practice questions for med surg II final

The HIV-infected patient is taught health promotion activities including good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? A Delaying disease progression B Preventing disease transmission C Helping to cure the HIV infection D Enabling an increase in self-care activities

A Delaying disease progression

The most common signs and symptoms of leukemia related to bone marrow involvement are which of the following? A Petechiae, fever, fatigue B Headache, papilledema, irritability C Muscle wasting, weight loss, fatigue D Decreased intracranial pressure, psychosis, confusion"

A Petechiae, fever, fatigue

Which action by a nursing assistant (NA) when caring for a patient who is pancytopenic(infection and bleeding) indicates a need for the nurse to intervene? A The NA assists the patient to use dental floss after eating. B The NA makes an oral rinse using 1 teaspoon of salt in a liter of water. C The NA adds baking soda to the patient's saline oral rinses. D The NA puts fluoride toothpaste on the patient's toothbrush.

A The NA assists the patient to use dental floss after eating.

The blood test used to identify a response to HIV infection is: A Western blot B Elisa test C CD-4 cell count D CBC

A Western blot

a nurse ic completing discharge teaching with a client who has a permanent pacemaker. which of the following statements by the client indicates understanding of the teaching? A. "i will notify the airport screeners about my pacemaker" B. i will expect to have occasional hiccups C. i will have to disconnect my garage door opener D. i will take my pulse ever 2-3 days

A. "i will notify the airport screeners about my pacemaker"

A nurse is admitted a client to the orthopedic unit following a toal knee arthroplasty. which of the following actions by the nurse are approparatie? (select all that apply A. check continuous passive motion device setting B. palpate dorsal pedal pulses C. place pillow behind the knee D. elevate heels off bed E. apply heat therapy to incision

A. check continuous passive motion device setting B. palpate dorsal pedal pulses D. elevate heels off bed

a nurse is planning discharge teaching for a client who had a total hip arthroplasty. which of the following should the nurse include in teaching? (select all that apply) A. clean the incision daily with soap and water B. turn the toes inward when sitting or lying C. sit in a straight backed armchair D. bend at the waist when putting on socks E. use a raised toilet seat

A. clean the incision daily with soap and water C. sit in a straight backed armchair E. use a raised toilet seat

a nurse is caring for a client following the insertion af a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. which of the following findings should the nurse report to the provider? (select all that apply) A. cool and clammy foot with capillary refill of 5 seconds B. observed pacing spike followed by a QRS complex C.persistent hiccups D. heart rate 84/minute E. blood pressure 104/62 mmHg

A. cool and clammy foot with capillary refill of 5 seconds C.persistent hiccups

a nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. which of the following should the nurse include in the teaching plan (slect all that apply) A. encourage complete autologous blood donation B. sit in a low reclining chair C. instruct the client to roll onto the operative hip D. use an abductor pillow when turning the client E. perform isometric exercises

A. encourage complete autologous blood donation D. use an abductor pillow when turning the client E. perform isometric exercises

a nurse is caring for a client who experienced defibrillation. which of the following should be included in the documnnetaiton of this procedure? (select all that apply) A. follow up ECG B. energy settings used C. IV fluid intake D. urinary output E. skin condition under electrodes

A. follow up ECG B. energy settings used E. skin condition under electrodes

a nurse is caring for a client who has DIC. which of the following medications should the nurse anticipate administering? A. heparin B. vitamin K C. mefoxin D. simvastatin

A. heparin

a nurse in the clinic is teaching a client who has ulcerative colitis. which of the following statements by the client indicates understanding of the teaching? A. i will plan to limit fiber in my diet B. i will restrict fluid intake during meals C. i will switch to black teach instead of drinking coffee D. i wil try to eat three moderate to large meals a day

A. i will plan to limit fiber in my diet -the nurse should plan to administer a fluid challenge for hypovolemia,w which is indicated by the clients low urinary output and blood pressure

a nurse is an outpatient clinic is assessing a client who reports night sweats and fatigue. he states he has had a cough along with nausea and diarrhea. his temperature is 38.1 (100.6). the client is afraid he has HIV. which of the following actions should the nurse take? (select all that apply) A. perform a physical assessment B. determine when manifestations began C. teach the client about HIV transmission D. draw blood for HIV testing E. obtain a sexual history

