170 Nurse Zone Medical-surgical Nursing Application Exam Part 2 (1 To 25)

Vitamins A, C, E, and selenium are known to support and enhance the body's natural defense mechanisms. These vitamins and minerals have antioxidant properties that help protect the body against free radicals and oxidative stress, which can weaken the immune system. Therefore, a diet high in these nutrients would provide the necessary support for the client's natural defense mechanisms.

The nurse did not observe the correct steps and interpretation of the skin test. The result must be read 48 to 72 hours after the skin test to obtain an accurate result. Therefore, the nurse's interpretation of the test result as negative after only 5 to 8 minutes is incorrect.

After initiating the transfusion of whole blood, the nurse should stay with the client for 15 minutes to assess for any reactions. This is important because transfusion reactions can occur, and immediate assessment is necessary to identify and manage any adverse reactions. Checking vital signs every half hour is not sufficient for timely detection of reactions. Adding the total number of milliliters transfused to the intake and output is not directly related to monitoring for transfusion reactions. Discontinuing the primary IV of dextrose is not necessary unless there is a specific indication to do so.

If a client who is receiving a blood transfusion experiences an acute hemolytic reaction, the most important nursing intervention is to immediately stop the transfusion to prevent further complications. Infusing normal saline solution helps to maintain the client's fluid balance and stabilize their blood pressure. Notifying the blood bank is crucial for further investigation and ensuring patient safety. Lastly, calling the physician is necessary to report the reaction and seek further medical guidance.

Sitting upright, leaning slightly forward is the correct instruction for a client with epistaxis (nosebleed) caused by thrombocytopenia. This position helps to minimize the risk of blood flowing down the throat and potentially causing choking or aspiration. It also helps to reduce the amount of blood that may flow into the nasal passages, making it easier to control the bleeding. Lying supine with the neck extended or bending forward at the waist can increase the risk of blood flowing into the throat. Blowing the nose or putting lateral pressure on the nose can aggravate the bleeding.

The patient's symptoms of anemia, yellowish skin and sclera, and a positive Coomb's test indicate that the patient is experiencing a delayed hemolytic reaction. This type of reaction occurs when antibodies in the recipient's blood destroy the transfused red blood cells. Fluid support is given to manage the patient's symptoms.

The assessment findings of dry skin, dry mouth, scant and dark yellow urine, and elevated sodium levels suggest hypovolemic hypernatremia. Hypovolemic refers to a decrease in blood volume, which can lead to dehydration. Hypernatremia refers to an elevated sodium level in the blood. This combination suggests that Mrs. Romero is dehydrated and experiencing an imbalance in her body's water and sodium levels.

The most appropriate outcome is "No occurrence of further deterioration of the oral mucous membranes and moist oral mucous membranes maintained." This outcome aligns with the nurse's diagnosis of altered oral mucous membranes related to lack of body water secondary to hypernatremia. By maintaining moist oral mucous membranes, the nurse can prevent further deterioration and promote the patient's overall oral health.

Renal insufficiency can be a result of increased BUN. BUN is a waste product that is filtered out of the blood by the kidneys. When the kidneys are not functioning properly, they are unable to effectively filter out BUN, leading to an increase in its levels in the blood. This can be indicative of renal insufficiency, which is a condition where the kidneys are not able to adequately perform their function of filtering waste products from the blood. This can result in various symptoms and complications, including changes in level of consciousness and dry skin and mouth, as seen in the given situation.

The finding of a large number of immature leukocytes in the bone marrow biopsy would strongly support the diagnosis of acute leukemia. Leukocytes are white blood cells, and an increased number of immature leukocytes indicates abnormal cell proliferation and maturation, which is characteristic of acute leukemia. Lymphocytes, thrombocytes, and reticulocytes are not specific to leukemia and would not provide as strong of evidence for the diagnosis.

Conducting a complete nutritional assessment of the client is the most appropriate nursing intervention based on the client's hematocrit and hemoglobin levels. These levels indicate anemia, which can be caused by a deficiency in essential nutrients such as iron, vitamin B12, or folate. By conducting a nutritional assessment, the nurse can identify any deficiencies and develop a plan to address them, such as recommending dietary changes or supplements. Advising the client to have the test repeated in three months or doing nothing because these values are expected for their age would not address the underlying cause of the anemia. Mild anemia is not an expected response to the aging process, so this option is also not appropriate.

The client's age is the factor that would add most to the danger posed by her illness. As an older adult, her immune system may not be as strong, making her more susceptible to infections. Additionally, her age may make it more difficult for her body to fight off the bacterial pneumonia.

