Immune And Hematologic Disorders

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1. A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective?

Explanation

RATIONALE: Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, the client shouldn't experience increased salivation or tearing. Because decongestants alleviate congestion, they also relieve headaches, which may be caused by congestion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1870.

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About This Quiz
Immune And Hematologic Disorders - Quiz

This quiz assesses knowledge in managing immune and hematologic disorders, focusing on conditions like AIDS, Kaposi's sarcoma, and idiopathic thrombocytopenia purpura. It evaluates understanding of patient rights, treatment protocols, and emergency procedures, crucial for healthcare professionals.

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2. A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern?

Explanation

RATIONALE: In the classic lupus rash, lesions appear on the cheeks and the bridge of the nose, creating a characteristic butterfly pattern. The rash may vary in severity from malar erythema to discoid lesions (plaque). Papular and pustular rashes aren't associated with SLE. The bull's eye rash is classic in client's with Lyme disease.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1911.

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3. A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

Explanation

RATIONALE: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1805.

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4. A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

Explanation

RATIONALE: Signs of iron deficiency anemia include dyspnea, tachycardia, and pallor, as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome. Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1046.

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5. A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600 mg P.O. every 6 hours. Which statement by the client indicates understanding of the adverse effects of the medication?

Explanation

RATIONALE: The client with rheumatoid arthritis typically takes a relatively high dosage of aspirin for its anti-inflammatory effect. The nurse should instruct the client to report signs and symptoms of aspirin toxicity, such as tinnitus (ringing in the ears). Dysuria, leg cramps, and constipation aren't associated with aspirin use or toxicity.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 147.

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6. A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?

Explanation

RATIONALE: The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1786.

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7. A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

Explanation

RATIONALE: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1123.

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8. A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?

Explanation

RATIONALE: The donor and recipient must have compatible blood and tissue types. They should be fairly close in size and age, but these factors aren't as important as compatible blood and tissue types. When a living donor is considered, it's preferable to have a blood relative donate the organ. Need is important but it can't be the critical factor if a compatible donor isn't available.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1560.

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9. A client on the oncology floor is ordered a blood transfusion. The nurse explains the procedure and informs the client that an informed consent form must be signed before the blood may be administered. The client asks why consent is necessary. Which response by the nurse best explains why consent is necessary for blood transfusions?

Explanation

RATIONALE: Informed consent provides clients with information needed to make informed decisions about their health care. Clients need information about their health care regardless of the requirements mandated by the Joint Commission. Telling the client that blood transfusions may be administered without a signed informed consent in an emergency doesn't explain the purpose of signing a consent form. Informed consent provides the client with more information about blood transfusions than the hazards.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 133.

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10. A client diagnosed with acquired immunodeficiency syndrome is admitted to the emergency department with a closed head injury after being found unconscious on the kitchen floor by her neighbor. Based on information from the client's neighbor, the staff suspects domestic abuse. The client has a restraining order against the husband. The husband repeatedly attempts to visit the client. Which nursing action ensures client safety?

Explanation

RATIONALE: The nurse should inform hospital security personnel about the restraining order and formulate an action plan with security that protects the client. Placing the client in a reverse isolation room isolates the client and doesn't incorporate protective measures. Instructing the client to use her call light if her husband enters the room may alert hospital staff but doesn't allow for implementation of safety measures. Measures should be in place to stop the husband before he enters the client's room. Admitting the client to the pediatric unit doesn't protect the client from harm.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 675.

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11. A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate?

Explanation

RATIONALE: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. The nurse should caution the client not to have unprotected sex because continued exposure to HIV in a seropositive client may hasten the course of the disease or result in infection with another strain of HIV. Hormonal contraceptives, implants, and injections offer no protection against HIV transmission. The intrauterine device isn't recommended for a client with HIV because it may increase her susceptibility to pelvic inflammatory disease.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1842.

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12. While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?

Explanation

RATIONALE: A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 376.

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13. A nurse assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?

Explanation

RATIONALE: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1910.

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14. A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used:

Explanation

RATIONALE: A PICC provides long-term access (longer than 2 weeks) to central veins. It can be used to administer blood products, medications, I.V. fluids, and total parenteral nutrition. Moreover, the PICC can be used to obtain blood specimens. As with any other central venous catheter, this catheter shouldn't be inserted when systemic infection (infection in the blood) is present.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1706.

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15. Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis?

Explanation

RATIONALE: In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Therefore, Acute pain related to sickle cell crisis is the appropriate choice. Although nutrition is important, poor nutritional intake isn't necessarily related to sickle cell crisis. During sickle cell crisis, pain or another internal stimulus is more likely to disturb the client's sleep than external stimuli. Although clients with sickle cell anemia can develop chronic leg ulcers caused by small vessel blockage, they don't typically experience pruritus.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1058.

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16. A client was recently discharged with a peripherally inserted central catheter, and the home care nurse begins teaching him how to care for the catheter. The client states, "I'm so confused. The nurses in the hospital started to show me how to care for this catheter, but I don't think I'll be able to keep it all straight." Which response by the nurse is most appropriate?

Explanation

RATIONALE: The client received instruction before discharge, so the home care nurse should ask the client to demonstrate what he learned while hospitalized. The home care nurse can then develop her teaching plan based on the client's learning needs. Telling the client not to worry and that home care staff will care for the catheter doesn't promote client autonomy. The nurse shouldn't increase the client's anxiety level by mentioning that insurance covers only two home visits. Telling the client not to underestimate himself minimizes the client's concerns.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 522.

