FUCKING TEST 2 Flashcards
1
Q
The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count
is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iro
A
ANS: A
This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she
remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from
alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the
CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for
people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of
the disease.
2
Q
The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count
is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iro
A
ANS: A
This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she
remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from
alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the
CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for
people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of
the disease.
3
Q
The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count
is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iro
A
ANS: A
This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she
remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from
alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the
CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for
people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of
the disease.
4
Q
- The nurse is presenting information to a community group on safer sex practices. The nurse should teach
that which sexual practice is the riskiest?
a. Anal intercourse
b. Masturbation
c. Oral sex
d. Vaginal intercourse
A
ANS: A
Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry
for human immune deficiency virus.
5
Q
- The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with
human immune deficiency virus (HIV) from clients. Which practice is most effective?
a. Consistent use of Standard Precautions
b. Double-gloving before body fluid exposure
c. Labeling charts and armbands HIV+
d. Wearing a mask within 3 feet of the client
A
ANS: A
According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is
consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this
fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask
within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.
6
Q
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?
a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.
A
ANS: C
Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune
response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of
TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative
testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.
7
Q
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for
human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really
worried about that result. What action by the nurse is most important?
a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.
A
ANS: A
The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to
making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the clients sexual behavior further to determine the proper response. The other
actions are not the most important, but discussing safer sex practices is always appropriate.
8
Q
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?
a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.
A
ANS: B
Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their
medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased
dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be
needed.
9
Q
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?
a. Administer sleeping medication. b. Perform most activities for the client.
c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest.
A
ANS: D
This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should
not do everything for the client but rather let the client do as much as possible within limits and allow for
adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution.
Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the clients
activity.
10
Q
- 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?
a. Chooses high-protein food
b. Has decreased oral discomfort
c. Eats 90% of meals and snacks
d. Has a weight gain of 2 pounds/1 month
A
ANS: D
The weight gain is the best indicator that goals for this client problem have been met because it demonstrates
that the client not only is eating well but also is able to absorb the nutrients.
11
Q
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma
lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most
important?
a. Adhering to Standard Precautions
b. Assessing tolerance to dressing changes
c. Performing hand hygiene before and after care
d. Disposing of soiled dressings properly
A
ANS: D
All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of
soiled dressings is vital.
12
Q
A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self- management by teaching what principle of medical management?
a. Infusions will be scheduled every 3 to 4 weeks. b. Treatment is aimed at treating specific infections. c. Unfortunately, there is no effective treatment. d. You will need many immunoglobulin A infusions
A
ANS: B
Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inacc
13
Q
. An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the
nurse is most appropriate?
a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.
A
ANS: D
Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care
workers. Use of Standard Precautions is sufficient to care for this client.
14
Q
- A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and
does not know what to do. What intervention by the nurse is best?
a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.
A
ANS: A
This client needs the assistance of support systems. The nurse should help the client identify them and what
role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements
about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not
want the family to know.
15
Q
- A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The
nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the
disease. What action by the nurse is best?
a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.
A
ANS: A
The professional nurse should be able to confront unethical behavior assertively. The staff should not be
talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more
comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first
step. Telling the client that others are talking about him or her does not accomplish anything.
16
Q
A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should
be listed instead. What action by the nurse is best?
a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.
A
ANS: A
The client should make his or her wishes known and formalize them through advance directives. The nurse
should help the client by contacting someone to help with this process. Ignoring the mother or telling the client
that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize
gay marriage, this issue will continue to evolve.
17
Q
- A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and
several medications are prescribed in addition to the regimen already being used. What action by the nurse is
most important?
a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times
A
ANS: A
The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be
given at specific times of the day, and that have many interactions with other drugs. The nurse should consult
with a pharmacist about possible interactions. Client teaching is important but does not take priority over
ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence
of symptoms.
18
Q
A client with acquired immune deficiency syndrome has been hospitalized with suspected
cryptosporidiosis. What physical assessment would be most consistent with this condition?
a. Auscultating the lungs
b. Assessing mucous membranes
c. Listening to bowel sounds
d. Performing a neurologic examination
A
ANS: B
Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess
signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.
19
Q
- A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the
client does not have a history of seizures. What response by the nurse is best?
a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug
c. This drug helps treat the pain from nerve irritation. d. You are at risk for seizures due to fungal infections.
A
ANS: C
Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as
gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse
does not know the answer, he or she should find out for the client.
20
Q
. A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which
client should the nurse assess first?
a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4
F (39.1 C)
b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching
c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion
d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
A
ANS: A
A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be
assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs
and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the
nurse may want to delegate this task to someone else while attending to the most seriously ill client.
21
Q
- An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada
(emtricitabine and tenofovir). What information is most important to teach the client about this drug?
a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis
A
ANS: A
Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human
immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not
reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need
HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure
prophylaxis.
22
Q
A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about
HIV infection are correct? (Select all that apply.)
a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly
d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.
A
ANS: A, B, C, D
In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do
not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two
leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of
the disease.
23
Q
Which findings are AIDS-defining characteristics? (Select all that apply.)
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 deficiency virus (HIV)
d. Presence of HIV wasting syndrome
e. Taking antiretroviral medications
A
ANS: A, B, D
A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than
200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic
infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking
antiretroviral medications are not AIDS-defining characteristics.
24
Q
A nurse is traveling to a third-world country with a medical volunteer group to work with people who are
infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following
might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.)
a. Clean drinking water
b. Cultural beliefs about illness
c. Lack of antiviral medication
d. Social stigma
e. Unknown transmission routes
A
ANS: A, B, C, D
Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not
otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural
beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal
transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids
during birth, and through breast-feeding.
25
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.)
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
ANS: A, D, E
The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes,
low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range
for a client with an AIDS-defining infection. The creatinine level is normal.
26
. A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does
the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.
ANS: B, C, E
The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other
professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes
are harsh and drying and should not be used.