Breathing humidified air would most likely help liquefy the viscous secretions in a client with bacterial pneumonia. Humidified air can help to moisten and thin the secretions, making it easier for the client to cough them up. This can help to clear the airways and improve breathing. Other measures such as postural drainage, clapping and percussing, and coughing and deep-breathing exercises may also be beneficial in promoting the clearance of secretions, but breathing humidified air specifically targets the viscosity of the secretions.

Before administering a blood transfusion, it is important to verify the physician's order. This ensures that the blood transfusion is necessary and appropriate for the client. The other steps mentioned, such as verifying the blood product and client identity, and assessing the IV site, are also important but should be done after verifying the physician's order.

Supine position is the correct answer for positioning a patient undergoing bone marrow transplantation of the sternum on the operating table. The supine position refers to lying face up, with the back and palms facing upward. This position allows for easy access to the sternum for the procedure and ensures the patient's comfort and safety during the surgery.

The correct answer is "Altered health maintenance related to lack of knowledge of disease process, treatment regimen and risk control methods." This nursing diagnosis is appropriate because it addresses the client's lack of knowledge about their hypersensitivity disorder, which can affect their ability to properly maintain their health. By identifying this diagnosis, the nurse can develop a care plan that includes education and support to help the client understand their disease process, treatment options, and methods to control their symptoms and reduce risk. This will ultimately improve the client's ability to manage their condition effectively.

The priority nursing diagnosis for this client would be "Potential self-care deficit related to fatigue." This is because the client is experiencing moderate shortness of breath, which can lead to fatigue and difficulty performing self-care activities. The other options are not as relevant to the client's current condition.

The nurse would respond by saying, "I am not allowed to provide any information over the phone... it is better for you to visit her." This response indicates that the nurse cannot give any updates or prognosis over the phone and suggests that it would be beneficial for the family to visit Mrs. Romero in person.

Frequent linen changes should be included in the plan of care for this client because she is diaphoretic, which means she is sweating excessively. Sweating can cause the linens to become damp and uncomfortable for the client, increasing the risk of skin breakdown and infection. Therefore, frequent linen changes are necessary to maintain the client's comfort and hygiene.

Graft-versus-host disease (GVHD) is a complication that can occur after a bone marrow transplant, where the donor's immune cells attack the recipient's tissues. One of the common signs and symptoms of GVHD is an erythematosus rash on the palms, soles, ears, and trunk. This rash is a result of inflammation and immune response in the skin. Therefore, the nurse should be alert for this specific symptom to identify and manage GVHD in post bone marrow transplant patients.

The correct answer indicates that the client understands the teaching regarding the medication. It shows that the client knows that the antihistamine prescribed, loratadine (Claritin), will not cause drowsiness. This is important because drowsiness is a common side effect of many antihistamines, but loratadine is known to have a lower incidence of causing drowsiness. The client's statement also demonstrates that she is happy she can still supervise the carpenters, indicating that she is aware of the potential side effects and is relieved that drowsiness will not be an issue for her.

To prevent further fluid and electrolyte shifts in the elderly tube-fed resident, several precautions need to be taken. Monitoring the client's response to IV fluid replacement of hypoosmolar electrolyte solutions (option 1) is important to ensure that the fluid and electrolyte balance is being restored effectively. Similarly, monitoring the patient for absence of clinical manifestations of hypernatremia and return to normal sodium levels (option 2) is necessary to ensure that the electrolyte levels are within the normal range. Preventing osmotic diuresis from D5W by maintaining the prescribed rate (option 3) helps to prevent excessive fluid loss. Initiating safety and seizure precautions if the patient manifests weakness or cerebral changes (option 5) is important to ensure the safety of the patient. Therefore, all options except option 6 are needed to prevent further fluid and electrolyte shifts.

The client needs further teaching if he states that "Leukemia is triggered by toxic substances that stimulate enhanced cell mediated immune process." This statement is incorrect because leukemia is not triggered by toxic substances that stimulate an enhanced cell-mediated immune process. Leukemia is a cancer of the blood and bone marrow, and its causes are not fully understood. While exposure to certain chemicals and radiation may increase the risk of developing leukemia, it is not triggered by toxic substances that stimulate an enhanced immune process.

The correct answer is 1, 2 and 4.

The nurse's home instructions for the child with red, pruritic rashes on the cheeks and forehead include using gentle soaps (1) to avoid further irritation, instructing the parent to keep the child's fingernails trimmed (2) to prevent scratching and causing more damage to the skin, and applying petroleum jelly to affected areas after bathing (4) to help soothe and moisturize the skin. Bathing the child in cool water (3) may provide temporary relief from itching, but it is not mentioned in the given instructions. Therefore, the correct options are 1, 2 and 4.

The nurse should obtain the body temperature at the rectum because the client is experiencing a productive cough and difficulty breathing. Rectal temperature is considered the most accurate method for measuring body temperature in critically ill patients. It provides a more reliable reading than oral, axillary, or groin fold measurements.