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17. A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:

Explanation

RATIONALE: Autonomy is the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence, promoting and doing good, and justice (being fair) aren't the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 102.

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18. A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?

Explanation

RATIONALE: The nurse should listen actively and nonjudgmentally as the client expresses feelings. Telling the client not to worry would provide false reassurance. A psychiatric consultation would be appropriate only after further assessment. Stating that the client's friends aren't true friends would discount the client's feelings.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1849.

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19. Which type of white blood cell (WBC) is the most numerous?

Explanation

RATIONALE: Neutrophils are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most abundant. Eosinophils account for about 2%, whereas basophils are the least abundant.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1037.

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20. A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

Explanation

RATIONALE: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1562.

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21. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

Explanation

RATIONALE: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1093.

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22. A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The nurse's most appropriate response is:

Explanation

RATIONALE: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help both 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. Offering to get the nursing supervisor also ignores the client's feelings. Ignoring the client's feelings by leaving suggests that the nurse has no interest in what the client has said.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 376.

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23. A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain?

Explanation

RATIONALE: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain, gait problems, or changes in muscle mass.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 147.

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24. A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

Explanation

RATIONALE: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1052.

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25. A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?

Explanation

RATIONALE: HIV is transmitted through infected blood, semen, and certain other body fluids. Although a transfusion with infected blood may cause HIV infection in the recipient, a person can't become infected by donating blood. The other options reflect accurate understanding of HIV transmission.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1816.

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26. A college student comes to the campus health care center complaining of headache, malaise, and a sore throat that has worsened over the past 10 days. The nurse measures a temperature of 102.6° F (39.2° C) and finds an enlarged spleen and liver and exudative tonsillitis. Laboratory tests reveal a leukocyte count of 20,000/mm3, antibodies to Epstein-Barr virus, and abnormal liver function tests. These findings suggest:

Explanation

RATIONALE: The client's clinical manifestations and laboratory test results suggest infectious mononucleosis. Mumps, a viral disease, usually causes an earache and fever from parotid gland involvement. Poliomyelitis is an acute communicable disease that has been largely eradicated by the polio vaccine. Although its symptoms resemble those of mononucleosis, it typically has a central nervous system component, causing back, neck, and arm pain or paralysis. Herpangina is an acute viral infection that causes seizures, vomiting, stomach pain, and grayish papulovesicles on the soft palate.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2477.

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27. The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns?

Explanation

RATIONALE: Option 1 provides correct information about advance directives. The advance directive outlines the client's treatment wishes should he be unable to communicate his wishes at any time during his illness. The physician continues to provide care for clients admitted to hospice care. Option 2 invalidates the client's fears and doesn't emphasize the physician's role or the client's role in his care plan. Option 3 doesn't address the purpose of the advance directive, and it discusses treatment options that may not have been discussed with the client. Option 4 doesn't provide evidence-based information about advance directives.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 174.

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28. A nurse is teaching a female client, who is positive for human immunodeficiency virus, about pregnancy. The nurse should know more teaching is necessary when the client says:

Explanation

RATIONALE: The client requires more teaching if she states she'll need to have a cesarean birth if she becomes pregnant. HIV is transmitted from mother to child via the transplacental route, but a cesarean birth isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV-positive can give birth to a baby who's HIV-negative; however, all neonates born to HIV-positive mothers will be HIV-positive for about 6 months because of maternal antibodies.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 353.

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29. A nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. The client experiences an adverse effect related to the destruction of the normal flora in the GI tract. What finding does the nurse expect to assess?

Explanation

RATIONALE: Broad-spectrum antibiotics that destroy aerobic and anaerobic bacteria also destroy the normal flora of the GI tract, which are responsible for absorbing water and certain nutrients (such as vitamin K). Destruction of the GI flora, in turn, leads to diarrhea. Although antibiotics may cause platelet dysfunction, stomatitis, renal dysfunction (indicated by oliguria and dysuria), and liver dysfunction, these adverse effects don't result from destruction of the GI flora.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1559.

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30. A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?

Explanation

RATIONALE: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1109.

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31. A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?

Explanation

RATIONALE: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1044.

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32. A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

Explanation

RATIONALE: Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1738.

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33. During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and "horse barn"-smelling diarrhea. It would be most important for the nurse to advise the physician to order:

Explanation

RATIONALE: Immunosuppressed clients — for example, clients receiving chemotherapy — are at risk for infection with C. difficile, which causes "horse barn"-smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus and isn't indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn"-smelling diarrhea.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2476.

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34. A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

Explanation

RATIONALE: The nurse should instruct the client to monitor body temperature. Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1911.

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35. A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for her personal identification number (PIN) to log in. What is the nurse' best response?

Explanation

RATIONALE: By telling the staff member she'll contact information services, the nurse is providing support and help without disclosing private information. Although telling the staff member that her request is inappropriate maintains confidentiality and security, this response may create interpersonal tension. Sharing a PIN or allowing someone to chart under another person's name may inadvertently put confidential client information at risk.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 130.

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36. After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?

Explanation

RATIONALE: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator, as ordered. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1868.

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37. When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?

Explanation

RATIONALE: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1850.