27
A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions
does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assessing the clients fluid and electrolyte status
b. Assisting the client to get out of bed to prevent falls
c. Obtaining a bedside commode if the client is weak
d. Providing gentle perianal cleansing after stools
e. Reporting any perianal abnormalities
ANS: B, C, D, E
The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the
clients perianal area after bowel movements, and report any abnormal observations such as redness or open
areas. The nurse assesses fluid and electrolyte status.
28
A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for
an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.)
a. Assess the clients mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the clients abdomen
ANS: A, C, D
Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the
client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic
procedure.
29
The student nurse learning about cellular regulation understands that which process occurs during the S
phase of the cell cycle?
a. Actual division (mitosis)
b. Doubling of DNA
c. Growing extra membrane
d. No reproductive activity
ANS: B
During the S phase, the cell must double its DNA content through DNA synthesis. Actual division, or mitosis, occurs during the M phase. Growing extra membrane occurs in the G1 phase. During the G0 phase, the cell is
working but is not involved in any reproductive activity.
30
2. A student nurse asks the nursing instructor what apoptosis means. What response by the instructor is best?
a. Growth by cells enlarging
b. Having the normal number of chromosomes
c. Inhibition of cell growth
d. Programmed cell death
ANS: D
Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at
their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of
chromosomes is euploidy. Inhibition of cell growth is contact inhibition.
31
3. The nursing instructor explains the difference between normal cells and benign tumor cells. What
information does the instructor provide about these cells?
a. Benign tumors grow through invasion of other tissue. b. Benign tumors have lost their cellular regulation from contact inhibition. c. Growing in the wrong place or time is typical of benign tumors. d. The loss of characteristics of the parent cells is called anap
ANS: C
Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow
through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of
cancer cells.
32
. A group of nursing students has entered a futuristic science contest in which they have developed a cure for
cancer. Which treatment would most likely be the winning entry?
a. Artificial fibronectin infusion to maintain tight adhesion of cells
b. Chromosome repair kit to halt rapid division of cancer cells
c. Synthetic enzyme transfusion to allow rapid cellular migration
d. Telomerase therapy to maintain chromosomal immortality
ANS: A
Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is
part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having
too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division. Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much
telomerase.
33
Which statement about carcinogenesis is accurate?
a. An initiated cell will always become clinical cancer. b. Cancer becomes a health problem once it is 1 cm in size. c. Normal hormones and proteins do not promote cancer growth. d. Tumor cells need to develop their own blood supply
ANS: D
Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs
a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A
1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.
34
The nurse caring for oncology clients knows that which form of metastasis is the most common?
a. Bloodborne
b. Direct invasion
c. Lymphatic spread
d. Via bone marrow
ANS: A
Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic
spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in
the bone marrow
35
A nurse is assessing a client with glioblastoma. What assessment is most important?
a. Abdominal palpation
b. Abdominal percussion
c. Lung auscultation
d. Neurologic examination
ANS: D
A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.
36
A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching?
a. Foods high in vitamin A and vitamin C are important. b. Ill have to cut down on the amount of bacon I eat. c. Im so glad I dont have to give up my juicy steaks. d. Vegetables, fruit, and high-fiber grains are important.
ANS: C
To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal
fat. The other statements are correct.
37
A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the
clients chart that the cancer classification is TISN0M0. What does the nurse conclude about this clients cancer?
a. The primary site of the cancer cannot be determined. b. Regional lymph nodes could not be assessed. c. There are multiple lymph nodes involved already. d. There are no distant metastases noted in the report.
ANS: D
TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no
distant metastasis.
38
A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What
response by the nurse is best?
a. Maybe; preservatives, dyes, and preparation methods may be risk factors. b. No; research studies have never shown those things to cause cancer. c. There are other things you can do that will more effectively lower your risk. d. Yes; preservatives and dyes are well known to be carcinogens
ANS: A
Dietary factors related to cancer development are poorly understood, although dietary practices are suspected
to alter cancer risk. Suspected dietary risk factors include low fiber intake and a high intake of red meat or
animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer- promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give
the client concrete information about how to do so, and also does not answer the clients question.
39
The nursing student learning about cancer development remembers characteristics of normal cells. Which
characteristics does this include? (Select all that apply.)
a. Differentiated function
b. Large nucleus-to-cytoplasm ratio
c. Loose adherence
d. Nonmigratory
e. Specific morphology
ANS: A, D, E
Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller
nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.
40
The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.)
a. Exposure to carcinogens
b. Genetic predisposition
c. Immune function
d. Normal doubling time
e. State of euploidy
ANS: A, B, C
The three interacting factors needed for cancer development are exposure to carcinogens, genetic
predisposition, and immune function.
41
A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse
most likely to engage? (Select all that apply.)
a. Demonstrating breast self-examination methods to women
b. Instructing people on the use of chemoprevention
c. Providing vaccinations against certain cancers
d. Screening teenage girls for cervical cancer
e. Teaching teens the dangers of tanning booths
ANS: B, C, E
Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary
prevention includes screening and early diagnosis. Primary prevention activities include teaching people about
chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of
tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.
42
A nurse is providing community education on the seven warning signs of cancer. Which signs are included?
(Select all that apply.)
a. A sore that does not heal
b. Changes in menstrual patterns
c. Indigestion or trouble swallowing
d. Near-daily abdominal pain
e. Obvious change in a mole
ANS: A, B, C, E
The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or
bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or
elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or
hoarseness. Abdominal pain is not a warning sign.
43
A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?
a. Call the client at home the next day to review teaching. b. Give the client information about a cancer support group. c. Provide all the preoperative instructions in writing. d. Reassure the client that surgery will be over soon.
ANS: A
Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a
major operation so soon. This stress significantly impacts the clients ability to understand, retain, and recall
information. The nurse should call the client at home the next day to review the teaching and to answer
questions. The client may or may not be ready to investigate a support group, but this does not help with
teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching
44
A nurse reads on a hospitalized clients chart that the client is receiving teletherapy. What action by the nurse
is best?
a. Coordinate continuation of the therapy. b. Place the client on radiation precautions. c. No action by the nurse is needed at this time. d. Restrict visitors to only adults over age 18.
