likely return when eyelid swelling is decreased. Knowing the drugs the client consistently takes can be determined after the airway is secured.
A 62 year old male reports to the ER with dark purple/cyanosis in the face and observed on the mucous membranes. He also reports intense itching. He appears hypoxic, and is showing symptoms of thrombosis. What diagnosis would be suspected? A. Polycythemia Vera B. Aplastic Anemia C. Immunohemolytic Anemia D. G6PD Anemia
Answer: A
A 56 year old African American woman reports to the ER with an elevated reticulocyte count, decreased hematocrit, elevated WBC count and complains of severe joint pain. What diagnosis would the nurse consider in this patient? A. Sickle Cell Crisis B. Iron Deficiency Anemia C. Thrombocytopenia D. Acute Lymphoblastic Lymphoma
Answer: A Rationale: Sickle Cell Crisis is characterized by severe pain in the joints and muscles, anemia, and often infection.
Which of the following are true regarding immunity in the older adult? Select All That Apply. A. Nutrition status, environmental conditions, drug, disease, and age change immunity B. Microbiome changes; overgrowth of more pathogenic organisms occurs C. Higher T-cell function D. B-lymphocytes take longer to become sensitized and begin to make antibodies to new antigen exposures E. Circulating autoantibodies decreases
Answer- A, B, D Rationale: There is a lower T cell function. Circulating autoantibodies increases.
Put the sequence of the inflammatory response in order. A. Phagocyte and antibacterial exudate destroy bacteria. B. Phagocytes migrate to the site of inflammation (Chemotaxis) C. Tissue damage causes a release of vasoactive and chemotactic factors that trigger an increase in blood flow and capillary permeability. D. Permeable capillaries allow an influx of fluid and cells.
Answer- C, D, B, A
Which of the following are ways that HIV may be transmitted? Select All That Apply. A. Sharing household utensils, towels, linens and toilets. B. Casual Contact. C. Parenterally. D. Via Mosquitos and Insects. E. Sexual Contact. F. Perinatal Contact.
Answer- C, E, F
When the body makes antibodies directed against self cells that have some form of foreign protein attached to them, what is this known as? A. Hypersensitivity type 3 B. Acute Kidney Injury C. Type 2 Cytotoxic Reactions D. Infection
Answer- Type 2 Cytotoxic Reactions Rationale: This happens when patients receive the wrong type of blood transfusions.
What is the priority nursing intervention when caring for an older client with a history of diverticular disease and pernicious anemia? A. Preventing falls B. Monitoring intake and output C. Turning the client every 2 hours D. Encouraging a diet high in vitamin B12
Answer- A Rationale: The client will have difficulty absorbing vitamin B12 because of diverticular disease and may have developed paresthesia in the feet, increasing the risk for falls. Anemia may also increase the client's symptom of weakness, thereby increasing fall risk. Preventing falls is a priority intervention in the care of older clients. All other interventions can take place after safety has been ensured.
Which primary prevention strategy does the nurse recommend to a client concerned about development of cancer? A. Removal of mole on the abdomen B. Have a fecal occult blood test annually C. Obtain a baseline colonoscopy at 50 years old D. Women should speak to their provider about a mammogram
Answer- A rationale: Primary prevention of cancer involves removal of "at risk" tissue. The other choices listed are secondary prevention strategies, which involve screening for early detection of cancer.
Rheumatoid arthritis is characterized by tissue destruction, fibrotic changes, and scarring. Which of the following are early signs of the disease? A. Joint inflammation B. General weakness C. Fatigue D. Joint deformity E. Subcutaneous nodules
Answer- A, B, C Rationale: Joint deformity and subcutaneous nodules are late signs.
The nursing student is caring for a patient who has experienced a drop in platelets to 190,00. The patient is experiencing ecchymosis, purpura, and bleeding. The nursing student knows that which of the following are treatments for thrombocytopenia? Select All That Apply. A. Platelet transfusions B. Anticoagulants C. Splenectomy D. Bone marrow aspiration E. Chemotherapy Agents
Answer- A, B, C Rationale: bone marrow aspiration and chemotherapy are not used when when treating thrombocytopenia.
