Test 3

The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response? "A PFT measures how elastic your lungs are." "A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood." "A PFT measures how much air moves in and out of your lungs when you breathe." "A PFT measures how much energy you get from the oxygen you breathe."

"A PFT measures how much air moves in and out of your lungs when you breathe." Explanation: PFTs are routinely used in clients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.

A parent calls the clinic and tells the nurse that the parent's toddler has a temperature of 102°F (38.9°C). What should the nurse teach the parent about the child's fever? "Neutrophils release pyrogen, a fever-causing substance, which helps act as a catalyst for the body's inflammatory and immune responses." "Inflammation causes the activation of a chemical called Hageman factor that initiates a process to bring more blood to the injured area and allows white blood cells to escape into the tissues." "A fever is the body's way of fighting an infection and supporting the body's immune system." "Leukotrienes activated by arachidonic acid attract neutrophils to start the process of fighting inflammation."

"A fever is the body's way of fighting an infection and supporting the body's immune system." Explanation: The best response by the nurse would be that a fever actually increases the efficiency of the immune and inflammatory responses, helping the body to fight the infection. While the other three statements are correct, they are more technical and include terminology that a new mother may not understand or even care about. If the appropriate response does not suffice and the mother still has questions, the nurse would then go into more detail and use the rationale from the other options to explain in greater detail.

The nurse is caring for a 41-year-old male client with rheumatoid arthritis. Which of the following would be the best time to plan ambulation? Just before the patient's noontime meal After the patient returns from physical therapy After the patient has a bath When the patient first awakens in the morning

After the patient has a bath

A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization which will allow for the release of what? Phagocytes Antigens Cytokines Antibodies

Antibodies Explanation: Immunizations activate the humoral immune response, culminating in antibody production. Antigens are the substances that induce the production of antibodies. Immunizations do not prompt cytokine or phagocyte production.

The family nurse practitioner is caring for an adult client who has been noncompliant with the care regimen previously outlined for treatment of sinusitis. What should the nurse practitioner do to best promote compliance? Provide the instructions in large type. Assess the reasons why the client did not comply with treatment. Give the treatment instructions to the client's spouse. Give the treatment instructions to a member of the client's family.

Assess the reasons why the client did not comply with treatment. Explanation: Before performing any interventions, it is important that the nurse assess the reasons why the client did not comply. These findings would inform the nurse's choice of subsequent interventions.

The nurse is caring for a client who is scheduled to receive a local anesthetic. The nurse understands that vital signs should be monitored at what point? After the procedure During the procedure Before, during, and after the procedure Before the procedure

Before, during, and after the procedure Explanation: Vital signs are monitored before, during, and after a procedure when local anesthetic is used.

A client is in the clinic to have blood drawn to assess theophylline levels. The client appears to being responding well to the medication and is not experiencing any adverse effects. What serum level will the nurse expect the client to have? Between 40 and 50 mcg/mL Between 25 and 35 mcg/mL Between 0.5 and 5 mcg/mL Between 10 and 20 mcg/mL

Between 10 and 20 mcg/mL Explanation: Therapeutic theophylline levels should be between 10 and 20 mcg/mL. A level between 0.5 and 5 mcg/mL would be low and would not produce a therapeutic effect. Levels between 25 and 50 mcg/mL would be too high and could cause serious adverse effects.

A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? Skin sloughing Butterfly rash Petechiae Jaundice

Butterfly rash Explanation: An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Clients with SLE do not typically experience jaundice or skin sloughing.

A client being prepared for surgery has been prescribed antibiotics as prophylaxis. Which medication would the nurse anticipate being ordered? Penicillin G Amoxicillin Doxycycline Cephalosporin

Cephalosporin Explanation: Clinical indications for the use of cephalosporins include surgical prophylaxis and treatment of infections of the respiratory tract, skin and soft tissues, bones and joints, urinary tract, brain and spinal cord, and bloodstream (septicemia). In most infections with streptococci and staphylococci, penicillins are more effective and less expensive.

Prostaglandins are: Chemical mediators released in the periphery, which prevent sensitization of pain receptors to various chemical substances released by damaged cells. Chemical mediators found in most body tissues; they participate in the inflammatory response. Sensitized pain receptors; they participate in the inflammatory response. Chemical mediators which produce chronic, painful, inflammatory disorders that affect the synovial tissue of hinge-like joints.

Chemical mediators found in most body tissues; they participate in the inflammatory response. Explanation: Prostaglandins are chemical mediators found in most body tissues; they help regulate many cell functions and participate in the inflammatory response. They are formed when cellular injury occurs and phospholipids in cell membranes release arachidonic acid.

A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize? Smoking up to three cigarettes weekly is generally allowable. Minor respiratory infections are considered to be self-limited and are not treated with medication. Activities of daily living (ADLs) should be clustered in the early morning hours. Chronic inhalation of indoor toxins can cause lung damage.

Chronic inhalation of indoor toxins can cause lung damage. Explanation: Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all clients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit clients to perform these without excessive distress.

What is the best indicator of decreased nausea after administering ondansetron (Zofran) IV? Blood pressure 110/64 Heart rate 64 bpm Client is hungry Client states, "I feel less nauseated."

Client states, "I feel less nauseated." Explanation: Monitor patient response to the drug (relief of nausea and vomiting). Nausea is a subjective symptom. The patient telling you that they are less nauseated would be the best indication the drug is working.

A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? Inspiratory wheezes Expiratory wheezes Crackles Rhonchi

Crackles Explanation: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.

The nurse is assessing a postoperative client whom the nurse suspects may have developed atelectasis. What assessment finding by the nurse best supports this suspicion? Hemoptysis (blood-tinged sputum) Oral temperature of 37.4°C (99.3°F) Chest pain on exertion Crackles on lung auscultation

Crackles on lung auscultation Explanation: Clients with atelectasis may present with crackles, dyspnea, fever, cough, hypoxia, and changes in chest wall movement. This client's temperature is within normal ranges. Hemoptysis and chest pain are not normally associated with atelectasis.

When the nurse administers warfarin, it is expected that the drug will have what effect on the body? Increase in vitamin K-dependent factors in the liver Increase in prothrombin Decrease in production of vitamin K-dependent clotting factors Increase in procoagulation factors

Decrease in production of vitamin K-dependent clotting factors Explanation: Warfarin, an oral anticoagulant drug, causes a decrease in the production of vitamin K-dependent clotting factors in the liver. The eventual effect is a depletion of these clotting factors and a prolongation of clotting times. It is used to maintain a state of anticoagulation in situations in which the client is susceptible to potentially dangerous clot formation. It does not increase prothrombin, vitamin K-dependent factors in the liver, or procoagulation factors.

The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a client's room. The nurse asks the client when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take? Add a small amount of normal saline to moisten the specimen. Immediately take the sputum specimen to the laboratory. Discard the specimen and assist the client in obtaining another specimen. Refrigerate the sputum specimen and submit it once it is chilled.

Discard the specimen and assist the client in obtaining another specimen. Explanation: Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions.

Which of the following laboratory test results supports the diagnosis of systemic lupus erythematosus (SLE)? Increased platelet count Elevated blood urea nitrogen (BUN) Elevated antinuclear antibody (ANA) titer Elevated liver function levels

Elevated antinuclear antibody (ANA) titer

A client is administered a third-generation cephalosporin. The broad-spectrum agents like cephalosporins are most effective in treating which type of microorganism? Gram positive Gram negative Virus Fungi

Gram negative Explanation: Cephalosporins are broad-spectrum agents with activity against both gram-positive and gram-negative bacteria. But they are, in general, less active against gram-positive organisms and more active against gram-negative ones. Cephalosporins are not effective against fungi or viruses.

A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which of the following complications of therapy? Agranulocytosis Immunosuppression Anemia Thrombocytopenia

Immunosuppression Explanation: Corticosteroids such as prednisone can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts.

A gerontologic nurse is caring for an older adult client who has a diagnosis of pneumonia. What age-related change increases older adults' susceptibility to respiratory infections? Decreased diaphragmatic muscle tone Atrophy of the thymus Bronchial stenosis Impaired ciliary action

Impaired ciliary action Explanation: As a consequence of impaired ciliary action due to exposure to smoke and environmental toxins, older adults are vulnerable to lung infections. This vulnerability is not the result of thymus atrophy, stenosis of the bronchi, or loss of diaphragmatic muscle tone.

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? Intermittent positive-pressure breathing (IPPB) Bronchoscopy Incentive spirometry Positive end-expiratory pressure (PEEP)

Incentive spirometry Explanation: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In clients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

When discussing cephalosporins with the nursing class, the pharmacology instructor explains that this classification of drug is primarily excreted through which organ? Kidney Skin Liver Lung

Kidney Explanation: The cephalosporins are primarily metabolized in the liver and excreted in the urine. These drugs cross the placenta and enter breast milk. They are not excreted through the lungs, the liver, or the skin.

The nurse is caring for a client with chronic obstructive pulmonary disease. The plan of care will focus on what client problem? Adverse effects of medication therapy Risk for aspiration Lack of patent airway Activity intolerance

Lack of patent airway Explanation: Asthma, emphysema, chronic obstructive pulmonary disease (COPD), and respiratory distress syndrome (RDS) are pulmonary obstructive diseases. All but RDS involve obstruction of the major airways. RDS obstructs the alveoli. Pain, activity intolerance, and adverse effects of medication therapy are conditions identified to detect, manage, and minimize the unexpected outcomes the nurse should be especially aware of the potential for an obstructed airway in these clients.

The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit? Last bowel movement Latex allergy Number of pregnancies Difficulty falling asleep

Latex allergy Explanation: Due to the increased number of clients with latex allergies, it is essential to identify this allergy early on so precautions can be taken in the OR. The anesthetist should be informed of any allergies. This is a priority over pregnancy history, insomnia, or recent bowel function, though some of these may be relevant.

The nurse is collecting a nursing history from a preoperative client who is to receive local anesthesia. While taking the admission history, the client reports an allergy to lidocaine. What is the nurse's priority action? Notify the surgeon. Notify the anesthesiologist. Cancel the surgery. Tell the perioperative nurse.

Notify the anesthesiologist. Explanation: The priority action is to inform the anesthesiologist who will administer the anesthetic because local anesthesia often involves use of lidocaine. It is not within the nurse's scope of practice to cancel surgery. Notifying the surgeon and the perioperative nurse is appropriate but is not the priority of care.

A client has been diagnosed with stenosis of the pulmonary artery that inhibits the flow of unoxygenated blood between the right ventricle and the alveoli. What function will be impaired in this client? Expiration Diffusion Ventilation Perfusion

Perfusion Explanation: The lung tissue receives its blood supply from the bronchial artery, which branches directly off the aorta. The alveoli receive unoxygenated blood from the right ventricle via the pulmonary artery. The delivery of this blood to the alveoli is referred to as pulmonary perfusion, not diffusion. Expiration is the act of exhaling to rid the body of excess carbon dioxide. Ventilation is the movement of air in and out of the lungs.

A client who is receiving an immune suppressant has been admitted to the hospital unit. What action should the nurse prioritize? Monitor the client's nutritional status. Place the client on protective isolation. Provide client teaching regarding pharmacokinetics. Provide support and comfort measures related to adverse effects.

Place the client on protective isolation. Explanation: Clients taking immune suppressant drugs are more susceptible to infection because the client's normal body defenses will be diminished. As a result, the priority action by the nurse would to protect the client from exposure to infection through room selection, good hand hygiene, and taking care to avoid exposure to sick staff members. Nutritional status is important, as are comfort and support measures and other instructions concerning the drug. However, protecting the client from infection should be the priority action because this involves client safety.

After an extensive diagnostic workup, a client is diagnosed with systemic lupus erythematosus (SLE). Which statement about the incidence of SLE is true? SLE affects more Caucasians than African-Americans SLE is most common in women between ages 45 and 60 SLE tends to occur in families SLE is more common in underweight than overweight persons

SLE tends to occur in families

Which of the following goals for medication prescribed to treat rheumatoid arthritis is correct? To prevent osteoporosis To encourage bone regeneration To cure the disease To control inflammation

To control inflammation

A client has just been diagnosed with HIV. When developing the teaching plan, what information would the nurse share with this client related to use of alternative or complementary therapies? "Researchers have not looked at the benefits of alternative therapy for clients with HIV, so it is suggested you avoid these therapies until research data are available." "Alternative therapies have benefits and risks. Are there any types of alternative or complementary therapies that you follow or are there any herbs or supplements that you take?" "You do not take herbs or practice some type of alternative medicine such as acupuncture, massage therapy, hypnosis or diet therapy, do you?" "Complementary therapies such as acupuncture or herbal therapy are generally considered to be dangerous to clients with HIV, so we discourage them."

"Alternative therapies have benefits and risks. Are there any types of alternative or complementary therapies that you follow or are there any herbs or supplements that you take?" Explanation: With a new diagnosis of HIV, it is important for the nurse to assess the client for use of alternative therapies because some alternative therapies are contraindicated while on antiviral medication. The nurse should avoid negative statements that discourage the client from sharing information with the nurse. The statement about lack of research gives the client information but does not elicit information in return and is therefore inappropriate for the nurse to use.

The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the client? "Can you tell me what concerns you most about dying?" "Would you like me to have the chaplain come speak with you?" "You need to maintain hope because you may live for several years." "You'll learn much about the promise of a cure for HIV."

"Can you tell me what concerns you most about dying?" Explanation: The nurse can help the client verbalize feelings and identify resources for support. The nurse should respond with an open-ended question to help the client to identify fears about being diagnosed with a life-threatening chronic illness. Immediate deferral to spiritual care is not a substitute for engaging with the patient. The nurse should attempt to foster hope, but not in a way that downplays the client's expressed fears.

The nurse is admitting a 12-year-old child to the acute care facility and notices discolored secondary teeth. The parent doesn't know why the teeth are discolored and reports that the child is very good about brushing and flossing and sees the dentist regularly. What question should the nurse ask? "Have they ever received gentamicin?" "Have they ever received cephalexin?" "Have they ever received tetracycline?" "Have they ever received ampicillin?"

"Have they ever received tetracycline?" Explanation: The nurse would question whether the child was ever given tetracycline because this drug is commonly associated with discoloration of secondary teeth when it is administered to children who still have their primary teeth. Gentamicin, ampicillin, and cephalexin are not associated with discoloration of the teeth.

