Title: ASN 210 UNIT EXAM# 2 (Remotely Proctored)
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I > Section: Week 4

Inflammation & Immunity
Cancer Development
Patients with Cancer
Arthritis & CT Disorders
HIV & Immune Deficiencies & Infections
Allergies & Autoimmunity

This is examination is TIMED and you are allotted 2 hours to complete it.
Be sure you are taking this exam on a reliable computer with reliable internet source, if you lose connection you will NOT be allowed to log into the exam again.
Once you start the exam you will need to complete the exam in one setting.
The exam will shut off automatically after the allotted time has elapsed.
This is NOT an open book exam.  This exam contains 75 NCLEX-RN Style Questions and is worth 150 POINTS (15% of your ASN 210 Grade)
No collaboration allowed during this exam or it will be noted as a breach of academic integrity.
You must send a message to the instructor immediately (within 10 minutes) with any technical issues or irregularities related to the exam.

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Q: 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?
- Artificial fibronectin infusion to maintain tight adhesion of cells
- Chromosome repair kit to halt rapid division of cancer cells
- Synthetic enzyme transfusion to allow rapid cellular migration
- Telomerase therapy to maintain chromosomal immortality
A: Artificial fibronectin infusion to maintain tight adhesion of cells
If right: 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.
If wrong: 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.

Q: 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?
- “Foods high in vitamin A and vitamin C are important.”
- “I’ll have to cut down on the amount of bacon I eat.”
- “I’m so glad I don’t have to give up my juicy steaks.”
- “Vegetables, fruit, and high-fiber grains are important.”
A: “I’m so glad I don’t have to give up my juicy steaks.”
If right: 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.
If wrong: 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.

Q: A nurse is assessing a client with glioblastoma. What assessment is most important?
- Abdominal palpation
- Abdominal percussion
- Lung auscultation
- Neurologic examination
A: Neurologic examination
If right: A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.
If wrong: A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.

Q: A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? <b>(Select all that apply.)</b>
- Demonstrating breast self-examination methods to women
- Instructing people on the use of chemoprevention
- Providing vaccinations against certain cancers
- Screening teenage girls for cervical cancer
- Teaching teens the dangers of tanning booths
A: Instructing people on the use of chemoprevention; Providing vaccinations against certain cancers; Teaching teens the dangers of tanning booths
If right: 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.
If wrong: 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.

Q: A nurse is providing community education on the seven warning signs of cancer. Which signs are included? <b>(Select all that apply.)</b>
- A sore that does not heal
- Changes in menstrual patterns
- Indigestion or trouble swallowing
- Near-daily abdominal pain
- Obvious change in a mole
A: A sore that does not heal; Changes in menstrual patterns; Indigestion or trouble swallowing; Obvious change in a mole
If right: The seven warning signs for cancer can be remembered with the acronym CAUTION: <u>c</u>hanges in bowel or bladder habits, <u>a</u> sore that does not heal, <u>u</u>nusual bleeding or discharge, <u>t</u>hickening or lump in the breast or elsewhere, <u>i</u>ndigestion or difficulty swallowing, <u>o</u>bvious change in a wart or mole, and <u>n</u>agging cough or hoarseness. Abdominal pain is not a warning sign.
If wrong: The seven warning signs for cancer can be remembered with the acronym CAUTION: <u>c</u>hanges in bowel or bladder habits, <u>a</u> sore that does not heal, <u>u</u>nusual bleeding or discharge, <u>t</u>hickening or lump in the breast or elsewhere, <u>i</u>ndigestion or difficulty swallowing, <u>o</u>bvious change in a wart or mole, and <u>n</u>agging cough or hoarseness. Abdominal pain is not a warning sign.

Q: A student nurse asks the nursing instructor what “apoptosis” means. What response by the instructor is best?
- Growth by cells enlarging
- Having the normal number of chromosomes
- Inhibition of cell growth
- Programmed cell death
A: Programmed cell death
If right: 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.
If wrong: 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.

Q: The nurse caring for oncology clients knows that which form of metastasis is the most common?
- Bloodborne
- Direct invasion
- Lymphatic spread
- Via bone marrow
A: Bloodborne
If right: 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.
If wrong: 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.

Q: The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? <b>(Select all that apply.)</b>
- Exposure to carcinogens
- Genetic predisposition
- Immune function
- Normal doubling time
- State of euploidy
A: Exposure to carcinogens; Genetic predisposition; Immune function
If right: The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.
If wrong: The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

Q: The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells?
- Benign tumors grow through invasion of other tissue.
- Benign tumors have lost their cellular regulation from contact inhibition.
- Growing in the wrong place or time is typical of benign tumors.
- The loss of characteristics of the parent cells is called anaplasia.
A: Growing in the wrong place or time is typical of benign tumors.
If right: 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.
If wrong: 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.