ANS: A
The client needs to continue with radiation therapy, and the nurse can coordinate this with the appropriate
department. The client is not radioactive, so radiation precautions and limiting visitors are not necessary.
45
A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action
by the nurse is best?
a. Ensure the client is placed in protective isolation. b. Hand off a pregnant client to another nurse. c. No special action is necessary to care for this client. d. Read the policy on handling radioactive excreta.
ANS: D
This type of radioisotope is excreted in body fluids and excreta (urine and feces) and should not be handled
directly. The nurse should read the facilitys policy for handling and disposing of this type of waste. The other
actions are not warranted.
46
A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation
therapy for breast cancer. What response by the nurse is most appropriate?
a. Are you getting adequate rest and sleep each day?
b. It is normal to be fatigued even for years afterward. c. This is not normal and Ill let the provider know. d. Try adding more vitamins B and C to your diet.
ANS: B
Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months or years after
treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client
understands this is normal.
47
A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation
treatments for cancer. What response by the nurse is most appropriate?
a. Avoid getting salt water on the radiation site. b. Do not expose the radiation area to direct sunlight. c. Have a wonderful time and enjoy your vacation!
d. Remember you should not drink alcohol for a year
ANS: B
The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been
completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1
year after treatment has been completed. The other statements are not appropriate.
48
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
a. Assessing the IV site every hour
b. Educating the client on side effects
c. Monitoring the client for nausea
d. Providing warm packs for comfort
ANS: A
Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is
prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility
policy. Education and monitoring for side effects such as nausea are important for all clients receiving
chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the
nurse needs to assess further.
49
A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the
clients oral chemotherapy medications. What action by the nurse is most appropriate?
a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications
ANS: D
During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications
cannot be crushed, split, or chewed. Giving one at a time is not needed.
50
The nurse working with oncology clients understands that which age-related change increases the older
clients susceptibility to infection during chemotherapy?
a. Decreased immune function
b. Diminished nutritional stores
c. Existing cognitive deficits
d. Poor physical reserves
ANS: A
As people age, there is an age-related decrease in immune function, causing the older adult to be more
susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive
dysfunction, or poor physical reserves.
51
After receiving the hand-off report, which client should the oncology nurse see first?
a. Client who is afebrile with a heart rate of 108 beats/min
b. Older client on chemotherapy with mental status changes
c. Client who is neutropenic and in protective isolation
d. Client scheduled for radiation therapy today
ANS: B
Older clients often do not exhibit classic signs of infection, and often mental status changes are the first
observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of
infection. The nurse should assess the older client first. The other clients can be seen afterward.
52
A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?
a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facility's standing policy. d. Place the client on protective isolation precautions.
ANS: B
A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client
should be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a
deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts
53
A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse
prepare to administer?
a. Epoetin alfa (Epogen)
b. Filgrastim (Neupogen)
c. Mesna (Mesnex)
d. Oprelvekin (Neumega)
ANS: A
The clients hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating
factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease
bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.
54
A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
a. Helping clients adjust to their appearance
b. Reassuring clients that this change is temporary
c. Referring clients to a reputable wig shop
d. Teaching measures to prevent scalp injury
ANS: D
All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse
should first teach ways to prevent scalp injury.
55
A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?
a. Blood pressure
b. Lung assessment
c. Oral mucous membranes
d. Skin integrity
ANS: A
Interleukins can cause capillary leak syndrome and fluid shifting, leading to intravascular volume depletion. Although all assessments are important in caring for clients with cancer, blood pressure and other assessments
of fluid status take priority.
56
4. A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best?
a. It causes rapid lysis of the cancer cell membranes. b. It destroys the enzymes needed to create cancer cells. c. It prevents the start of cell division in the cancer cells. d. It sensitizes certain cancer cells to chemotherapy.
ANS: C
Rituxan prevents the initiation of cancer cell division. The other statements are not accurate.
57
Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse
assess first?
a. Client with dry, itchy, peeling skin
b. Client with a serum calcium of 9.2 mg/dL
c. Client with a serum potassium of 2.8 mEq/L
d. Client with a weight gain of 0.5 pound (1.1 kg) in 1 day
ANS: C
TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this client
first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse
should assess that client next because of the potential for discomfort and infection. This calcium level is
normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.
58
A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to
notify the provider immediately?
a. Irregular menses
b. Edema in the lower extremities
c. Ongoing breast tenderness
d. Red, warm, swollen calf
ANS: D
All clients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a
manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the
lower extremities, and breast tenderness are common side effects of the therapy
59
A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important?
a. Assess the clients gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the clients job risks.
ANS: A
This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may
affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but
with his history of prostate cancer, this should not be where the nurse starts investigating.
60
The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates
that more teaching is needed?
a. I should take my temperature daily and when I dont feel well. b. I will wash my toothbrush in the dishwasher once a week. c. I wont let anyone share any of my personal items or dishes. d. Its alright for me to keep my pets and change the litter box.
ANS: D
Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The
other statements are appropriate for self-management.
61
A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most
important?
a. Assess the client for a headache. b. Assist the client in getting out of bed. c. Instruct the client to reduce salt intake. d. Weigh the client daily before the client eats.
ANS: B
Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the
clients risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention
are not side effects of this drug.
62
A nurse working with clients who experience alopecia knows that which is the best method of helping
clients manage the psychosocial impact of this problem?
a. Assisting the client to pre-plan for this event
b. Reassuring the client that alopecia is temporary
c. Teaching the client ways to protect the scalp
d. Telling the client that there are worse side effects
ANS: A
Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action
by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for
this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a
wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the
clients own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both
patronizing and do not give the client tools to manage this condition.
63
A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?
a. Administer a dose of allopurinol (Aloprim). b. Assess the clients serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery.
ANS: C
Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable,
the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of
potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.
64
A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important?
a. Assessing the clients abdomen beforehand
b. Ensuring that informed consent is on the chart
c. Marking the clients bilateral pedal pulses
d. Reviewing client teaching done previously
ANS: B
This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.
