When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

When the nurse administers intravenous gamma-globulin
infusion, she recognizes that which of the following complaints, if
reported by the patient, may indicate an adverse effect of the
infusion?
a) Tightness in the chest
Flank pain, tightness in the chest, or hypotension indicates adverse
effects of gamma-globulin infusion.
b) Nasal stuffiness
Nasal stuffiness is not recognized as an adverse effect of gammaglobulin infusion.
c) Increased thirst
Increased thirst is not recognized as an adverse effect of gammaglobulin infusion.
d) Burning urination
Burning urination is a sign of urinary tract infection, not an adverse
effect of gamma-globulin infusion.
by

1 Answer

Answer :

a) Tightness in the chest
Flank pain, tightness in the chest, or hypotension indicates adverse
effects of gamma-globulin infusion.
by

Related questions

When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Description : When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the ... or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Last Answer : a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma. b) normal. A class 1 Pap smear is interpreted as normal. c) probably normal. A class 2 Pap smear is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

Description : When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, ... is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

Last Answer : a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B may cause fever, chills and body aches. The administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to the administration of amphotericin B may prevent these side effects.

Description : A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of ... and cerebral spinal fluid (CSF) cultures. Blood and CSF cultures help diagnosis fungal encephalitis.

Last Answer : a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B ... 30 minutes prior to the administration of amphotericin B may prevent these side effects.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

After admitting the patient to the PACU, the first action of the nurse would be to A. Assess patency of the airway B. Check the rate of the IV infusion C. Monitor the vital signs D. Assess the clients pain

Description : After admitting the patient to the PACU, the first action of the nurse would be to A. Assess patency of the airway B. Check the rate of the IV infusion C. Monitor the vital signs D. Assess the clients pain

Last Answer : A. Assess patency of the airway

When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the patient is likely demonstrating signs of a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

Description : When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse ... heterotrophic ossification. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

Last Answer : a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

Description : When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi's sarcoma. Kaposi's sarcoma is ... syphilis. A painless chancre or ulcerated lesion is a typical finding in the patient with syphilis.

Last Answer : a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

33. The client is scheduled to undergo appendectomy. Preparation for appendectomy includes the following: 1. Intravenous infusion 2. Laxative 3. Pubic area shaving 4. Enema 5. Shower 6. Pain medication

Description : 33. The client is scheduled to undergo appendectomy. Preparation for appendectomy includes the following: 1. Intravenous infusion 2. Laxative 3. Pubic area shaving 4. Enema 5. Shower 6. Pain medication

Last Answer : B. 1, 3, and 5

The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

Description : The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a ... . d) local arterial insufficiency. Local arterial insufficiency is characterized by marked localized pallor.

Last Answer : a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which of the following electrolyte imbalances? a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Description : When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects ... and QT intervals, broad flat T waves), disorientation, depression, and hypotension.

Last Answer : a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

Description : Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs ... pain at the recipient site is anticipated since the wound has been protected by the graft.

Last Answer : a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of left-heart failure. b) Increased appetite Loss of appetite should be reported immediately. c) Weight loss Weight gain should be reported immediately. d) Ability to sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Description : The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of ... sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Last Answer : a) Persistent cough Persistent cough may indicate an onset of left-heart failure.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

Description : When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field ... . d) urgent care. Field triaged patients who require urgent care will be categorized as green.

Last Answer : a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

When the female patient demonstrates thickening, scaling, and erosion of the nipple and areola, the nurse recognizes that the patient is exhibiting signs of a) Paget’s disease. Paget’s disease is a malignancy of mammary ducts with early signs of erythema of nipple and areola. b) acute mastitis. Acute mastitis is demonstrated by nipple cracks or abrasions along with reddened and warm breast skin and tenderness.

Description : When the female patient demonstrates thickening, scaling, and erosion of the nipple and areola, the nurse recognizes that the patient is exhibiting signs of a) Paget's disease. Paget's disease ... the breast and demonstrates an orange peel apearance of breast skin with enlargement of skin pores.

Last Answer : a) Paget’s disease. Paget’s disease is a malignancy of mammary ducts with early signs of erythema of nipple and areola.

The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is an indicator of shock. c) Warm, dry skin Skin is generally cool and moist in shock. d) Increased urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Description : The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is ... urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Last Answer : a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate.

The nurse who admitted the patient recognizes that Billroth II procedure means A. Enterostomy B. Esophagojejunostomy C. Gastroduodenostomy D. Gastrojejunostomy

Description : The nurse who admitted the patient recognizes that Billroth II procedure means A. Enterostomy B. Esophagojejunostomy C. Gastroduodenostomy D. Gastrojejunostomy

Last Answer : D. Gastrojejunostomy

When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient’s serum electrolytes anticipating which abnormality? a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). b) Hypercalcemia Hypercalcemia would likely be demonstrated by asystole. c) Hypomagnesemia Hypomagenesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. d) Hyponatremia Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Description : When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hyperkalemia ... likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Last Answer : a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).

When the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for redness and palpated for hardening. b) drainage. Drainage at the site does not indicate a reaction to the tubercle bacillus. c) tissue sloughing. Sloughing of tissue at the site of injection does not indicate a reaction to the tubercle bacillus. d) bruising. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Description : When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for ... site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Last Answer : a) redness and induration. The site is inspected for redness and palpated for hardening.

Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or return to the ED if the patient a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Description : Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or ... for short periods of time. Difficulty in waking the patient should be reported or treated immediately.

Last Answer : a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

71. Before the nurse administers the medication, which of the following is most relevant for the nurse to ask?

Description : 71. Before the nurse administers the medication, which of the following is most relevant for the nurse to ask?

Last Answer : C. “When was your last menstruation?”

The preferred route of administration of medication in the most acute care situations is which of the following routes? a) Intravenous The IV route is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and reliably. b) Epidural Epidural administration is used to control postoperative and chronic pain. c) Subcutaneous Subcutaneous administration results in slow absorption of medication. d) Intramuscular Intramuscular administration of medication is absorbed more slowly than intravenously administered medication.

Description : The preferred route of administration of medication in the most acute care situations is which of the following routes? a) Intravenous The IV route is the preferred ... ) Intramuscular Intramuscular administration of medication is absorbed more slowly than intravenously administered medication.

Last Answer : a) Intravenous The IV route is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and reliably.

The nurse places the patient after liver biopsy in which of the following positions? a) On the right side In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded.

Description : The nurse places the patient after liver biopsy in which of the following positions? a) On the right side In this position, the liver capsule at the site of penetration is compressed against the chest ... . d) High Fowler's High Fowler's position is not indicated for the patient after liver biopsy.

Last Answer : a) On the right side In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded.

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

Description : When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test ... When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

Last Answer : a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Description : 51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Last Answer : C. Sit the client upright and lean forward

When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together, she records her finding as a) pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. b) crackles. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. c) sonorous wheezes. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. d) sibilant wheezes. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

Description : When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together, she records her finding as a) pleural friction rub. A ... wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

Last Answer : a) pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid.

The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

Description : The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent ... is noted. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

Last Answer : a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer? a) Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer.

Description : The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer? a) Mother affected by cancer before 60 years of age Risk for breast cancer increases ... in women who consume even one drink daily and doubles among women drinking three drinks daily.

Last Answer : a) Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as a) clean contaminated. Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled. b) clean. Clean cases are those with no apparent source of potential infection. c) contaminated. Contaminated cases are those that contain an open and obvious source of potential infection. d) dirty. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

Description : When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as a) clean contaminated. Clean-contaminated cases are those with a potential, limited ... with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

Last Answer : a) clean contaminated. Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled.

The nurse who effectively analyzes the communication process recognizes the messages are A. Connotative and denotative B. Learned and unlearned C. Verbal and non-verbal D. Native as well as foreign

Description : The nurse who effectively analyzes the communication process recognizes the messages are A. Connotative and denotative B. Learned and unlearned C. Verbal and non-verbal D. Native as well as foreign

Last Answer : C. Verbal and non-verbal

Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints. b) achalasia. Achalasia presents as difficulty in swallowing both liquids and solids. c) gastroesophageal reflux. Gastroesophageal reflux presents as burning in the esophagus, indigestion, and difficulty in or pain upon swallowing. d) hiatal hernia. Hiatal hernia presents as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

Description : Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour ... as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

Last Answer : a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints.

The nurse teaches the patient with peripheral vascular disease to refrain from smoking because nicotine causes a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. b) slowed heart rate. Nicotine has stimulant effects. c) depression of the cough reflex. Nicotine does not suppress cough. Smoking irritates the bronchial tree, causing coughing. d) diuresis. Nicotine does not cause diuresis.

Description : The nurse teaches the patient with peripheral vascular disease to refrain from smoking because nicotine causes a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the ... the bronchial tree, causing coughing. d) diuresis. Nicotine does not cause diuresis.

Last Answer : a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities.

Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts. b) Requires a physician’s order. Teaching, as a function of nursing, is included in all state nurse practice acts. c) Must be approved by the physician. Health education is a primary responsibility of the nursing profession. d) Must focus on wellness issues. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Description : Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state ... restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Last Answer : a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts.

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient’s posturing as a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

Description : When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's ... rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Last Answer : a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log every injection of Demerol B. Make fraction dosage like 0.5 ml as 1 ml C. Demerol inventory must be checked every endorsement by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

A patient of acute myocardial infarction being treated in intensive care unit developed left ventricular failure with raised central venous pressure. It was decided to use glyceryl trinitrate. Which route/method of administration would be most suitable. (a) Sublingual (b) Oral (c) Intravenous bolus injection (d) Slow intravenous infusion

Description : A patient of acute myocardial infarction being treated in intensive care unit developed left ventricular failure with raised central venous pressure. It was decided to use glyceryl trinitrate. Which route/ ... (a) Sublingual (b) Oral (c) Intravenous bolus injection (d) Slow intravenous infusion

Last Answer : Ans: D

A semiconscious patient of haemorrhagic cerebral stroke has been brought to the emergency. His blood pressure is 240/120 mmHg. Select the procedure to lower his blood pressure as rapidly as possible: A. Sublingual nifedipine B. Intramuscular injection of hydralazine C. Intravenous infusion of sodium nitroprusside D. Intravenous injection of clonidin

Description : A semiconscious patient of haemorrhagic cerebral stroke has been brought to the emergency. His blood pressure is 240/120 mmHg. Select the procedure to lower his blood pressure as ... injection of hydralazine C. Intravenous infusion of sodium nitroprusside D. Intravenous injection of clonidin

Last Answer : C. Intravenous infusion of sodium nitroprussid