Q: The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? <b>(Select all that apply.)</b>
- Differentiated function
- Large nucleus-to-cytoplasm ratio
- Loose adherence
- Nonmigratory
- Specific morphology
A: Differentiated function; Nonmigratory; Specific morphology
If right: 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.
If wrong: 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.

Q: The student nurse learning about cellular regulation understands that which process occurs during the S phase of the cell cycle?
- Actual division (mitosis)
- Doubling of DNA
- Growing extra membrane
- No reproductive activity
A: Doubling of DNA
If right: 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 G<sub>1</sub> phase. During the G<sub>0</sub> phase, the cell is working but is not involved in any reproductive activity.
If wrong: 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 G<sub>1</sub> phase. During the G<sub>0</sub> phase, the cell is working but is not involved in any reproductive activity.

Q: Which statement about carcinogenesis is accurate?
- An initiated cell will always become clinical cancer.
- Cancer becomes a health problem once it is 1 cm in size.
- Normal hormones and proteins do not promote cancer growth.
- Tumor cells need to develop their own blood supply.
A: Tumor cells need to develop their own blood supply.
If right: 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.
If wrong: 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.

Q: A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important?
- “Avoid large crowds and people who are ill.”
- “Check over-the-counter meds for acetaminophen.”
- “Take this medicine exactly as prescribed.”
- “You have a higher risk of developing cancer.”
A: “Avoid large crowds and people who are ill.”
If right: Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).
If wrong: Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

Q: A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best?
- “It increases the elimination of T lymphocytes from circulation.”
- “It inhibits cytokine production in most lymphocytes.”
- “It prevents DNA synthesis, stopping cell division in activated lymphocytes.”
- “It prevents the activation of the lymphocytes responsible for rejection.”
A: “It increases the elimination of T lymphocytes from circulation.”
If right: Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.
If wrong: Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.

Q: A client’s white blood cell count is 7500/mm<sup>3</sup>. Calculate the expected range for this client’s neutrophils. (<i>Record your answer using whole numbers separated with a hyphen; do not use commas.</i>)<i> </i>______/mm<sup>3</sup>
Feedback: 4125-5625/mm^3 The normal range for neutrophils is 55% to 75% of the white blood cell count. 7500 ´ 0.55 = 4125 7500 ´ 0.75 = 5625 So the range would be expected to be 4125/mm^3 to 5625/mm^3.

Q: A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
- Assessing vaccination records for booster shot needs
- Encouraging the client to eat a nutritious diet
- Instructing the client to wash minor wounds carefully
- Teaching hand hygiene to prevent the spread of microbes
A: Assessing vaccination records for booster shot needs
If right: Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.
If wrong: Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

Q: A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?
- Blood urea nitrogen (BUN) of 18 mg/dL
- Cloudy, foul-smelling urine
- Creatinine of 3.9 mg/dL
- Urine output of 340 mL/8 hr
A: Creatinine of 3.9 mg/dL
If right: A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.
If wrong: A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

Q: A nurse is assessing an older client for the presence of infection. The client’s temperature is 97.6° F (36.4° C). What response by the nurse is best?
- Assess the client for more specific signs.
- Conclude that an infection is not present.
- Document findings and continue to monitor.
- Request that the provider order blood cultures.
A: Assess the client for more specific signs.
If right: Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.
If wrong: Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

Q: A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?
- Bone marrow
- Spleen
- Thymus
- Tonsils
A: Bone marrow
If right: The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.
If wrong: The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

Q: A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? <b>(Select all that apply.)</b>
- Basophils are only involved in the general inflammatory process.
- Eosinophils increase during allergic reactions and parasitic invasion.
- Macrophages can participate in many episodes of phagocytosis.
- Monocytes turn into macrophages after they enter body tissues.
- Neutrophils can only take part in one episode of phagocytosis.
A: Eosinophils increase during allergic reactions and parasitic invasion.; Macrophages can participate in many episodes of phagocytosis.; Monocytes turn into macrophages after they enter body tissues.; Neutrophils can only take part in one episode of phagocytosis.
If right: Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in <i>both</i> the general inflammatory response and allergic or hypersensitivity responses.
If wrong: Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in <i>both</i> the general inflammatory response and allergic or hypersensitivity responses.