65
A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel
(UAP). What action by the UAP requires intervention from the nurse?
a. Allowing a very tired client to skip oral hygiene and sleep
b. Assisting clients with washing the perianal area every 12 hours
c. Helping the client use a soft-bristled toothbrush for oral care
d. Reminding the client to rinse the mouth with water or saline
ANS: A
Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other
options are all appropriate.
66
. A client with cancer has anorexia and mucositis, and is losing weight. The clients family members
continually bring favorite foods to the client and are distressed when the client wont eat them. What action by
the nurse is best?
a. Explain the pathophysiologic reasons behind the client not eating. b. Help the family show other ways to demonstrate love and caring. c. Suggest foods and liquids the client might be willing to try to eat. d. Tell the family the client isnt able to eat now no matter what they bring.
ANS: B
Families often become distressed when their loved ones wont eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to
help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and
mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good
idea but does not suggest to the family anything that they can do for the client. Simply telling the family the
client is not able to eat does not give them useful information and is dismissive of their concerns.
67
A client in the emergency department reports difficulty breathing. The nurse assesses the clients appearance as depicted below:
What action by the nurse is the priority?
a. Assess blood pressure and pulse. b. Attach the client to a pulse oximeter. c. Have the client rate his or her pain. d. Start high-dose steroid therapy.
ANS: A
This client has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked. Decreased cardiac output can occur. The nurse should assess indicators of cardiac output, including blood
pressure and pulse, as the priority. The other actions are also appropriate but are not the priority.
68
The student nurse caring for clients who have cancer understands that the general consequences of cancer
include which client problems? (Select all that apply.)
a. Clotting abnormalities from thrombocythemia
b. Increased risk of infection from white blood cell deficits
c. Nutritional deficits such as early satiety and cachexia
d. Potential for reduced gas exchange
e. Various motor and sensory deficits
ANS: B, C, D, E
The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).
DIF: Remembering/Knowledge REF: 384
KEY: Cancer| pathophysiology MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
69
A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that
apply. )
a. Chemo gloves
b. Facemask
c. Isolation gown
d. N95 respirator
e. Shoe covers
ANS: A, B, C
The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed
safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or
chemo gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required.
70
A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse
delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Apply moisturizers to dry skin. b. Apply steroid creams to the skin.
c. Bathe the client using mild soap. d. Help the client with a hot water bath. e. Teach the client to avoid sunlight.
ANS: A, C
The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not
used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.
71
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel
(UAP)? (Select all that apply.)
a. Apply the clients shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care.
ANS: A, B, D
Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs
the UAP to put the clients shoes on before getting the client out of bed, assist with ambulation, shave the client
with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush
for oral care.
72
. A client has mucositis. What actions by the nurse will improve the clients nutrition? (Select all that apply.)
a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. d. Provide local anesthetic medications to swish and spit. e. Remind the client to brush teeth gently after each me
ANS: A, B, D, E
Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or
saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit
anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids
would be painful for the client.
73
A clients family members are concerned that telling the client about a new finding of cancer will cause
extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions
by the nurse are most appropriate? (Select all that apply.)
a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the clients right to know and ask for their assistance. d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will not be kept from the client
ANS: A, B, C
The clients right of autonomy means that the client must be fully informed as to his or her diagnosis and
treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the
family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or
ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the
clients right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for
this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not
keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy
would be acceptable, but this by itself is not.
74
A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are
most appropriate? (Select all that apply.)
a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.
ANS: A, C, D, E
Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing
all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the
venous access device, and recording vital signs. Eating meat and poultry is allowed.
75
The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess the clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients room.
ANS: D
Infection can occur when microorganisms from another person or from the environment are transferred to the
client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most
effective technique for preventing infection transmission.
76
The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent
infection by autocontamination?
a. Use a disposable blood pressure cuff to avoid sharing with other clients.
b. Change gloves between wound care on different parts of the clients body.
c. Use the closed method of burn wound management for all wound care.
d. Advocate for proper and consistent handwashing by all members of the staff.
ANS: B
Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for
infection, only changing gloves between performing wound care on different parts of the clients body can
prevent anticontamination.
77
The nurse teaches burn prevention to a community group. Which statement by a member of the group
should cause the nurse the greatest concern?
a. I get my chimney swept every other year.
b. My hot water heater is set at 120 degrees.
c. Sometimes I wake up at night and smoke.
d. I use a space heater when it gets below
ANS: C
House fires are a common occurrence and often lead to serious injury or death. The nurse should be most
concerned about a person who wakes up at night and smokes. The nurse needs to question this person about
whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep
with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does
not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water
heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to
ensure that the person does not allow it to get near clothing or bedding.
78
A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the
nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will help.
d. You shouldnt start worrying about your appearance right now.
ANS: C
Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or
equal in quality to the preburn state. The nurse should provide accurate information that includes something to
hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family
should be taught the expected cosmetic outcomes.
79
A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive
perspective of his or her appearance?
a. I will allow my spouse to change my dressings.
b. I want to have surgical reconstruction.
c. I will bathe and dress before breakfast.
d. I have secured the pressure dressings as ordered.
ANS: C
Indicators that the client with a burn injury has a positive perception of his or her appearance include a
willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self- worth, which are closely linked to body image. Allowing others to change the dressing and discussing future
reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in
decreasing complications but will not enhance self-perception.
80
The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands
the psychosocial impact of a severe burn injury?
a. It is normal to feel some depression.
b. I will go back to work immediately.
c. I will not feel anger about my situation.
d. Once I get home, things will be normal.
ANS: A
During the recovery period, and for some time after discharge from the hospital, clients with severe burn
injuries are likely to have psychological problems that require intervention. Depression is one of these
problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to
know that problems of physical care and psychological stresses may be overwhelming.
81
An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops
a loud, brassy cough. Which action should the nurse take first?
a. Apply oxygen and continuous pulse oximetry.
b. Provide small quantities of ice chips and sips of water.
c. Request a prescription for an antitussive medication.
d. Ask the respiratory therapist to provide humidified
ANS: A
Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to
give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips
and humidified room air will not help the problem, and antitussives are not warranted.
