MED SURGE 2024 QUIZ WITH CORRECT/VERIFIED SOLUTIONS GRADED A, Exams of Nursing

Download MED SURGE 2024 QUIZ WITH CORRECT/VERIFIED SOLUTIONS GRADED A and more Exams Nursing in PDF only on Docsity! MED SURGE 2024 QUIZ WITH CORRECT/VERIFIED SOLUTIONS GRADED A  Which characteristic is common to all types of hypersensitivity reactions? a. Decreased inflammatory responses b. Presence of tissue-damaging reactions c. Enhanced natural killer cell activity d. Inability to recognize extraneous cells ANS: B The defining difference between a normal immune response and that termed hypersensitivity is that the immune system reacts excessively or inappropriately, with resultant tissue damage and pathology.  What intervention does the nurse implement to provide for client safety during intradermal allergy testing? a. Stay with the client and ensure that emergency equipment is in the room. b. Pretreat the skin area to be tested with a cortisone-based cream. c. Apply oxygen by mask or nasal cannula before injecting the test agent. d. Cover the examination table and pillow with plastic or an ultrafine mesh. ANS: A Although it is usually a safe procedure, intradermal testing increases the risk for an adverse reaction, including anaphylaxis. Emergency equipment should be available. Pretreating the skin with cortisone will not decrease the risk of anaphylaxis. Applying oxygen will not help prevent a reaction. Covering the examination table will also not prevent allergic reactions.  What is most important for the nurse to teach the client with allergic rhinitis and glaucoma? a. “If your heartbeat increases, be sure to contact your health care provider.” b. “Avoid allergy drugs containing pseudoephedrine or phenylephrine.” c. “Be sure to drink plenty of water with antihistamines.” d. “You should use an eye-moistening agent such as Restasis.” ANS: B Ephedrine, phenylephrine, and pseudoephedrine may cause vasoconstriction, increase blood pressure, and increase intraocular pressure. The client should avoid these drugs. An increased heart rate is not a reason to call the health care provider. The client may be thirstier when on allergy medications, or the client may need an eye-moistening agent, but these are not the most important things for the nurse to teach.  A client has received diphenhydramine (Benadryl) and is currently oriented but drowsy. What is the best action for the nurse to take? a. Perform a neurologic assessment every 2 hours. b. Document the response and continue to monitor. c. Prepare to administer epinephrine subcutaneously. d. Have the nursing assistant stimulate the client every hour. ANS: B The client is experiencing normal side effects of the medication. The nurse will continue to monitor for additive effects. Performing a neurologic assessment is not necessary, nor is administration of epinephrine. There is no reason for the client to be stimulated hourly.  A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate? a. Elevate the head of the client’s bed to 45 degrees. b. Have another nurse call the Rapid Response Team. c. Prepare to administer diphenhydramine (Benadryl). d. Slow the rate of the IV infusion. ANS: B This client has early signs of anaphylaxis. The nurse must notify the Rapid Response Team but also needs to stay with the client in case of cardiovascular collapse. The nurse’s best action is to ask another nurse to call the Team while he or she continues to assess the client. The nurse will prepare to administer epinephrine. Slowing the IV rate will not help the situation; if the client is reacting to the antibiotic, the nurse should change the IV tubing and solution. If the client is not hypotensive, the nurse can raise the head of the bed.  A client has angioedema of the lower face. What will the nurse assess next? a. Pulse oximetry b. Airway patency c. Breath sounds d. Chest wall symmetry ANS: B Angioedema of the lower face includes the mouth and can rapidly lead to laryngeal edema and obstruction of the airway. Other assessments of the client’s respiratory status could be done after the airway is assessed, such as pulse oximetry, breath sounds, and chest symmetry.  A client states that he is “allergic” to poison ivy. Which statement by the client indicates a good understanding of this type of sensitivity? a. “Drinking 3 liters of water a day will prevent kidney damage.” b. “I will always wear a medical alert bracelet for this allergy.” c. “I need to try to avoid coming into contact with poison ivy.” d. “I should carry diphenhydramine (Benadryl) with me at all times.” ANS: C Reactions to poison ivy are a type IV hypersensitivity reaction. They are cell mediated by T- lymphocytes in the skin. Avoidance of the offending allergen is the most appropriate intervention. The complexes do not form or precipitate in the kidney. This type of hypersensitivity does not represent an immediate life-threatening emergency and does not respond to histamine antagonists (diphenhydramine).  