Which of the following statements indicates that a client understands the measures used to treat systemic lupus erythematous (SLE)? "I should apply SPF 10 sunscreen when I go to the beach." "I will be able to continue with my tanning bed appointments." "I can go visit my grandmother this weekend who has been ill with a cold." "I can go for a walk on the beach after 4:00 pm."

"I can go for a walk on the beach after 4:00 pm."

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the patient about methods to manage fatigue. Which statement by the client indicates a need for further instructions? "I should do some exercises, such as walking, when I am not fatigued." "I should sit whenever possible to conserve my energy." "I should avoid long periods of immobility because it causes joint stiffness." "I should take hot baths because they are very relaxing."

"I should take hot baths because they are very relaxing."

The nurse has provided client teaching for a client who will be discharged to home on an anti-infective. What statement made by the client indicates the nurse needs to provide additional teaching concerning the use of anti-infectives? "Antibiotics will not help me when I have a viral infection." "It's not unusual to develop diarrhea as a result of taking an antibiotic." "I will stop taking the antibiotic once my symptoms have resolved." "A bacterial culture will be done before antibiotics are prescribed for me."

"I will stop taking the antibiotic once my symptoms have resolved." Explanation: Compliance with anti-infective therapy is a concern. Patients tend to stop taking the drugs when they begin to "feel better." A nurse should instruct the client to take the entire course of prescribed drug to ensure a sufficient period to rid the body of pathogens and to help prevent the development of resistance. Antibiotics are not prescribed for viral infections. It is important that cultures be performed before antibiotics are prescribed to determine what organism is causing the infection so that the correct drug is prescribed. Diarrhea is the most common adverse effect from anti-infectives.

An older adult client taking high-dose corticosteroids to treat arthritis requests a measles vaccine. What is the nurse's best response? "Live virus vaccines cannot be given to people whose immune systems are suppressed." "Clients taking corticosteroids are well protected from viruses and do not need vaccines." "Corticosteroids interact with the measles vaccine to create serious adverse effects." "Measles vaccines are only given if you are at risk for serious complications of the disease."

"Live virus vaccines cannot be given to people whose immune systems are suppressed." Explanation: Corticosteroids block the inflammatory response and are very helpful in conditions such as arthritis. However, they also block the immune response, making a person immunosuppressed. The vaccine would not be given to this client because of the increased risk for infection. Vaccination against measles is universally recommended. Corticosteroids do not protect against viruses. The vaccine is contraindicated because of risk for infection and not because of a potential drug-drug interaction.

The client in the clinic receives a prescription for an anti-infective to treat a urinary tract infection. The client asks the nurse, "Would you ask the doctor to give me refills on this prescription? I get a urinary tract infection every few months, it seems, and I'd like to have a refill on hand for next time." What is the nurse's best response? "Most medications, if not used, should be discarded after a year so it is better to get a new prescription next year when you need it." "Sure, I'd be glad to ask. How many refills do you think you would need?" "Saving antibiotics for another time and trying to diagnose your own health problems can lead to resistant organisms that no longer respond to drugs." "This antibiotic doesn't destroy every virus that could cause a urinary tract infection so it is better to get a different antibiotic next time."

"Saving antibiotics for another time and trying to diagnose your own health problems can lead to resistant organisms that no longer respond to drugs." Explanation: Clients should not be given refills to use indiscriminately. The priority is teaching this client about drug-resistant organisms and how they can be prevented, as well as what happens if an infection results from a resistant organism. The expiration date of medications is not relevant to the discussion. Antibiotics are not used to treat viruses.

A client presents to the clinic and is diagnosed with a vaginal fungal infection. What should the nurse teach the client about self-administration of the prescribed vaginal antifungal medication? "Stay lying down for at least 15 minutes after insertion." "Gently rub the cream into your vaginal wall after insertion." "Insert low into the opening of the vagina." "Temporarily discontinue the medication when you're menstruating."

"Stay lying down for at least 15 minutes after insertion." Explanation: The client should remain recumbent at least 10 to 15 minutes after the medication is deposited high in the vagina so that leakage will not occur and absorption will take place. The effectiveness of the medication is determined by the consistent application for each specified dose for maximal results. The nurse would instruct the client to continue the medication during menstruation. Stopping the drug and restarting it later can lead to the development of resistant strains of the drug. The cream need not be rubbed into the vaginal wall as it will coat the wall naturally after insertion.

The nurse is caring for a client who is immunocompromised and is explaining the function of cytotoxic T cells. What should the nurse explain to this client? "Cytotoxic T cells are programmed to identify specific proteins or antigens that are foreign to your body." "These are cells that respond to rising levels of chemicals associated with an immune response in order to suppress or slow the reaction." "These T cells can either destroy a foreign cell or mark it for aggressive destruction by another cell." "These cells respond to chemical indicators of immune activity and stimulate other lymphocytes to be more aggressive and responsive."

"These T cells can either destroy a foreign cell or mark it for aggressive destruction by another cell." Explanation: Effector or cytotoxic T cells either destroy a foreign cell or make it available for aggressive destruction. Cells that identify specific proteins or antigens are B cells. Cells that respond to chemical indicators to stimulate other cells are helper T cells. Cells that suppress or slow the reaction are suppressor T cells.

The nurse is caring for a client in the postoperative period following an abdominal hysterectomy. The client states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication? "You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you won't get better faster?" "Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and won't have any problems." "Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery." "You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time."

"You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time." Explanation: Postoperatively, medications are given to relieve pain and maintain comfort without increasing the risk of inadequate air exchange. The nurse should address the client's concerns about drug dependency and the nurse's need to increase the client's ability to move and recover from surgery. The other responses offer incorrect information, such as increasing the client's ability to breathe or specifying the time needed to take the medication. Opioids will cause respiratory depression.

The nurse in the clinic is caring for a client who has seasonal rhinitis and the client wants to know what causes this to occur. What is the nurse's best response? "Your sympathetic nervous system is responding to stress in your life causing you to have nasal congestion." "You are experiencing symptoms because bacteria have entered the nose and caused a local infection." "Your symptoms are happening because pathogens are invading the tissues in your nose and causing necrosis of the superficial cells." "Your upper airways are inflamed because you inhaled an antigen, causing sneezing and watery eyes."

"Your upper airways are inflamed because you inhaled an antigen, causing sneezing and watery eyes." Explanation: Seasonal rhinitis usually occurs when the upper airways become inflamed because of the body's response to an inhaled antigen. The sympathetic system's response to stress usually opens the airways and does not cause inflammation. Bacteria entering the nose do not cause inflammation of the rest of the upper airways or necrosis.

A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold? 75 cells/mm3 of blood 325 cells/mm3 of blood 450 cells/mm3 of blood 200 cells/mm3 of blood

200 cells/mm3 of blood Explanation: When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.

A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response? Antibodies are made by B lymphocytes in response to a specific antigen. Specialized cells recognize and ingest cells that are recognized as foreign. T lymphocytes are assisted by cytokines to fight infection. Lymphocytes are stimulated to become cells that attack microbes directly.

Antibodies are made by B lymphocytes in response to a specific antigen. Explanation: The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. Phagocytosis and direct attack on microbes occur in the context of the cellular immune response.

What intervention does the nurse include in the plan of care for a client receiving a continuous intravenous infusion of heparin? Measuring hourly urinary outputs Avoid IM injections Assessing for symptoms of respiratory depression Monitoring BP hourly

Avoid IM injections Explanation: The most commonly encountered adverse effect of the anticoagulants is bleeding, ranging from bleeding gums during toothbrushing to severe internal hemorrhage. Avoid all invasive procedures, including giving IM injections, while the client is on heparin therapy. It would not be necessary to assess for respiratory depression, measure hourly output, or monitor the BP hourly as related because of heparin administration.

The nurse is teaching a group of adults about health promotion. What should the nurse recommend in order to minimize participants' risk of COPD? Get the annual influenza vaccination. Avoid smoking Get screened for the genetic markers for COPD. Minimize exposure to dust and mold.

Avoid smoking Explanation: COPD is a permanent, chronic obstruction of airways, often related to cigarette smoking. Vaccines do not confer protection and dust and mold are not normally implicated. Genetic factors are minimal; smoking is the most salient risk factor.

A client with SLE has the classic rash of lesions on the cheeks and bridge of the nose. What term does the nurse use to describe this characteristic pattern? Papular rash Pustular rash Butterfly rash Bull's eye rash

Butterfly rash

A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? The nurse should administer albuterol 30 to 45 minutes prior to the test. The client must not have received an immunization within 7 days. Prophylactic epinephrine should be given before the test. Emergency equipment should be readily available.

Emergency equipment should be readily available. Explanation: Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing.

The nurse is caring for a client experiencing acute bronchospasm. What drug is most likely to meet this client's needs? Cromolyn Ipratropium bromide Ephedrine Epinephrine

Epinephrine Explanation: Epinephrine may be injected subcutaneously in an acute attack of bronchoconstriction, with therapeutic effects in 5 minutes that last 4 hours. It is considered the drug of choice for the treatment of acute bronchospasm. Ipratropium bromide has an onset of action of 15 minutes when inhaled with a duration of 3 to 4 hours. Cromolyn is not for use during acute times of bronchospasm but is used to help prevent bronchospasm. Ephedrine can be used in acute bronchospasm, but epinephrine remains the drug of choice.

A client has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the client's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply. Insect stings Autoimmunity Environmental pollutants Medications Foods

Foods Medications Insect stings Explanation: Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities.

The client is at an increased risk for hearing loss if taking furosemide with what medication? Digoxin Gentamicin Codeine Ciprofloxacin

Gentamicin Explanation: The risk of ototoxicity increases if loop diuretics are combined with aminoglycoside antibiotics (gentamicin) or cisplatin. No known increased risk of ototoxicity exists when furosemide is taken with codeine, ciprofloxacin, or digoxin.

A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in laboratory values? Decreased blood glucose Increased serum albumin Increased neutrophils Increased eosinophils

Increased eosinophils Explanation: Higher percentages of eosinophils are considered moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and is found in clients with allergic disorders. Hypersensitivity does not result in hypoglycemia or increased albumin and neutrophil counts.

A client's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at this client's site of inflammation? Neutrophils Red blood cells Lymphocytes Eosinophils

Neutrophils Explanation: Neutrophils are the first cells to arrive at the site where inflammation occurs. Eosinophils increase in number during allergic reactions and stress responses, but are not always present during inflammation. RBCs do not migrate during an immune response. Lymphocytes become active but do not migrate to the site of inflammation.

The circulating nurse will be participating in a 78-year-old client's total hip replacement. What consideration should the nurse prioritize during the preparation of the client in the OR? Pressure points should be assessed and well padded. The client should be placed in Trendelenburg position. The preoperative shave should be done by the circulating nurse. The client must be firmly restrained at all times.

Pressure points should be assessed and well padded. Explanation: The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the client is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly client is at an increased risk of injury and impaired skin integrity. A Trendelenburg position is not indicated for this client. Once anesthetized for a total hip replacement, the client cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.

In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client's arterial oxygen saturation (SaO2). What procedure will best accomplish this? Arterial blood gas (ABG) measurement Peak flow measurement Pulse oximetry Incentive spirometry

Pulse oximetry Explanation: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the client no discomfort. An incentive spirometer is used to assist the client with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some clients with asthma use peak flow meters to measure levels of expired air.

The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? Risk for Ineffective Role Performance Related to Dermatitis Risk for Self-Care Deficit Related to Skin Lesions Risk for Disuse Syndrome Related to Dermatitis Risk for Disturbed Body Image Related to Skin Lesions

Risk for Disturbed Body Image Related to Skin Lesions Explanation: The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of clients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit.

The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following? Spleen Kidney Pancreas Thyroid gland

Spleen Explanation: A history of surgical removal of the spleen, lymph nodes, or thymus may place the client at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system.

The nurse is assessing a client who is being considered for anticoagulant therapy. What aspect of the client's health history should the nurse follow up most closely? The client has a history of GI ulcers. The client has a history of recurrent urinary tract infections. The client's last menstrual period was 10 days ago. The client's body mass index is 32 (obese).

The client has a history of GI ulcers. Explanation: Beginning anticoagulant therapy with active GI ulcers could result in severe bleeding. The date of this client's last menstrual period presents no obvious safety risk. Recurrent urinary tract infections and obesity should not impact anticoagulant therapy.

A client has come into the free clinic asking to be tested for HIV infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what? The client has been infected with HIV. The client's immune system is intact. The client is immune to HIV. The client has AIDS-related complications.

The client has been infected with HIV. Explanation: Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications.

An older adult client has been diagnosed with COPD. What characteristic of the client's current health status would rule out the safe and effective use of a metered-dose inhaler (MDI)? The client has not yet quit smoking. The client has cataracts. The client requires both corticosteroids and beta2-agonists. The client has severe arthritis in her hands.

The client has severe arthritis in her hands. Explanation: Safe and effective MDI use requires the client to be able to manipulate the device independently, which may be difficult if the client has arthritis. Smoking does not preclude MDI use. A modest loss of vision does not preclude the use of an MDI and a client can safely use more than one MDI.

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is the nurse's priority for health education? The need for the child to avoid all foods that have a high potential for allergies The need to vigilantly maintain the child's immunization status The need for the parents to carry an epinephrine pen The need to begin immunotherapy as soon as possible

The need for the parents to carry an epinephrine pen Explanation: All clients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. The child does not necessarily need to avoid all common food allergens. Immunotherapy is not indicated in the treatment of childhood food allergies. Immunizations are important, but do not address food allergies.

The nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency diseases? They are communicable. They have a genetic origin. They require IVIG as treatment. They are the result of intrauterine infection.

They have a genetic origin. Explanation: Primary immunodeficiency diseases are genetic in origin and result from intrinsic defects in the cells of the immune system. Primary immunodeficiency diseases do not always need IVIG as treatment, and they are not communicable. Primary immunodeficiencies do not result from intrauterine infection.

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? To prevent chronic obstructive pulmonary disease (COPD) To prevent pneumothorax To promote optimal lung expansion To enhance peripheral circulation

To promote optimal lung expansion Explanation: One goal of preoperative nursing care is to teach the client how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation.

A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? Face tent Venturi mask Non-rebreather air mask Tracheostomy collar

Venturi mask Explanation: The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.

A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug? "I seem to have lost my appetite, which is unusual for me." "When I eat a meal that's high in fat, I get really nauseous." "I feel so foggy in the mornings and it takes me so long to wake up." "I have this ringing in my ears that just won't go away."