82
A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The
client asks, Why am I taking this medication? How should the nurse respond?
a. Tagamet stimulates intestinal movement so you can eat more.
b. It improves fluid retention, which helps prevent hypovolemic shock.
c. It helps prevent stomach ulcers, which are common after burns.
d. Tagamet protects the kidney from damage caused by dehydration.
ANS: C
Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result
of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the
sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and
release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent
83
A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which
action should the nurse take first?
a. Assess the level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and bronchi.
d. Measure abdominal girth and auscultate bowel sounds.
ANS: C
Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing
can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over
the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing
the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food
intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth
is not relevant in this situation.
84
A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation
per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which
prescription should the nurse question?
a. Increase intravenous fluids by 100 mL/hr.
b. Administer furosemide (Lasix) 40 mg IV push.
c. Continue to monitor urine output hourly.
d. Draw blood for serum electrolytes STAT.
ANS: B
The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be
inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such
as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to
maintain hourly urine output at 0.5 mL/kg/hr. Based on this clients inadequate urine output, fluids need to be
increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure
appropriate fluids are being infused.
85
A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result
should the nurse report to the health care provider immediately?
a. Arterial pH: 7.32
b. Hematocrit: 52%
c. Serum potassium: 6.5 mEq/L
d. Serum sodium: 131 mEq/L
ANS: C
The serum potassium level is changed to the degree that serious life-threatening responses could result. With
such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and
death. All the other findings are abnormal but do not show the same degree of severity; they would be
expected in the emergent phase after a burn injury.
86
A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate
of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next?
a. Administer furosemide (Lasix).
b. Perform chest physiotherapy.
c. Document and reassess in an hour.
d. Place the client in an upright position.
ANS: D
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young
healthy person. Placing the client in an upright position can relieve lung congestion immediately before other
measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid
overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin;
therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.
87
A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection
decrease? How should the nurse respond?
a. When the antibiotic therapy is complete.
b. As soon as his albumin levels return to normal.
c. Once we complete the fluid resuscitation process.
d. When all of his burn wounds have closed.
ANS: D
Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has
passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin
closure to decrease the clients risk for infection.
88
A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory
value should the nurse monitor while the client is prescribed this therapy?
a. Creatinine
b. Red blood cells
c. Sodium
d. Magnesium
ANS: A
Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney
function. Any client receiving gentamicin by any route should have kidney function monitored. Topical
gentamicin will not affect the red blood cell count or the sodium or magnesium levels.
89
. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to
appropriately reduce the clients pain?
a. Administer the prescribed intravenous morphine sulfate.
b. Apply ice to skin around the burn wound for 20 minutes.
c. Administer prescribed intramuscular ketorolac (Toradol).
d. Decrease tactile stimulation near the burn injuries.
ANS: A
Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of
problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be
kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be
used for pain management.
90
A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and
reports a headache. Which action should the nurse take?
a. Increase the clients oxygen and obtain blood gases.
b. Draw blood for a carboxyhemoglobin level.
c. Increase the clients intravenous fluid rate.
d. Perform a thorough Mini-Mental State Examination
ANS: B
These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for
carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not
provide information related to carbon monoxide poisoning.
91
A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in
this clients discharge teaching?
a. You should change the batteries in your smoke detector once a year.
b. Join a program that assists burn clients to reintegration into the community.
c. I will demonstrate how to change your wound dressing for you and your family.
d. Let me tell you about the many options available to you for reconstructive surgery
ANS: C
Teaching clients and family members to perform care tasks such as dressing changes is critical for the
progressive goal toward independence for the client. All of the other options are important in the rehabilitation
stage. However, dressing changes have priority.
92
A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the
wheezing is no longer heard. Which action should the nurse take?
a. Document the findings and reassess in 1 hour.
b. Loosen any constrictive dressings on the chest.
c. Raise the head of the bed to a semi-Fowlers position.
d. Gather appropriate equipment and prepare for an emergency airway
ANS: D
Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective
movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients
can lose their airways very quickly, so prompt action is needed. The client requires establishment of an
emergency airway. Swelling usually precludes intubation. The other options do not address this emergency
situation.
93
. A nurse uses the rule of ninesto assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns?
a. 9%
b. 18%
c. 27%
d. 36%
ANS: C
According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body
surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In
this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.
94
A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
a. Partial pressure of arterial oxygen (PaO2
) of 80 mm Hg
b. Urine output of 20 mL/hr
c. Productive cough with white pulmonary secretions
d. Core temperature of 100.6 F (38C)
ANS: B
A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If
fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs,
including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other
manifestations are not complications of burn injuries.
95
A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the
nurse include when delegating this activity?
a. Keep the water temperature constant when showering the client.
b. Assess the wound beds during the hydrotherapy treatment.
c. Apply a topical enzyme agent after bathing the client.
d. Use sterile saline to irrigate and clean the clients wounds.
ANS: A
Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water
temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this
act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile
saline.
96
A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities
during this phase? (Select all that apply.)
a. Administer analgesics.
b. Prevent wound infections.
c. Provide fluid replacement.
d. Decrease core temperature.
e. Initiate physical therapy.
ANS: A, B, C
Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ
perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through
careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is
inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.
97
A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic
comfort measures should the nurse implement? (Select all that apply.)
a. Music as a distraction
b. Tactile stimulation
c. Massage to injury sites
d. Cold compresses
e. Increasing client control
ANS: A, B, E
Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.
98
A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients
plan of care to ensure adequate nutrition? (Select all that apply.)
a. Provide at least 5000 kcal/day.
b. Start an oral diet on the first day.
c. Administer a diet high in protein.
d. Collaborate with a registered dietitian.
e. Offer frequent high-calorie snacks
ANS: A, C, D, E
A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie
snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and
high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.