Allergens are contracted via which of the following routes? Select All That Apply. A. Inhaled (plant pollens, fungal spores, animal dander, house dust, grass, ragweed) B. Ingested (foods, food additives, drugs) C. Injected (insect or other venom, drugs, biologic substances such as contrast dyes) D. Skin or mucous membrane contacted (latex, pollens, foods, environmental proteins)
Answer- A, B, C, D
What cluster of symptoms would the assess for in a patient with suspected HIV? Select All That Apply. A. Opportunistic infections. B. Malignancies. C. Endocrine complications. D. Cardiovascular complications.
Answer- A, B, C, D
When performing a psychosocial assessment for a patient with a new diagnosis of leukemia, which of following factors would be assessed? Select All That Apply. A. Anxiety B. Fear C. Lifestyle choices D. Work/medical leave for treatment
Answer- A, B, C, D
The nurse understands that normal cells and benign cells share which characteristics?(Select all that apply.) A. No migration B. Orderly growth C. Tight adherence D. Specific morphology E. Large nuclear-to-cytoplasmic ratio
Answer- A, B, C, D Rationale: Normal cells and benign cells do not migrate, have orderly growth, demonstrate tight adherence, and have specific morphology. A cancerous (malignant) cell's nucleus is larger than that of a normal cell and the cancer cell is smaller than a normal cell. The nucleus occupies much of the space within the cancer cell, creating a large nuclear-to-cytoplasmic ratio.
Which of the following are risk factors for pressure ulcers? Select All That Apply. A. Bedrest, immobility B. Incontinence C. Diabetes mellitus and/or peripheral vascular disease D. Malnutrition E. Decreased sensory perception or cognitive problems
Answer- A, B, C, D, E
A client has been admitted to the medical-surgical floor with multiple problems. Which assessment finding does the nurse identify that is consistent with AIDS? Select all that apply. A. Persistent pain B. Persistent diarrhea C. Kaposi's sarcoma D. Wasting syndrome E. Esophageal candidiasis
Answer- A, B, C, D, E Rationale: All assessment findings are consistent with AIDS.
The nurse is preparing to administer transfusion therapy, which of the following are responsibilities of the nurse? Select All That Apply. Review agency policy A. Verify prescription with another RN B. Test donor's/recipient's blood for compatibility C. Use two identifiers for patients who receive transfusion; verify with another RN D. Examine blood bag label, attached tag, and requisition slip for ABO and Rh compatibility with the client E. Check expiration date/time with another RN F. Inspect blood for discoloration, gas bubbles, cloudiness
Answer- A, B, C, D, E, F
Which of the following are Oncologic Emergencies? Select All That Apply. A. Sepsis and Disseminated Intravascular Coagulation B. Syndrome of Inappropriate Antidiuretic Hormone C. Spinal cord compression D. Hypercalcemia E. Superior vena cava syndrome F. Tumor lysis syndrome
Answer- A, B, C, D, E, F
Which of the following interventions would be appropriate for health promotion and maintenance? Select All That Apply. A. Avoid known allergens B. Wear medical alert bracelet C. Notify health care personnel about specific allergies D. Carry anaphylaxis kit or epinephrine injector E. Health records should prominently display list of specific allergens F. Implement precautionary measures if drug or agent must be used despite history of allergic reaction
Answer- A, B, C, D, E, F
Which of the following are functions of the skin? Select All That Apply. A. Protection B. Homeostasis/ Water Balance C. Temperature regulation sweat glands D. Sensory Organ nerve impulses E. Vitamin Synthesis of vitamin B12 F. Psychosocial body image
Answer- A, B, C, D, F Rationale: Vitamin synthesis of Vitamin D, not B12
What treatment does the nurse anticipate will be ordered by the provider? (Select all that apply.) A. Oxygen B. IV fluids C. Epinephrine D. Acetaminophen E. Diphenhydramine
Answer- A, B, C, E Rationale: If the reaction is severe, the provider may order the first-line drug epinephrine for the client. Antihistamines such as diphenhydramine are second-line drugs and are usually given for angioedema and urticaria. Acetaminophen is not indicated. IV fluids are usually started when a reaction is suspected, and the provider may order oxygen to address the client's shortness of breath.
When assessing a client's skin, which lesion finding requires further nursing intervention? Select all that apply. A .Asymmetry B. Color variation C. Diameter of 4 mm D. Irregularity of borders E. Growth in last 2 month
Answer- A, B, D, E Rationale: Asymmetry of shape, border irregularity, color variation, diameter >6 mm, and/or evolving or changing features of any kind require further nursing intervention. The lesion that is 4 mm does not need further nursing intervention, unless other symptoms are present.