A client is hospitalized with Goodpasture’s syndrome. Which intervention by the nurse takes priority? a. Monitor urine output and renal function tests. b. Teach the client to manage peritoneal dialysis. c. Administer antibiotics strictly on time. d. Have separate IV access for immune globulin (IVIG) administration. ANS: A The main cause of death in clients with Goodpasture’s syndrome is renal failure. The nurse must monitor renal function meticulously. Some, but not all, clients need dialysis and IVIG infusions. Antibiotics are not used in the management of this condition. Immune compromised clients should avoid having reptiles or turtles as pets and should avoid changing cat litter to help prevent opportunistic infections. Drinking juice that has been at room temperature for longer than 1 hour can lead to opportunistic infection and should be avoided. Clients should clean their toothbrushes daily by running them in the dishwasher or rinsing them in liquid laundry bleach.  The nurse is working with a client at a public health clinic. The client says to the nurse, “The doctor said that my CD4+ count is 450. Is that good?” What is the nurse’s best response? a. “Your count is high so you can cut back on your medication.” b. “Your count is normal because your medications are working well.” c. “Your count is a bit low and you are susceptible to infection.” d. “Your count is very low and you actually now have AIDS.” ANS: C A CD4+ T-cell count of 450 cells/mm3 of blood is low, and the client is at increased risk for developing an infection. Normal CD4+ counts range from 800 to 1000 cells/mm3. To be diagnosed with AIDS, a client must have a CD4+ T-cell count of <200 cells/mm3 (or a CD4+ T-cell percentage of <4%) and/or an opportunistic infection.  The nurse is caring for a young woman at the primary health care clinic. Which assessment finding leads the nurse to question the client about risk factors for HIV? a. Six vaginal yeast infections in the last 12 months b. Unable to become pregnant for the last 2 years c. Severe cramping and irregular periods d. Very heavy periods and breakthrough bleeding ANS: A Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women. Decreased immune function allows overgrowth of this fungus. Infertility, heavy periods, and cramping are not generally indicative of HIV.  A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first? a. Assess the client’s deep tendon reflexes. b. Ask the client to place his chin on his chest. c. Start an IV line with normal saline. d. Assess the client’s pupil reaction. ANS: B The client’s symptoms are associated with cryptococcal meningitis, so the nurse should first ask the client to place the chin on his or her chest. The presence of nuchal rigidity (pain when flexing the chin to the chest) helps confirm the diagnosis. An IV line may be started after the neurologic assessment is completed.  The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis. Which is the best nursing intervention for this client? a. Initiate respiratory isolation for the next 72 hours. b. Initiate seizure precautions with padded siderails. c. Thicken the client’s liquids to honey consistency. d. Administer IV pentamidine isethionate (Pentam). ANS: B Cryptococcosis is a debilitating form of meningitis that can cause seizures, so seizure precautions should be initiated. Respiratory isolation is not indicated. Dysphagia is not seen with cryptococcal meningitis, so thickened liquids are not indicated. Pentam is given for Pneumocystis jiroveci pneumonia (PJP).  A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The client’s purified protein derivative (PPD) test, placed 3 days ago in the clinic, is negative. Which action by the nurse is most appropriate? a. Place the client in Airborne Precautions. b. Facilitate the client’s chest x-ray. c. Initiate a 3-day calorie count. d. Start an IV of normal saline. ANS: A The client’s symptoms are indicative of tuberculosis (TB). With AIDS, the client’s CD4+ T- cell count is so low that the client cannot mount an immune response to the PPD; thus it appears negative. The client needs to be placed in Airborne Precautions until other diagnostic tests rule out TB. The other interventions are appropriate, but they do not take priority over infection control principles.  