99
A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with
their complications from the burn injuries? (Select all that apply.)
a. Slower healing time Increased risk for loss of function from contracture formation
b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure
c. Reduced thoracic compliance Increased risk for atelectasis
d. High incidence of cardiac impairments Increased risk for acute kidney injury
e. Thinner skin May not exhibit a fever when infection is present
ANS: A, C, D
Slower healing time will place the older adult client at risk for loss of function from contracture formation due
to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute
kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for
atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response,
including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.
100
A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent
infection in the client? (Select all that apply.)
a. Ask all family members and visitors to perform hand hygiene before touching the client.
b. Carefully monitor burn wounds when providing each dressing change.
c. Clean equipment with alcohol between uses with each client on the unit.
d. Allow family members to only bring the client plants from the hospitals gift shop.
e. Use aseptic technique and wear gloves when performing wound care.
ANS: A, B, E
To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing
wound care. The client should have disposable equipment that is not shared with another client, and plants
should not be allowed in the clients room.
101
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that
the client has a 60pack-year smoking history. Which action is most important for the nurse to take when
interviewing this client?
a. Tell the client that he needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.
ANS: C
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled
substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude
during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any
of these substances are used now or were used in the past. Assess whether the client has passive exposure to
smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether
he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs
smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further
cancer development. This statement would be giving the client false hope, which should be avoided, but is not
as important as maintaining a nonjudgmental attitude.
102
A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct
intervention?
a. Client states he is dizzy. Nurse applies oxygen and pulse oximetry. b. Clients heart rate is 55 beats/min. Nurse withholds pain medication. c. Client has reduced breath sounds. Nurse calls physician immediately. d. Clients respiratory rate is 18 breaths/min. Nurse decreases oxygen flow rate.
ANS: C
A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent
breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an
expected finding. If the clients heart rate is 55 beats/min, no reason is known to withhold pain medication. A
respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.
103
A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain?
a. Average daily fluid intake
b. Neck circumference
c. Height and weight
d. Occupation and hobbies
ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a clients
occupation and hobbies. Although it will be important for the nurse to assess the clients fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the clients
neck circumference will not be an important part of a respiratory assessment.
104
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse
take first?
a. Encourage the client to increase fluid intake. b. Assess the clients level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen
ANS: B
Assessing the clients level of consciousness will be most important because it will show how the client is
responding to the presence of the infection. Although it will be important for the nurse to encourage the client
to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify
the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is
present.
105
A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly
matched to the nurses primary intervention?
a. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate. b. Crackles are heard in bases. The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. The nurse has the client breathe
ANS: C
Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds
are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need
a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client
expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.
106
A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
a. Are you taking any medications or herbal supplements?
b. Do you have any chronic breathing problems?
c. How often do you perform aerobic exercise?
d. What is your occupation and what are your hobbies?
ANS: B
The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter
approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel
chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive
pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for
many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked
but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although
occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first.
107
A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires
immediate action?
a. Increased temperature
b. Absent breath sounds
c. Productive cough
d. Incisional discomfort
ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle
biopsy or open lung biopsy. The other manifestations are not life threatening.
108
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the
nurse complete prior to the procedure?
a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client
ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client
understands complications and explaining the procedure to be performed will be done by the physician or
nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a
procedure unique to a thoracentesis.
109
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 liters of oxygen. d. The trachea is deviated toward the opposite side of the neck
ANS: D
A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other
findings are normal or near normal
110
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which
action should the nurse take next?
a. Call the physician and request a prescription for food and water
b. Provide the client with ice chips instead of a drink of water. c. Assess the clients gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.
ANS: C
The topical anesthetic used during the procedure will have affected the clients gag reflex. Before allowing the
client anything to eat or drink, the nurse must check for the return of this reflex.
111
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a
flight of stairs. Which intervention should the nurse include in this clients plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 liters per nasal cannula
d. Complete bedrest with frequent repositioning
ANS: A
A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III
dyspnea. The nurse should provide assistance with activities of daily living. These clients should be
encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to
tolerate daily physical therapy, and only need oxygen if hypoxia is present.
112
. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse
include in this clients teaching?
a. Make a list of reasons why smoking is a bad habit. b. Rise slowly when getting out of bed in the morning. c. Smoking while taking this medication will increase your risk of a stroke. d. Stopping this medication suddenly increases your risk for a heart attack.
ANS: C
Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart
attack. Nurses should teach clients not to smoke while taking this drug. The other responses are inappropriate
113
. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client
presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the clients peripheral pulses. d. Obtain blood and sputum cultures.
Notify rapid response team
114
A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse
take first?
a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowlers position. d. Administer prescribed albuterol.
ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the
trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the clients position because the finding is normal.
115
A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which
manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.)
a. Visual hallucinations
b. Tachycardia
c. Decreased cravings
d. Impaired judgment
e. Increased thirst
ANS: A, D
Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and
hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired
judgment and visual hallucinations. Tachycardia and increased thirst are not adverse effects of this medication. Decreased cravings is a therapeutic response to this medication.
116
A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the
nurse include in this clients plan of care? (Select all that apply.)
a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily
ANS: A, C, D
Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the
respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty
bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used
to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.
117
While obtaining a clients health history, the client states, I am allergic to avocados. Which responses by the
nurse are best? (Select all that apply.)
a. What response do you have when you eat avocados?
b. I will remove any avocados that are on your lunch tray. c. When was the last time you ate foods containing avocados?
d. I will document this in your record so all of your providers will know. e. Have you ever been treated for this allergic reaction?
ANS: A, D, E
Nurses should assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse should also document the allergies in a prominent place in the clients medical record. The nurse
should collaborate with food services to ensure no avocados are placed on the clients meal trays. Asking about
the last time the client ate avocados does not provide any pertinent information for the clients plan of care.
118
. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests?
(Select all that apply.)
a. I held the clients morning bronchodilator medication. b. The client is ready to go down to radiology for this examination. c. Physical therapy states the client can run on a treadmill. d. I advised the client not to smoke for 6 hours prior to the test. e. The client is alert and can follow your commands.
