Ati n120n122 med surg exam
Total Questions : 23
Showing 23 questions, Sign in for moreA nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?
Explanation
A. Ensuring the blood is compatible with the client's blood type is critical in preventing an acute hemolytic reaction, as incompatible blood transfusions can cause serious, potentially life-threatening reactions.
B. Administering the transfusion rapidly can increase the risk of complications and does not prevent hemolytic reactions; transfusions should be given at a safe rate based on the client's condition.
C. Using a blood warmer is not a standard intervention to prevent hemolytic reactions; it's typically used in specific cases such as massive transfusions or hypothermia, but it does not address compatibility.
D. Administering prophylactic antihistamines is not a recommended practice to prevent hemolytic reactions; it is more relevant for preventing allergic reactions associated with transfusions.
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). The nurse notes white lesions on the client's tongue. What opportunistic infection is this client experiencing?
Explanation
A. Candidiasis, commonly known as thrush, is characterized by white lesions on the tongue and is a common opportunistic infection in clients with AIDS due to their compromised immune system.
B. Xerostomia refers to dry mouth and does not cause white lesions; it can occur in various conditions but is not an opportunistic infection.
C. Halitosis is bad breath and does not correlate with white lesions on the tongue; it can result from various causes but is not an infection.
D. Gingivitis involves inflammation of the gums and may present with red, swollen gums but does not typically cause white lesions on the tongue.
A nurse is planning care for a client with pernicious anemia. Which intervention should the nurse plan to implement?
Explanation
A. Blood transfusions are not a primary treatment for pernicious anemia; they may be used in severe cases but do not address the underlying cause of the condition, which is vitamin B12 deficiency.
B. Daily hydroxyurea is primarily used to treat certain types of cancer and sickle cell disease, not pernicious anemia.
C. Iron supplements are not effective in treating pernicious anemia, as the condition is due to a deficiency of vitamin B12, not iron.
D. Vitamin B injections are the correct intervention for pernicious anemia because the condition results from an inability to absorb vitamin B12 due to a lack of intrinsic factor, making injections necessary to restore vitamin levels.
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Explanation
A. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction.
B. Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin.
C. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction.
D. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.
A nurse is providing education to a client diagnosed with sickle cell anemia. Which of the following can be anticipated will be a trigger for a sickle cell crisis?
Explanation
A. Over-hydration is not a trigger for a sickle cell crisis; in fact, adequate hydration helps prevent sickling of the cells.
B. Dehydration is a significant trigger for sickle cell crises, as it can lead to increased blood viscosity and sickling of red blood cells.
C. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used to manage pain associated with sickle cell crises, but they do not trigger a crisis.
D. Vaccinations are important for preventing infections in individuals with sickle cell anemia but are not associated with triggering a sickle cell crisis.
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which manifestation(s) should the nurse include?
Explanation
A. Fungal and bacterial infections can occur later as the immune system becomes compromised, but they are not initial symptoms of HIV infection.
B. Flu-like symptoms and night sweats are common initial manifestations of acute HIV infection, often occurring within 2-4 weeks after exposure.
C. Kaposi's sarcoma is a type of cancer associated with advanced HIV/AIDS and not an initial symptom of infection.
D. Pneumocystis lung infection typically occurs later in the course of HIV disease when the immune system is severely weakened, not during the initial infection stage.
A nurse is caring for a client with sickle cell anemia. The client asks, "Why am I in so much pain?" What is an appropriate response from the nurse to make to this client?
Explanation
A. While deep breathing can help alleviate pain, it is not the primary cause of pain in sickle cell anemia; this response could minimize the client's experience.
B. Sickle cell anemia causes red blood cells to become rigid and shaped like a sickle, which can obstruct blood flow and lead to vaso-occlusive crises, resulting in pain.
C. Although sickle cell anemia is a genetic disorder, simply stating that the mutated gene causes increased pain is too vague and does not explain the pain mechanism adequately.
D. While anemia can contribute to fatigue and some discomfort, the pain in sickle cell anemia is primarily due to the sickling of red blood cells and subsequent blockage of blood flow, rather than just the lack of hemoglobin.
A nurse is caring for a client with HIV. Which laboratory test would be used to assess the effectiveness of therapy?
Explanation
A. Viral load count is the primary test used to assess the effectiveness of HIV therapy by measuring the amount of HIV RNA in the blood, indicating how well the treatment is controlling the virus.
B. The Western blot is used as a confirmatory test for HIV diagnosis rather than monitoring therapy effectiveness.
C. The Enzyme immunoassay (EIA) test is used for initial HIV screening but does not measure viral load or therapy effectiveness.
D. Platelet count can be affected in HIV infection, especially with advanced disease, but it does not directly measure the effectiveness of HIV therapy.
A nurse is caring for a client who has human immunodeficiency virus (HIV). Which laboratory value should the nurse alert the provider of?
Explanation
A. A positive Western blot test indicates an HIV diagnosis, which is expected in a client with HIV and does not require urgent intervention.