The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide (Fuzeon). Which precaution is important for the nurse to communicate to this client? a. “Stop taking the medication if you develop a fever.” b. “Rotate the sites where you will be giving the injections.” c. “Take this medication with a snack or a small meal.” d. “Do not drive or operate machinery while taking this drug.” ANS: B Fuzeon is available only as a subcutaneous injection and can cause injection site reactions and nodules. The client should be taught the subcutaneous technique, including rotation of sites. The client should not stop taking this medication for fever, it can be given without regard to food, and the drug will not make the client sleepy or drowsy, so caution with driving or operating machinery is not needed.  A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, “The doctor said that my viral load is reduced. What does this mean?” What is the nurse’s best response? a. “The HAART medications are working well right now.” b. “You are not as contagious as you were anymore.” c. “Your HIV infection is becoming resistant to your medications.” d. “You are developing an opportunistic infection.” ANS: A The fact that the amount of virus is reduced means that the HAART regimen is working well to suppress viral replication. The risk of becoming infected by an HIV-positive person is always present. The reduced viral load is not related to an opportunistic infection or to resistance to medication.  The nurse is seeing clients at a drop-in primary health clinic. Which client does the nurse teach about the risks of acquiring HIV? a. Middle-aged woman with a new sexual partner b. Young male who has male sexual partners c. All clients who come to the clinic d. Young woman having her first gynecologic examination ANS: C All sexually active people should know their HIV status, and all people need to have education on their risk of acquiring HIV infection. Anyone who engages in sexual activity has some risk.  An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate? a. Renal function studies b. Liver enzymes c. Blood glucose monitoring d. Albumin and prealbumin ANS: B Kaletra can cause liver complications, and clients taking it should have liver function studies. The client’s symptoms could indicate a liver problem. Renal function and blood glucose are not affected by Kaletra. The client may have an albumin and a prealbumin drawn if he or she has lost a great deal of weight and malnutrition is suspected, but the more common diagnostic test for a client taking Kaletra would be liver function studies.  The nurse is teaching a client how to prevent transmitting HIV to his sexual partner. Which statement by the client indicates that additional teaching is needed? a. “I can throw the condoms in the trash after I have used them.” b. “I will store my condoms in my wallet so they are always handy.” c. “Water-based lubricants are best to prevent condom breakage.” d. “The condom needs to stay on until I withdraw my penis.” ANS: B Condoms should be stored in a cool, dry place. Wallets are not recommended because body heat can weaken the latex in the condom. The condom should stay on the penis until it is completely withdrawn. Condoms should be used only once and then discarded. Oil-based lubricants can weaken latex, possibly causing tearing or leakage, so only water-based lubricants are recommended.  The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a student indicates that additional teaching is required? a. “A woman can still get pregnant if she is HIV positive.” b. “I won’t get HIV if I only have oral sex with my partner.” c. “Showering after intercourse will not prevent HIV transmission.” d. “People with HIV are still contagious even if they take HAART drugs.” ANS: B HIV may be transmitted via oral sex when mucous membranes or nonintact skin comes in contact with infected body fluids (semen or vaginal secretions) or blood. Women who are HIV positive may get pregnant, and showering after intercourse will not reduce the risk of HIV transmission. HAART will lower viral loads, but the client will still be able to transmit the HIV virus to others.  The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed? a. “I will wash my hands whenever I get home from work.” b. “I will make sure to have my own tube of toothpaste at home.” c. “I will run my toothbrush through the dishwasher every evening.” d. “I will be sure to eat lots of fresh fruits and vegetables every day.” ANS: D The client should avoid eating raw fruits, vegetables, and salads because of the risk of infection. Hands should be washed whenever returning home, and immune compromised clients should not share toothbrushes or toothpaste. Toothbrushes should be run through the dishwasher nightly.  