The nurse is educating a client newly diagnosed with dandruff. Which teaching will the nurse include? A. "It is a cosmetic problem." B. "An oily scalp contributes to dandruff." C. "Your scalp is too dry and needs moisture." D. "Untreated severe dandruff can lead to hair loss." E. "Diffuse white or gray scales may occur on the scalp surface."
Answer- A, B, D, E Rationale: Dandruff is a collection of patchy or diffuse white or gray scales on the surface of the scalp. It is common. The flaking that occurs with dandruff causes many people to mistakenly think the scalp is too dry; however, it is a problem of excessive oil production. Dandruff is a cosmetic problem. A very oily scalp can induce inflammatory changes with redness and itching. Severe inflammatory dandruff can extend to the eyebrows and the skin of the face and neck. If severe dandruff is not treated, hair loss can occur. Teach the client that dandruff is not caused by dryness and should be treated to prevent hair loss.
How is MRSA spread? Select All That Apply. A. Indwelling urinary catheters B. Vascular access devices C. Glove to Glove contact D. Open wounds E. Endotracheal tubes
Answer- A, B, D, E Rationale: Gloves are contaminated in any procedure. They are removed after performing care. They are disposed of and there arenot a significant risk of MRSA spead.
Four days later, the client with sickle cell crisis is preparing for discharge. Which teaching point will the nurse provide? (Select all that apply.) A. Be sure to get a flu shot annually. B. Drink at least 3 to 4 L of fluid daily. C. Alcoholic beverages may be consumed moderately. D. Get genetic testing to prevent passing this disease to children. E. Engage in mild low-impact exercise three times weekly when not in crisis.
Answer- A, B, E Rationale: Hydration helps decrease the duration of pain episodes. Flu shots are important because the client is at risk for infections due to decreased spleen function. Low-impact exercise is recommended, but clients should avoid strenuous exercise. Genetic testing is a very personal choice and should not be emphasized unless the client desires. Also, genetic testing does not ensure that a disease is or is not passed on to others. Alcohol should be avoided.
A client with AIDS is having difficulty maintaining body weight. Which intervention will the nurse provide? Select all that apply. A. Ensure regular mouth care. B. Provide three large meals daily. C. Encourage low fat food choices. D. Provide foods that are high in calories. E. Encourage drinking at least 1 L of fluid per day. F. Collaborate with the registered dietician nutritionist.
Answer- A, C, D, F Rationale: Clients should be drinking at least 2 to 3 L of fluids per day. Collaboration with the dietician is important to include high calorie, high protein foods. Avoid dietary fat, because fat intolerance often occurs as a result of the disease and as a side effect of some antiretroviral drugs. Provide small, frequent meals as they are often better tolerated than large meals. Mouth care can improve appetite.
Which of the following assessment findings would indicate malignant lymphoma? Select All That Apply. A. Large lymph nodes. B. Painful lymph nodes. C. Weight gain. D. Fevers. E. Night sweats. F. No symptoms at all.
Answer- A, D, E, F Rationale: Lymph nodes would be painless and a manifestation of weight loss would be noted.
Which of the following descriptions would fall into HIV Stage 2? Select All That Apply. A. Patient develops a first positive HIV test result within 6 months after a negative HIV test result. CD4+ T-cell counts are usually in the normal range, and no AIDS-defining condition is present. B. Patient has a confirmed HIV infection, but no information regarding CD4+ T-cell counts, CD4+ T-cell percentages, and AIDS-defining illnesses is available. C. Patient has a CD4+ T-cell count of less than 200 cells/mm3 (0.2 X 109/L) or a percentage of less than 14%. Any patient, regardless of CD4+ T-cell counts or percentages who has an AIDS-defining illness. AIDS diagnosis. D. Patient has a CD4+ T-cell count of greater than 500 cells/mm3 (0.5 X 109/L) or a percentage of 29% or greater. No AIDS-defining illnesses are present. E.Patient has a CD4+ T-cell count between 200 and 499 cells/mm3 (0.2 to 0.499 X 109/L) or a percentage between 14% and 28%. No AIDS-defining illnesses are present.
Answer- A, D, and E Rationale: B is an unknown stage and C is HIV Stage 3.