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38. A client with mild dementia related to end-stage acquired immunodeficiency syndrome is preparing for discharge. He has decided against further curative treatment and wishes to return home. Before discharge, he develops ocular cytomegalovirus (CMV). His physician recommends treatment with a ganciclovir-impregnated implant (Vitrasert), which requires a surgical procedure. The client's partner feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which answer from the nurse best answers the partner's question reflecting client advocacy?

Explanation

RATIONALE: In option 4, the nurse is advocating for the client's wishes. She is explaining the client's wishes for no further curative treatment, yet promoting an improved quality of life and safety while the client is being cared for at home. Option 1 answers the partner's question, but it doesn't advocate for the client's needs. Option 2 provides factual information, but it's delivered in a confrontational manner. Option 3 also provides factual information but doesn't show client advocacy.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 102.

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39. A client newly diagnosed with multiple sclerosis worries that his employer will fire him now that he has a condition that might interfere with his work. How should the nurse respond?

Explanation

RATIONALE: The nurse should refer the client to organizations with appropriate resources, such as the National Multiple Sclerosis Society. She shouldn't assure the client that his physician will help him deal with work-related limitations; the physician isn't adequately qualified to advise the client about his relationship with his employer. By telling the client he doesn't have to tell his employer that he has a chronic illness, the nurse is making a legal determination without benefit of legal consultation; she could be performing duties beyond her scope of practice. The Americans with Disabilities Act provides valuable protections, but unless the nurse has definite knowledge of the legal issues involved, she should refer the client to specialized organizations that have resources to guide him in this area of need.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 527.

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40. A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?

Explanation

RATIONALE: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1083.

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41. A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety?

Explanation

RATIONALE: When the client places the walker directly in front of him, he creates a stable base for forward movement and reduces the likelihood of falls. The client shouldn't set the back leg down first because this creates an unstable base that could lead to a fall. The client should firmly grip the side bars; doing so provides a more stable base of support than gripping the front bar. The nurse shouldn't suggest that the client use a walker with wheels. Only a physician or physical therapist may order a walker with wheels.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1305.

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42. A nurse on the hematology floor feels the charge nurse has been unfairly assigning complex clients to her by not dividing enough of the workload among the rest of the staff. This nurse is creating tension among the staff. What is the charge nurse's best approach?

Explanation

RATIONALE: Before taking punitive action, the charge nurse should meet with the staff member privately to enhance communication and model problem-solving behaviors. Instructing the staff member in how to present her concerns and assuring her that she's distributing assignments fairly are linear and directive; these responses don't give the staff member adequate opportunity to interact with the charge nurse in a productive manner. Writing the nurse up and providing counseling is a better response, but writing the nurse up may not be necessary if the charge nurse takes time to talk with her.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 541.

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43. A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is her neighbor's son. What action should the nurse take to protect the client's right to privacy?

Explanation

RATIONALE: Under the Health Insurance Portability and Accountability Act, personal health information may not be used for purposes not related to health care. The nurse director found reading the chart isn't providing health care to the client and, therefore, doesn't require access to the chart. The nurse should confront the nurse director and ask her to return the client's chart. The director shouldn't have access to this client's health care information regardless of his HIV status. If she doesn't comply with the nurse's request, the nurse should report the incident to her nurse manager, so the infraction can be reported through the proper channels. The staff nurse shouldn't report the incident to the medical director. Asking the nurse director if she has permission to read the chart doesn't protect client confidentiality.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 129.

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44. A nurse is caring for a client with acquired immunodeficiency syndrome. To adhere to standard precautions, the nurse should:

Explanation

RATIONALE: Standard precautions stipulate that a health care worker wear gloves when contact with a client's blood or body fluids is anticipated, such as when providing mouth care. Such barrier protection helps prevent viruses from entering the bloodstream. Maintaining strict isolation isn't needed because human immunodeficiency virus is spread by contact with contaminated blood or body fluids, which can be avoided by following standard precautions. A private room wouldn't provide barrier protection, which is needed for standard precautions. Wearing a gown is appropriate only when anticipating splashing of blood or body fluids.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 717.

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45. A client with acquired immunodeficiency syndrome (AIDS) is ordered zidovudine (azidothymidine, AZT [Retrovir]), 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?

Explanation

RATIONALE: To be effective, zidovudine must be taken every 4 hours around the clock. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the physician before taking OTC medications.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1224.

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46. A nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

Explanation

RATIONALE: It's essential for clients with AIDS to follow safer-sex practices to prevent transmission of the human immunodeficiency virus. Although it's helpful if clients with AIDS avoid using recreational drugs and alcohol, it's more important that I.V. drug users use clean needles and dispose of used needles for purposes of avoiding transmission. Whether the client with AIDS chooses to tell anyone about the diagnosis is his decision; there is no legal obligation to do so.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1841.

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47. A client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?

Explanation

RATIONALE: Taking piroxicam with food or an antacid decreases the risk of GI upset. The client may take the full piroxicam dosage once daily or may divide it in half and take a smaller dose every 12 hours; dosing every 4 hours isn't recommended. Because piroxicam may not produce therapeutic effects for 2 to 4 weeks, the client should take it for more than a short time. The client shouldn't adjust the dosage of piroxicam or any medication unless directed to do so by a physician.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 958.

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48. Which step must be done first when administering a blood transfusion?

