Med Surg
Which of the following laboratory findings would indicate a client is at an increased risk for infection and requires neutropenic precautions?
A) Total white blood cell (WBC) count of 8,000/mm³ (5,000-10,000)
B) Absolute neutrophil count (ANC) of 900/mm³ (>1,000)
C) Total WBC count of 12,000/mm³ (5,000-10,000)
D) Neutrophil count of 5,500/mm³ (>1,000)
B) Absolute neutrophil count (ANC) of 900/mm³
Rationale: Neutropenic precautions are essential for clients with an ANC less than 1,000/mm³, as they are at a significantly increased risk for infection. An ANC less than 1,000/mm³ indicates the need for protective measures, such as restricting visitors and ensuring strict hygiene protocols.
What is a key consideration when conducting skin testing for allergens?
A) The client should be on corticosteroid therapy to minimize skin reactions.
B) Blood allergy testing is a safer alternative for clients with a history of anaphylaxis.
C) The test is performed by applying allergens to the skin for 30 minutes before evaluating.
D) The nurse should prepare the skin using alcohol to remove oil.
D) The nurse should prepare the skin using alcohol to remove oil.
Rationale: For skin testing, it is important to prepare the skin by using alcohol to remove oils and other substances that might interfere with the allergen’s absorption. Option A is incorrect because corticosteroids and antihistamines should be withheld for 48 hours to 2 weeks prior to the test to avoid interference with results. Option C is incorrect because the reaction is typically assessed 15 to 20 minutes after allergen application. Option D is also incorrect because blood allergy testing is generally used when the risk of a hypersensitivity reaction is high, but skin testing is often preferred for its broader range of allergens.
A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infection. Which of the following interventions is the nurse’s priority?
A. Performing hand hygiene before and after contact with the client
B. Reducing the clients anxiety due to isolation procedures
C. Assisting the client with making nutritional choices
D. Monitoring the. clients intake and output
A. Performing hand hygiene before and after contact with the client
Rationale: The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces 2 virulent exotoxins to attack the lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The spores spread easily by contact with body fluids and inanimate objects. The greatest risk to this client, the nurse, and others is injury from infection transmission; therefore, the priority intervention is hand hygiene.
Which of the following cancer treatment methods is used to reduce or remove tumors, and may include procedures like cryosurgery or laser therapy?
A) Chemotherapy
B) Surgery
C) Radiation therapy
D) Tumor reduction procedures
D) Tumor reduction procedures
Rationale: Tumor reduction procedures such as cryosurgery, laser therapy, and ablation are used to reduce or remove tumors. These procedures focus on destroying the tumor and its surrounding blood supply. Surgery is also part of cancer treatment but is a broader category that can include removal of tumors, biopsy, and other interventions.
Which of the following nursing actions is a priority for a client undergoing chemotherapy to prevent complications associated with neutropenia?
A) Encourage the client to drink liquids with meals
B) Place the client in a private room and ensure proper hand hygiene
C) Advise the client to use an electric razor for shaving
D) Encourage high-protein, high-calorie snacks
B) Place the client in a private room and ensure proper hand hygiene
Rationale: Neutropenia, caused by chemotherapy-induced bone marrow suppression, increases the risk of infection. Placing the client in a private room and practicing proper hand hygiene for both the client and staff are crucial in reducing exposure to infection. Options A, C, and D are related to other care aspects but are not specific to preventing infection in neutropenia.
Which of the following is a characteristic of active immunity?
A) Immunity is transferred from one individual to another.
B) Immunity develops quickly but is short-lived.
C) Immunity develops through vaccination or exposure to a pathogen.
D) Immunity is provided by administering immune globulins to an individual.
C) Immunity develops through vaccination or exposure to a pathogen.
Rationale: Active immunity develops when the body produces antibodies in response to exposure to an antigen, either through natural infection or vaccination. It is a long-lasting form of immunity. In contrast, passive immunity is temporary and involves receiving antibodies from another source, such as through immune globulins or from a mother to her infant. Option D refers to passive-artificial immunity.
Which of the following vaccines is contraindicated for a pregnant woman?
A) Measles, mumps, and rubella (MMR) vaccine
B) Inactivated influenza vaccine (IIV)
C) Hepatitis B vaccine
D) Zoster vaccine
A) Measles, mumps, and rubella (MMR) vaccine
Rationale: The MMR vaccine, contains live attenuated viruses, is contraindicated during pregnancy because it can potentially harm the fetus. Pregnant women should avoid this vaccine due to the risks associated with the live virus components. The hepatitis B vaccine and the inactivated influenza vaccine (IIV) are safe for pregnant women. The zoster vaccine, while contraindicated in pregnancy due to its live virus content, is more commonly used in older adults and immunocompromised individuals, but it should be avoided during pregnancy.
Which of the following nursing interventions is most important for a patient with systemic lupus erythematosus (SLE) who is receiving corticosteroid therapy?
