Med/surg II Final exam with complete solution graded A+

Priority action by nurse for client w/ compromised immune system? - Hand hygiene Client w/ wound is worried about drainage being present, best response by nurse? - Some drainage is to be expected & normal inflammatory response, if it smells foul or looks like pus that's a sign of infection Precautions for HIV patient? - Standard precautions What signifies advancement of HIV to AIDS? - Opportunistic infections -pneumonistic, C diff etc When ambulating client w/ anemia, what assessments to be done in order to check tolerance? - RR, HR, O2 sat/oxygenation- if any abnormals then not being tolerated well. What does it mean if someone is anemic? - Low iron & low oxygenation What to ask client w/ lots of bruising? - Are you taking any anticoagulant/anti platelet drugs? Client w/ platelet count of 30,000 is at risk for what? - LOW platelet count =bleeding risk What patient history info would correlate w/ diagnosis of iron deficient anemia? - Vegetarian- no meat=lack of iron in diet Normal platelet count? & risks associated w/ abnormal values? - 150,000-400,000 *low= thrombocytopenia/bleeding risk *high= thrombocythemia Normal hemoglobin levels? - Males=14-18g/dLFemales=12-16g/dL **low Hgb may indicate anemia Normal hematocrit level? - Males=42-52% Females=37-47% What can high hematocrit level indicate? - Levels about 52%(M)/47%(F) can mean erythrocytosis, severe dehydration, polycythemia