Explanation

RATIONALE: The nurse must first verify the physician's order and then make sure the informed consent form is signed. Next, the nurse should make sure that an appropriate-size I.V. catheter is in place and she should assess the site for patency. After doing so, the nurse should verify the blood product and client identity with another nurse.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1737.

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49. A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?

Explanation

RATIONALE: Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates complement. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1857.

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50. A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Explanation

RATIONALE: In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1847.

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51. A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

Explanation

RATIONALE: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1907.

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52. A client with lymphoma tells the nurse that he's found an overseas holistic physician who can cure him with coffee enemas. What should the nurse say?

Explanation

RATIONALE: In this situation, the nurse should try to maintain open communication and a strong therapeutic connection with the client. Although the treatment may be unproven, questionable, dangerous, or illegal, telling the client so may make the nurse appear to be harsh and judgmental, shut down dialog, and alienate the client. By referring the client to the physician, the nurse keeps lines of communication open and gives the client an opportunity to discuss treatment options in a difficult life situation.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 747.

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53. A client with human immunodeficiency virus undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:

Explanation

RATIONALE: Anergy testing determines the level of immune response an individual has to common microbes. A normal response is a local skin reaction to all the antigens injected intradermally. Absence of a response within 3 days suggests the individual is immunodeficient and can't produce a normal immune response. It doesn't imply nonexposure to the antigens, which are environmentally prevalent. A positive skin reaction demonstrates presence of antibodies to the antigens. An expected reaction to the antigens isn't considered an allergic or hypersensitive reaction.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1831.

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54. A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change?

Explanation

RATIONALE: Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 983.

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55. A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving:

Explanation

RATIONALE: An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1109.

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56. A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?

Explanation

RATIONALE: The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1811.

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57. Which finding should a nurse identify as requiring further investigation?

Explanation

RATIONALE: A platelet count of 115,000/μl is abnornal and requires further investigation. Normal values are 150,000 to 300,000 platelets/μl; 5,000 to 10,000 WBCs/μl; 4.5 to 5.5 million RBCs/μl; and an average hematocrit of 45%.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1042.

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58. A home care nurse is making the initial home visit to a client with lung cancer who had a peripherally inserted central catheter placed during hospitalization for an upper respiratory infection. During the visit, the nurse must administer an antibiotic, teach the client how to care for the catheter, and provide information about when to notify the home care agency and physician. When the nurse arrives at the client's home, the client's face is flushed and he complains of feeling tired. Which actions should the nurse take first?

Explanation

RATIONALE: The nurse should assess the client to see why his condition has changed since discharge. After assessment, the nurse should notify the physician of the change in the client's condition. The nurse shouldn't just obtain vital signs and administer the antibiotic without further assessing the client. It's inappropriate for the nurse to begin a teaching session when the client isn't physically able.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 241.

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59. A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Explanation

RATIONALE: These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1076.

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60. A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

Explanation

RATIONALE: The client demonstrates understanding of rheumatoid arthritis if he expresses that it's an unpredictable disease characterized by periods of exacerbation and remission. There's no cure for rheumatoid arthritis, but symptoms can be managed. Surgery may be indicated in some cases.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1908.

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61. A client has had heavy menstrual bleeding for 6 months. Her physician diagnoses microcytic hypochromic anemia and orders ferrous sulfate (Feosol), 300 mg P.O. daily. Before initiating iron therapy, the nurse reviews the client's medical history. The nurse should question this order when she notes that the client:

Explanation

RATIONALE: Conditions that contraindicate the use of ferrous sulfate include primary hemochromatosis, infectious kidney disease in the acute phase, peptic ulcer, regional enteritis, ulcerative colitis, and known hypersensitivity to iron. Iron dextran requires cautious use in pregnant or breast-feeding clients and in those with severely impaired liver function, significant allergies, or asthma.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 513.

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62. The couple with the lowest risk of having a child with sickle cell anemia disease is the one in which the:

Explanation

RATIONALE: If the father has normal hemoglobin (HbA) and the mother has sickle cell anemia (HbS), the couple has a 0% chance of having a child with sickle cell anemia. If both parents have sickle cell anemia, the couple has a 100% chance of having a child with sickle cell anemia. If the father has sickle cell anemia and the mother has sickle cell trait (HbAS), the couple has a 50% chance of having a child with sickle cell anemia. If both parents have sickle cell trait, the couple has a 25% chance of having a child with sickle cell anemia.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1056.

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63. A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects he has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?

Explanation

RATIONALE: In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is commonly used to replace clotting factors. Normal saline or lactated Ringer's solution is used to increase volume and blood pressure; however, too much colloid will hemodilute the blood and doesn't improve oxygen-carrying capacity as well as packed RBCs do.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1103.

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64. A client takes prednisone (Deltasone), as ordered, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as:

Explanation

RATIONALE: Common adverse reactions to prednisone and other steroids include sodium retention, fluid retention, and weight gain. Tetany and tremors are occasional adverse reactions to certain other drugs such as antipsychotics. Anorexia, abdominal cramps, and diarrhea are common adverse reactions to many drugs, but not to steroids.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 976.