A) Monitor for signs of infection, as corticosteroids suppress the immune system
B) Encourage the patient to engage in high-impact exercise to maintain bone density
C) Provide the patient with high-protein meals to prevent weight loss
D) Monitor the patient's intake of vitamin C to prevent scurvy
A) Monitor for signs of infection, as corticosteroids suppress the immune system
Rationale: Corticosteroids are immunosuppressive agents, which can significantly increase the risk of infection in patients with lupus. Monitoring for signs of infection is critical to ensure timely intervention. High-protein meals are not the primary concern for patients on corticosteroids, and high-impact exercise should generally be avoided due to the increased risk of fractures in patients on long-term steroid therapy. Vitamin C intake is unrelated to the primary concerns associated with corticosteroid therapy in lupus patients.
A nurse is caring for a client who has cancer and is experiencing chronic pain due to nerve involvement. The client is prescribed gabapentin for neuropathic pain management. Which of the following adverse effects should the nurse monitor for when administering gabapentin?
A) Constipation
B) Urinary retention
C) Insomnia
D) Dizziness
D) Dizziness
Gabapentin, commonly used for neuropathic pain, can cause dizziness as a side effect, especially when starting the medication or adjusting the dose. It is important to monitor for this effect and educate the client to avoid activities that require full mental alertness, such as driving, until they understand how the medication affects them. Constipation and urinary retention are more common with opioid use, and insomnia is not a typical adverse effect of gabapentin.
Which chemotherapy-related adverse effect is managed with medications such as ondansetron or aprepitant?
A) Alopecia
B) Anemia
C) Nausea and vomiting
D) Mucositis
C) Nausea and vomiting
Rationale: Nausea and vomiting are common chemotherapy side effects, and antiemetic medications such as ondansetron or aprepitant are used to prevent or treat these symptoms.
Which of the following is the primary goal of highly active antiretroviral therapy (HAART) in the treatment of HIV infection?
A) To increase the CD4+ T-cell count above 500 cells/mm³
B) To completely eliminate HIV from the body
C) To reduce the viral load to undetectable levels and prevent resistance
D) To prevent the transmission of HIV to others
C) To reduce the viral load to undetectable levels and prevent resistance
Rationale: The primary goal of HAART is to reduce the viral load to undetectable levels, which significantly lowers the risk of HIV progression and transmission. It also helps prevent the development of drug resistance. HAART is a combination of three or more antiretroviral drugs from different classes, which works to inhibit the virus at various
A nurse is caring for a a. client. with Clostridium difficile who has contact isolation precautions in place. Which of the following actions should the nurse take?
A. Instruct visitors to maintain a distance of at least 3 feet from the client
B. Wash hands with antimicrobial soap after leaving the clients room
C. Use dedicated equipment for the client
D. Keepthe doors to the client's room closed at all times
C. Use dedicated equipment for the client
Rationale: The nurse should use dedicated equipment that is left in the room for a client who has contact isolation precautions in place.
A nurse is contributing to the plan of care for a client with AIDS who has developed stomatitis. Which of the following interventions should the nurse recommend for the plan of care?
A. Rinse the mouth with chlorhexidine solution every 2 hours
B. Limit fluid intake with meals
C. Provide oral hygiene with a firm-bristled toothbrush after each meal
D. Avoid salty foods
D. Avoid salty foods
Stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations. Foods that are spicy, acidic, or salty should be avoided to prevent further irritation and damage to the oral mucosa.
A nurse is caring for a client with Clostridium difficile who has contact isolation precautions in place. Which of the following actions should the nurse take?
A. Instruct visitors to maintain a distance of at least 1 m (3 feet) from the client
B. Wash hands with antimicrobial soap after leaving the client's room
C. Use dedicated equipment for the client
D. Keep the doors to the client's room closed at all times
C. Use dedicated equipment for the client
The nurse should use dedicated equipment that is left in the room for a client who has contact isolation precautions in place.
A nurse is reinforcing teaching with a client who has a recent diagnosis of Raynaud’s disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should limit my exposure to sunlight."
B. "I should avoid drinking alcohol.
C. "I should not smoke."
D. "I should limit my intake of foods high in purine."
C. "I should not smoke."
Rationale: Raynaud’s disease is a disorder of the vessels that supply blood to the skin. It causes the distal extremities to feel numb and cool in response to cold temperatures or stress. During a Raynaud’s attack, these arteries narrow, limiting blood circulation to affected areas. Strong emotion or exposure to the cold causes these areas to become white due to a lack of blood flow. The areas turn blue as tiny blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood returns, the area becomes red and then later returns to normal color. This can cause tingling, swelling, and painful throbbing. The attacks can last from minutes to hours. If the condition progresses, blood flow to the area could become permanently decreased, causing the fingers to become thin and tapered, with smooth, shiny skin and slow-growing nails. If an artery becomes blocked completely, gangrene or ulceration of the skin can occur. Smoking cessation (not just reduction) is an action the client should take to prevent the onset of the manifestations of Raynaud’s disease.
Which of the following is the most common cause of gouty arthritis?