A client comes to the ED with mild shortness of breath and a runny nose. The triage nurse notes that the client's lips and eyes are somewhat swollen. What action will the nurse take at this time?
Answer- An accurate and detailed history is important; the nurse will begin collecting this information as long as the client is not in imminent danger, although the client will likely be triaged back to the environment of care right away, given the risk of this condition progressing quickly. The client should be asked to describe the onset and duration of problems related to possible allergen exposure. Ask about work, school, and home environments and possible exposures through food, hobbies, leisure, or sports activities. The client should also be asked about the presence of allergies among close relatives because of the tendency for type I allergies to be inherited
A patient presents with a red, macular, facial rash ("butterfly") to sun-exposed areas, and chronic lesions and inflammation to mucous membranes. What does the nurse suspect pending ANA, hematologic, and neuro assessments? A. Psoriasis B. SLE C. Eczema D. Rheumatoid Arthritis
Answer- B
Which of the following is not a factor in analyzing cues for the patient with HIV? A. Pain. B. Fashion sense C. Cognitive decline. D. Diarrhea. E. Psychosocial distress
Answer- B
Which of the following would you expect the provider to perform on a patient with a suspicious lesion smaller than an eraser head? A. No biopsy is needed for lesions that small. B. Punch biopsy C. Shave biopsy D. Excisional biopsy
Answer- B
Which assessment finding alerts the nurse to determine that inflammation has progressed to the cellular level? A. Pus B. Warmth C. Redness D. Swelling
Answer-A Rationale: Responses at the tissue level cause the five cardinal symptoms of inflammation: warmth, redness, swelling, pain, and decreased function. Stage II is the cellular exudate part of the response. In this stage, neutrophilia (an increased number of circulating neutrophils) occurs. Exudate in the form of pus occurs, containing dead WBCs, necrotic tissue, and fluids that escape from damaged cells.
When caring for four clients, which client does the nurse identify at highest risk for infection? A. 20-year-old with stomach pain B. 31-year-old with chronic kidney disease C. 44-year-old using a 10-day steroid taper D. 62-year-old with history of prostate hyperplasia
Answer- B Rationale: The client's immune status plays a large role in determining risk for infection. Congenital abnormalities, acquired health problems (for example, kidney injury, steroid dependence, cancer, AIDS) and advancing age can increase a client's risk of developing immunologic deficiencies. Chronic physical and psychological stress can also depress the immune system, making the client more susceptible to infection.
The nurse is preparing to admit a client who is 80 years old from a long-term care facility. The client has end-stage COPD, is on oxygen, is unable to ambulate, and is incontinent of bowel and bladder. Two days later, the client's sacral area appears to have an abrasion where the skin is not intact. What is the nurse's interpretation of this new finding? A. Stage I pressure injury B. Stage II pressure injury C. Stage III pressure injury D. Stage IV pressure injury
Answer- B Rationale: With stage II pressure ulcers, the skin is not intact. There is partial thickness loss of the epidermis or dermis. The ulcer is superficial and may look like an abrasion, a blister, or a shallow crater.
The nurse asks the client about a history of any allergies. The client, who reports coming straight from work as a nursing assistant, admits to a peanut allergy, but denies eating today. Which laboratory test does the nurse anticipate the provider will order? (Select all that apply.) A. Electrolytes B. Immunoglobulin E C. CBC with differential D. Liver function tests (LFT) E. Kidney function tests (KFT)
Answer- B, C Rationale: With the CBC with differential (diff), look for increased eosinophils, which may be as high as 12% (normal = 1%). Some clients may also have a higher than normal total WBC count. Normal IgE levels are about 39 IU/mL (<100 IU/mL). This level is greatly increased with allergies.
Radiation therapy for cancer uses high-energy radiation to kill cancer cells, with the goal of having minimal damaging effects on surrounding normal tissue. It is usually given in divided doses over a set time, and can be used as standalone treatment or combined with other treatments. Which of the following is important for the nurse to tell the client? A. Once therapy is completed you will never get cancer again. B. You should shower only once per week. C. You should be careful to not wash the ink or dye markings off. D. It is ok to wash the ink markings off after a days.