"I have this ringing in my ears that just won't go away." Explanation: Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance of high-fat meals, or anorexia.

A nurse is preparing to discharge a client who has been prescribed warfarin. While assessing the client's knowledge of the drug, what statement should the nurse address? "I aim to walk 2 miles a day." "I take aspirin to help with the pain of my arthritis." "I drink a glass of wine with dinner some evenings." "I take vitamin C when I feel like I'm getting a cold."

"I take aspirin to help with the pain of my arthritis." Explanation: Increased bleeding can occur if a salicylate is taken in combination with warfarin. The nurse will instruct the client to stop taking aspirin. Walking, taking vitamin C, and drinking an occasional glass of wine should not interfere with the therapeutic effects of warfarin.

The nurse determines that teaching about warfarin is successful when the client makes what statement? "If I miss a dose, I will take 2 pills the next day." "I will check with my health care provider before taking any herbal supplements." "I will make sure to get my annual flu vaccine this fall." "I will minimize my physical activity so I don't start bleeding."

"I will check with my health care provider before taking any herbal supplements." Explanation: Warfarin is involved in many drug-drug and drug-herb interactions, so the client's statement about checking with the doctor before starting any new drugs or supplements would be correct. The other statements made by the client indicate the need for further teaching because he or she should not take two pills after missing a dose. The client should make an effort to avoid preventable injuries, but minimizing physical activity in general would not be necessary or beneficial. Vaccinations are beneficial but not to any greater extent than with a client who is not taking warfarin.

A client presents at the clinic with signs and symptoms of seasonal allergic rhinitis. The client is prescribed a nasal steroid to relieve symptoms. Two days later, the client calls the clinic stating that he is not experiencing any relief. What is the most appropriate response by the nurse? "You probably need to try a different nasal steroid. This one should be effective by now." "It could be that you are administering the drug incorrectly. Come in and we can review the process." "The drug must not work for you. I'll contact your provider to see if you can change to an oral steroid." "It may take up to 2 weeks to get the full clinical effect. Try to keep using the drug as prescribed."

"It may take up to 2 weeks to get the full clinical effect. Try to keep using the drug as prescribed." Explanation: Nasal steroids require about 2 weeks to reach their full clinical effect so the client should be encouraged to use the drug for that length of time before changing drugs or giving up. The other responses could be appropriate if after 2 weeks the client is still not getting relief.

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." "OA originates with an infection. RA is a result of your body's cells attacking one another." "OA is associated with impaired immune function; RA is a consequence of physical damage." "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

"OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis with a noninflammatory etiology, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints, with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. The diseases are not distinguished by the joints affected and neither has an infectious etiology.

An adolescent presents to the free clinic with reports of allergic rhinitis. The adolescent asks the nurse what makes the nose get so stuffy. What is the nurse's best response? "The inside of the nose swells because the blood vessels expand." "Cells called leukotrienes are attacking the mucous membranes of your nose and causing irritation." "Allergies make the sinuses drain into the nasal passages and it stuffs them up." "The inside of the nose swells closed because of drainage from the sinuses."

"The inside of the nose swells because the blood vessels expand." Explanation: Histamine is the major mediator of allergic reactions in the nasal mucosa. Tissue edema results from vasodilation and increased capillary permeability. Tissue edema is not caused by drainage from the sinuses or from leukotrienes.

A client who is using a topical antifungal agent to treat mycosis calls the clinic to report a severe rash that is accompanied by blisters. What should the nurse instruct the client to do? "Scrub the rash gently with soap and water." "Stop using the drug immediately." "Decrease the amount of the medication used." "Make an appointment so you can be tested for allergies."

"Stop using the drug immediately." Explanation: The client should stop using the drug. The rash could indicate sensitivity to the drug or worsening of the condition being treated. Scrubbing the rash could cause further irritation and increase the risk for other infections. Continuing the drug could cause further complications. Decreasing the medication would be ineffective in treating the infection while continuing to risk further complications. It would be unnecessary to have clinical allergy testing prior to discontinuing the medication.

The nurse has provided health teaching for a 15-year-old client newly diagnosed with asthma. What statement made by the client indicates a good understanding of the teaching the nurse has done regarding inhalers? "I need to take 3 short, quick breaths when I administer the inhaler." "I should hold my breath when administering a puff." "I should insert the inhaler about 1 inch into my mouth." "The aerosol canister should be shaken well before using."

"The aerosol canister should be shaken well before using." Explanation: Inhalers should be shaken well, immediately before each use. It would not be appropriate to teach the client to hold his breath when administering a puff because this would inhibit inhalation. The client should hold the device around one inch from the open mouth, not inside it. There is no need to take three quick breaths.

The nurse is caring for a patient newly diagnosed with multiple sclerosis. The patient asks why MS is called an autoimmune disease. What would be the nurse's best response? "The body attacks its own cells because it responds to specific self-antigens to produce antibodies." "The body responds to a cell invaded by bacteria with antibody production against similar cells." "Production of autoantibodies is a normal process that goes on all the time, but immunosuppression limits B-cell response." "People with multiple sclerosis have a genetic predisposition to destroy autoantibodies."

"The body attacks its own cells because it responds to specific self-antigens to produce antibodies." Explanation: Autoimmune disease occurs when the body responds to specific self-antigens to produce antibodies or cell-mediated immune responses against its own cells. The actual cause of autoimmune disease is not known, but theories speculate that (1) it could be a result of response to a cell that was invaded by a virus, leading to antibody production to similar cells; (2) production of autoantibodies is a normal process that goes continuously, but in a state of immunosuppression, the suppressor T cells do not suppress autoantibody production; or (3) a genetic predisposition to develop autoantibodies is present.

A nurse is teaching a client who has just been prescribed lansoprazole . What statement would indicate that the client correctly understands the action of this medication? "The medication will repair my ulcer." "The medication is an analgesic." "The medication inhibits acid secretions." "The medication is an antibiotic."

"The medication inhibits acid secretions." Explanation: The gastric acid pump or proton pump inhibitors suppress gastric acid secretion by specifically inhibiting the hydrogen-potassium adenosine triphosphatase (H+,K+-ATPase) enzyme system on the secretory surface of the gastric parietal cells. The statement, "The medication inhibits acid secretions," indicates that the client understands that the medication inhibits acid secretion. This medication does not act as an antibiotic or analgesic, nor will it repair the ulcer.

A client who has been newly diagnosed with chronic obstructive pulmonary disease (COPD) calls the clinic and asks the nurse to explain what the newly prescribed medications are for. What would be the most appropriate response by the nurse? "The medications that have been ordered for you are what the physician thinks will help your breathing the most." "The medications that have been ordered for you are to help relieve the inflammation and to open your airways." "The medications that have been ordered for you are to help you breathe with less resistance from your diaphragm." "The medications that have been ordered for you are designed to work together to reduce your oxygen requirements."

"The medications that have been ordered for you are to help relieve the inflammation and to open your airways." Explanation: Drug treatment of asthma and COPD aims to relieve inflammation and promote bronchial dilation. Drugs affecting the lower airway do not normally affect the diaphragm. They do not reduce the body's oxygen demand. Stating that the physician thinks they are best is not a sufficient or helpful response.

A client has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young I used to take antihistamines, but they always put me to sleep." How should the nurse best respond? "The newer antihistamines are different than in years past, and cause less sedation." "Most people find that they develop a tolerance to sedation after a few months." "Newer antihistamines are combined with a stimulant that offsets drowsiness." "Have you considered taking them at bedtime instead of in the morning?"

"The newer antihistamines are different than in years past, and cause less sedation." Explanation: Unlike first-generation H1 receptor antagonists, newer antihistamines bind to peripheral rather than central nervous system H1 receptors, causing less sedation, if at all. Tolerance to sedation did not usually occur with first-generation drugs and newer antihistamines are not combined with a stimulant.

The nurse is preparing a client for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment by the client would best indicate informed consent? "Because the physician isn't taking my ovaries, I'll still be able to have children." "The physician is going to remove my uterus and told me about the risk of bleeding." "I know I'll be fine because the physician said he has done this procedure hundreds of times." "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum."

"The physician is going to remove my uterus and told me about the risk of bleeding." Explanation: The surgeon must inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the physician. In the correct response, the client is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the client has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. The other listed statements do not reflect an understanding of the surgery to be performed.

The nurse admits a client with septicemia (infection in the bloodstream). The client denies any allergies, and the doctor has ordered cefuroxime based on blood culture and sensitivity testing. The client states, "I'd prefer vancomycin because I've been reading about drug-resistant bacteria and I don't want to take any chances." What is the nurse's best response? "You can't believe anything you read on the internet because most of it is just someone's opinion and not fact." "I appreciate your concern but you can certainly rest assured that the health care provider ordered the right medication for your needs." "Vancomycin is a powerful drug with many adverse effects and it is generally reserved for when no other drug will work." "There are some resistant infections that require vancomycin so you are right to prefer a stronger antibiotic."

"Vancomycin is a powerful drug with many adverse effects and it is generally reserved for when no other drug will work." Explanation: The client is right in saying that vancomycin is effective against drug-resistant bacteria but needs help to understand that he or she does not have a resistant infection as indicated by the culture and sensitivity and that use of such a powerful drug when it is not needed increases risk of developing a vancomycin-resistant infection. It is never right to tell a client "not to worry" because they have every right to participate in his or her own care and should not be patronized. Although some information on the internet may not be accurate, it would be incorrect to say it is all just someone's opinion and not fact, especially given that the client's information is accurate.

A client with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the client expresses anger and irritation when her call bell isn't answered immediately. What would be the most appropriate response? "You seem like you're feeling angry. Is that something that we could talk about?" "Would you like to talk about the problem with the nursing supervisor?" "I can see you're angry. I'll come back when you've calmed down." "Try to remember that stress can make your symptoms worse."

"You seem like you're feeling angry. Is that something that we could talk about?" Explanation: The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care, as well as sensitivity to the psychological reactions of the client. Offering to listen to the client express anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge her feelings. Ignoring the client's feelings suggests that the nurse has no interest in what the client has said. Offering to get the nursing supervisor also does not acknowledge the client's feelings.

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for the specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client? "The presence of food in the stomach interferes with the absorption of anesthetic agents." "You will need to have food and fluid restricted before surgery so you are not at risk for choking." "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."

"You will need to have food and fluid restricted before surgery so you are not at risk for choking." Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific basis for withholding food and the development of pneumonia or interference with absorption of anesthetic agents. Constipation in clients in the postoperative period is related to the anesthesia, not from withholding food or fluid in the hours before surgery.

The nurse is caring for a number of clients. Which client has lost a barrier defense, increasing the client's risk for infection? 68-year-old client diagnosed with prostate cancer 24-year-old client diagnosed with partial-thickness burns 72-year-old client diagnosed with bacterial pneumonia 13-year-old client diagnosed with chickenpox

24-year-old client diagnosed with partial-thickness burns Explanation: A burn client loses the protective barrier of the skin and is at risk for infection. In a partial-thickness burn, the glands of the skin secrete chemicals that destroy many pathogens and also the normal flora that live on the skin. A cancer client has decreased cellular defenses. The client with chickenpox and the client with pneumonia both have a diminished immune defense along with the prostate cancer client but still are at less risk for infection than the burn client.

The nurse is assessing a client whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client? Long, thin fingers A barrel chest Signs of oxygen toxicity Chronic chest pain

A barrel chest Explanation: In COPD clients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The nurse most likely would not assess chest pain or long, thin fingers; these are not characteristic of emphysema. The client would not show signs of oxygen toxicity unless they received excess supplementary oxygen.

The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. What client is having this type of reaction? An older adult with rheumatoid arthritis A client with a diagnosis of myasthenia gravis A client with a skin reaction resulting from adhesive tape A child with an anaphylactic reaction after a bee sting

A child with an anaphylactic reaction after a bee sting Explanation: Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specific antigen. Skin reactions are more commonly type IV and myasthenia gravis is thought to be a type II reaction. Rheumatoid arthritis is not a type I hypersensitivity reaction.

The ED nurse is assessing a client complaining of dyspnea. The nurse auscultates the client's chest and hears wheezing throughout the lung fields. What might this indicate about the client? A narrowed airway. Hemothorax. The need for physiotherapy. Pneumonia.

A narrowed airway. Explanation: Wheezing is a high-pitched, musical sound that is often the major finding in a client with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem? Acute respiratory failure Pneumoconiosis Pleural effusion Pneumonia

Acute respiratory failure Explanation: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A client is being treated for a pulmonary embolism and the medical nurse is aware that the client suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology? pH balance in the pulmonary veins and arteries Maintenance of constant osmotic pressure in the alveoli Maintenance of muscle tone in the diaphragm Adequate flow of blood through the pulmonary circulation.

Adequate flow of blood through the pulmonary circulation. Explanation: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure.

A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? Utilize a peak flow monitoring device Administer corticosteroids by metered dose inhaler Administer inhaled anticholinergics Administer an inhaled beta-adrenergic agonist

Administer an inhaled beta-adrenergic agonist Explanation: Asthma exacerbations are best managed by early treatment and education of the client. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in clients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath.

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? Heart rate and rhythm Skin integrity Airway patency Core body temperature

Airway patency Explanation: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

When describing the location where gas exchange takes place, what part of the anatomy should the nurse explain the function of? Alveoli Bronchi Trachea Bronchioles

Alveoli Explanation: Gas exchange occurs across the respiratory membrane in the alveolar sac. It does not occur in the bronchioles, the trachea, or the bronchi.

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the client is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client's blood? A complete blood count (CBC) A capillary blood sample Pulse oximetry An arterial blood gas (ABG) study

An arterial blood gas (ABG) study Explanation: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate. A CBC does not indicate the concentration of oxygen.

The nurse is caring for a diverse group of clients on a hospital medical unit. What client is most likely to experiencing a superinfection? a client who has acute kidney injury following Escherichia coli infection a client who is recovering from viral meningitis an older adult client with Clostridium difficile-associated diarrhea a client who has been admitted for the treatment of a dehisced and infected surgical incision

An older adult client with Clostridium difficile-associated diarrhea Explanation: In recent years the emergence of Clostridium difficile infections has been associated with the use of specific antibiotics. An E. coli infection, meningitis and an infected abdominal incision are not as likely to be the consequence of a superinfection.

An office worker takes a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? Anaphylactic (type 1) Immune complex (type III) Delayed-type (type IV) Cytotoxic (type II)

Anaphylactic (type 1) Explanation: The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.