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65. A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:

Explanation

RATIONALE: The client with ITP is at greatest risk for cerebral hemorrhage when the platelet count falls below 10,000/μl. Although platelet counts of 20,000/μl and 75,000/μl are below normal and increase the client's risk for bleeding, they don't increase the risk as much as a platelet count below 10,000/μl. A platelet count of 135,000/μl is normal and wouldn't occur in a client with ITP.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1088.

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66. A client being treated for iron deficiency anemia with ferrous sulfate (Ferasol) continues to be anemic despite treatment. The nurse should assess the client for use of which medication?

Explanation

RATIONALE: The nurse should assess the client for possible use of antacids such as aluminum hydroxide. Clients should take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1050.

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67. A physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?

Explanation

RATIONALE: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1911.

Submit
68. A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client?

Explanation

RATIONALE: Reduced HCT is caused by hemodilution, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbunimemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced HCT level in this situation. Erythropoietin factor is reduce if kidney failure occurs; however, lack of erythropoietin factor doesn't impact hematocrit level.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2005.

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69. A client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing end-stage Kaposi's sarcoma. Concerned that the health care team is investing too much energy in keeping him alive, he asks that they not attempt any more interventions. How should a nurse respond to this client?

Explanation

RATIONALE: The nurse should tell the client he must sign an advance directive to prevent future health care interventions. This client has lived with AIDS for many years; suggesting that he talk with a therapist or reconsider his decision is disrespectful and disregards his experience of the disease. An advance directive doesn't require a physician's order.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 175.

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70. A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?

Explanation

RATIONALE: Offering a face mask is the best approach; it protects the child while supporting the family and using the situation as an opportunity for learning. Instructing family members that it isn't healthful to share food and to avoid the child if they're sick are technically correct, but these responses don't include a rationale that enables the family to understand why these actions are important. The nurse should have posted an isolation sign on the child's door long before the time of his discharge.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 508.

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71. A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:

Explanation

RATIONALE: The protozoal enteric infection caused by Cryptosporidium results in profuse watery diarrhea. Because diarrhea will lead to dehydration, the nurse should focus on fluid replacement. Pain management is also a concern in the care of a client with AIDS. However, with Cryptosporidium, the main concern is hydration. Antiretroviral therapy is most useful when a client with human immunodeficiency virus doesn't have opportunistic infections. With the wasting associated with AIDS, high-calorie nutrition is important, but with Cryptosporidium-related diarrhea, hydration takes precedence.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1846.

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72. A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

Explanation

RATIONALE: Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 605.

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73. A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse?

Explanation

RATIONALE: Two people with the beta-thalassemia trait have a 25% chance of having a child with thalassemia major, a potentially life-threatening disease. Iron supplements aren't used to treat thalassemia; in fact, they could contribute to iron overload. Vitamin B12 injections are used to treat pernicious anemia, not thalassemia. Thalassemia occurs primarily in people of Italian, Greek, African, Asian, Middle Eastern, East Indian, and Caribbean descent.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1061.

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74. A client diagnosed with systemic lupus erythematosus 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?

Explanation

RATIONALE: Hypertension, osteoporosis, muscle wasting, and truncal obesity are all adverse effects of long-term corticosteroid therapy; however, osteoporosis commonly causes compression fractures of the spine. Hypertension, muscle wasting, and truncal obesity aren't likely to cause severe back pain.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1064.

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75. A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?

Explanation

RATIONALE: Connective tissue disorders are considered autoimmune disorders. Clients with autoimmune disorders may have either false-positive or false-negative serologic tests for syphilis. Other common laboratory findings in these clients include Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins. No cure exists for autoimmune disorders; treatment centers on controlling symptoms. Autoimmune disorders aren't distinctive; they share common features, making differential diagnosis difficult.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1796.

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76. A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity?

Explanation

RATIONALE: A diet containing excessive fat, such as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues. Raisins, carrot sticks, fruit, mineral water, applesauce, and saltine crackers are snacks containing adequate amounts of vitamin A, zinc, and carotene, which are beneficial for the body.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1797.

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77. A client with acquired immunodeficiency syndrome is receiving zidovudine (azidothymidine, AZT [Retrovir]). Which laboratory value indicates an adverse reaction to zidovudine?

Explanation

RATIONALE: Because anemia (characterized by a decrease in RBCs below 4.0 million/μl) is a major adverse effect of zidovudine, the nurse should monitor the client's RBC count and assess for signs and symptoms of decreased cellular oxygenation. Zidovudine doesn't affect the blood glucose level, serum calcium level, or platelet count and the values listed are within normal limits.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1224.

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78. Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia?

Explanation

RATIONALE: Neutropenia occurs when the absolute neutrophil count falls below 1,000/mm3, reflecting a severe risk of infection. The nurse should provide a low-bacterial diet, which means eliminating fresh fruits and vegetables, avoiding invasive procedures such as enemas, and practicing frequent hand washing. Using a soft toothbrush, avoiding straight-edged razors and enemas, and monitoring for bleeding are precautions for clients with thrombocytopenia. Putting on a mask, gown, and gloves when entering the client's room are reverse isolation measures. A neutropenic client doesn't need a clear liquid diet or sodium restrictions.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1069.

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79. A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address?

Explanation

RATIONALE: Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1007.

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80. A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

Explanation

RATIONALE: Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1076.

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81. A client diagnosed with metastatic cancer is preparing for discharge. The physician orders morphine sulfate controlled-release tablets 100 mg every 12 hours as needed after discharge. What legal rights and responsibilities should the nurse address when teaching the client about morphine sulfate use?