ANS: A, D, E
To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in
the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow
basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the
bedside. A treadmill is not used for this test.
119
A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include
in this clients teaching? (Select all that apply.)
a. Find an activity that you enjoy and will keep your hands busy. b. Keep snacks like potato chips on hand to nibble on. c. Identify a punishment for yourself in case you backslide. d. Drink at least eight glasses of water each day. e. Make a list of reasons you want to stop smoking
ANS: A, D, E
The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands
busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a
list of reasons for quitting smoking. The nurse should also encourage the client not to be upset if he or she
backslides and has a cigarette.
120
A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing
what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%
ANS: B
Room air is 21% oxygen.
121
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion
ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority
122
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and
the eyelids are swollen. What action by the nurse takes priority?
a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the
tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation.
If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable,
the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for
the unstable client.
123
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What
action by the nurse is best?
a. Elevate the head of the clients bed. b. Measure and compare cuff pressures.
c. Place the client on NPO status
d. Request that the client have a swallow study
ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal
passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts
of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and
compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO
status, and requesting a swallow study will not correct this situation.
124
An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
a. Assess the clients lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.
ANS: A
The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been
assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP
should have reported the incident immediately, but addressing that issue is not the immediate priority.
125
A student nurse is providing tracheostomy care. What action by the student requires intervention by the
instructor?
a. Holding the device securely when changing ties
b. Suctioning the client first if secretions are present
c. Tying a square knot at the back of the neck
d. Using half-strength peroxide for cleansing
ANS: C
To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be
placed at the side of the clients neck, not in back. The other actions are appropriate.
126
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student
demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time
ANS: A
Suction should only be applied while withdrawing the catheter. The other actions are appropriate.
127
A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that
goals for a priority diagnosis are being met?
a. 100% of meals being eaten by the client
b. Intact skin behind the ears
c. The client understanding the need for oxygen
d. Unchanged weight for the past 3 days
ANS: B
Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for
Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but
would not take priority over a physical problem
128
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing
with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the
nurse is most appropriate?
a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.
ANS: D
This client may have a tracheainnominate artery fistula, which can be a life-threatening emergency if the artery
is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client
and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the
tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.
129
. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best
indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection
ANS: B
The client joining a book club that meets outside the home and requires him or her to go out in public is the
best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not
relate to this nursing diagnosis.
130
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the clients nose. d. Turn the client every 2 hours or as needed.
ANS: A
Oxygen can be drying, so the UAP can apply water-soluble lubricant to the clients lips and nares. The UAP
should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort
measures for oxygen.
131
A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the
nurse is best?
a. Assess the clients oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.
ANS: B
Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has
approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about
this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered.
132
3. The nurse assesses the client using the device pictured below to deliver 50% O2:
The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the
oxygen is 3 L/min. What action by the nurse is best?
a. Assess the clients oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min.
ANS: C
For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and
10 L/min. The clients flow rate is too low and the nurse should increase it. After increasing the flow rate, the
nurse assesses the oxygen saturation and documents the findings.
133
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse
assess when determining if the client is using the oxygen safely? (Select all that apply.)
a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage
d. Household light bulbs are the fluorescent type.
e. The client does not have pets inside the home.
ANS: A, B, C
Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good
shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light
bulbs and pets are not related to oxygen safety.
134
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to
unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Applying water-soluble lip balm to the clients lips
b. Ensuring the humidification provided is adequate
c. Performing oral care with alcohol-based mouthwash
d. Reminding the client to cough and deep breathe often
e. Suctioning excess secretions through the tracheostomy
ANS: A, D
The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding
the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal
saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the
tracheostomy are nursing functions.
135
A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse
offer to help the client maintain self-esteem? (Select all that apply.)
a. Create a communication system. b. Dont go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.
ANS: A, D, E
The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound
communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the
client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the
stoma. Keeping the client homebound is not good advice.
136
. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse
need to assess before teaching this particular client? (Select all that apply.)
a. Cognition
b. Dexterity
c. Hydration
d. Range of motion
e. Vision
ANS: A, B, D, E
The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could
limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the
ability to perform self-care.
137
. A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which
complications does the nurse plan to teach the client? (Select all that apply.)
a. Absorptive atelectasis
b. Combustion
c. Dried mucous membranes
d. Oxygen-induced hyperventilation
e. Toxicity
ANS: A, B, C, E
Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and
oxygen toxicity. Oxygen-induced hypoventilation is also a complication.
138
1.A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a
blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the clients lung sounds. b. Notify the Rapid Response
Team.
c. Provide reassurance to the client. d. Take a full set of vital signs.
ANS: B
This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid
Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the
priority.
139
.A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no
known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is
found.
ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client
with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is
healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of
disease where no cause is ever found, this assumption is premature.
140
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen
saturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation. b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs
d. The client needs immediate intubation and mechanical ventilation
ANS: C
A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is
dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow
breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise
physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to
be mechanically ventilated, but without concrete data on FiO2 and SaO2
, the nurse cannot make that judgment.
141
A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial
thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate. b. Increase the heparin rate.
c. No change to the heparin rate. d. Stop heparin; start warfarin
(Coumadin).
ANS: B
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is
working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be
increased. Warfarin is not indicated in this situation.
142
5.A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals
the client has an alteration in the gene CYP2C19. What action by the nurse is best?
a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC)
filter.
c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.
ANS: B
Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a
variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side
effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would
be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this
is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a
safety measure for clients on anticoagulation therapy.
143
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates
that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count:
8.7/mm3
ANS: B
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal
for either gender.
144
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central
supply. d. Tell the client to take slow, deep breaths.
ANS: A
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more
thorough assessment. The other actions are not appropriate for a hypoxic client.
145
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to
intubate for 40 seconds. What action by the nurse takes priority?
a. Ensure the client has adequate sedation. b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen. d. Monitor the clients oxygen saturation.
ANS: C
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should
interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation
during the procedure and monitor the clients oxygen saturation, but these do not take priority. Finding another
provider is not appropriate at this time.
