Literally Exam 4 NUR265 (Answered with RATIONARE) Complete Solution updated april 2023

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 2 The nurse is caring for a client with AIDS who hasjust been diagnosed with cryptococcal meningitis.Which of the following actions should the nurse take? ANSWER: Initiate seizure precautions with padded side rails RATIONALE: Pg.965. Patients may have seizures. The nurse working in a community health center hasinstructed a group of clients who have acquiredimmune deficiency syndrome (AIDS) about ways to prevent infection. Which of the following statements, if made by a client, would indicate the need for additional teaching? ANSWER: “I will wear a surgical mask when I change my cat’slitter box.” RATIONALE: Pg. 974. Do not change cat’s litter box. Wear gloves and immediately wash hands. The nurse is caring for a client who had a heart transplant 24 hours ago. Which ofthe following findingsindicates the clients developing a complication? ANSWER: Hypotension 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. 3 RATIONALE: Pg.983. This is not an appropriate intervention. 4 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 ANSWER:Blood pressure of 172/96 5 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 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?