Explanation

RATIONALE: Federal law prevents the refill of opioids. Therefore, the nurse should tell the client to contact the physician for a new prescription when the current prescription is empty. The client should be instructed to avoid driving or operating hazardous machinery while under the effects of morphine; however, this is a safety issue not a legal one. Long-term morphine sulfate use may lead to drug tolerance; however, this isn't a legal issue surrounding its use. The client with metastatic cancer will most likely require pain medication for the rest of his life.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 785.

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82. Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?

Explanation

RATIONALE: Iron-rich foods include lamb and peaches. Shrimp, tomatoes, lobster, squash, cheese, and bananas aren't high in iron content.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1050.

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83. A nurse is poviding care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?

Explanation

RATIONALE: Progressive systemic sclerosis is a connective tissue disease characterized by fibrosis and degenerative changes of the skin, synovial membranes, and digital arteries. Therefore, the nurse is most likely to formulate a nursing diagnosis of Risk for impaired skin integrity. Because clients with the disease are prone to diarrhea from GI tract hypermotility (caused by pathologic changes), Constipation is an unlikely nursing diagnosis. Progressive systemic sclerosis doesn't cause Ineffective thermoregulation. GI hypermotility may lead to malabsorption, and esophageal dysfunction may cause dysphagia; these conditions put the client with the disease at risk for inadequate nutrition, making Risk for imbalanced nutrition: More than body requirements an improbable nursing diagnosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1912.

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84. When a relief charge nurse posts assignments, a nurse notes that she is no longer assigned to a client whom she has cared for the previous 2 nights. How should the nurse respond to this assignment?

Explanation

RATIONALE: Asking the charge nurse if there's a reason why she changed the assignment is the most professional response. This response encourages communication and exchange of ideas. Although it's acceptable for this nurse to tell the charge nurse she'd like to continue with the same assignment or accept the assignment and discuss the change with the charge nurse at a later time, these responses don't give the nurse an opportunity to resolve her concerns. Telling the charge nurse that she feels she's the best person to care for a particular client is too direct and could put the charge nurse in a defensive position.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 172.

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85. A nurse is monitoring a client who developed facial edema after receiving a medication. Which white blood cells stimulated the edema?

Explanation

RATIONALE: The client's edema is related to an allergic reaction to the medication. Basophils are responsible for releasing histamine during an allergic reaction. Eosinophils' major function is phagocytosis of antigen-antibody complexes that are formed in allergic reactions. Monocytes and neutrophils are predominately phagocytic.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1785.

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86. A nurse is caring for a client with human immunodeficiency virus (HIV). To determine the effectiveness of treatment the nurse expects the physician to order:

Explanation

RATIONALE: Quantification of T-lymphocytes is used to monitor the effectiveness of treatment for HIV. E-rosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test. The Western blot test — electrophoresis of antibody proteins — detects HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone and doesn't monitor the effectiveness of treatment.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1826.

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87. Nurses were identified by the Centers for Disease Control and Prevention (CDC) as the people most likely to care for clients infected after the intentional release of the smallpox virus. Based on CDC guidelines, which group should volunteer to receive the smallpox vaccine?

Explanation

RATIONALE: The CDC recommends the smallpox vaccine for nurses who received the vaccine as children (which includes those older than age 50) who work in the emergency department; emergency department nurses are most likely to care for those infected with the smallpox virus. Nurses born after 1971 weren't previously vaccinated against smallpox so the vaccine isn't currently recommended for those nurses. Military history doesn't dictate whether or not the vaccine is recommended. Nurses who work in the pediatric unit aren't at high risk for smallpox exposure; therefore, the vaccine isn't recommended for this group.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Wharton M., et al. (2003, April 4). "Recommendations for Using Smallpox Vaccine in a Pre-Event Vaccination Program" [Online]. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5207a1.htm [2007, April 23].

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88. A nurse is caring for a client with the following laboratory values: white blood cell count (WBC) 4,500/mm3, neutrophils 15%, and bands 1%. Based on the client's absolute neutrophil count (ANC), what is the client's risk of infection?

Explanation

RATIONALE: The nurse should calculate the ANC using this formula:
Total WBC count × (% neutrophils + % bands)/100
4,500 × (15 + 1)/100 = 720/mm3.
If a client's ANC is greater than 1,000/mm3, the client has no increased risk of infection. If the ANC is less than 1,000/mm3, the risk of infection is significant. The risk of infection is high with an ANC of less than 500/mm3 and the risk of infection is almost certain if the ANC is less than 100/mm3.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1067.

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89. Which client is most likely to develop systemic lupus erythematosus (SLE)?

Explanation

RATIONALE: SLE strikes nearly 10 times as many women as men and is most common in women between ages 15 and 40. SLE affects more black women than white women; its incidence is about 1 in every 250 black women, compared to 1 in every 700 white women.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1909.

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90. Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are:

Explanation

RATIONALE: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats/minute) when the client rises from a lying position.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 537.

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91. Clients with cancer who receive multiple blood transfusions are at risk for forming antibodies against the blood. What precautions should the nurse take when administering blood to a client with a history of multiple transfusions?