Answer- C
The nurse is conducting a handwashing refresher session. For which situation will the the nurse remind all staff that cleansing hands with an alcohol-based hand rub is appropriate? A. After using the bathroom B. To cleanse visibly soiled hands C. After handing oral medications to a client D. After caring for a client with Clostridium difficile
Answer- C Rationale: Alcohol-based hand rubs (ABHRs) are not appropriate if one's hands are visibly dirty, soiled, or feel sticky, or after toileting. In these cases, the nurse will teach to wash hands instead of using ABHRs. ABHRs are also ineffective against spore-forming organisms such as C. difficile. The only situation where using an ABHR is appropriate is after handing an oral medication to a client.
What does the nurse teach a client undergoing chemotherapy about the expected outcome related to hair loss? A. Hair loss may be permanent. B. Viable treatments exist for the prevention of alopecia. C. Hair regrowth usually begins about 1 month after completion of chemotherapy. D. New hair growth is usually identical to previous hair growth in color and texture.
Answer- C Rationale: Chemotherapy-induced hair loss is usually temporary, and regrowth usually begins 1 month after chemotherapy is finished. New hair growth may differ from the original hair in color, texture, and thickness. No known treatment completely prevents alopecia.
In Type I Hypersensitivity (Also called rapid hypersensitivity, or atopic allergy) is the most common type, results from the increased production of the immunoglobulin E (IgE) antibody class. Which of the following would not be considered a condition associated with Type 1 Hypersensitivity? A. Angioedema B. Anaphylaxis C. Dependent pitting edema D. Allergic asthma
Answer- C Rationale: Dependent pitting edema is generally caused by peripheral vascular issues.
A client is being transitioned from IV heparin to oral warfarin. Which laboratory finding does the nurse identify confirming that warfarin treatment is effective? A. Bleeding time of 5 minutes B. Prothrombin time (PT) of 18 seconds C. International normalized ratio (INR) of 2.5 D. Partial thromboplastin time (PTT) of 24.3 seconds
Answer- C Rationale: INR is a more accurate measure of anticoagulation therapy because of variations in PT values across different laboratories. The goal of warfarin therapy is usually to maintain the client's INR between 2.0 and 3.0 regardless of the actual PT in seconds.
Upon receiving a new IV medication, a client becomes short of breath with itching and hives. What is the priority nursing action? A. Assess vital signs B. Review the client's allergies C. Stop the intravenous infusion D. Administer diphenhydramine as ordered
Answer- C Rationale: If an IV drug is suspected to be causing the anaphylaxis, stop the drug immediately but do not remove the venous access because restarting an IV is difficult when the client is severely hypotensive. Other actions can be done after the new medication infusion is stopped.
Upon removing a dressing from a wound, the nurse notices a strong odor. What is the appropriate nursing action? A. action is necessary at this time. B. Notify the health care provider of a possible wound infection. C. Clean the wound and reassess for presence of infection. D. Culture the wound and anticipate an order for antibiotics.
Answer- C Rationale: Wound fluid and debris often interact with the dressing and may result in an odor when the dressing is removed. Gently clean the wound and reassess. Signs of infection are most frequently stalled wound healing, presence of purulent exudate, increased wound size or depth, fever, elevated WBC count, and increased pain. Cultures are not usually obtained.
A student nurse is preparing the patient for a bone marrow biopsy procedure, which of the following would indicate a need for re-teaching? A. Provides accurate information and emotional support. B. Explains procedure and answers questions. C. Teaches to inspect the site every 4 hours for 24 hours. D. Avoid activity that could result in trauma, take aspirin-free analgesics and apply ice packs to the site.
Answer- C Rationale: the site should be inspected every 2 hours post-op for 24 hours.
Which provider order will the nurse implement first when caring for a 44 year old client with Breast cancer and dehydration who has a Groshong port? A. Feed clear liquid diet B. Apply support stockings C. Obtain laboratory samples D. Administer D5½ NS at 125 mL/hr
Answer- D Rationale: Based on the client's diagnosis, IV fluids should be started first. The client is admitted with dehydration, so the Groshong port should be accessed and IV fluids initiated immediately. The provider has ordered clear liquids, but because the client has been experiencing nausea and vomiting, she may not be able to ingest enough fluids to correct the dehydration. The laboratory values are ordered for the morning, so they should not be obtained until then. The support stockings can be obtained by the AP while IV fluids are started.