Q: An older adult has a mild temperature, night sweats, and productive cough. The client’s tuberculin test comes back negative. What action by the nurse is best?
- Recommend a pneumonia vaccination.
- Teach the client about viral infections.
- Tell the client to rest and drink plenty of fluids.
- Treat the client as if he or she has tuberculosis (TB).
A: Treat the client as if he or she has tuberculosis (TB).
If right: Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the client’s TB test could be a false negative.
If wrong: Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the client’s TB test could be a false negative.

Q: For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? <b>(Select all that apply.)</b>
- Antibody-mediated immunity
- Cell-mediated immunity
- Inflammation
- Red blood cells
- White blood cells
A: Antibody-mediated immunity; Cell-mediated immunity; Inflammation
If right: The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.
If wrong: The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

Q: The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? <b>(Select all that apply.)</b>
- Edema
- Pulselessness
- Pallor
- Redness
- Warmth
A: Edema; Redness; Warmth
If right: The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.
If wrong: The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

Q: The nurse understands that which type of immunity is the longest acting?
- Artificial active
- Inflammatory
- Natural active
- Natural passive
A: Natural active
If right: Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. “Inflammatory” is not a type of immunity.
If wrong: Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. “Inflammatory” is not a type of immunity.

Q: The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ?
- Child
- Identical twin
- Parent
- Same-sex sibling
A: Identical twin
If right: The recipient’s immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.
If wrong: The recipient’s immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

Q: A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?
- Assess the client for a headache.
- Assist the client in getting out of bed.
- Instruct the client to reduce salt intake.
- Weigh the client daily before the client eats.
A: Assist the client in getting out of bed.
If right: Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the client’s 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.
If wrong: Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the client’s 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.

Q: A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? <b>(Select all that apply.)</b>
- Apply the client’s shoes before getting the client out of bed.
- Assist the client with ambulation.
- Shave the client with a safety razor only.
- Use a lift sheet to move the client up in bed.
- Use the Waterpik on a low setting for oral care.
A: Apply the client’s shoes before getting the client out of bed.; Assist the client with ambulation.; Use a lift sheet to move the client up in bed.
If right: Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client’s 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.
If wrong: Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client’s 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.

Q: A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer?
- Epoetin alfa (Epogen)
- Filgrastim (Neupogen)
- Mesna (Mesnex)
- Oprelvekin (Neumega)
A: Epoetin alfa (Epogen)
If right: The client’s 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.
If wrong: The client’s 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.

Q: A client in the emergency department reports difficulty breathing. The nurse assesses the client’s appearance as depicted below:<br><br><img width="338" height="210" align="bottom" alt="mc025-1.jpg" src="ppg/examview/ASN_210_W3_PATIENTS_WITH_CANCER/00001_res/mc025-1.jpg" border="0"><br><br>What action by the nurse is the priority?
- Assess blood pressure and pulse.
- Attach the client to a pulse oximeter.
- Have the client rate his or her pain.
- Start high-dose steroid therapy.
A: Assess blood pressure and pulse.
If right: 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.
If wrong: 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.

Q: 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?
- “Are you getting adequate rest and sleep each day?”
- “It is normal to be fatigued even for years afterward.”
- “This is not normal and I’ll let the provider know.”
- “Try adding more vitamins B and C to your diet.”
A: “It is normal to be fatigued even for years afterward.”
If right: 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.
If wrong: 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.

Q: A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?
- Administer a dose of allopurinol (Aloprim).
- Assess the client’s serum potassium level.
- Gently inquire about advance directives.
- Prepare the client for emergency surgery.
A: Gently inquire about advance directives.
If right: 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.
If wrong: 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.

Q: 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?
- Assessing the client’s abdomen beforehand
- Ensuring that informed consent is on the chart
- Marking the client’s bilateral pedal pulses
- Reviewing client teaching done previously
A: Ensuring that informed consent is on the chart
If right: 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.
If wrong: 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.

Q: A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
- Assessing the IV site every hour
- Educating the client on side effects
- Monitoring the client for nausea
- Providing warm packs for comfort
A: Assessing the IV site every hour
If right: 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.
If wrong: 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.

Q: A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?
- Blood pressure
- Lung assessment
- Oral mucous membranes
- Skin integrity
A: Blood pressure
If right: 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.
If wrong: 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.