The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The client states, “I’m an old woman! I cannot possibly get HIV.” What is the nurse’s best response? a. “Your vaginal walls become thicker after menopause, which increases your risk.” b. “Women in your age-group are the fastest growing population of AIDS clients today.” c. “Hormonal fluctuations after menopause make it harder to fight off infection.” d. “You might be right. How often do you engage in sexual activities?” ANS: B infections, PCP (pneumocystis carini pneumonia, now known as pneumocystis jiroveci pneumonia, PJP), protozoal infections, and skin disorders. • The initial diagnostic test for HIV, is the enzyme-linked immunosorbent assay (ELISA), which is performed to detect anti-HIV antibodies. It does not detect the HIV. • Nonnucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) are types of drug that work to combat HIV by interfering with the replication of the virus. • Cat feces haves the potential to infect the patient with toxoplasmosis. The HIV+ patient should not empty the cat litter box. • Process of HIV invasion sequence: a) HIV attaches to CD4 receptor sites on T helper cells; b) infected cells replicates millions of times; c) T helper cells fail to activate phagocytes; d) immune system is unable to respond effectively, and e) opportunistic infections occur. • Examples of immunosupressed patients include: those on chemotherapy for cancer; people using corticosteroids; long-term diabetics; patients recovering from joint replacement; people receiving immunesupressants to prevent organ transplant rejection, and those diagnosed with HIV. • Immunosuppressed patients require extended precautions which are included in the neutropenic precautions, reverse isolation or protective isolation. This includes restrict eating fresh fruits; avoid bringing potted plants into the patient’s room; employ reverse isolation; use filters on air conditioner vents, and of course, also Standard Precautions. • Transmission-Based Precautions (Contact, Droplet, Air-borne Precautions) are not indicated unless the patient has an additional infection that requires such precautions. • HIV-positive health care workers should not perform direct patient care when they (the health care workers) have open sores. • The autoimmune disease occurs when the immune system cannot not differentiate between foreign cells and body cells, and the body attacks itself, causing diffuse inflammatory responses. • When the patient receiving any medication breaks out in hives and begins to itch, or begins to wheeze and gasp for breathing (signs of allergic reaction), the drug should be stopped as a first intervention, and then a subcutaneous shot of epinephrine is the initial line of defense to reverse anaphylaxis. • The defining difference between a normal immune response and that termed hypersensitivity or allergic is that in the hypersensitivity the immune system reacts excessively or inappropriately, with resultant tissue damage and pathology. • Although it is usually a safe procedure, intradermal testing increases the risk for an adverse reaction, including anaphylaxis. Emergency equipment should be available. Pretreating the skin with cortisone will not decrease the risk of anaphylaxis. Applying oxygen will not help prevent a reaction. Covering the examination table will also not prevent allergic reactions. • RBC: Erythrocytes. Carry gases (O2 and CO2). 5M/mm3 (5 million) average(range:4.5- 5.5). Slightly higher in men (4.7-6.1M/mm3), or lower in women (4.2-5.4M/mm3). • Hematocrit: 42-52% in men; 37-47% in women. • Hemoglobin: 14-18 g/dL in men; 12-16 g/dL in women. • WBC: Leukocytes. General function: defensive cells. 5K-10K/mm3 (5 thousand- 10 thousand). • -Neutrophils: phagocytes (vs. bacteria). 55-70% • -Eosinophils: fight parasites. It is involved in allergic reactions. 1-4% • -Basophils: Inflammatory response (produce histamine) and also produce heparin which prevents abnormal coagulation. 0.5%-1% • -Monocytes: Large phagocytes (macrophages precursors). 2-8% • -Lymphocytes: Immunity. 20-40%. By activation after exposed to a foreign cell, B- lymphocytes evolve into plasma cells which produce the antibodies, and T-lymphocytes evolve into cytotoxic cells that destroy foreign cells. Both types of lymphocytes also, after activation, produce the memory cells that will protect the organism against same type of foreign cell in further exposures (this is immunity). • Platelets: Thrombocytes. Hemostasis and blood clotting (coagulation). 150K-400K/mm3.