A. perform a physical assessment B. determine when manifestations began E. obtain a sexual history

a nurse is planning care for a client who has Hgb 7.5 and Hct 21.5%. which of the following actions should the nurse include in the plan of care? (select all that apply) A. provide assistance with ambulation B. monitor oxygen saturation C. obtain stool specimen for occult blood D. schedule daily rest periods E. weight the client weekly

A. provide assistance with ambulation B. monitor oxygen saturation C. obtain stool specimen for occult blood D. schedule daily rest periods

a nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. which of the following nursing actions should the nurse use to promote client safety? (select all that apply) A. wear gloves when handling pacemaker leads B. ensure electronic equipment has three pronged grounding plugs C. minimize the clients shoulder movements D. hold the lead wires taut when turning the client E. keep extra pacemaker batteries at least 300 ft away forth client

A. wear gloves when handling pacemaker leads C. minimize the clients shoulder movements

a nurse caring for a client who is suspected of having HIV. the nurse should identify with of the following diagnostic test and ab values are used to confirm HIV infection? (select all that apply) A. western blot B. indirect immunofluorsecnce assay C. CD4+ T-lymphocyte count D. HIV RNA quanitidicaiton test E. cerebrospinal fluid (CSF) analysis

A. western blot B. indirect immunofluorsecnce assay

a nurse is providing discharge teaching to a client who had a gastrectomy of stomach cancer.w hick of the following information should the nurse include in teaching? Select all that apply A. you will need a monthly injection of vitamin B12 of r the rest of ur life B. using the nasal spray form of vitamin B 12 on a daily basis can be an option C. an oral supplement of vitamin B12 taken on a daily basis can be an option D. you should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet E. add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia

A. you will need a monthly injection of vitamin B12 of r the rest of ur life B. using the nasal spray form of vitamin B 12 on a daily basis can be an option

Which information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider? A Hemoglobin of 10 g/L B WBC count of 1700/µl C Platelets of 65,000/µl D Serum creatinine level of 1.2 mg/dl

B

The patient is admitted to the ED with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing measures will help identify the need for further assessment of the cause of this patient's manifestations (select all that apply)? A Assessment of lung sounds B Assessment of sexual behavior C Assessment of living conditions D Assessment of drug and syringe use

B Assessment of sexual behavior D Assessment of drug and syringe use

The nurse is caring for a patient newly diagnosed with HIV. The patient asks what would determine the actual development of AIDS. The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS? A Presence of HIV antibodies B CD4+ T cell count below 200/µL C Presence of oral hairy leukoplakia D White blood cell count below 5000/µl

B CD4+ T cell count below 200/µL

A client is beginning a regimen of ferrous sulfate or iron. As you prepare to administer the medication, it is important for you to advise the client that A Her urine will turn a dark orange B Her bowel movements will be dark and tarry C Her appetite will be diminished D Her vision will become slightly blurred

B Her bowel movements will be dark and tarry

The nurse writes a nursing problem of "altered nutrition" for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented? A Administer an antidiarrheal medication prior to meals B Monitor the client's serum albumin levels C Assess for signs and symptoms of infection D Provide skin care to irradiated areas

B Monitor the client's serum albumin levels

In formulating a nursing diagnosis of risk for infection for a client with chronic lymphoid leukemia (CLL), nursing measures should include: (Select all that apply.) A Maintaining a clean technique for all invasive procedures. B Placing the client in protective isolation. C Limiting visitors who have colds and infections. D Ensuring meticulous handwashing by all persons coming in contact with the client.

B Placing the client in protective isolation. C Limiting visitors who have colds and infections. D Ensuring meticulous handwashing by all persons coming in contact with the client.

A patient with sickle cell anemia is admitted to the hospital with a sickle cell crisis. While caring for the patient during the crisis, it is important for the nurse to A limit the patient's intake of oral and IV fluids. B evaluate the effectiveness of opioid analgesics. C encourage the patient to ambulate as much as tolerated. D teach the patient about high-protein, high-calorie foods.

B evaluate the effectiveness of opioid analgesics.

Your primary goal in the care of the patient with DIC is to A provide emotional support. B recognize early signs of occult or overt bleeding. C monitor nutritional intake. D report abnormal laboratory results.