Explanation

RATIONALE: The nurse should make sure that leukocyte-reduced blood products are ordered to reduce the risk of a blood transfusion reaction caused by antibody formation. Filter use doesn't guarantee leukocyte removal. The nurse may ask the client about previous blood transfusions, but doing so doesn't protect the client from a transfusion reaction. Using allogeneic blood products isn't always possible in clients with a history of multiple blood transfusions.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1717.

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92. A nurse is assigned to a client with polymyositis. Which expected outcome in the care plan relates to a potential problem associated with polymyositis?

Explanation

RATIONALE: An expected outcome of no signs or symptoms of aspiration relates to symmetrical muscle weakness — a potential problem associated with polymyositis that may lead to speaking and swallowing problems. A client with a potential swallowing problem is at risk for inadequate nutrition and shouldn't be placed on a calorie-restricted diet; an expected outcome focusing on maintaining weight would be more appropriate than an outcome based on losing weight. Polymyositis doesn't affect bowel or bladder function or mental status; it isn't necessary to develop outcomes based on these parameters.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1913.

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93. Which one do you like?

Explanation

RATIONALE: Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush her eyes with water. She should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse her eyes may allow viral transmission through contact with the mucous membranes.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 717.

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94. A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. His family members report that he has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms?

Explanation

RATIONALE: Excessive thirst, constipation, dehydration, confusion, and altered mental state are possible signs of hypercalcemia. Hypercalcemia is common in multiple myeloma because of the increased bone destruction. A platelet count of 300,000/mm3 is normal and wouldn't cause the client's symptoms. A sodium level of 133 mEq/L is slightly decreased but wouldn't cause confusion and excessive thirst. A hemoglobin of 9.8 g/dl level is slightly low but isn't likely responsible for the client's symptoms.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1083.

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95. A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

Explanation

RATIONALE: A client with DIC is at risk for Impaired skin integrity related to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin. The nurse should perform mouth care using sponge swabs and baking soda solution, not lemon-glycerin swabs, because lemon-glycerin swabs can dry the oral mucosa, which may lead to bleeding. I.M. injections should be avoided in clients with DIC because of the potential for bleeding.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1096.

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96. Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:

Explanation

RATIONALE: Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given I.V. to treat acute organ rejection, but it's ineffective against hyperacute rejection.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1562.

Submit
97. A physician orders gentamicin sulfate (Garamycin), 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least:

Explanation

RATIONALE: The nurse should infuse gentamicin sulfate I.V. over at least 30 minutes. Infusing the drug more rapidly may increase the client's risk of adverse reactions.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 568.

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98. A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within:

Explanation

RATIONALE: Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1717.

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99. In a client infected with human immunodeficiency virus (HIV), CD4+ levels are measured to determine the:

Explanation

RATIONALE: CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's immune system. The test indicates the individual's risk of an opportunistic infection but doesn't identify specific infections. Viral loads and resistance to specific antigens are determined using other diagnostic tests.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1826.

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100. A nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client's blood and body fluids, the nurse uses standard precautions, which include:

Explanation

RATIONALE: Disposing of needles uncapped is a standard precaution; most accidental needle sticks result from missed needle recapping. Standard precautions also include not cutting, breaking, or bending a needle after use because doing so may release aerosolized blood from the needle shaft; not leaving used needles lying around; and disposing of needles only in appropriately labeled, impermeable needle containers. Gloves aren't necessary when touching the client, and urine collection by catheterization doesn't require use of gloves, gown, and protective eyewear. It isn't necessary to wear gloves when instilling eyedrops.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 717.

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101. A person visiting with a client asks the nurse what's wrong with the client. The nurse's best response is:

Explanation

RATIONALE: Because the nurse doesn't know the visitor's identity, it's most appropriate for her to ask if the person is a relative or friend before determining whether she should share information or refer the visitor directly to the client. Declining to provide information or asking if the visitor is related to the client could be construed as rude and inhibits communication.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 129.

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102. Which client is most at risk for developing disseminated intravascular coagulation (DIC)?

Explanation

RATIONALE: The client with the amniotic fluid embolism is at greatest risk for developing DIC. Other risk factors for developing DIC include trauma, cancer, shock, and sepsis. Possible cocaine overdose, a stage IV pressure ulcer, and heart failure and renal failure aren't risk factors for DIC.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1093.

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103. A client is to receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. The nurse identifies the client using two client identifiers, then prepares to administer the transfusion. Place the following steps in the order the nurse should follow to administer this product. Use all options.
1. Flush the I.V. Tubing and line with NSS.
2. Check blood bag against the client's information.
3. Watch for a transfusion reaction.
4. Record vital signs.
5. Put on gloves, a gown, and a face shield.
6. Check packed RBCs for the date and abnormalities

Explanation

The correct answer is 4,6,2,5,1,3.

RATIONALE: To administer a blood transfusion, the nurse should first record the client's vital signs. Next, she should check the packed RBCs for abnormal color, clumping, gas bubbles, and expiration date. The nurse should also verify the blood bag identification, ABO group, and Rh compatibility against the client's information. She should then put on gloves, a gown, and a face shield. The nurse should flush the I.V. tubing and line with normal saline solution (NSS). Finally, the nurse should remain with the client and watch for signs of a transfusion reaction. Note that the transfusion may be withheld if the client's temperature is 100° F (37.7° C) or higher.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1737.

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104. For a client diagnosed with idiopathic thrombocytopenia purpura (ITP), which nursing intervention is appropriate?