The nurse is providing discharge teaching for a client who developed a pulmonary embolism after total knee surgery. The client has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client? Anticoagulant therapy usually lasts between 3 and 6 months. Warfarin must be taken concurrent with ASA to achieve anticoagulation. Warfarin will continue to break up the clot over a period of weeks He should take a vitamin supplement containing vitamin K

Anticoagulant therapy usually lasts between 3 and 6 months. Explanation: Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.

A resident of an extended-care facility has athlete's foot. After applying the prescribed antifungal cream, what should the nurse do next? Apply clean, dry socks. Wrap a sterile rolled gauze dressing around both feet. Elevate the client's feet for 30 minutes. Wipe away excess medication from the affected area.

Apply clean, dry socks. Explanation: Clean dry socks should be applied when treating athlete's foot to help eradicate the infection because they will keep the feet dry as well as prevent the cream from being wiped away. A rolled gauze dressing is not necessary as it would bind the feet and interfere with mobility and increase the risk of systemic absorption. Medication should not be removed once applied, and there is no need to elevate the feet unless another medical condition warrants this action.

A hospital client is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? Send the client to the x-ray department, and have the staff in the department wear masks. Ensure that the radiology department has been disinfected prior to the test. Have the client wear a mask to the x-ray department. Arrange for a portable x-ray machine to be used.

Arrange for a portable x-ray machine to be used. Explanation: A client who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the client's room. This confers more protection than disinfecting the radiology department or using masks.

A client is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which procedure will be involved? Myelography Angiography Paracentesis Arthrocentesis

Arthrocentesis Explanation: Arthrocentesis involves needle aspiration of synovial fluid. Angiography is an x-ray study of circulation with a contrast agent injected into a selected artery. Myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions.

The nurse is planning client teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? During the intraoperative period When the client returns from the PACU As soon as possible before the surgical procedure Upon the client's admission to the postanesthesia care unit (PACU)

As soon as possible before the surgical procedure Explanation: Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physician's office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the client is usually drowsy, making this an inopportune time for teaching. Upon the client's return from the PACU, the client may remain drowsy. During the intraoperative period, anesthesia alters the client's mental status, rendering teaching ineffective.

A child has been transported to the emergency department (ED) after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply. Measure the child's oxygen saturation by oximeter. Facilitate lung function testing. Assess the child's respiratory rate. Assess breath sounds. Monitor the child's respiratory pattern.

Assess breath sounds. Measure the child's oxygen saturation by oximeter. Monitor the child's respiratory pattern. Assess the child's respiratory rate. Explanation: The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties, low oxygen saturation, or abnormal lung sounds such as wheezing. Lung function testing is a lengthy procedure that is not appropriate in an emergency context.

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse? Assess for signs and symptoms of anaphylaxis. Assess for erythema and urticaria. Administer epinephrine. Administer an over-the-counter (OTC) antihistamine.

Assess for signs and symptoms of anaphylaxis. Explanation: If a client is experiencing an allergic response, the nurse's initial action is to assess the client for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction.

The nurse is admitting an adult client to the preoperative unit in preparation for an elective inguinal hernia repair procedure to be performed under general anesthesia. What is the nurse's initial priority nursing assessment related to the anesthesia? Assess the client's veins for ideal intravenous access sites. Assess the client's expectations for recovery. Assess the client's apical heart rate and rhythm. Assess the client's weight.

Assess the client's weight. Explanation: Weighing the client is an initial priority because his or her weight will be used to determine appropriate dosing of all medications and will establish a baseline used for evaluation of any potential adverse effects. The other options are all actions the nurse will need to perform, but none are of higher priority than weighing the client with regard to anesthesia.

A client's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? Administer the treatment with the client in a high Fowler's or semi-Fowler's position. Apply percussion firmly to bare skin to facilitate drainage. Assist the client into a position that will allow gravity to move secretions. Perform the procedure immediately following the client's meals.

Assist the client into a position that will allow gravity to move secretions. Explanation: Postural drainage is usually performed two to four times per day. The client uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not given in an upright position or directly following a meal.

An adolescent client's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this client consequently faces an increased risk of what health problem? Systemic lupus erythematosus (SLE) Asthma Rheumatoid arthritis Bronchitis

Asthma Explanation: Nurses should be aware that atopic dermatitis is often the first step in a process that leads to asthma and allergic rhinitis. It is not linked as closely to bronchitis, SLE, and RA.

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? Pulmonary embolism Acute respiratory distress syndrome (ARDS) Aspiration Atelectasis

Atelectasis Explanation: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? Atelectasis Peripheral edema Dehydration Anemia

Atelectasis Explanation: Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis

A 71-year-old client with a history of atrial fibrillation, chronic obstructive pulmonary disease, and type 2 diabetes has had an antihistamine prescribed. What assessment should the nurse prioritize? Chest auscultation and assessment of respiratory rate Assessment of orientation and level of consciousness Auscultation of apical heart rate and rhythm Q4h blood glucose checks

Auscultation of apical heart rate and rhythm Explanation: Antihistamines have been associated with prolongation of the QT interval, which can lead to potentially fatal cardiac arrhythmias. The client's history of an arrhythmia heightens the importance of assessing cardiac function. Assessing the client's blood glucose every four hours is likely beyond what is necessary. Respiratory assessment is necessary because of the client's history of COPD, but antihistamines do not exacerbate this condition. Cognitive changes are not expected.

A nurse practitioner provides primary care in a rural setting. The nurse should perform what actions in order to minimize the emergence of drug-resistant microbials? Select all that apply. Avoid the use of broad-spectrum antibacterial drugs when treating trivial or viral infections. Use narrow-spectrum agents if they are thought to be effective. Do not use vancomycin. Give antibiotics every time the patient wants them. Start antibiotics promptly before the culture and sensitivity report returns. Administer the highest tolerated dosage.

Avoid the use of broad-spectrum antibacterial drugs when treating trivial or viral infections. Use narrow-spectrum agents if they are thought to be effective. Do not use vancomycin. Explanation: Exposure to an antimicrobial agent leads to the development of resistance, so it is important to limit the use of antimicrobial agents to the treatment of specific pathogens known to be sensitive to the drug being used. Drug dosage is important in preventing the development of resistance. Doses should be high enough and the duration of drug therapy should be long enough to eradicate even slightly resistant microorganisms, but the prescriber does not aim for the highest possible tolerated dose. It is best to wait until cultures return before initiating antibiotics when possible, but clients with severe infections may be started on broad-spectrum antibiotics while waiting for culture results.

The nurse has cared for an increasing number of clients who have antibiotic resistance. What principles should the nurse and the other members of the care team follow in order to prevent antibiotic resistance? Select all that apply. Teach clients not to save antibiotics for self-medication in the future. Avoid the use of broad-spectrum antibacterial drugs when treating trivial or viral infections. Perform culture and sensitivity testing immediately after starting a course of antibiotics. Treat infections with tetracyclines or penicillins whenever possible. Use narrow-spectrum agents if they are thought to be effective.

Avoid the use of broad-spectrum antibacterial drugs when treating trivial or viral infections. Use narrow-spectrum agents if they are thought to be effective. Teach clients not to save antibiotics for self-medication in the future. Explanation: To prevent or contain the growing threat of drug-resistant strains of bacteria, it is very important to use antibiotics cautiously, to complete the full course of an antibiotic prescription, and to avoid saving antibiotics for self-medication in the future. Antibiotic treatment of minor or viral infections is linked to antibiotic resistance. Narrow-spectrum antibiotics are less likely, overall, to lead to resistance. The use of tetracyclines or penicillins does not necessarily reduce antibiotic resistance. Culture and sensitivity testing should take place before beginning therapy, whenever possible.

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? Increased anterior-posterior (AP) diameter Shallow respirations Bilateral wheezes Bradypnea

Bilateral wheezes Explanation: The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the child's AP diameter does not normally change.

The nurse is preparing a client for surgery. The client states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? Call the physician to review the procedure with the client. Explain the procedure clearly to the client and her family. Have the client sign the informed consent and place it in the chart. Provide the client with a pamphlet explaining the procedure.

Call the physician to review the procedure with the client. Explanation: While the nurse may ask the client to sign the consent form and witness the signature, it is the surgeon's responsibility to provide a clear and simple explanation of what the surgery will entail prior to the client giving consent. The surgeon must also inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the physician. The consent formed should not be signed until the client understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the client about the surgical procedure, but will not substitute for the information provided by the physician.

While assessing a new client on the unit, the nurse notes the following: productive cough, respiratory rate of 22, oxygen saturation of 90%, afebrile, and increased secretions. The client has a 20-year history of smoking 1.5 packs of cigarettes daily. What diagnosis is most likely? Pneumonia Cystic fibrosis Chronic obstructive pulmonary disease (COPD) Pleural effusion

Chronic obstructive pulmonary disease (COPD) Explanation: Chronic obstructive pulmonary disease (COPD) is a permanent, chronic obstruction of airways, often related to cigarette smoking. It is caused by two related disorders, emphysema and chronic bronchitis, both of which result in airflow obstruction on expiration, as well as overinflation of the lungs and poor gas exchange. Emphysema is characterized by loss of the elastic tissue of the lungs, destruction of alveolar walls, and resultant alveolar hyperinflation with a tendency to collapse with expiration. Chronic bronchitis is a permanent inflammation of the airways with mucus secretion, edema, and poor inflammatory defenses. Characteristics of both disorders often are present in the person with COPD. Pneumonia would likely cause a fever. Because of the client's smoking history, COPD is more likely than pleural effusion. Cystic fibrosis is a genetic disease of excessive pulmonary tract secretions and GI tract involvement.

A clinic nurse is caring for a client who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The client asks the nurse what he could have done to minimize the risk of contracting this disease. What should the nurse describe as the most significant risk factor? Inadequate exercise Exposure to dust and pollen Cigarette smoking Exposure to occupational toxins

Cigarette smoking Explanation: The most important risk factor for COPD is cigarette smoking. Lack of exercise and exposure to dust and pollen are not risk factors for COPD. Occupational risks are significant but are far exceeded by smoking.

Microscopic, hair-like projections of the nasal cell membranes transport foreign substances toward the throat. What structures perform this role? Goblet cells Cilia Alveolar sacs Sinuses

Cilia Explanation: Cilia are found in the epithelial cells of the lining of the nasal cavity and are constantly in motion directing mucus and trapped substances down toward the throat. Goblet cells are found in the epithelial lining and produce mucus, which traps foreign substances. Alveolar sacs are located in the lower respiratory tract and are considered the functional units of the lung. Sinuses are air-filled passages through the skull, which open into the nasal cavity.

The nurse is planning care for a client with AIDS who has developed chronic severe diarrhea secondary to adverse effects of the antiviral drugs prescribed. What goal should the nurse prioritize during this client's care? Client will remain free of electrolyte disturbances. Client will show improved nutritional status evidenced by weight gain. Client will be able to demonstrate the effectiveness of the teaching plan. Client will state that comfort and safety measures are effective and show compliance with the regimen.

Client will remain free of electrolyte disturbances. Explanation: Severe chronic diarrhea is likely to result in malnutrition and weight loss along with potential alterations in fluid and electrolyte balance. Of these, electrolyte imbalances are the most acute threat. Electrolyte imbalances would be prioritized over comfort and education because of their serious consequences.

A client with asthma has been prescribed an anti-inflammatory medication. How does an anti-inflammatory drug reduce this client's bronchoconstriction? Decreases formation of mucus secretions Decreasing airway hyperreactivity to stimuli Increasing uptake of corticosteroids to medication Increasing ability to metabolize medication

Decreasing airway hyperreactivity to stimuli Explanation: Bronchodilators, or antiasthmatics, are medications used to facilitate respirations by dilating the airways. They are helpful in symptomatic relief or prevention of bronchial asthma and for bronchospasm associated with chronic obstructive pulmonary disease (COPD). Reducing inflammation prevents and reduces bronchoconstriction by decreasing airway hyperreactivity to various stimuli that decreases mucosal edema and formation of mucus secretions that narrow airways. Anti-inflammatory drugs do not increase the ability to metabolize medication or increase uptake of steroids.

When describing gas exchange, the nurse should teach a client that oxygen and carbon dioxide enter and leave the body by what method? Active transport Diffusion Passive transport Osmosis

Diffusion Explanation: The alveolar sac holds the gas, allowing needed oxygen to diffuse across the respiratory membrane into the capillary, whereas carbon dioxide, which is more abundant in the capillary blood, diffuses across the membrane, and enters the alveolar sac to be expired.

A client presents to the emergency department (ED) having an acute asthma attack and has been prescribed epinephrine. The nurse should assess what therapeutic effect of this drug? Decreased inflammatory response in the airways Dilation of the bronchi with increased rate and depth of respiration Reduced surface tension within the alveoli allowing for gas exchange Inhibition of histamine and slow-reacting substance of anaphylaxis (SRSA) to prevent the allergic asthmatic response

Dilation of the bronchi with increased rate and depth of respiration Explanation: Epinephrine will cause the bronchi to dilate and also cause the rate and depth of respiration to increase. Inhaled steroids decrease the inflammatory response, and lung surfactants reduce the surface tension within the alveoli. Mast cell stabilizers inhibit the release of histamine and SRSA to prevent the allergic response.

While the surgical client is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the client's weight. How should the nurse best respond? Ignore the comment because the patient is unconscious. Realize that humor is needed in the workplace. Report the comment immediately to a supervisor. Discourage the colleague from making such comments.

Discourage the colleague from making such comments. Explanation: Clients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the client and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.

The perioperative nurse is planning the care of a client who will soon undergo surgery with general anesthetic. What nursing diagnoses should the nurse consider in this client's care plan? Select all that apply. Disturbed sensory perception related to anesthesia Chronic confusion related to central nervous system depression Imbalanced nutrition: Less than body requirements related to fasting for surgery Unilateral neglect related to temporary loss of neuromuscular function Anxiety related to risks of surgery

Disturbed sensory perception related to anesthesia Anxiety related to risks of surgery Explanation: Disturbed sensory perception can create a risk for injury, and anxiety is a common preoperative (and post-operative) phenomenon. General anesthetics affect cognition, but this does not lead to chronic confusion. Short-term fasting does not normally threaten a client's nutritional status. Loss of sensory and motor function does not create a risk of neglecting one side of the body exclusively.