B recognizae early signs of occult or overt bleeding.

a nurse is completing discharge teaching with a client who has crohns disease.w hick of the following instructions should the nurse include in the teaching? A. decrease intake of calorie dense foods B. drink canned protein supplements C. increase intake of high fiber foods D. take bulk forming laxative daily

B. drink canned protein supplements

a nurse is reviewing the serum lab data of a client who has an acute exacerbation of corohns disease. which of the following lab test should the nurse expect to be elevated? select all that apply A. hematocrit B. erythrocyte sedimentation rate C. WBC D. folic acid E. albumin

B. erythrocyte sedimentation rate C. WBC

a nurse on a cardiac unit is caring for a client who is on telemetry. the nurse recognizes the clients heart rate is 46/min and notifies the provider. the nurse should anticipate that which of the following management strategies will be used of this client? A. defibrillation B. pacemaker insertion C. synchronized cardioversion D. administration of IV lgidocin e

B. pacemaker insertion

a nurse is completing an integumentary assessment of client who has anemia. which of the following findings should the nurse expect? A. absent turgor B. spoon shaped nails C. shiny, hairless legs D. yellow mucous membranes

B. spoon shaped nails

a nurse in a clinic receives phone call form a client seeking information about a new prescription for erythropoietin which of the following information should the nurse review with the client? A. the client needs an erythrocyte sedimentation rate (ESR) test weekly B. the client should have his hemoglobin checked twice a week C. oxygen saturation levels should be monitored D. folic acid production will increase

B. the client should have his hemoglobin checked twice a week

A patient who is having a sickle cell crisis asks the nurse why the sickling causes such pain. The nurse explains that the pain of sickling is caused by A Spasms of the blood cells as they change shape B Deposition of sickled red cells in the bone marrow C Tissue hypoxia caused by small blood vessel occlusion D Infectious processes in organs affected by the sickling

C Tissue hypoxia caused by small blood vessel occlusion

Transmission of HIV from an infected individual to another most commonly occurs as a result of A transmission from mother to infant during labor and delivery and breastfeeding. B low levels of virus in the blood and high levels of CD4+ T cells. C unprotected anal or vaginal sexual intercourse. D sharing of drug-using equipment, including needles, syringes, pipes, and straws

C unprotected anal or vaginal sexual intercourse.

as part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). the nurse understands that further teaching is needed if the client makes which statement? A. i should avoid blowing my nose B. i may need a platelet transfusion if my platelet count is too low C. I'm going to take aspirin for my headache as soon as i get home D. i will count the number of pads and tampons i use when menstruating

C. I'm going to take aspirin for my headache as soon as i get home

a nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. the nurse should recognize which of the following findings as the priority? A. clients report difficult sleeping B. the clients urine is positive for glucose C. client reports having an elevated body temp D. client reports gaining 4lb in the last 6 months

C. client reports having an elevated body temp -the greatest risk to the client is infection because prednisone can cause immmunosupression therefore, the nurse should identify indications of an infection, such as an elevated body temperature, as the priority finding

a nurse is assessing a client and suspect the client is experiencing DIC> which of the following physical findings should the nurse anticipate? A. bradycardia B. hypertension C. epistaxis D. xerostomia

C. epistaxis

a nurse is teaching a client who has a new prescription for ferrous sulfate. which of the following information should the nurse include in the teaching? A. stools will be dark red B. take with a glass of milk if gastrointestinal distress occurs C. foods high in vitamin c will promote absorption D. take for 14 days

C. foods high in vitamin c will promote absorption

a nurse is planning care for a client who has post renal AKI due to metastatic cancer. the client has serum creatinine of 5 mg/dL. which of the following interventions should the nurse include in the plan? (select all that apply) A. provide a high protein diet B. assess the urine for blood C. monitor for intermittent anuria D. weight the client once per week E. provide NSAIDs for pain

C. monitor for intermittent anuria

the nurse is monitoring a client for sings and symptoms related to superior vena cava syndrome. which is an early sign of this oncological emergency? A. cyanosis B. arm edema C. periorbital edema D. mental status change

C. periorbital edema

a nurse is planning care for a client who has pre-renal acute kidney injury (AKI) following abdominal aortic aneurysm repair. urianry output is 60 mL in the past 2 hours, and blood pressure is 92/58 mmHg. the nurse should anticipate which of the following interventions? A. prepare the client for a CT scan with contrast dye B. plan to administer nitroprusside C. prepare to administer a fluid challenge D. plan to position the client in trendelenburg

