PN2 Exam 2 based on study guide-Completed A

PN2 Exam 2 based on study guides The student nurse learns that the most important function of inflammation and immunity is which purpose? Providing protection against invading organisms A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? Purulent drainage The nurse understands that which type of immunity is the longest acting? Natural active A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? “Avoid large crowds and people who are ill.” The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? Suppressor T cells A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? Creatinine of 3.9 mg/dL A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? Acetaminophen (Tylenol) An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? Use an abduction pillow. The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client’s surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? Assess neurovascular status in both legs. A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? Client with a red, hot, swollen right wrist A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like “pins and needles” and that the neck is very painful since returning from surgery. What action by the nurse is best? Notify the provider immediately. The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren’s syndrome? Visual acuity The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? Attends meetings of a book club The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? Client with a fever and cough who is taking tofacitinib (Xeljanz) A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? Giving subcutaneous injections A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? Assess medication records for steroid use. The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? Creatinine: 3.9 mg/dL A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? Help the client create backup plans to minimize disruption. The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? “Drink 1 to 2 liters of water each day.” A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started “acting up,” especially both hips and knees. What action by the nurse is best? Assess the client for the presence of subcutaneous nodules or Baker’s cysts. A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? Use aseptic technique for dressing changes. A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? “I will not sit with my legs crossed.” A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? “I always wear long sleeves, pants, and a hat when outdoors.” A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? Ensure that a consent for transfusion is on the chart. An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? Prepare to administer epoetin alfa (Epogen). A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? Have adequate help to transfer the client. A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? “Notify your provider at once if you get a fever.” A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden’s nodules. What assessment technique is correct? Inspect the client’s distal finger joints. A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? Consult with the health care provider about administering both drugs to the client. A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? Place the client under Airborne Precautions. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? Assess the client for adherence to the drug regimen. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace activities, allowing for adequate rest. A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? Has a weight gain of 2 pounds/1 month A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi’s sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? Disposing of soiled dressings properly A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client’s partner is listed as the emergency contact, but the client’s mother insists that she should be listed instead. What action by the nurse is best? Contact the social worker to assist the client with advance directives. A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4° F (39.1° C) A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) ADE a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L A nurse works in an allergy clinic. What task performed by the nurse takes priority? What action by the nurse takes priority Checking emergency equipment each morning A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate? “Antihistamines do not help poison ivy.” A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? “I don’t need to go to the hospital after using it.” A client is in the hospital and receiving IV antibiotics. When the nurse answers the client’s call light, the client presents an appearance as shown below: Ensure a patent airway while calling the Rapid Response Team. The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) ACD a. Type I – Examples include hay fever and anaphylaxis b. Type II – Mediated by action of immunoglobulin M (IgM) c. Type III – Immune complex deposits in blood vessel walls d. Type IV – Examples are poison ivy and transplant rejection e. Type V – Examples include a positive tuberculosis test and sarcoidosis A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? Heart rate of 120 beats/min A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? Pulse decreased from 100 beats/min to 80 beats/min A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? A 45-year-old American Indian woman with diabetes mellitus An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? “I get short of breath when I climb stairs.” A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? Disorientation and confusion A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? Assess the color and temperature of the left leg. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? Slurred speech and confusion A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? Allergies to iodine-based agents A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? Location A, ANS: A The aortic valve is auscultated in the second intercostal space just to the right of the sternum Which findings are AIDS-defining characteristics? Select hat apply.) ABD a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) ACE a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? (Record your answer using a whole number, and rounding to the nearest drop.) _____ drops/min ANS: 31 drops/min A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? A 36-year-old woman with aortic stenosis A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? “I must stop halfway up the stairs to catch my breath.” While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? Assess for symptoms of left-sided heart failure. A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client’s teaching? “Avoid using salt substitutes.” A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? Administer PRN acetaminophen. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, “I know a transplant is my last chance, but I don’t want to become a vegetable.” How should the nurse respond? “Would you like information about advance directives?” A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) ABC a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? Triglycerides: 198 mg/dL A client is taking warfarin (Coumadin) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? “No, it may interfere with the warfarin.” A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? Assess distal pulses and skin color. A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? Appropriate hand hygiene before giving care A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? Oxygen saturation of 98% A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? Apply a warm moist pack. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? Measure for new compression stockings. A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? Consult with the Wound Ostomy Care Nurse. A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? “I can use a heating pad on my legs if it’s set on low.” A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best? “It inhibits thrombin.” A nurse caring for a client with sickle cell disease (SCD) reviews the client’s laboratory work. Which finding should the nurse report to the provider? Creatinine: 2.9 mg/dL A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? Give the client pain medication if it is time for another dose. A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? 0.45% normal saline A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? Administer oxygen. A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the client’s white blood cell count (WBC) is high. What response by the registered nurse is best? “Those WBCs are abnormal and don’t provide protection.” The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? Doing activities of daily living (ADLs) using rest periods A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important? Taking a set of vital signs and notifying the surgeon A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? Calling the Rapid Response Team A nurse is preparing to administer a blood transfusion. What action is most important? Ensuring informed consent is obtained if required A nurse is preparing to hang a blood transfusion. Which action is most important? Putting on a pair of gloves A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? Double-checking the client and blood product identification A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? Keep the lower extremities warm. The nurse assesses a client’s oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate? Teach the client about cobalamin therapy. 2. A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.)ACE a. Chemical exposure b. Genetically modified foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections