NUR 265 Exam 4 with Complete Solution Graded A+

The nurse working in the ED is triaging a client who has presented with chest pain, shortness of breath, a productive cough, and reports nights sweats. That clients health history includes the presence of acquired immunodeficiency syndrome (AIDS) and the recent laboratory results that reveal a low CD4+ count. Airborne precautions have been initiated. Which of the following actions should the nurse take next? ANSWER: Check the client’s temperature RATIONALE: A fever is a symptom of AIDS exacerbation. The newly hired nurse is developing a plan of care for a client who has acquired AIDS and was just diagnosed with pneumocystis jiroveci pneumonia and pain. Which of the following interventions should the nurse preceptor question? ANSWER: Placing the client on a pressure-relieving mattress RATIONALE: That is not an appropriate intervention. The nurse had provided medication instructions to a client who has human immunodeficiency virus (HIV) and has been prescribed combination antiretroviral therapy (cART). Which of the following client statements indicates a correct understanding of the teaching? ANSWER:“I can avoid developing drug resistance if I take 90% of my drugs on time.” RATIONALE: Pg. 976. It is important to teach patients to take at least 90% of their meds on time to prevent drug resistance. The nurse is precepting a newly hired nurse who is caring for a client who has AIDS and has developed Kaposil’s sarcoma. It requires additional teaching by the preceptor if the newly hired nurse ANSWER: Applies a surgical mask before entering the client’s room. RATIONALE: Pg.983. This is not an appropriate intervention. lOMoARcPSD| The nurse is caring for a client who just received a pneumococcal polysaccharide vaccine. The client reports feeling anxious, SOB, dizzy, and has an audible wheezing. Which actions from the box below should the nurse take? ANSWER:1,2,3,4 RATIONALE: Initiate oxygen via a nonrebreather mask, obtain IV access with a large bore IV, Administer IM epinephrine 0.3 mL, Have a crash cart available in the client’s room The nurse is caring for a client who had a lung transplant 10 days ago. It would be a priority for the nurse to notify the PHCP if the client has ANSWER: Developed sputum that is yellow tinged RATIONALE: This is a sign of infection. KEY WORD: “DEVELOPED” The nurse is caring for a client who had a liver transplant 48 hours ago, which findings from the box below is a priority for the nurse to report to the PCHP? ANSWER: 2,4,5,6 RATIONALE: An increase in AST, increase in PT, INR, and bilirubin levels. PT: 11-13.5 INR: 0.8-1.1 The nurse is caring for a client who had a kidney transplant two weeks ago. Which of the following findings should the nurse correlate to possible organ rejection? RATIONALE: Pg.3615. Vital signs with special attention to BP. The nurse working in a primary health care providers office has just administer a routine immunization to a client. The client is asked to wait in the waiting room for the next 15 mins. 5 mins later the time client developed swelling of the eyes and reports feeling anxious, SOB, and dizzy. Which of the following actions should the nurse take first? ANSWER: Perform a respiratory assessment RATIONALE: Pg.1009. Immediately assess the respiratory status The newly hired nurse as attended a continuing education conference regarding anaphylaxis work allergen exposure. Which of the following statements by the newly hired nurse indicates a correct understanding of assessment findings in the client? ANSWER: The client will present with widespread hives and hypoxia. RATIONALE: Table 20-2. Hypoxia and widespread hives The nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings would the nurse identity as a complication of the disease? ANSWER:Blood pressure of 172/96 lOMoARcPSD| The nurse is teaching a 25 year old female client who has SLE. Which of the following statements claims correct understanding of the teaching? ANSWER: I should take my prescribed steroids in the morning to get the best benefit RATIONALE: Pg.917. Remind patients to take their medication early in the morning before breakfast because that is the time when the body’s natural corticosteroid level is the lowest. The nurse preceptor observing a newly hired nurse care for a client who has systemic sclerosis (scleroderma) and esophagitis. Which of the following actions by the newly hired nurse requires immediate intervention by the nurse preceptor? ANSWER: Providing ice packs to the client’s hands to help with pain RATIONALE: Pg. 921. On exposure to cold or emotional stress, the small arteries in the digits of both hands and feet rapidly constrict, which causes decrease in blood flow. The nurse is assessing a client who is suspected of having lung cancer. Which of the following findings is consistent with this diagnosis? ANSWER: Reoccurring bronchitis RATIONALE: Table 30-5. Recurring episodes of pleural effusion, pneumonia, or bronchitis RATIONALE: Major skin manifestation of SLE is a dry, scale, raised rash on the face. Non scarring and may increase in a lupus flare and disappear when the disease is in remission. The nurse is obtaining a health history on a 40 year old client who has presented to the PHCP’s office for a routine physical. The client tells the nurse that there is a family history of colon cancer. Which of the following actions should the nurse take next? ANSWER: Inform the PCHP of the client’s family hx. RATIONALE: Pg.2881. When an adult turns 40, they should discuss with MD the need for a colon cancer screening. The nurse is assessing clients for the risk of developing breast cancer. The nurse should recognize that the clients that are at greatest risk for breast cancer is a client who is a ANSWER: 64 YO Jewish female who had her first child at age 38 and has a BRCA1 gene RATIONALE: Table 70-1. Increased age, female, BRCA1 inherited mutation, women who bear their first child near or after 30. The nurse is assessing clients who are at risk of developing cervical cancer. The nurse should recognize that at greatest risk is a client who is a ANSWER: 24 yo AA who was diagnosed with HPV a year ago RATIONALE: Table 71-2. Cervical cancer risk factor is an infection of HPV.