When the nurse cares for a client receiving an antibiotic, what instructions should the nurse provide no matter what medication is prescribed? Select all that apply. Take antibiotic with food to avoid gastrointestinal (GI) upset. Report difficulty breathing, severe headache, or changes in urine output. Drink plenty of fluids to avoid kidney damage. Take all medications as prescribed until all of the medication is gone. Take safety precautions such as changing position slowly

Drink plenty of fluids to avoid kidney damage. Take all medications as prescribed until all of the medication is gone. Report difficulty breathing, severe headache, or changes in urine output. Explanation: The client taking any antibiotic needs to drink plenty of fluids to avoid kidney damage and improve excretion of the metabolized drug; take all medications as prescribed until all of the medication is gone to avoid developing a resistant strain of bacteria; and report any difficulty breathing, severe headache, or changes in urine output because these are primary manifestations of serious adverse effects. Although some antibiotics need to be taken with food, others may be best taken on an empty stomach so this does not apply to all antibiotics. Not all antibiotics are associated with central nervous system (CNS) toxicity so taking safety precautions need only be included in client teaching if they are taking a drug associated with CNS adverse effects.

The nurse is administering morphine to a trauma client for acute pain. What is a common side effect of morphine? Occipital headache Paresthesia in lower extremities Increased intracranial pressure Drowsiness

Drowsiness Explanation: Dizziness, drowsiness, and visual changes are common side effects. If any of these occur, avoid driving, operating complex machinery, or performing delicate tasks. If these effects occur in the hospital, the side rails on the bed may be raised for your own protection. Morphine does not generally cause paresthesia in the lower extremities, an occipital headache, or increased intracranial pressure.

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? Early ambulation Increased dietary intake of protein Maintaining the client in a supine position Administering aspirin with warfarin

Early ambulation Explanation: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.

A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize what intervention? Screening programs for youth and young adults Appropriate use of standard precautions Lifestyle actions that improve immune function Educational programs that focus on control and prevention

Educational programs that focus on control and prevention Explanation: Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions applies to very few cases of HIV infection.

A client is admitted to the hospital with deep vein thrombosis. An infusion of heparin is established. What action best protects the client's safety? Ensure that the client's call light is easily accessible. Have two nurses independently monitor the client's heparin infusion. Ensure that protamine sulfate is readily available Keep a preloaded syringe of vitamin K in the room.

Ensure that protamine sulfate is readily available Explanation: The antidote for heparin is protamine sulfate, and it is prudent to have this on hand if a client is receiving an infusion of heparin. Vitamin K reverses the effect of warfarin. The administration of heparin must be established and monitored carefully, but it is not usual practice for two nurses to maintain the infusion independent of one another and could lead to errors and omissions. Clients' call lights should always be available, but this is less significant than ensuring the availability of the antidote.

A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis (RA). Which medical facts about RA are essential in developing a plan of care? SELECT ALL THAT APPLY Erythrocyte sedimentation rate (ESR) is elevated and x-rays can show erosions and decalcification of involved joints The only treatment is high dose therapy with NSAIDs Inflamed synovial membranes and cartilage trigger complement activation which stimulates the release of additional inflammatory mediators Onset is acute and usually between ages 20-40 The patient experiences stiff, swollen joints bilaterallyThe patient may not exercise once the disease is diagnosed

Erythrocyte sedimentation rate (ESR) is elevated and x-rays can show erosions and decalcification of involved joints Inflamed synovial membranes and cartilage trigger complement activation which stimulates the release of additional inflammatory mediators The patient experiences stiff, swollen joints bilaterally

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. At present, members of what group are most affected by new cases of HIV? Gay, bisexual, and other men who have sex with men Blood transfusion recipients Recreational drug users Health care providers

Gay, bisexual, and other men who have sex with men Explanation: Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 4% of the male population but 63% of the new infections. This exceeds the incidence among drug users, health care workers, and transfusion recipients.

The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees? Apply the condom prior to erection. Grasp the condom by the cuff after withdrawal. A condom may be reused with the same partner if ejaculation has not occurred. Use skin lotion as a lubricant if alternatives are unavailable.

Grasp the condom by the cuff after withdrawal. Explanation: The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, or cold cream should not be used with condoms because they cause latex deterioration/condom breakage. The condom should be held during withdrawal so it does not come off the penis. Condoms should never be reused.

A clinic nurse is caring for a client admitted with AIDS. The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication? Wasting syndrome HIV encephalopathy B-cell lymphoma Kaposi's sarcoma

HIV encephalopathy Explanation: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations.

A nurse is about to administer a parenteral benzodiazepine to a client in the hospital before the performance of an invasive diagnostic procedure. What action should the nurse prioritize before administration of the drug? Auscultate the client's lungs and set up pulse oximetry monitoring. Ask all visitors to leave the room and remain in the waiting area. Close the blinds and ensure appropriate room temperature for the client. Help the client out of bed to the bathroom and encourage the client to void.

Help the client out of bed to the bathroom and encourage the client to void. Explanation: The priority action would be to help the client up to void. After the medication is administered, the client should not get out of bed because of possible injury due to drowsiness. Safety should always be the priority concern. Respiratory assessment is not a priority, since respiratory depression does not normally occur. Creating a calm environment and asking visitors to leave may be necessary for the diagnostic procedure, but these actions do not have to precede benzodiazepine administration.

A client is admitted with an asthma attack caused by an allergic reaction to a medication. The immediate release of which substance is most likely causing this severe allergic response? Epinephrine Histamine Surfactant Antihistamine

Histamine Explanation: Asthma is characterized by reversible bronchospasm, inflammation, and hyperactive airways. The hyperactivity is triggered by allergens or nonallergic inhaled irritants or by factors such as exercise and emotions. The trigger causes an immediate release of histamine, which results in bronchospasm in about 10 minutes. An antihistamine is used to treat allergic responses because it counteracts the effects of histamine. Surfactant is a lubricating substance that is necessary to keep the alveoli open. Epinephrine is a medication used to treat acute allergic responses.

A client is receiving subcutaneous heparin 5,000 units every 8 hours. An activated thromboplastin time (aPTT) is drawn 1 hour before the 8:00 AM dose; the aPTT is at 3.5 times the control value. What is the nurse's priority action? Hold the dose and call the result to the prescriber. Check the client's vital signs prior to administering the dose. Give the dose as ordered and chart the results. Give a larger dose to increase the aPTT.

Hold the dose and call the result to the prescriber. Explanation: The therapeutic level of heparin is demonstrated by an activated partial thromboplastin time (aPTT) that is 1.5 to 3 times the control value. The client's value is 3.5 times control, which indicates clotting time is a bit too delayed and the dosage will likely either be reduced or a dosage may be held according to the order received from the physician. It would be inappropriate to give two doses at once, give the dose and chart the results, or simply check the vital signs without holding the dose and calling the physician.

The nurse is caring for a client who is receiving IV gentamicin and who reports difficulty hearing this morning. What should the nurse do? Administer the dose and report this information to the oncoming nurse. Hold the dose and notify the provider immediately. Administer the dose and document the finding in the client's health record. Make a referral for auditory testing.

Hold the dose and notify the provider immediately. Explanation: Aminoglycosides are contraindicated in the following conditions: known allergy to any of the aminoglycosides; renal or hepatic disease that could be exacerbated by toxic aminoglycoside effects and that could interfere with drug metabolism and excretion, leading to higher toxicity; preexisting hearing loss, which could be intensified by toxic drug-related adverse effects on the auditory nerve. Ototoxicity should be reported, and the drug should be stopped. Hearing assessment may be deemed necessary, but the priority is to hold the dose and contact the provider.

The nurse is providing care for a client who has recently been diagnosed with COPD. When educating the client about exacerbations, the nurse should prioritize what topic? Prompt administration of corticosteroids during exacerbations The importance of prone positioning during exacerbations Identifying specific causes of exacerbations The relationship between activity level and exacerbations

Identifying specific causes of exacerbations Explanation: Prevention is key in the management of exacerbations, and it is important for the client to identify which factors cause exacerbations. Corticosteroids are not normally used as a "rescue" medication and prone positioning does not enhance oxygenation. Activity may or may not cause a client to have exacerbations; inactivity is not a risk factor.

A client is experiencing an allergy to a penicillin antibiotic. What immunoglobulin (Ig) will most directly relate to this immune response? IgM IgA IgE IgG

IgE Explanation: Five different types of immunoglobulins have been identified: IgE is present in small amounts and seems to be related to allergic responses and to the activation of mast cells. The first immunoglobulin released is M (IgM). It contains the antibodies produced at the first exposure to the antigen. IgG, another form of immunoglobulin, contains antibodies made by the memory cells that circulate and enter the tissue; most immunoglobulin found in the serum is IgG. IgA is found in tears, saliva, sweat, mucus, and bile. It is secreted by plasma cells in the GI and respiratory tracts and in epithelial cells. These antibodies react with specific pathogens that are encountered in exposed areas of the body.

A client has come to the clinic for an allergy shot. The client asks the nurse what immunoglobulin (Ig) is located in the body's tissues and is thought to be responsible for allergic reactions. What is the nurse's appropriate response? IgG IgE IgA IgM

IgE Explanation: IgE is the immune globulin that is associated with allergic reactions. These antibodies react with mast cells, causing the release of histamine and other inflammatory chemicals when they have combined with the antigen. IgG, IgA, and IgM are not involved in allergic reactions.

A nurse received the seasonal influenza vaccine 10 weeks ago has now been exposed to that strain of the influenza virus. What immunoglobulin will hasten the nurse's immune response to this pathogen? IgA IgG IgE IgM

IgG Explanation: Five different types of immunoglobulins have been identified: IgA is found in tears, saliva, sweat, mucus, and bile. It is secreted by plasma cells in the GI and respiratory tracts and in epithelial cells. IgE is present in small amounts and seems to be related to allergic responses and to the activation of mast cells. The first immunoglobulin released is M (IgM); it contains the antibodies produced at the first exposure to the antigen. IgG, another form of immunoglobulin, contains antibodies made by the memory cells that circulate and enter the tissue; most of the immunoglobulin found in the serum is IgG and vaccinations make use of this immunoglobulin's characteristics. These antibodies react with specific pathogens that are encountered in exposed areas of the body.

The nurse is caring for a client with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection, because the most recent blood work looks fine." What principle should guide the nurse's response to the colleague? Infections in immunodeficient clients have a slower onset but a more severe course. Laboratory blood work is often inaccurate in immunodeficient clients. Immunodeficient clients do not develop symptoms of infection. Immunodeficient clients will usually exhibit subtle and atypical signs of infection.

Immunodeficient clients will usually exhibit subtle and atypical signs of infection. Explanation: Immunodeficient clients often lack the typical objective and subjective signs and symptoms of infection. However, this does not mean that they wholly lack symptoms. Infections do not normally have a slower onset. Blood work may not be a reliable diagnostic tool, but that does not mean that the results are inaccurate.

A client with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin? Immunoglobulin A Immunoglobulin M Immunoglobulin E Immunoglobulin G

Immunoglobulin E Explanation: Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions.

A nurse is caring for an 80-year-old client with pneumonia. What would be the most appropriate nursing diagnosis for this client? Risk for aspiration Ineffective health maintenance Impaired gas exchange Decreased cardiac output

Impaired gas exchange Explanation: Pneumonia causes swelling, engorgement, and exudation of protective sera in the lower respiratory tract. The respiratory membrane is affected, resulting in decreased gas exchange. Pneumonia does not directly affect cardiac output. There is also no indication that this client has pneumonia because of ineffective health maintenance. Aspiration is a common cause of pneumonia but is not normally a consequence.

A client has been prescribed an aminoglycoside. In order to prevent accumulation of the drug, what should the nurse encourage the client to do? Increase fluid intake. Take diuretics as prescribed. Perform moderate exercise daily, if possible. Take the drug on an empty stomach.

Increase fluid intake. Explanation: To prevent the accumulation of antiinfective drugs in the kidneys, which can damage the kidney, clients taking antiinfective drugs should be well hydrated. Diuretics do not have this effect. Exercising does not prevent accumulation and taking a drug on an empty stomach does not affect accumulation.

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? Increase activity. Lie in a low Fowler or supine position. Increase oral fluids unless contraindicated. Call the nurse for oral suctioning, as needed.

Increase oral fluids unless contraindicated. Explanation: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action? Smoking decreases the amount of mucus production. Smoke particles compete for binding sites on hemoglobin. Smoking causes atrophy of the alveoli. Smoking damages the ciliary cleansing mechanism.

Increase oral fluids unless contraindicated. Explanation: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

A nurse is caring for a client with COPD. The client's medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. Therapeutic effects of this medication would include which of the following? Select all that apply. Increased viscosity of lung secretions Increased expiratory flow rate Relief of dyspnea Increased respiratory rate Negative sputum culture

Increased expiratory flow rate Relief of dyspnea Explanation: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the client's respiratory status. Bronchodilators would not have a direct result on the client's infectious process.

The nurse is performing a preoperative assessment on a client going to surgery. The client informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties should the nurse anticipate for this client? Increased risk for postoperative complications Nonadherence to prescribed treatment after surgery following surgery Alcohol withdrawal syndrome upon administration of general anesthesia Increased risk for allergic reactions

Increased risk for postoperative complications Explanation: Alcohol use increases the risk of complications. Withdrawal does not occur immediately upon administration of anesthesia. Alcohol does not increase the risk of allergies and is not necessarily a risk factor for nonadherence.

A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect? Increases the amount of mucus production Collapses the alveoli in the lungs Destabilizes hemoglobin Shrinks the alveoli in the lungs

Increases the amount of mucus production Explanation: Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung.

A nurse is planning the care of a client with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client? Activity Intolerance Ineffective Airway Clearance Impaired Oral Mucous Membranes Imbalanced Nutrition: Less than Body Requirements

Ineffective Airway Clearance Explanation: Although all these nursing diagnoses are appropriate for a client with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the client with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns because of the immediacy of the health consequences.

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? Hyperglycemia Falls Infection Azotemia

Infection Explanation: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative client who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.

A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the client's physician because these symptoms are suggestive of what? Lung tumors Pneumothorax Infection Pulmonary edema

Infection Explanation: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.

An immunocompromised client is being treated in the hospital. The nurse's assessment reveals that the client's submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurse's most appropriate action? Implement standard precautions in the client's care. Monitor the client's vital signs q2h for the next 24 hours. Inform the client's primary care provider of this finding. Administer a PRN dose of acetaminophen as ordered.