B. A CD4-T-cell count of 180 cells/mm³ is significantly low (normal range: 500 to 1500 cells/mm³) and indicates severe immunosuppression, putting the client at increased risk for opportunistic infections, warranting immediate attention from the provider.
C. A platelet count of 150,000/mm³ is at the lower end of the normal range and does not typically require immediate intervention unless there are clinical symptoms associated.
D. A WBC count of 5,000/mm³ is within the normal range and does not indicate a need for urgent intervention.
Which of the following are components of the complete blood count (CBC)? Select all that apply.
Explanation
A. Hemoglobin level is a key component of the CBC, reflecting the oxygen-carrying capacity of the blood.
B. Blood glucose level is not part of the CBC; it is typically measured separately in metabolic panels or glucose tests.
C. White blood cell count is included in the CBC and is important for assessing the immune response.
D. Platelet count is also part of the CBC and is essential for evaluating clotting function.
E. Red blood cell count is included in the CBC and is crucial for assessing overall blood health and anemia status.
The client with sickle cell disease (SCD) has recently been sick and is now experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?
Explanation
A. Encouraging frequent ambulation is not appropriate during a vaso-occlusive crisis, as it can exacerbate pain and further compromise blood flow.
B. While monitoring the RBC count is important, it is not the most immediate intervention during a crisis. The focus should be on managing pain and preventing complications.
C. Treating the client in an outpatient setting is inappropriate during a vaso-occlusive crisis, which typically requires inpatient care for effective pain management and hydration.
D. Maintaining IV fluids, administering pain medications, and providing supplemental oxygen are critical interventions that address the acute needs of the client in crisis, aiming to alleviate pain and improve oxygenation.
A nurse is caring for a client who is on anti-retroviral therapy (ART), which includes indinavir sulfate (Crixivan), a protease inhibitor, for the treatment of HIV. Which client statement demonstrates that teaching was effective?
Explanation
A. This statement accurately reflects the importance of adherence to ART; if medication is missed, the virus may replicate unchecked, leading to drug resistance, which is a significant concern in HIV treatment.
B. This statement is incorrect because the conversion of RNA to DNA is a normal part of the HIV life cycle and is not directly prevented by taking medication on time.
C. While protease inhibitors do help prevent the assembly of new virions, the primary concern when missing doses is the risk of resistance rather than assembly prevention.
D. This statement is misleading; while effective ART can lead to an increase in CD4 counts over time, missing doses would not directly cause an increase in CD4 lymphocyte counts.
A nurse is teaching a client with a history of ulcerative colitis and a new diagnosis of anemia. Which of the following symptoms from ulcerative colitis is a contributing factor to the development of anemia?
Explanation
A. Dietary iron restrictions may affect iron intake, but they are not a direct symptom of ulcerative colitis that contributes to anemia.
B. Intestinal parasites can cause anemia but are not a common complication associated with ulcerative colitis.
C. Chronic bloody diarrhea is a significant symptom of ulcerative colitis and leads to iron loss and depletion, contributing to the development of anemia due to the loss of blood and iron.
D. Intestinal malabsorption syndrome can lead to anemia; however, it is not a primary symptom of ulcerative colitis itself, making chronic bloody diarrhea the more direct contributing factor.
A nurse is caring for a client who has chronic renal disease and is taking epoetin alfa (Procrit). Which laboratory result would be used to assess the effectiveness of this medication?
Explanation
A. Red blood cells (RBC) and hemoglobin (Hg) levels are directly affected by epoetin alfa, which stimulates red blood cell production in the bone marrow, making these values essential for assessing the medication's effectiveness.
B. The leukocyte count (WBC) is not relevant to the effects of epoetin alfa, as this medication primarily influences erythropoiesis rather than white blood cell production.
C. The erythrocyte sedimentation rate (ESR) is a non-specific test used to detect inflammation but does not provide information regarding the effectiveness of epoetin alfa.
D. The thrombocyte count does not assess the effectiveness of epoetin alfa, as this medication is specifically aimed at increasing red blood cell production.
A client with iron deficiency anemia is prescribed ferrous sulfate. Which instruction by the nurse is most appropriate to include in the client's teaching plan?
Explanation
A. Decreasing intake of foods high in fiber is not necessary; in fact, fiber can help prevent constipation, a common side effect of iron supplements.
B. Vitamin C actually enhances the absorption of iron; thus, avoiding it is incorrect. Clients should be encouraged to consume vitamin C alongside their iron supplements to improve absorption.
C. Stools becoming darker in color is a common and expected side effect of ferrous sulfate due to the presence of unabsorbed iron. It is important for clients to know this to avoid unnecessary alarm.
D. Taking the medication on a full stomach may decrease absorption; it is generally recommended to take iron supplements on an empty stomach for optimal absorption unless gastrointestinal upset occurs.
A nurse is assessing a client who is receiving a unit of packed red blood cells. Which client statement suggests manifestation of an acute hemolytic reaction?