Which of the following is true regarding WBC? A. Eosinophils account for 15% of WBC B. Basophils account for 10% of WBC C. Tissue mast cells have binding sites for IgM D. Neutrophils account for for 55-70 % of normal WBC
Answer- D Rationale: Eosinophils account for 1-4%, Basophils account for 1% of WBC. Tissue mast cells have binding sites for IgE.
Which of following statements about the effects of HIV is false? A. When HIV enters a CD4+ T-cell, the host cell stops being an active immune system cell and becomes a virus factory . B. Gradually, CD4+ T-cell count falls, viral numbers (viral load) rises. C. Immune system weakens. D. Everyone with HIV has AIDS.
Answer- D Rationale: Everyone with Stage HIV- III has AIDS, Not everyone with HIV has AIDS
A 40-year-old client with polycystic kidney disease is to receive a kidney transplant. When the nurse begins to administer 2 units of leukocyte-poor packed red blood cells to treat a low hemoglobin, the client asks why this has been prescribed. What is the appropriate nursing response? A. "It causes fewer blood reactions for pre-transplant patients." B. "It is less likely to causes hemolysis, or destruction of the blood cells, after transfusion." C. "All pre-transplant patients receive leukocyte-poor blood because it is absorbed better by the body." D. "It will decrease the risk of obtaining white blood cells from the donor that could make it harder for your transplanted kidney to function."
Answer- D Rationale: Human leukocyte antigens (HLAs) are found on the surface of all body cells and serve as a "cellular fingerprint" recognizing self and non-self cells. When the HLAs of the immune system encounter a cell that is foreign, the immune system cell then takes action to neutralize, destroy, or eliminate this foreign invader. Transfusion of blood that contains leukocytes increases the number of HLAs introduced to the body. Evidence shows that leukocytes present in cellular blood products are the main component involved in the occurrence of HLA immunization, and several studies show that leukocyte-poor blood products are less able to induce it. HLA immunization through blood transfusion will make it harder to find an acceptable kidney transplant match for the patient (for example, HLA match for kidney transplant).
The health care provider's orders include hydroxyurea. The client asks about the purpose of this medication, which of the following statements indicates the client will need further education about this drug? A. This drug will reduce the sickling of my blood cells. B. This medication will suppress my bone marrow C. I will need to have my complete blood counts checked frequently. D. This medication will cure my Sickle Cell Disease
Answer- D Rationale: Hydroxyurea may be helpful in preventing sickle cell crisis but cannot cure the disease.
A patient receiving ACE Inhibitors develops lip swelling, firm swelling of face, tongue, and neck. The patient also had difficulty speaking and swallowing, which are all symptoms f angioedema, What should the nurse do immediately to stop the reaction? A. Apply O2 via NC B. Flush the IV line C. Put in an NG tube D. Stop the medication
Answer- D Rationale: In order to stop the reaction, you must stop the medication. Nasal an oral swelling are present in angioedema, so applying O2 via NC may not be effective and you should consider preserving the airway with a trach or intubation, the first intervention however is to stop the medication.
The health care provider diagnoses the client with acute sickle cell crisis. Which drug does the nurse anticipate will be prescribed for pain control at this time? (Select all that apply.) A. Meperidine IV push prn B. Acetaminophen rectally prn C. Morphine sulfate IM scheduled doses D. Hydromorphone IV push scheduled doses E. Morphine sulfate IV push scheduled doses
Answer- D, E Rationale: A client in sickle cell crisis often needs approximately 48 hours of IV analgesia. Morphine and hydromorphone (Dilaudid) are given IV on a regular schedule, or by using a patient-controlled analgesia (PCA) pump. Once relief is obtained, the IV dose can be tapered and oral drugs may be given. PRN dosages should be avoided because they do not provide adequate pain relief. Acetaminophen will not address the degree of pain that is being experienced. IM injections should be avoided because absorption is impaired by poor perfusion and sclerosed skin.
A client who engages in sex with men and women asks the nurse about ways to prevent HIV transmission. Which method will the nurse teach? Select all that apply. A. Begin antiviral drug therapy B. Take an HIV home screening test C. Engage only in vaginal intercourse D. Use condoms during sexual activity E. Discuss PrEP with a health care provider
Answer- D, E Rationale: Clients who wish to prevent HIV transmission should use condoms during sexual activity to reduce risk of exposure. Clients who are HIV-negative but at high risk for exposure to HIV should be taught to discuss PrEPwith a health care provider. Beginning antiviral drug therapy is reserved for clients who have tested HIV positive. Taking an HIV home screening test may reveal the client's HIV status, but this does not prevent transmission. Engaging only in vaginal intercourse does not assure that HIV will not be transmitted.