Q: A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best?
- “It causes rapid lysis of the cancer cell membranes.”
- “It destroys the enzymes needed to create cancer cells.”
- “It prevents the start of cell division in the cancer cells.”
- “It sensitizes certain cancer cells to chemotherapy.”
A: “It prevents the start of cell division in the cancer cells.”
If right: Rituxan prevents the initiation of cancer cell division. The other statements are not accurate.
If wrong: Rituxan prevents the initiation of cancer cell division. The other statements are not accurate.

Q: A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? <b>(Select all that apply.)</b>
- Apply moisturizers to dry skin.
- Apply steroid creams to the skin.
- Bathe the client using mild soap.
- Help the client with a hot water bath.
- Teach the client to avoid sunlight.
A: Apply moisturizers to dry skin.; Bathe the client using mild soap.
If right: 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.
If wrong: 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.

Q: A client receiving chemotherapy has a white blood cell count of 1000/mm<sup>3</sup>. What actions by the nurse are most appropriate?<i> </i><b>(Select all that apply.)</b>
- Assess all mucous membranes every 4 to 8 hours.
- Do not allow the client to eat meat or poultry.
- Listen to lung sounds and monitor for cough.
- Monitor the venous access device appearance with vital signs.
- Take and record vital signs every 4 to 8 hours.
A: Assess all mucous membranes every 4 to 8 hours.; Listen to lung sounds and monitor for cough.; Monitor the venous access device appearance with vital signs.; Take and record vital signs every 4 to 8 hours.
If right: 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.
If wrong: 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.

Q: A client has a possible connective tissue disease and the nurse is reviewing the client’s laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? <b>(Select all that apply.)</b>
- Elevated antinuclear antibody (ANA) – Normal value; no connective tissue disease
- Elevated sedimentation rate – Rheumatoid arthritis
- Lowered albumin – Indicative only of nutritional deficit
- Positive human leukocyte antigen B27 (HLA-B27) – Reiter’s syndrome or ankylosing spondylitis
- Positive rheumatoid factor – Possible kidney disease
A: Positive human leukocyte antigen B27 (HLA-B27) – Reiter’s syndrome or ankylosing spondylitis; Positive rheumatoid factor – Possible kidney disease
If right: The HLA-B27 is diagnostic for Reiter’s syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.
If wrong: The HLA-B27 is diagnostic for Reiter’s syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.

Q: A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? <b>(Select all that apply.)</b>
- Acupuncture
- Stretching
- Supplements
- Tai chi
- Vigorous aerobics
A: Acupuncture; Stretching; Tai chi
If right: There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.
If wrong: There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.

Q: A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best?
- Assess the client’s culture more thoroughly.
- Discuss options for performing duties.
- See if the client will call a community meeting.
- Suggest the client give up the role of elder.
A: Assess the client’s culture more thoroughly.
If right: The nurse needs a more thorough understanding of the client’s culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.
If wrong: The nurse needs a more thorough understanding of the client’s culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

Q: A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best?
- “A little sedation will help you get some rest.”
- “Depression often accompanies fibromyalgia.”
- “This drug works in the brain to decrease pain.”
- “You will have more energy after taking this drug.”
A: “This drug works in the brain to decrease pain.”
If right: Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.
If wrong: Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.

Q: A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?
- “Be sure you get enough sleep at night.”
- “Eat plenty of high-protein, high-iron foods.”
- “Notify your provider at once if you get a fever.”
- “Weigh yourself every day on the same scale.”
A: “Notify your provider at once if you get a fever.”
If right: Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.
If wrong: Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.

Q: A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? <b>(Select all that apply.)</b>
- Grab bars to reach high items
- Long-handled bath scrub brush
- Soft rocker-recliner chair
- Toothbrush with built-up handle
- Wheelchair cushion for comfort
A: Grab bars to reach high items; Long-handled bath scrub brush; Toothbrush with built-up handle
If right: Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.
If wrong: Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

Q: A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?
- “Let’s ask the provider about increasing your pain pills.”
- “Hold ice bags against your hands before quilting.”
- “Try a paraffin wax dip 20 minutes before you quilt.”
- “You need to stop quilting before it destroys your fingers.”
A: “Try a paraffin wax dip 20 minutes before you quilt.”
If right: Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a “hot” or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.
If wrong: Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a “hot” or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

Q: A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started “acting up,” especially both hips and knees. What action by the nurse is best?
- Assess the client for the presence of subcutaneous nodules or Baker’s cysts.
- Inspect the client’s feet and hands for podagra and tophi on fingers and toes.
- Prepare to teach the client about an acetaminophen (Tylenol) regimen.
- Reassure the client that the problems will fade as the weather changes again.
A: Assess the client for the presence of subcutaneous nodules or Baker’s cysts.
If right: Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker’s cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.
If wrong: Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker’s cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