Inform the client's primary care provider of this finding. Explanation: Swollen lymph nodes are suggestive of infection and warrant prompt medical assessment and treatment. Acetaminophen is an ineffective response. The nurse should monitor the client's vital signs closely, but the physician should also be informed. Standard precautions should be in place regardless of the client's status.

A client with SLE has come to the clinic for a routine check-up. When auscultating the client's apical heart rate, the nurse notes the presence of a distinct "scratching" sound. What is the nurse's most appropriate action? Inform the primary provider that a friction rub may be present. Inform the primary provider that the client may have pneumonia. Reposition the client and auscultate posteriorly. Document the presence of S3 and monitor the client closely.

Inform the primary provider that a friction rub may be present. Explanation: Clients with SLE are susceptible to developing a pericardial friction rub, possibly associated with myocarditis and accompanying pleural effusions; this warrants prompt medical follow-up. This finding is not characteristic of pneumonia and does not constitute S3. Posterior auscultation is unlikely to yield additional meaningful data.

A client has been diagnosed with asthma and prescribed inhaled steroids. What should the nurse teach the client about this treatment? Systemic adverse effects should be expected and can be serious. Inhaled corticosteroids should not be used on an emergency basis. Effective levels are usually reached within 72 hours of starting treatment. The drug will stimulate the sympathetic nervous system.

Inhaled corticosteroids should not be used on an emergency basis. Explanation: Inhaled steroids are not for emergency use and not for use during an acute asthma attack or status asthmaticus. They do not stimulate the sympathetic nervous system. Because of the route of administration, systemic side effects are uncommon. Effective levels may take 2 to 3 weeks to be reached.

A postsurgical client is being sent home on enoxaparin. The nurse should describe what benefit of this medication? Dissolving any clots that form Enhancing the flow of blood in peripheral vessels Stimulating production of certain clotting factors Inhibiting the formation of clots

Inhibiting the formation of clots Explanation: Low molecular weight heparins inhibit thrombus and clot formation by blocking factors Xa and IIa. Because of the size and nature of the molecules, these drugs do not greatly affect thrombin, clotting, or the PT; therefore, they cause fewer systemic adverse effects. Enoxaparin does not dissolve existing clots or directly enhance blood flow. It does not stimulate the production of clotting factors.

A client is reporting an inability to breathe nasally because of severe rhinitis. The nurse should identify what important role in breathing that is disrupted when the nasal passages are blocked? Phagocytosis of pathogens. Respiratory regulation of acid-base balance Inspired air is warmed and humidified. Exhalation of carbon dioxide.

Inspired air is warmed and humidified. Explanation: Air usually moves into the body through the nose and into the nasal cavity. The nasal hairs catch and filter foreign substances that may be present in the inhaled air. The air is warmed and humidified as it passes by blood vessels close to the surface of the epithelial lining in the nasal cavity. Phagocytosis happens in goblet cells in the nose, but these are not wholly limited to that location. Carbon dioxide is exhaled through the mouth, not just the nose. Similarly, acid-base balance is not threatened by blocked nasal passages.

The nurse is providing preoperative teaching to a client scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the client gives the nurse a list of medications she takes, the dosage, and frequency. What intervention provides the client with the most accurate information? Instruct the client to continue any herbal supplements unless otherwise instructed, and inform the client that these supplements have minimal effect on the surgical procedure. Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. Instruct the client to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. Instruct the client to discontinue Synthroid due to its effect on blood coagulation and the potential for heart dysrhythmias.

Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. Explanation: Because of the potential effects of herbal medications on coagulation and potential lethal interactions with other medications, the nurse must ask surgical clients specifically about the use of these agents, document their use, and inform the surgical team and anesthesiologist, anesthetist, or nurse anesthetist. Currently, it is recommended that the use of herbal products be discontinued at least 2 weeks before surgery. Clients with uncontrolled thyroid disorders are at risk for thyrotoxicosis and respiratory failure. The administration of Synthroid is imperative in the preoperative period. The use of ephedrine in the preoperative phase can cause hypertension and should be avoided.

The case manager for a group of clients with COPD is providing health education. What is most important for the nurse to assess when providing instructions on self-management to these clients? Knowledge of the pathophysiology of the disease process Knowledge about self-care and their therapeutic regimen Knowledge of alternative treatment modalities Family awareness of functional ability and activities of daily living (ADLs)

Knowledge about self-care and their therapeutic regimen Explanation: When providing instructions about self-management, it is important for the nurse to assess the knowledge of clients and family members about self-care and the therapeutic regimen. This supersedes knowledge of alternative treatments or the pathophysiology of the disease, neither of which is absolutely necessary for clients to know. The client's own knowledge is more important than that of the family.

A nurse practitioner is teaching a group of nurses about actions that have the potential to prevent antibiotic resistance. What teaching point should the nurse practitioner include? It is very important to take the full course of an antibiotic as prescribed and not save remaining drugs for future infections. Antibiotic dosage should be reduced and used for shorter periods of time to reduce unnecessary exposure to the drug. Standing prescriptions for antibiotics should be available to clients so they can be filled as soon as clients suspect they have an infection. Antibiotics should be taken promptly to treat colds and other viral infections before the invading organism has a chance to multiply.

It is very important to take the full course of an antibiotic as prescribed and not save remaining drugs for future infections. Explanation: Teaching clients to take the full course of their antibiotic as prescribed can help to decrease the number of drug-resistant strains. Antibiotics should only be used to treat bacterial infections that have been cultured to identify the antibiotic sensitivity and then clients should be instructed to use the antibiotic for the prescribed course, which will help to eliminate drug-resistant strains. Reducing dosage and time intervals increases the chance for drug resistance because antiinfectives are most effective when taken exactly as indicated.

A client is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe? It limits lung expansion within the thoracic cavity. It lubricates the movement of the thorax and lungs. It prevents the lungs from collapsing within the thoracic cavity. It allows for full expansion of the lungs within the thoracic cavity.

It lubricates the movement of the thorax and lungs. Explanation: The visceral pleura cover the lungs; the parietal pleura line the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleura do not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? Joint stiffness, especially in the morning Signs of systemic infection Cool joints with decreased range of motion Visible atrophy of the knee and shoulder joints

Joint stiffness, especially in the morning Explanation: In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.

A client has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the client to do? Wear powdered latex gloves when in public. Wash her hands with antibacterial soap every few hours. Maintain room temperature at 75 to 80°F (24° to 27°C) whenever possible. Keep her hands well moisturized at all times.

Keep her hands well moisturized at all times. Explanation: Powdered latex gloves can cause contact dermatitis. Skin should be kept well hydrated and should be washed with mild soap. Maintaining room temperature at 75 to 80°F (24° to 27°C) is excessively warm.

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery? Leg exercise help increase the client's level of consciousness after surgery. Leg exercises improve circulation and prevent venous thrombosis. Leg exercises increase the client's muscle mass postoperatively. Leg exercises help to prevent pressure sores to the sacrum and heels.

Leg exercises improve circulation and prevent venous thrombosis. Explanation: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the client's level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.

The nurse is caring for a patient who is receiving an opioid analgesic. What would be a priority assessment by the nurse? Pain intensity and blood glucose level Respiratory rate and electrolytes Level of consciousness and respiratory rate Urine output and pain intensity

Level of consciousness and respiratory rate Explanation: The nurse should assess respiratory rate and level of consciousness because respiratory depression and sedation are adverse effects of opioid analgesics. Blood glucose levels, electrolytes, and urine output are not priority assessments with opioid ingestion.

The nurse provides care for numerous children with asthma. The nurse should expect to administer what drugs? Select all that apply. Topical steroid nasal decongestants Long-acting inhaled steroids Xanthines Leukotriene-receptor antagonists Beta-agonists

Long-acting inhaled steroids Leukotriene-receptor antagonists Beta-agonists Explanation: Antiasthmatics are frequently used in children. The leukotriene-receptor antagonists have been found to be especially effective for long-term prophylaxis in children. Acute episodes are best treated with a beta-agonist and then a long-acting inhaled steroid or a mast cell stabilizer. Xanthines (e.g., theophylline) have been used in children, but because of their many adverse effects and the better control afforded by newer agents, their use is reserved for clients who do not respond to other therapies. Topical steroid nasal decongestants may be used for symptom relief for nasal congestion but are not a regular part of asthma therapy in children.

The nurse is caring for a client who suffered a head injury and is now having difficulty breathing. The client should be assessed for damage to what part of the central nervous system? Medulla oblongata Cerebral cortex Hypothalamus Cerebellum

Medulla oblongata Explanation: The act of breathing is controlled by the medulla, which depends on a functioning muscular system and a balance between the sympathetic and parasympathetic systems. The cerebral cortex, cerebellum, and hypothalamus are not directly involved with this process.

The home care nurse is taking care of a client on IV vancomycin for cellulitis of the left calf. The client's lack of response to treatment suggests possible resistance. What process may have caused this phenomenon? Microorganisms may have stopped healthy somatic cells from reproducing. Microorganisms may have produced a chemical that is an antagonist to the drug. Microorganisms may have changed their cell membrane to mimic that of the drug. Microorganisms may have altered the blood supply to the infected region.

Microorganisms may have produced a chemical that is an antagonist to the drug. Explanation: Microorganisms develop resistance in a number of ways, including the following: changing cellular permeability to prevent the drug from entering the cell or altering transport systems to exclude the drug from active transport into the cell; altering binding sites on the membranes or ribosomes, which then no longer accept the drug; and producing a chemical that acts as an antagonist to the drug. Microorganisms do not alter the blood supply to the infection or stop a cell from reproducing. Anti-infectives are chemicals; they do not have cell membranes.

An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? Providing emotional support to family Maintaining a clean environment Maintaining the client's cognitive status Monitoring the client's physiologic status

Monitoring the client's physiologic status Explanation: During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the client's cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

The client returns to the unit following surgery. The client reports being in pain. After checking the medication administration record in the client's chart, the nurse sees that the client has not received the morphine the health care provider has ordered for over an hour. As the order reads q 1-2 hours, the nurse administers the low dose of the morphine. The PACU nurse calls to tell the floor nurse that the nurse forgot to chart the last dose of morphine the client had received just before the client was transferred to the floor. What drug would the floor nurse be sure to have on the unit that is used to reverse the effects of opioids? Butorphanol Naloxone hydrochloride (Narcan) tartrate Nalbuphine hydrochloride (Nubain) Buprenorphine (Buprenex)

Naloxone hydrochloride (Narcan) tartrate Explanation: Naloxone is the drug of choice for treatment of opioid overdose. Butorphanol is a morphinan-type synthetic opioid analgesic. Brand name Stadol was recently discontinued by the manufacturer. It is now only available in its generic formulations. Buprenex (buprenorphine hydrochloride) is a narcotic under the Controlled Substances Act due to its chemical derivation from thebaine. Nalbuphine is a synthetic opioid used commercially as an analgesic under a variety of trade names, including Nubain.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? Have the client go to the bathroom. Wait until the client gets to the operating room and is catheterized. Offer the client a bedpan or urinal. Assist the client to the bathroom.

Offer the client a bedpan or urinal. Explanation: If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a urinal. The client should not get out of bed because of the potential for lightheadedness.

A client with SLE comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain? Osteoporosis Hypertension Hyperglycemia Truncal obesity

Osteoporosis

The OR nurse acts in the circulating role during a client's scheduled cesarean section. For what task is this nurse solely responsible? Performing documentation Estimating the client's blood loss Setting up the sterile tables Keeping track of drains and sponges

Performing documentation Explanation: Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the client and documents specific activities throughout the operation to ensure the client's safety and well-being. Estimating the client's blood loss is the surgeon's responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.

A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of what? Apoptosis Phagocytic cells Interferons Cytokines

Phagocytic cells Explanation: Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken glass. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. Apoptosis, or programmed cell death, is the body's way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Cytokines are the various proteins that mediate the immune response. These do not migrate to injury sites.

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do? Place the bed in a low position with the side rails up. Encourage light ambulation. Take the client's vital signs every 15 minutes. Tell the client that he will be asleep before he leaves for surgery.

Place the bed in a low position with the side rails up. Explanation: When the preoperative medication is given, the bed should be placed in low position with the side rails raised. The client should not get up without assistance. The client may not be asleep, but he may be drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not normally required every 15 minutes after administration.

The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? Ability to demonstrate deep inspiration Absence of nausea Presence of a cough and gag reflex Oxygen saturation of ≥92%

Presence of a cough and gag reflex Explanation: After the procedure, it is important that the client takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration.

A client is scheduled for a bowel resection in the morning and the client's orders include a cleansing enema tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? Preventing potential contamination of the peritoneum Preventing aspiration of gastric contents Facilitating better absorption of medications Preventing the accumulation of abdominal gas postoperatively

Preventing potential contamination of the peritoneum Explanation: The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The client should expect to develop gas in the postoperative period.

Indications for the nurse to administer heparin include what? Select all that apply. Treatment of hemophilia Diagnosis and treatment of disseminated intravascular coagulation (DIC) Prevention and treatment of venous thrombosis Treatment of atrial fibrillation with embolization Prevention and treatment of pulmonary emboli

Prevention and treatment of pulmonary emboli Treatment of atrial fibrillation with embolization Prevention and treatment of venous thrombosis Diagnosis and treatment of disseminated intravascular coagulation (DIC) Explanation: Indications include prevention and treatment of venous thrombosis and pulmonary emboli, treatment of atrial fibrillation with embolization, and diagnosis and treatment of DIC. Heparin is not given to clients with hemophilia because the drug would worsen bleeding.

The nurse is caring for a client who is going home on warfarin. What lab test(s) will the client require to evaluate therapeutic effects of the drug? Prothrombin time (PT) and international normalized ratio (INR) Activated partial thromboplastin time (APTT) Platelet levels Prothrombin time (PT) and activated partial thromboplastin time (APTT)

Prothrombin time (PT) and international normalized ratio (INR) Explanation: PT and INR are ordered to evaluate for therapeutic effects of warfarin. Normal values of PT is 1.3 to 1.5 times the control value, and the ratio of PT to INR is 2 to 3.5.

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? Infection Sepsis Hematoma Pulmonary embolism

Pulmonary embolism Explanation: Clients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.

A geriatric client received a narcotic analgesic before leaving the postanesthesia care unit to return to the regular unit. What is the priority nursing intervention for the nurse receiving the client on the regular unit? Create a restful, dark, quiet environment. Maintain the head of the client's bed at ≥ 45°. Put side rails up and place bed in low position. Encourage fluid intake.