C. prepare to administer a fluid challenge

a nurse is assessing a client who has pre-renal AKI. which of the following findings should the nurse expect? select all that apply A. reduced BUN B. elevated cardiac enzymes C. reduced urine output D. elevated serum creatinine E. elevated serum calcium

C. reduced urine output D. elevated serum creatinine

the nurse should plan to implement which intervention the care of a client experiencing neutropenia as a result of chemotherapy A. restrict all visitors B. restrict fluid intake C. teach the client and family about the need for hand hygiene D. insert an indwelling urinary catheter to prevent skin breakdown

C. teach the client and family about the need for hand hygiene

a student nurse is observing a cardioversion procedure and hears the team leader call out "stand clear." the student should recognize the purpose of this action is to alert personnel that... A. the cardioverter is being charged to the appropriate setting B. they should initiate CPR due to pulseless electrical activity C. they cannot be in contact with equipment connected to the client D. a time out is being called to verify correct protocols

C. they cannot be in contact with equipment connected to the client

What is the most appropriate nursing intervention to help an HIV-infected patient adhere to a treatment regimen? A Give the patient a video and a brochure to view and read at home. B Tell the patient that the side effects of the drugs are bad but that they go away after a while. C "Set up" a drug pillbox for the patient every week. D Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.

D Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.

When discussing appropriate food choices with a patient who has iron-deficiency anemia and follows a low-cholesterol diet, the nurse will encourage the patient to increase the dietary intake of A eggs and muscle meats. B nuts and cornmeal. C milk and milk products. D legumes and dried fruits

D legumes and dried fruits

a nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. the nurse should recognize which of the following findings as contraindications to this procedure? A. 78 yrs old B. history of cancer C. previous joint replacement D. bronchitis 2 weeks ago

D. bronchitis 2 weeks ago

the nurse manager is teaching the nursing staff about sings and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency? A. headache B. dysphagia C. constipation D. elctrocardiographic changes

D. elctrocardiographic changes

a client admitted to the hospital with a suspected diagnosis of hodgkins disease. which assessment finding would he nurse expect to not specifically in the client? A. fatigue B. weakness C. weight gain D. enlarged lymph nodes

D. enlarged lymph nodes

a nurse is teaching a newly licensed nurse about heparin induced thrombocytenia. which of the following risk factors for this disorder should the nurse include in the teaching? A. warfarin therapy for a-fib B. placental abruption C. systemic lupus erythematosus D. heparin therapy for DVT

D. heparin therapy for DVT

a nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintainng a normal weight. which of the following statement say the client should indicate to the nurse an understanding of teaching? A. i will choose a diet high infant to hep gain weight B. i will be sure to eat three large ears daily C. i will drink up to 1 liter of liquid each day D. i will add high protein foods to my diet

D. i will add high protein foods to my diet

a nurse is providing teaching for a client who has stage 3 HIV disease. which of the following statements by the client should indicate to the nurse an understanding of teaching? A. i will wear gloves while changing the pet litter box B. i will rinse raw fruits with water before eating them C. i will wear a mask when around family members who are ill D. i will cook vegetables before eating them

D. i will cook vegetables before eating them A client with AIDS should cook vegetables before eating to kill bacteria that cause opportunitiesc infections

a nurse is assessing a client for HIV. the nurse should identify that which of the following are risk factors associated with this virus ? select all that apply A. perinatal exposure B. pregnancy C. monogamous sex partner D. older adults woman E. occupational exposure

D. older adults woman E. occupational exposure A. perinatal exposure

a client with a hip fractures asks the nurse why bucks (extension) traction is being applied before surgery? the nurse provides a response based on which purpose of bucks (extension) traction? A. allows bony healing to being before surgery B. provides rigid immobilization of the fracture site C. lengthens the fractured leg to prevent severing of blood vessels D. provide comfort by reducing muscle spasms and provides fracture immobilization

D. provide comfort by reducing muscle spasms and provides fracture immobilization bucks traction is type of skin traction often applied after hip fracture before the fracture is reduced in surgery. traction reduces muscle spasms and helps immobilize the fracture. traction does not allow for bony healing to being or provide rigid immobilization. traction does not lengthen the leg for the purpose of preventing blood vessel severance.