Explanation

RATIONALE: The nurse should take measures to prevent bleeding because the client with ITP is at increased risk for bleeding. Straining at stool causes the Valsalva maneuver, which may raise intracranial pressure (ICP), thus increasing the risk for intracerebral bleeding. Therefore, the nurse should give stool softeners to prevent straining, which may result from constipation. Teaching coughing techniques would be inappropriate because coughing raises ICP. Platelets rarely are transfused prophylactically in clients with ITP because the cells are destroyed, providing little therapeutic benefit. Aspirin interferes with platelet function and is contraindicated in clients with ITP.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1089.

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105. Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child?

Explanation

RATIONALE: Establishing a written emergency plan that includes what to do in specific situations helps the family provide safety measures for their child with hemophilia. Padding corners of furniture and using kneepads don't help provide a safe home environment for children of all ages. Telling the parents to be a role model by wearing a bike helmet is only applicable to children who are old enough to emulate their parent's behaviors. Having the child problem-solve hypothetical health situations doesn't help provide a safe environment; it addresses problem solving.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1091.

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106. When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching. When urticaria, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?

Explanation

RATIONALE: ABO incompatibility, such as from an incompatible blood transfusion, is a type II hypersensitivity reaction. Transfusions of more than 100 ml of incompatible blood can cause severe and permanent renal damage, circulatory shock, and even death. Drug-induced hemolytic anemia is another example of a type II reaction. A type I hypersensitivity reaction occurs in anaphylaxis, atopic diseases, and skin reactions. A type III hypersensitivity reaction occurs in Arthus reaction, serum sickness, systemic lupus erythematosus, and acute glomerulonephritis. A type IV hypersensitivity reaction occurs in tuberculosis, contact dermatitis, and transplant rejection.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1109.

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107. A nurse is planning care for a client with human immunodeficiency virus (HIV). She's being assisted by a licensed practical nurse (LPN). Which statements by the LPN indicate her understanding of HIV transmission? Select all that apply.

Explanation

RATIONALE: Standard precautions include wearing gloves for any known or anticipated contact with blood or other body fluids, tissue, mucous membranes, or nonintact skin. If the task may result in splashing or splattering of blood or body fluids to the face, a mask and goggles or face shield should be worn. If the task may result in splashing or splattering of blood or body fluids to the body, a fluid-resistant gown or apron should be worn. Hands should be washed before and after client care and after removing gloves. A gown, mask, and gloves aren't necessary for client care unless contact with body fluids, tissue, mucous membranes, or nonintact skin is expected. Nurses have an increased, not decreased, risk of occupational exposure to blood-borne pathogens. HIV isn't transmitted in sputum unless blood is present.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1816.

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108. A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every:

Explanation

RATIONALE: The nurse should instruct the graduate nurse to change the central venous catheter dressing every 48 hours or when the dressing becomes damaged or soiled.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1198.

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109. A nurse is preparing to discharge an adolescent with sickle cell anemia. What client need should the nurse emphasize in her discharge assessment?

Explanation

RATIONALE: Because many psychosocial and physiological issues affect the life of an adolescent with a chronic illness, assuring the existence of a good support structure is the most essential element of care. Availability of pain medication and adequate support are both important considerations, but it's more important to emphasize the need for an adequate support structure. The need for good hydration and follow-up visits are important, but a good support structure will help the adolescent with this treatment.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1060.

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110. A client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). He undergoes biopsies of facial lesions. The preliminary report indicates Kaposi's sarcoma. Which action by the nurse is most appropriate?

Explanation

RATIONALE: The nurse should help the client explore his feelings about his facial disfigurement because facial lesions can contribute to decreased self-esteem and an altered body image. Discussing AIDS with a client whose diagnosis isn't final may be inappropriate and doesn't provide emotional support. Pretending not to notice visible lesions ignores the client's concerns. The physician, not the nurse, should inform the client of the biopsy results.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1848.

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111. Which nonpharmacologic interventions should a nurse include in a care plan for a client who has moderate rheumatoid arthritis (RA)? Select all that apply.

Explanation

RATIONALE: Supportive, nonpharmacologic measures for the client with RA include applying splints to rest inflamed joints, using Velcro fasteners on clothes to aid in dressing, and applying moist heat to joints to relax muscles and relieve pain. Inflamed joints should never be massaged because doing so can aggravate inflammation. A physical therapy program, including ROM exercises and carefully individualized therapeutic exercises, prevents loss of joint function. Assistive devices should be used only when marked loss of ROM occurs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1909.

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112. What nursing interventions should a nurse expect to implement when caring for a child in acute sickle cell crisis? Select all that apply.

Explanation

RATIONALE: Because the child is in acute crisis, providing adequate hydration, controlling pain, and carefully monitoring vital signs are priority points of care. When the child's condition has stabilized, the nurse may evaluate family learning needs, encourage healthful eating habits, and attend to play needs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1059.

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113. A nurse is caring for a child in acute sickle cell crisis. Which laboratory values does the nurse expect to see? Select all that apply.

Explanation

RATIONALE: Sickle cell crisis typically presents with low MCH and a positive metabisulfate test. MCV will be low in sickle cell anemia. Presence of HbSS is a definitive indicator for sickle cell anemia. A positive, not negative, Howell-Jolly bodies test is a definitive indicator of sickle cell anemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1056.

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