Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?
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Solution
A client with cast on the right leg who states, “I have a funny feeling in my right leg.”
Option B: It may indicate neurovascular compromise, requires immediate assessment.
When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen?
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Solution
Strawberries
Option D: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs.
Options A, B, and C: Bread, carrots, and oranges rarely cause allergic reactions.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
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Solution
Platelet count, prothrombin time, and partial thromboplastin time
Option A: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors.
Options B, C, and D: Blood glucose levels, WBC count, calcium levels, and potassium levels aren’t used to confirm a diagnosis of DIC.
A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?
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Solution
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Option C: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases.
Option A: Possible renal failure is indicated by elevated BUN or creatinine levels.
Option B: Urine constituents aren’t found in the blood.
Option D: Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.
A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:v
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Solution
Western blot test with ELISA.
Option D: HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn’t specific when used alone.
Option A: E-rosette immunofluorescence is used to detect viruses in general; it doesn’t confirm HIV infection.
Option B: Quantification of T-lymphocytes is a useful monitoring test but isn’t diagnostic for HIV.
Option C: The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test.
During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:
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Solution
stool for Clostridium difficile test.
Option C: Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes “horse barn” smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test.
Option A: The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn’t indicated in this case.
Option B: An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren’t diagnostic for specific causes of diarrhea.
Option D: A flat plate of the abdomen may provide useful information about bowel function but isn’t indicated in the case of “horse barn” smelling diarrhea.
In an individual with Sjögren’s syndrome, nursing care should focus on:
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Solution
moisture replacement.
Option A: Sjogren’s syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy.
Options B and C: Though malnutrition and electrolyte imbalance may occur as a result of Sjogren’s syndrome effect on the GI tract, it isn’t the predominant problem.
Option D: Arrhythmias aren’t a problem associated with Sjogren’s syndrome.
A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?
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Solution
Lymphocyte
Option D: The lymphocyte provides adaptive immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively.
Option A: The neutrophil is crucial to phagocytosis.
Option B: The basophil plays an important role in the release of inflammatory mediators.
Option C: The monocyte functions in phagocytosis and monokine production.
Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
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Solution
bilateral hearing loss.
Option D: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued.
Options A and B: Aspirin doesn’t lead to weight gain or fine motor tremors.
Option C: Large or toxic salicylate doses may cause respiratory alkalosis, not respiratory acidosis.
After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?
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Solution
Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
Option B: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed.
Option A: The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don’t relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client.
Option C: No antidote for penicillin exists; however, the nurse should continue to monitor the client’s vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.