Put side rails up and place bed in low position. Explanation: Older clients are more susceptible to the central nervous system effects of narcotics; it is important to ensure their safety by using side rails and placing the bed in the low position in case the client tries to get up unaided. Postoperative clients are allowed nothing by mouth until bowel function returns so an oral medication or encouraging fluids would not be appropriate. This client will require careful observation for respiratory depression, so a dark room would be unsafe. There is no need to keep the head of the client's bed raised.

After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action? Keeping the cat restricted from the child's bedroom Removing the cat from the family's home Administering over-the-counter (OTC) antihistamines to the child regularly Maximizing airflow in the house

Removing the cat from the family's home Explanation: In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Fully removing the cat from the environment is preferable to just keeping the cat out of the child's bedroom. Avoidance therapy does not involve improving airflow or using antihistamines.

The nurse is developing a plan of care for a client whose scheduled surgery will last approximately 3 hours. What intraoperative nursing diagnosis should the nurse prioritize? Risk for impaired skin integrity related to immobility Risk for deficient fluid volume related to absence of oral intake Acute pain related to disruption of tissue during surgery Impaired swallowing related to intubation and mechanical ventilation

Risk for impaired skin integrity related to immobility Explanation: The client would need to be moved or turned periodically to prevent skin breakdown and the formation of decubitus ulcers. The client's risk for pain is addressed by the anesthesiologist through the administration of general anesthesia. The client's absence of swallowing is expected during general anesthesia. The nurse is not primarily responsible for monitoring the client's fluid balance during surgery.

A nurse caring for a client who has an immunosuppressive disorder knows that continual monitoring of the client is critical. What is the primary rationale behind the need for continual monitoring? So that the client's functional needs can be met immediately So that medications can be given as prescribed and signs of adverse reactions noted So that the nurse's documentation can be thorough and accurate So that early signs of impending infection can be detected and treated

So that early signs of impending infection can be detected and treated Explanation: Continual monitoring of the client's condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the client's status. Continual monitoring is not primarily motivated by the client's functional needs or medication schedule. The nurse's documentation is important, but less than infection control.

The nurse is doing preoperative client education with a 61-year-old male client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client? Stop smoking at least a month before the scheduled surgery to enhance pulmonary function and decrease infection. Reduce smoking by 50% to prevent the development of pneumonia. Stop smoking at least 4 months before the scheduled surgery to enhance pulmonary function and decrease infection. Aim to quit smoking in the postoperative period to reduce the chance of surgical complications

Stop smoking at least a month before the scheduled surgery to enhance pulmonary function and decrease infection. Explanation: The reduction of smoking will enhance pulmonary function; in the preoperative period, clients who smoke should be urged to stop 30 days before surgery.

The nursing instructor is discussing the need for lubrication of the alveoli for effective gas exchange. The students know that what substance is produced by type II cells of the alveoli? Erythrocytes Pleural fluid Surfactant Lymphatic fluid

Surfactant Explanation: Type II cells produce surfactant. Erythrocytes are made in the bone marrow. Lymphatic fluid is produced by lymph glands. Pleural fluid is secreted by cells in the pleural cavity.

A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? Oral temperature of 37.2°C (99°F) Weight loss of 0.45 kg (1 lb) since yesterday Tachypnea and restlessness Frequent loose stools

Tachypnea and restlessness Explanation: In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 37.2°C (99°F) is not considered a fever and would not be the first issue addressed.

The nurse is reviewing the discharge instructions with the client going home on an opioid analgesic for pain management. What would the nurse include in the instructions? Select all that apply. Keep a record of bowel movements. Keep the room well lit during the day. Limit fluid intake. Take a laxative/stool softener. Rise slowly from a sitting or lying position.

Take a laxative/stool softener. Keep the room well lit during the day. Rise slowly from a sitting or lying position. Keep a record of bowel movements. Explanation: Constipation is an issue in clients receiving opioid analgesics, therefore taking a laxative/stool softener may be necessary, as well as increasing fluid intake and keeping a record of bowel movements. A drop in blood pressure (orthostatic hypotension) would require care in rising from a sitting or lying position. Miosis (pinpoint pupils) decreases the ability to see in dim light.

A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing? Gradually increase levels of physical exertion. Change filters on heaters and air conditioners frequently. Take prescribed medications as scheduled. Avoid goose-down pillows.

Take prescribed medications as scheduled. Explanation: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.

What action by the client would indicate that the client understands how to use an inhaler? The client holds his or her breath for several seconds after compressing the canister. The client uses a spacer to administer a powdered medication. The client inhales as soon as the inhaler enters his or her mouth. The client exhales as soon as he or she compresses the inhaler.

The client holds his or her breath for several seconds after compressing the canister. Explanation: Holding the breath prevents exhalation of medication still remaining in the mouth. The client should inhale when the canister is compressed, not as soon as the inhaler enters his or her mouth. The client should only administer one dose of medication at a time, and the client should wait to exhale until after the breath has been held as long as possible. Spacers are not used with powdered medications.

The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? The grandmother's surgery has minimal relevance to the client's surgery. The client may be experiencing presurgical anxiety. The client may be at risk for malignant hyperthermia. The client may be at risk for a sudden onset of postsurgical infection.

The client may be at risk for malignant hyperthermia. Explanation: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the mortality rate is 50%. The client's anxiety is not relevant, the grandmother's surgery is very relevant, and all clients are at risk for hypothermia.

In anticipation of a client's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period. The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. Explanation: The client assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the client is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.

A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment? The client will remain in the clinic to be monitored for 30 minutes following the injection. The client will be given a low dose of epinephrine before the treatment. The allergen will be given by the peripheral intravenous route. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months.

The client will remain in the clinic to be monitored for 30 minutes following the injection. Explanation: Although severe systemic reactions are rare, the risk of systemic and potentially fatal anaphylaxis exists. Because of this risk, the client must remain in the office or clinic for at least 30 minutes after the injection and is observed for possible systemic symptoms. Therapeutic failure is evident when a client does not experience a decrease in symptoms within 12 to 24 months. Epinephrine is not given prior to treatment and the IV route is not used.

A client who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement? The client should take his corticosteroids regularly prior to testing. The client's test should be cancelled until he is off his corticosteroids. The nurse should have an emergency cart available in case of anaphylaxis during the test. The client should only be tested for grass, mold, and dust initially.

The client's test should be cancelled until he is off his corticosteroids. Explanation: Corticosteroids and antihistamines, including over-the-counter (OTC) allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. Emergency equipment must be at hand during allergy testing, but the test would be postponed.

A client's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary provider has added prednisone to the client's drug regimen. What principle will guide this aspect of the client's treatment? The drug should be used for as short a time as possible. The drug should be used at the highest dose the client can tolerate. The client must stop all other drugs 72 hours before starting prednisone. The client will need daily blood testing for the duration of treatment.

The drug should be used for as short a time as possible. Explanation: Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects. Daily blood work is not necessary and the client does not need to stop other drugs prior to using corticosteroids.

A client with a urinary tract infection has been prescribed Bactrim, a medication that is a combination of sulfamethoxazole and trimethoprim. What is the most likely rationale for the use of a combination antibiotic? The drugs' combined effect exceeds the sum of their individual effects. One antibiotic is narrow-spectrum and one is broad-spectrum. One of the antibiotics exists solely to facilitate absorption of the other. It is not possible to culture the microorganisms most likely responsible for the infection.

The drugs' combined effect exceeds the sum of their individual effects. Explanation: Some drugs are synergistic, which means that they are more powerful when given in combination. Combination drugs do not normally exist to promote absorption and they are not always a combination of narrow- and broad-spectrum. An inability to perform culture and sensitivity testing would not directly require combination therapy.

The operating room nurse is taking a male patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the operating room and nearly died 15 years ago. The nurse knows that the anesthetist is planning to use a volatile liquid as part of the anesthetic. What relevance is this information regarding the patient? The patient may be at risk for hypothermia. The patient may be nervous. The patient may be at risk for developing malignant hyperthermia. The grandmother's surgery has no relevance to the patient's surgery.

The patient may be at risk for developing malignant hyperthermia. Explanation: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying patients at risk is imperative because the mortality rate is 50%. All of these drugs have the potential to trigger malignant hyperthermia and should be used with caution in any patient at high risk for developing it to avoid development of malignant hyperthermia. The patient's nervousness is not relevant, the grandmother's surgery is very relevant, and all patients are at risk for hypothermia.

What is the best rationale for intubation during a surgical procedure? The tube provides an airway for ventilation. The patient may receive an anti-emetic through the tube. The tube protects the esophagus. The patient's heart rate can be monitored with the tube.

The tube provides an airway for ventilation. Explanation: Intubation and mechanical ventilation must be used in most cases of general anesthesia. The anesthetic is administered, and the patient's airway is maintained through either an intranasal intubation, oral intubation, or a laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the esophagus, because the tube goes into the lungs no medications are given through the tube. The patient's heart rate is not monitored through the tube.

The nurse is performing a respiratory assessment of an adult client and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis? Whether they are heard on inspiration or expiration The volume of the sounds Whether or not they are continuous breath sounds Their location over a specific area of the lung

Their location over a specific area of the lung Explanation: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Normal breath sounds are heard on both inspiration and expiration, and are continuous. They are not distinguished solely on the basis of volume.

A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse informs the client that she should self-administer epinephrine in what site? Forearm Thigh Abdomen Deltoid muscle

Thigh Explanation: The client is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will automatically inject a premeasured dose of epinephrine into the subcutaneous tissue.

A client is prescribed salmeterol with dosage on a 4- to 6-hour schedule for the treatment of exercise-induced asthma. What is the recommended dosing schedule of asthma experts regarding this drug? Thirty minutes prior to exercise to prevent dyspnea during exercise Immediately before and after exercise to prevent dyspnea As needed to treat or prevent dyspnea during exercise Every 1-2 hours to treat or prevent dyspnea during exercise

Thirty minutes prior to exercise to prevent dyspnea during exercise Explanation: Salmeterol adult and pediatric (age 12 years and older): one puff every 12 hours or one puff 30 minutes before exercise.

An adult client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to retch. What should the nurse do next? Apply a cool cloth to the client's forehead. Turn the client completely to one side. Offer the client a small amount of ice chips. Administer a dose of IV analgesic.

Turn the client completely to one side. Explanation: Turning the client completely to one side allows collected fluid to escape from the side of the mouth if the client vomits. After turning the client to the side, the nurse can offer a cool cloth to the client's forehead. Ice chips can increase feelings of nausea. An analgesic is not given for nausea and vomiting.

A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position? Inform that physician that the client is in a recumbent position and anticipate an order for a portable chest x-ray. Avoid turning the client, and assess the accessible breath sounds from the anterior chest wall. Turn the client to enable assessment of all the patient's lung fields. Obtain a pulse oximetry reading, and, if the reading is low, reposition the client and auscultate breath sounds.

Turn the client to enable assessment of all the patient's lung fields. Explanation: Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the client is recumbent, it is essential to turn the client to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes the other given options unacceptable.

A client's drug regimen includes diphenhydramine. What potential indications may this drug be used for? Select all that apply. Productive cough Motion sickness Angioedema Urticaria Vasomotor rhinitis

Urticaria Vasomotor rhinitis Motion sickness Angioedema Explanation: Diphenhydramine is used for the symptomatic relief of perennial and seasonal rhinitis, vasomotor rhinitis, allergic conjunctivitis, urticaria, and angioedema; it is also used for treating motion sickness and parkinsonism, as a nighttime sleep aid, and to suppress cough. It would not be used to treat a productive cough, because it is not an expectorant.

A nurse is caring for two clients who are status postoperative for abdominal surgery. What is the best way to evaluate pain response after administering analgesia? If a family member is present, ask him or her if the medication worked. Use a pain assessment tool before and 30 minutes after medication administration. Ask the non-licensed personnel (aide) to find out if the medication worked. The nurse should observe the client when the client is not aware the nurse is watching.

Use a pain assessment tool before and 30 minutes after medication administration. Explanation: A standard pain assessment tool should be used both pre- and post-analgesia. Observing when the client is not aware the nurse is watching, asking non-licensed personnel to find out if the medicine worked, or asking a family member if the medication worked are all inappropriate.

A nurse is providing discharge teaching for a client with COPD. What should the nurse teach the client about breathing exercises? Use diaphragmatic breathing Avoid pursed-lip breathing unless absolutely necessary. Lie supine to facilitate air entry Use chest breathing

Use diaphragmatic breathing Explanation: Inspiratory muscle training and breathing retraining may help improve breathing patterns in clients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing.

A 70-year-old client is being treated for chronic obstructive pulmonary disease (COPD) with theophylline. What will be a priority assessment by the nurse? Use of nicotine Activity level Intake of fatty foods Weight

Use of nicotine Explanation: Nutritional status, weight, and activity level would be important for a nurse to know about a COPD client. However, it would be most important for the nurse to know whether the client smokes or uses tobacco in other ways or smoking cessation methods that involve nicotine. Nicotine increases the metabolism of theophyllines; the dosage may need to be increased to produce a therapeutic effect.

An inhaled sympathomimetic drug has been ordered for a teenage athlete who has exercise-induced asthma. What should the client be instructed to do? Use the inhaler 30 to 60 minutes before exercising. Use the inhaler every day at the same time each day. Use the inhaler as soon as the symptoms start. Use the inhaler 2 to 3 hours before exercising to ensure peak effectiveness.

Use the inhaler 30 to 60 minutes before exercising. Explanation: Teaching a client about using an inhaled sympathomimetic for management of exercise-induced asthma should include instructions to use the inhaler 30 to 60 minutes before exercising to ensure therapeutic levels when needed. The inhaler would not be used daily and waiting until symptoms occur will be too late for prevention.

The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. Performing hand hygiene Using safe injection practices Using appropriate personal protective equipment Placing clients in positive pressure isolation rooms Placing clients in negative pressure isolation rooms

Using appropriate personal protective equipment Using safe injection practices Performing hand hygiene Explanation: Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions.

The nurse is caring for a client with influenza and is explaining why viruses are more difficult to treat than many bacteria. What should the nurse teach the client? Drugs exist to treat all viral infections but they carry serious adverse effects and the benefit often does not outweigh the risk. Individual antiviral drugs are often effective in treating many different viruses because one virus in a category behaves like others in the same category. Release of interferons by the host cell makes the virus replicate more quickly allowing the virus to spread. Viruses are contained inside the human cell and cannot be destroyed without destroying that cell.