A) Excessive diuretic use
B) Trauma to the affected joint
C) Primary hyperuricemia
D) Chronic kidney failure
C) Primary hyperuricemia
Rationale: Primary gout is the most common cause of gouty arthritis and is typically related to primary hyperuricemia, where there is increased production of uric acid or decreased excretion of uric acid by the kidneys. This leads to the deposition of uric acid crystals in the joints, causing inflammation. Although secondary causes like diuretic use, trauma, or chronic kidney failure can also lead to gout, they are less common than primary hyperuricemia.
A nurse is reinforcing teaching with a client who has a recent diagnosis of Raynaud’s disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should limit my exposure to sunlight."
B. "I should avoid drinking alcohol."
C. "I should not smoke."
D. "I should limit my intake of foods high in purine."
C. "I should not smoke."
Rationale:
A nurse is educating a client with rheumatoid arthritis who has been prescribed prednisone for an acute flare. Which of the following statements by the client indicates a need for further teaching?
A) "I will monitor my blood sugar regularly, as this medication may increase my glucose levels."
B) "I should avoid crowds to reduce the risk of infection while taking prednisone."
C) "I can stop the prednisone when I feel better."
D) "I should report any changes in my vision to my healthcare provider."
C) "I can stop the prednisone when I feel better."
Rationale: Prednisone, a corticosteroid, should never be abruptly discontinued because doing so can lead to adrenal insufficiency, a life-threatening condition. The medication should be gradually tapered as prescribed to avoid this risk.
A nurse is reinforcing teaching with a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should take this medication with food."
B. "I need to take a B-complex vitamin while taking this medication."
C. "I can expect this medication to turn my skin orange."
D. "I can expect this medication to make my vision blurry."
C. "I can expect this medication to turn my skin orange."
The nurse should instruct the client to expect the skin and or urine to turn reddish-orange while taking rifampin.
A nurse is reinforcing discharge teaching with a client who has HIV. Which of the following instructions about infection prevention should the nurse include in the teaching? (Select all that apply.)
A. Avoid large gatherings of people
B. Clean the toothbrush by running through the dishwasher
C. Change pet litter boxes with disposable gloves
D. Consume fresh fruit and raw vegetables
E. Avoid digging in the garden
Rationale: The nurse should instruct the client to avoid large crowds or gatherings of people, especially if individuals have been ill or exposed to illness. This can place clients who have HIV at risk for infection. Additionally, the nurse should instruct the client to clean the toothbrush by running it through the dishwasher. If the client does not have a dishwasher, rinsing the toothbrush with bleach followed by hot water is also effective in destroying bacteria. Finally, the nurse should instruct the client to avoid digging in the garden. Exposure to the dirt, which contains bacteria and organisms that the client is not immune to, increases the client’s risk of infection.
A nurse in a clinic is collecting data from a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following findings should the nurse report to the provider immediately?
A. Headache and fatigue
B. Swollen lymph nodes in the neck
C. Abdominal pain in the left upper quadrant
D. Fever and sore throat
C. Abdominal pain in the left upper quadrant
When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is left upper-quadrant pain, which can indicate an enlarged spleen. The spleen can rupture, leading to internal hemorrhaging. The nurse should encourage the client to refrain from engaging in strenuous activities until the splenomegaly is resolved.
A nurse is reinforcing teaching with a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching when she identifies which of the following as a factor that can exacerbate SLE?
A. Exercise
B. Pregnancy
C. Infection
D. Sunlight
A. Exercise
Rationale: SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and the manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with the provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active.
A nurse is reviewing laboratory results for a client suspected of having rheumatoid arthritis (RA). Which of the following results would be most indicative of the presence of RA?
A) Elevated C-reactive protein (CRP) and positive antinuclear antibody (ANA) titer
B) Elevated erythrocyte sedimentation rate (ESR) and positive rheumatoid factor (RF)
C) Low white blood cell (WBC) count and negative anti-CCP antibodies
D) Decreased hemoglobin (Hgb) and negative CRP levels
B) Elevated erythrocyte sedimentation rate (ESR) and positive rheumatoid factor (RF)
Rationale: In the diagnosis of rheumatoid arthritis, elevated ESR and positive rheumatoid factor (RF) are key indicators of systemic inflammation and autoimmune activity. ESR is commonly elevated in inflammatory conditions, including RA, and RF is present in approximately 70-80% of RA patients. While a positive ANA and CRP can be seen in RA, they are not as specific for RA as RF and ESR. Anti-CCP antibodies are highly specific for RA but are not part of the typical initial diagnostic process, making option B the most indicative combination for RA.
A nurse is reinforcing teaching with a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching?
A. Use an alcohol-based soap to clean lesions
B. Wear a condom during sexual activity when lesions are present
C. Take a sitz bath once per day
D. Pour running water over the lesions when urinating
D. Pour running water over the lesions when urinating
The nurse should instruct the client to pour running water over the lesions when urinating to relieve discomfort.
A nurse is reinforcing teaching with a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching?
A. Use an alcohol-based soap to clean lesions
B. Wear a condom during sexual activity when lesions are present
C. Take a sitz bath once per day
D. Pour running water over the lesions when urinating
D. Pour running water over the lesions when urinating
The nurse should instruct the client to pour running water over the lesions when urinating to relieve discomfort.