146
An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?
a. Determine if the tube is kinked. b. Ensure all connections are patent.
c. Listen to the clients lung sounds. d. Suction the endotracheal tube.
ANS: C
When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral
breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal,
the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction
147
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive
personnel (UAP)?
a. Assess the client for sedation needs. b. Get family permission for restraints.
c. Provide frequent oral care per
protocol. d. Use nonverbal pain assessment tools.
ANS: C
The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other
actions fall within the scope of practice of the nurse.
148
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with
the respiratory therapist, what should the nurse ensure as a priority?
a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate
humidification.
c. The upper peak airway pressure limit alarm is
off. d. The upper peak airway pressure limit alarm is on
ANS: D
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous
breathing is important for some modes of ventilation but not others. Adequate humidification is important but
does not take priority over preventing injury.
149
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
a. Assess the cause of the agitation. b. Reassure the client that he or she is
safe.
c. Restrain the clients hands. d. Sedate the client immediately.
ANS: A
The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients
anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the
cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also
important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.
150
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What
action by the nurse takes priority?
a. Assessing that the ventilator settings are correct
b. Ensuring there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the
room
ANS: B
Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist
is usually primarily responsible for setting up the ventilator, although the nurse should know and check the
settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or
may not need suctioning on arrival.
151
.A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since
the client only has lung problems. What response by the nurse is best?
a. It will increase the motility of the gastrointestinal tract. b. It will keep the gastrointestinal tract functioning normally.
c. It will prepare the gastrointestinal tract for enteral feedings. d. It will prevent ulcers from the stress of mechanical
ventilation.
ANS: D
Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic
medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and
proton pump inhibitors. Zantac is a histamine blocking agent.
152
A client has been brought to the emergency department with a life-threatening chest injury. What action by
the nurse takes priority?
a. Apply oxygen at 100%. b. Assess the respiratory rate.
c. Ensure a patent airway. d. Start two large-bore IV
lines.
ANS: C
The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a
patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs
153
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the
client needs more education regarding this medication?
a. Hamburger and French fries
b. Large chefs salad and muffin
c. No selection; spouse brings
pizza
d. Tuna salad sandwich and chips
ANS: B
Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K
thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely
has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not
particularly healthy, will not interfere with the medications mechanism of action.
154
.A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a
possible barrier to self-management?
a. Poor visual acuity
b. Strict vegetarian
c. Refusal to stop smoking
d. Wants weight loss
surgery
ANS: B
Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K
thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have
trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not
related
155
.A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student
requires immediate intervention by the supervising nurse?
a. Assessing the clients platelet count
b. Choosing an 18-gauge, 2-inch needle
c. Not aspirating prior to injection
d. Swabbing the injection site with
alcohol
ANS: B
Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are
appropriate.
156
A client in the emergency department has several broken ribs. What care measure will best promote
comfort?
a. Allowing the client to choose the position in bed
b. Humidifying the supplemental oxygen
c. Offering frequent, small drinks of water
d. Providing warmed blankets
ANS: A
Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are
less effective comfort measures.
157
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
a. Alteplase (Activase)
b. Enoxaparin (Lovenox)
c. Unfractionated heparin
d. Warfarin sodium
(Coumadin)
ANS: A
Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse
knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not
indicated in this setting.
158
1.A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients
chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is
cyanotic. What action by the nurse is the priority?
a. Administer oxygen and reassess. b. Auscultate the clients lung
sounds.
c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.
ANS: D
This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically
ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to
lung sounds. A chest x-ray will be taken after the client is intubated.
159
.A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is
best?
a. It is chronic hypoxemia that accompanies restrictive airway disease. b. It is hypoxemia from lung damage due to mechanical ventilation.
c. It is hypoxemia that continues even after the client is weaned from
oxygen. d. It is hypoxemia that persists even with 100% oxygen administration.
ANS: D
Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal
sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused
by the use of mechanical ventilation or by being weaned from oxygen.
160
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a
pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged man with an exacerbation of asthma
d. Older client who is 1-day post hip replacement
surgery
e. Young obese client with a fractured femur
ANS: B, D, E
Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous
catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of
thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or
prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.
161
When working with women who are taking hormonal birth control, what health promotion measures should
the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
a. Avoid drinking alcohol. b. Eat more omega-3 fatty
acids.
c. Exercise on a regular basis. d. Maintain a healthy weight.
e. Stop smoking cigarettes.
ANS: C, D, E
Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a
healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods
containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.
162
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate?
(Select all that apply.)
a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel
(UAP).
c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication.
e. Stay with the client and speak in a quiet, calm voice.
ANS: A, B, C, E
Clients with PEs are often anxious. The nurse can acknowledge the clients fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also
reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to
hypoxia. If the clients anxiety is interfering with diagnostic testing or treatment, they can be used, but there is
no evidence that this is the case.
163
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular
schedule
ANS: A, B, C, D
The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the
bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.
164
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this
client? (Select all that apply.)
a. Allow visitors at the clients bedside. b. Ensure the client can communicate if awake.
c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when
turning.
e. Turn the client every 2 hours or more.
ANS: A, B, D, E
There are many basic care measures that can be employed for the client who is on a ventilator. Allowing
visitation, providing a means of communication, massaging the clients skin, and routinely turning and
repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.
165
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning
failure. What age-related changes contribute to this? (Select all that apply.)
a. Chest wall stiffness
b. Decreased muscle
strength
c. Inability to cooperate
d. Less lung elasticity
e. Poor vision and hearing
ANS: A, B, D
Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include
increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older
adults have an inability to cooperate or poor sensory acuity.
166
A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause?
## Footnote
A diagnosis of diabetes treated with insulin and diet
An exercise regimen of jogging 3 miles four times a week
A history of cardiac disease
Advancing age
167
Sulfamethoxazole Side effects and use
Hepatitis, decreased sodium, thrombocytopenia, increased liver enzymes
Used to treat Pneumocystis jiroveci pneumonia