Viruses are contained inside the human cell and cannot be destroyed without destroying that cell. Explanation: Because viruses are contained inside human cells while they are in the body, researchers have difficulty developing effective drugs that destroy a virus without harming the human host. Interferons are released by the host in response to viral invasion of a cell and act to prevent the replication of that particular virus. Some interferons that affect particular viruses can now be genetically engineered to treat particular viral infections. Other drugs that are used in treating viral infections are not natural substances and have been effective against only a limited number of viruses. Very few viruses are treatable with medications; a few more can be prevented through immunization but most have no known treatment. Each antiviral is generally only suited to treat the single virus it was developed for and will not be effective against other viruses.

A nurse is planning patient education for a client being discharged home with a diagnosis of rheumatoid arthritis. The client has been prescribed antimalarials for treatment, so the nurse knows to teach the client to self-monitor for what adverse effect? Hirsutism Stomatitis Visual changes Tinnitus

Visual changes Explanation: Antimalarials may cause visual changes; regular ophthalmologic examinations are necessary. Tinnitus is associated with salicylate therapy and hirsutism is associated with corticosteroid therapy. Antimalarials do not normally cause stomatitis.

A nurse's assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the client is experiencing bronchospasm? Reduced respiratory rate or lethargy Wheezes or diminished breath sounds on auscultation Slow, deliberate respirations and diaphoresis Fine or coarse crackles on auscultation

Wheezes or diminished breath sounds on auscultation Explanation: Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies. Bronchospasm usually results in rapid, inefficient breathing and agitation.

A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled? Within the next week Without delay because the bleed is emergent Within 24 hours As soon as all the day's elective surgeries have been completed

Without delay because the bleed is emergent Explanation: Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team. An active bleed is considered an emergency, and the patient requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed.

During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses: acquired immunity. phagocytic immunity. humoral immunity. natural immunity.

acquired immunity. Explanation: Acquired immunity usually develops as a result of prior exposure to an antigen, often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three means of defense. The first line of defense, the phagocytic immune response, involves the WBCs that have the ability to ingest foreign particles. A second protective response is the humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells that manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present at birth.

While providing client teaching relative to inflammatory disorders, the nurse would explain the presence of inflammation as: a normal response to infection or trauma, which results in necrotic tissue formation. a typical response to bacterial infection. an attempt by the body to remove the damaging agent and repair the damaged tissue. the initial stage of infection, requiring antibiotic medication for resolution.

an attempt by the body to remove the damaging agent and repair the damaged tissue. Explanation: Inflammation is the normal body response to tissue damage from any source, and it may occur in any tissue or organ. Local manifestations are redness, heat, edema, and pain. Inflammation may be a component of virtually any illness. Inflammation can be a result of an infection, which may require antibiotic therapy.

A client is being treated for a herpes outbreak, and the healthcare provider has prescribed acyclovir. In order to screen for potential problems with the client's excretion of the drug, which assessment data should the nurse review? blood urea nitrogen and creatinine levels GGT, AST, ALT and bilirubin levels nutritional status complete blood count and WBC differential

blood urea nitrogen and creatinine levels Explanation: The nurse should evaluate the client's renal function tests to determine baseline function of the kidneys and to assess adverse effects on the kidney and need to adjust the dose of the drug. The client's white cell count, liver function, and nutritional status have comparatively minor effects on excretion.

The nurse in a long-term care facility is caring for a client who has developed oropharyngeal candidiasis. What medication is the nurse most likely to administer? posaconazole clotrimazole itraconazole fluconazole

clotrimazole Explanation: Clotrimazole is an effective treatment for oropharyngeal candidiasis (in troche form) or to prevent oropharyngeal candidiasis in clients receiving radiation or chemotherapy. Itraconazole, amphotericin B, and posaconazole would not be appropriate for this client because they do not normally treat oropharyngeal candidiasis infections.

The nurse is collaborating with the healthcare provider of a client who presented with signs and symptoms of an infection. What information should the nurse prioritize so that the healthcare provider can prescribe the proper antibiotic? the client's intake and output for past 2 days results of complete blood count with differential first day of infection symptoms culture and sensitivity test results

culture and sensitivity test results Explanation: Antibiotics are best selected based on culture results that identify the type of organism causing the infection and sensitivity testing that shows what antibiotics are most effective in eliminating the bacteria. First day of symptoms of infection is likely already known if culture and sensitivity testing has been performed. Although measurement of intake and output is one indicator of renal function, a blood-urea-nitrogen test and assessment of creatinine levels would be better ways of assessing renal function, which will be used to determine dose of medication but not for selection of the correct antibiotic. The white blood cell count and differential would indicate the possibility of an infection but are not needed in choosing the proper antibiotic.

A young adult client who has no significant prior health history has been prescribed antibiotics for the first time. What nursing diagnosis would be most appropriate for this client? constipation related to increased fluid absorption imbalance nutrition: less than body requirements related to multiple GI effects of the drug deficient knowledge regarding drug therapy acute pain related to gastrointestinal (GI) effects of the drug

deficient knowledge regarding drug therapy Explanation: Because this is the first time the client has taken antibiotics, he or she is likely to have limited knowledge about the drug. The client may not understand the importance of taking the medication as ordered to increase effectiveness of the drug or to report adverse effects. Because the client has not started the drug yet, there is no way to know what adverse effects, if any, he or she will experience.

The nurse is caring for a client who has been receiving a broad-spectrum anti-infective agent for several days. What signs and symptoms should the nurse monitor closely? destruction of normal flora increased inflammation tissue necrosis respiratory distress

destruction of normal flora Explanation: One common offshoot of the use of anti-infectives, especially broad-spectrum anti-infectives, is destruction of the normal flora resulting in superinfections. Tissue necrosis is a rare complication and inflammation would be unlikely to increase. Respiratory distress or other signs of anaphylaxis would be unlikely, since the client has been taking the drug for several days.

The nurse is providing health education to a client with an infection who lives in the community. What characteristic of the client's anti-infective regimen will best prevent the development of resistant strains of microbes? maximizing the frequency of drug ingestion ensuring that the duration of drug use is appropriate proactively addressing the possibility of adverse effects performing culture and sensitivity testing after the completion of treatment

ensuring that the duration of drug use is appropriate Explanation: Exposure of pathogens to an antimicrobial agent without cellular death leads to the development of resistance so it is important to limit the use of these agents to treat pathogens with a known sensitivity to the drug being used. The duration of drug use is critical to ensure that microbes are completely eliminated and not given the chance to grow and develop resistant strains. Adverse effects must be addressed, but this is not directly related to the development of resistance. Dosing frequency must be determined with the goal of enhancing the therapeutic action, but excessive frequency can cause problems with the client's adherence. Follow-up testing is not a major component of preventing resistance.

A client newly diagnosed with HIV is receiving client teaching from the clinic nurse about antiretroviral medications. The nurse should teach the client to report what adverse effect to a healthcare provider most promptly? constipation full body rash nausea dizziness

full body rash Explanation: All options provided have the potential to be an adverse effect of antiviral medications prescribed to treat HIV. Most can be managed through diet or over-the-counter medications but a rash needs to be reported immediately because it could indicate a potentially serious reaction and requires immediate intervention.

The nurse anticipates what nonspecific response to a client's abrasion injury? inhibition of cell growth and conservation of energy heat and swelling increased protein catabolism decreased serum pH

heat and swelling Explanation: The inflammatory response is the local reaction of the body to invasion or injury. Any insult to the body that injures cells or tissues sets of a series of events and chemical reactions known as the inflammatory response, which includes heat and swelling. Protein catabolism is the breakdown of protein into particles small enough to be carried into the cell and is an incorrect choice. Cellular injury does not inhibit cell growth or lower pH.

The nurse admitted a client diagnosed with a systemic fungal infection. Before administering ketoconazole as prescribed, what should the nurse confirm? complete blood count (CBC) and white cell differential blood type hepatic function height and weight

hepatic function Explanation: It would be important for the nurse to know the client's CBC, height, and weight. All of these factors could help determine a specific dosage. However, the most important factor would be the client's hepatic function because hepatotoxicity could occur quickly if the liver is not functioning properly. There is no obvious need to know the client's blood type.

A client has developed urosepsis following a urinary tract infection. The nurse is explaining how B cells are programmed to identify specific proteins or antigens in the fight against the client's infection. What process is the nurse describing? humoral immunity T-cell immunity passive immunity autoimmunity

humoral immunity Explanation: B cells are programmed to identify specific proteins, or antigens. They provide what is called "humoral immunity." Autoimmunity occurs when the body attacks its own self-cells. Passive immunity is the transfer of antibodies from one person to another. Active immunity is immunity produced by the body in response to an organism.

The nurse is assessing a client admitted with AIDS whose current antiretroviral regimen includes a nonnucleoside reverse transcriptase inhibitor. What nursing diagnosis related to drug therapy is most likely to be appropriate for this client? imbalanced nutrition: less than body requirements, related to gastrointestinal (GI) effects of the drugs deficient fluid volume related to diuretic effects risk for injury related to central nervous system (CNS) effects of the drug excess fluid volume related to renal failure

imbalanced nutrition: less than body requirements, related to gastrointestinal (GI) effects of the drugs Explanation: The adverse effects most commonly experienced with these drugs are GI related—dry mouth, constipation or diarrhea, nausea, abdominal pain, and dyspepsia. As a result, this client is most at risk for imbalanced nutrition; less than body requirements. CNS effects are not common with this classification of drug. Renal failure is not a common adverse effect. Diuresis is not expected.

A client states that he or she was exposed to chicken pox as a child, but he or she does not understand why that now makes him or her immune to subsequent infections with the same virus. During client teaching, the nurse should describe the actions of what immunoglobulin? immunoglobulin E immunoglobulin G immunoglobulin M immunoglobulin A

immunoglobulin G Explanation: After an active infection, the B memory cells will continue to make a supply of immunoglobulin, IgG, for use on future exposure to the chicken pox virus. The presence of this IgG confers immunity on the client. This is not a direct result of the actions of other immunoglobulins.

A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of: antibodies. capillaries. lymphocytes. cytoblasts.

lymphocytes. Explanation: The white blood cells involved in immunity (including lymphocytes) are produced in the bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels

What should the nursing instructor include when talking with students about anti-infective medication that are very selective in their actions? broad spectrum bactericidal narrow spectrum bacteriostatic

narrow spectrum Explanation: Some anti-infectives are so selective in their action that they are effective against only a few, or possibly only one, microorganism with a very specific metabolic pathway or enzyme. These drugs are said to have a narrow spectrum of activity. They are not called broad spectrum, which applies to a drug with little selectivity; bactericidal, which is a substance that causes death of bacteria; or bacteriostatic, which prevents replication of a bacterium.

The nurse is reviewing the results of the complete blood count of a client who is diagnosed with bacterial meningitis. What value should the nurse expect to see elevated? eosinophil count neutrophil count hematocrit basophil count

neutrophil count Explanation: During an acute infection, the neutrophils are rapidly produced in response to the interleukins released by active white blood cells. They move to the site of insult to attack the foreign substance. Eosinophils are often increased in an allergic response. Basophils would only increase with generalized bone marrow stimulation. The hematocrit level is increased in polycythemia.

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: extremities for signs of cyanosis. oxygen saturation level. level of consciousness (LOC). hemoglobin, hematocrit, and red blood cell levels.

oxygen saturation level. Explanation: The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

The nurse has administered the first dose of a client's newly-prescribed antibiotic. What assessment finding should the nurse interpret as adverse effect that suggests a more serious concern? decrease in blood pressure from 128/77 mm HG preadministration to 119/70 postadministration drowsiness new onset of pain rash to the face and trunk

rash to the face and trunk Explanation: A rash poses no threat in and of itself but suggests the possibility of drug intolerance or hypersensitivity. A modest decrease in blood pressure or level of consciousness would be less clinically significant. The nurse must address the client's pain, but this is unlikely to be a consequence of antibiotic use.

The nurse is admitting a client to the postanesthesia care unit (PACU) who received general anesthesia for the removal of a bunion. The nurse should prioritize what assessments? respirations and airway lung auscultation and apical heart rate pain and temperature skin integrity and peripheral perfusion

respirations and airway Explanation: Postanesthetic recovery requires frequent, comprehensive assessments including all of the listed parameters. Among the priority assessments, however, are the client's airway patency and respiratory status. This is because both are heavily influenced by anesthesia and have rapid, serious consequences if disrupted.

A client is preoperative and there is a need to decrease the client's sympathetic stimulation to ensure the client does not remember the procedure. The nurse should anticipate the use of what type of agent? antihistamine antiemetic sedative-hypnotic opioid agonist

sedative-hypnotic Explanation: Sedative-hypnotics relax the client, facilitate amnesia, and decrease sympathetic stimulation. Antihistamines decrease the chance of allergic reaction and help dry secretions. Antiemetics decrease the nausea and vomiting associated with gastrointestinal (GI) depression. Narcotics (opioid agonists) aid in the analgesic and sedative effects.

A client has been diagnosed with chronic obstructive pulmonary disease. The client has been prescribed bronchodilators by nebulizer for home use. The nurse should teach the client to: keep an extra oxygen tank on hand for propelling the medication. gargle with an alcohol-based mouthwash after each dose. sit in a fully upright position when administering the medication. take the exact number of puffs that have been prescribed.

sit in a fully upright position when administering the medication. Explanation: Clients should sit in the Fowler position when inhaling nebulized medications. Compressed air (not oxygen) is used. Inhalers require a prescribed number of "puffs," not nebulizers. The client should rinse his or her mouth after administration, but an alcohol-based solution is not necessary.

A client with a gram-negative infection is being treated with an aminoglycoside. What assessment should the nurse prioritize during treatment? breath sounds and oxygen saturation visual acuity muscle strength and coordination urine output and BUN and creatinine levels

urine output and BUN and creatinine levels Explanation: Renal function should be tested daily because aminoglycosides depend on the kidney for excretion and if the glomerular filtration rate (GFR) is abnormal, it may be toxic to the kidney. The results of the renal function testing could change the daily dosage. Aminoglycosides do not usually adversely affect respiratory or musculoskeletal function, although baseline data concerning these systems is always needed. Auditory effects are more likely than visual effects.

The nurse determines that which of the following nursing diagnoses has the highest priorityfor a client with rheumatoid arthritis? Fatigue Disturbed body image Ineffective role performance Pain

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