Which is not one of the hematological changes associated with aging? A. Decrease in blood volume with lower levels of plasma proteins. B. Bone marrow produces fewer blood cells C. Total RBC, WBC counts are lower. D. Lymphocytes are more reactive to antigens and gain immune function. E. Hemoglobin levels fall after middle-age.
Answer- D. Rationale: Lymphocytes are less reactive to antigens and lose immune function.
The client is very weak and reports anorexia, painful swallowing, severe diarrhea, and occasional vomiting. The nurse delegates mouth care to assistive personnel (AP). What instructions will the nurse provide to the AP?
Answer- The nurse will instruct the AP to offer the client rinses with sodium bicarbonate and normal saline every 2 hours, to use a soft toothbrush, to remind the client to drink plenty of fluids, and to report back, particularly if the client has any abnormal appearances in the mouth, or mouth pain.
Which of the following are cardiovascular symptoms of Anemia? Select All That Apply. A. Orthostatic Hypotension B. Brittle and concave nails. C. Joint and muscle pain. D. Continuous rapid heart rate that increases after meals and with activity. E. Severe migraines F. Murmurs and Gallops.
Answer: A, D, F Rationale: Brittle and concave nails are a sign of chronic anemia but are not a cardiovascular symptom. Joint and muscle pain, migraines are not symptoms typically associated with anemia.
The nurse has initiated a blood transfusion and has remained with the patient for the first 30 minutes of the transfusion, but she is called away to assess another patient. Which task would be appropriate to delegate to UAP? A. Ensure the blood products are infusing with Normal Saline and change bag when it runs out. B. Infuse a new bag of blood with RN when blood has infused and assess for fluid overload. C. Take vital signs every 15 minutes or as policy indicates and report findings to the RN D. Ensure the IV tubing has the proper filter device and replace if indicated.
Answer: C Rationale: Vital signs are the only task of the options that an unlicensed assistive person may perform within their scope. Blood transfusions must always be verified by two RNs. UAPs may not change out blood components or IV fluids.
Which of the following is a MRDO? A. Influenza B. Staphylococcus C. Urinary Tract Infection D. Vancomycin Resistant Enterococcus
Answer: D
An older adult client with a long history of congestive heart failure is being treated for a pressure injury over the coccyx that is 4 cm wide and 5 cm long, with eschar present. Which technique does the nurse anticipate will be used to remove the necrotic tissue? A .Surgical removal B. Biologic dressing C. Continuous dry gauze dressing D. Dressings along with a topical enzyme preparation
Answer: D Rationale: Although surgical removal of necrotic tissue may be indicated for some clients, those who are older but too ill or debilitated for surgery will require a nonsurgical approach to ulcer débridement. A biologic dressing is appropriate once the eschar has been removed. A continuous dry gauze dressing is not appropriate for débridement. Topical enzyme preparations help soften and remove eschar.
When does the nurse determine that a client with Non-Hodgkin's Lymphoma is at greatest risk of developing tumor lysis syndrome? A. After the first cycle of chemotherapy B. During the second cycle of chemotherapy C. Anytime during the client's treatment course D. While undergoing radiation and chemotherapy
Answer: D Rationale: Tumor lysis syndrome can occur when a large number of tumor cells are rapidly destroyed. This is usually seen in patients with high-grade cancers or those with bulky tumor burden, and occurs after receiving radiation and chemotherapy.
After a week, the client is being prepared for discharge to home, where the client lives with a spouse and 2 children. What teaching will the nurse provide to the family?
Answer: When the client is discharged, one of the most important things for him or her to remember is Standard Precautions and good handwashing.When at home, the client and family should have a good understanding that body fluids—including feces, vomitus, urine, blood, or any other body fluid—should be cleaned away with soap and water, and the area disinfected with a 1:10 bleach solution for at least 5 minutes. If bed linens or clothes become soiled, they should be washed in hot water with one cup of bleach added per load of laundry. Dispose of needles and other "sharps" in a labeled puncture-proof container to avoid needle stick injuries.