Explanation
A. Sharp pain in the lower back is a classic symptom of an acute hemolytic reaction, which can occur due to incompatible blood transfusions.
B. Coughing more could indicate a transfusion-related acute lung injury (TRALI) but is not a typical sign of an acute hemolytic reaction.
C. Ringing in the ears can occur with other conditions but is not a common sign of an acute hemolytic reaction.
D. Feeling needles poking in the feet is vague and not specifically associated with acute hemolytic reactions, which are characterized by more severe systemic symptoms.
A nurse is caring for a client who is coming to the clinic for human immunodeficiency virus (HIV) testing. The patient's enzyme-linked immunosorbent assay (ELISA) results are positive. Which test will be used to confirm the diagnosis of HIV?
Explanation
A. A quantitative RNA assay is used to measure the amount of HIV RNA in the blood and is not used for confirmatory diagnosis after a positive ELISA.
B. The Western blot analysis is the standard confirmatory test for HIV following a positive ELISA result, as it specifically detects the presence of antibodies to HIV proteins.
C. A viral load test assesses the level of virus in the blood but does not confirm the diagnosis of HIV.
D. The CD4+ T-cell count is used to assess immune function in individuals with HIV but is not a confirmatory test for the diagnosis of the virus.
Which nursing interventions are appropriate for a nurse administering a blood transfusion? [Select All That Apply]
Explanation
A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.
B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.
C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.
D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.
E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.
F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.
G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.
A nurse is providing education to a client with human immunodeficiency virus (HIV) who is experiencing wasting syndrome. Which of these suggestions is most appropriate?
Explanation
A. While legumes are a good source of protein, they do not provide the high-calorie density needed for someone experiencing wasting syndrome.
B. Consuming high-calorie snacks between meals is the most appropriate suggestion as it helps increase overall caloric intake, which is essential for clients with wasting syndrome to help maintain weight and improve nutritional status.
C. Using canola oil instead of butter may not significantly impact caloric intake, and clients with wasting syndrome may need higher-calorie options.
D. Adding celery to soups or salads adds volume but is low in calories and may not contribute significantly to the dietary needs of someone experiencing wasting syndrome.
A nurse is providing teaching to a client who has vitamin B12 deficiency. Which of the following foods should the nurse instruct the client to consume? Select all that apply.
Explanation
A. Bananas are not a significant source of vitamin B12.
B. Eggs are a good source of vitamin B12 and should be included in the diet of someone with a deficiency.
C. Spinach contains folate but is not a reliable source of vitamin B12.
D. Carrots are not a source of vitamin B12.
E. Beef is an excellent source of vitamin B12 and should be consumed to help correct the deficiency.
F. Milk is a good source of vitamin B12 and can help increase intake for clients with a deficiency.
G. Quinoa does not contain vitamin B12 and should not be relied upon for addressing this deficiency.
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. The client's hemoglobin is at 7 g/dL. Which of the following findings should the nurse expect this client to report?
Explanation
A. Diarrhea is not a typical finding associated with anemia from blood loss; it may occur for other reasons but is not directly related to low hemoglobin levels.
B. Fatigue is a common symptom in clients with anemia, particularly when hemoglobin levels are low, as there is reduced oxygen delivery to tissues, leading to feelings of weakness and tiredness.
C. Hypertension is unlikely to be present in a client with significant blood loss; instead, hypotension may be more expected due to reduced blood volume.
D. Bradycardia is not typically associated with anemia; in fact, tachycardia (increased heart rate) is more common as the body tries to compensate for reduced oxygen-carrying capacity.
A nurse is caring for a client with iron-deficiency anemia. When teaching the client about nutrition, the nurse should educate the client which of the following foods contains the most amount of iron?
Explanation
A. Milk and cheese are low in iron content and are not recommended for increasing iron levels in clients with iron-deficiency anemia.
B. Whole grain breads may contain some iron but are not as high in iron as other food sources.
C. Fresh fruits do not provide significant amounts of iron and are not a good source for addressing iron deficiency.
D. Red meat and organ meat are excellent sources of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant sources, making them the best choice for increasing iron intake in clients with iron-deficiency anemia.
A nurse is caring for a client with Acquired Immunodeficiency Syndrome (AIDS). Which client statement demonstrates a need for further education?
Explanation
A. Increasing the consumption of protein-rich foods like baked salmon is beneficial for clients with AIDS, as they often require higher protein intake to support their immune system and overall health.
B. Eating raw fruits and vegetables can pose a risk for clients with compromised immune systems, as these foods may harbor pathogens that can lead to infections. This statement indicates a need for further education regarding safe food handling and preparation.
C. Washing plates and utensils with soap and hot water is a proper practice to maintain hygiene and prevent infections, especially for clients with weakened immune systems.
D. Asking a partner to clean the cat's litter box is a good precaution since cat litter can be a source of toxoplasmosis, which can be harmful to immunocompromised individuals.
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