Q: A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?
- Have adequate help to transfer the client.
- Provide socks so the client can slide easier.
- Tell the client full weight bearing is allowed.
- Use a footstool to elevate the client’s leg.
A: Have adequate help to transfer the client.
If right: The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.
If wrong: The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

Q: A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important?
- Administer preoperative medications as prescribed.
- Ensure that a consent for transfusion is on the chart.
- Explain to the client how anemia affects healing.
- Teach the client about foods high in protein and iron.
A: Ensure that a consent for transfusion is on the chart.
If right: The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.
If wrong: The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

Q: A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?
- Giving subcutaneous injections
- Having a chest x-ray once a year
- Taking the medication with food
- Using heat on the injection site
A: Giving subcutaneous injections
If right: Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.
If wrong: Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

Q: A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?
- “I always wear long sleeves, pants, and a hat when outdoors.”
- “I try not to use cosmetics that contain any type of sunblock.”
- “Since I tend to sweat a lot, I use a lot of baby powder.”
- “Since I can’t be exposed to the sun, I have been using a tanning bed.”
A: “I always wear long sleeves, pants, and a hat when outdoors.”
If right: Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.
If wrong: Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

Q: A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best?
- Consult with the health care provider about administering both drugs to the client.
- Inform the client that the celecoxib will be started when he or she goes home.
- Teach the client that, since morphine is stronger, celecoxib is not needed.
- Tell the client he or she should not take both drugs at the same time.
A: Consult with the health care provider about administering both drugs to the client.
If right: Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.
If wrong: Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

Q: A client in the family practice clinic reports a 2-week history of an “allergy to something.” The nurse obtains the following assessment and laboratory data:<br><div style="font-size:2pt"></div><table cellpadding="0" cellspacing="0" width="90%" border="1"><tr valign="top"><td><div style="text-align:center"><b>Physical Assessment Data</b></div></td><td><div style="text-align:center"><b>Laboratory Results </b></div></td></tr><tr valign="top"><td>Reports sore throat, runny nose, headache<br>Posterior pharynx is reddened<br>Nasal discharge is seen in the back of the throat<br>Nasal discharge is creamy yellow in color<br>Temperature 100.2° F (37.9° C)<br>Red, watery eyes</td><td>White blood cell count: 13,400/mm<sup>3</sup><br>Eosinophil count: 11.5%<br>Neutrophil count: 82%</td></tr><tr height="0" style="border:none"><td width="64%"></td><td width="36%"></td></tr></table>About what medications and interventions does the nurse plan to teach this client? <b>(Select all that apply.)</b>
- Elimination of any pets
- Chlorpheniramine (Chlor-Trimaton)
- Future allergy scratch testing
- Proper use of decongestant nose sprays
- Taking the full dose of antibiotics
A: Chlorpheniramine (Chlor-Trimaton); Future allergy scratch testing; Proper use of decongestant nose sprays; Taking the full dose of antibiotics
If right: This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature.
If wrong: This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature.

Q: A client is in the hospital and receiving IV antibiotics. When the nurse answers the client’s call light, the client presents an appearance as shown below:<br><br><img width="300" height="291" align="bottom" alt="mc010-1.jpg" src="ppg/examview/ASN_210_W4_HIV-_ALLERGIES_-_AUTOIMMUNITY/00001_res/mc010-1.jpg" border="0"><br><br>What action by the nurse takes priority?
- Administer epinephrine 1:1000, 0.3 mg IV push immediately.
- Apply oxygen by facemask at 100% and a pulse oximeter.
- Ensure a patent airway while calling the Rapid Response Team.
- Reassure the client that these manifestations will go away.
A: Ensure a patent airway while calling the Rapid Response Team.
If right: The nurse should ensure the client’s airway is patent and either call the Rapid Response Team or delegate this to someone else. Epinephrine needs to be administered right away, but not without a prescription by the physician unless standing orders exist. The client may need oxygen, but a patent airway comes first. Reassurance is important, but airway and calling the Rapid Response Team are the priorities.
If wrong: The nurse should ensure the client’s airway is patent and either call the Rapid Response Team or delegate this to someone else. Epinephrine needs to be administered right away, but not without a prescription by the physician unless standing orders exist. The client may need oxygen, but a patent airway comes first. Reassurance is important, but airway and calling the Rapid Response Team are the priorities.

Q: A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best?
- Assess that the client has been NPO as directed.
- Communicate this information with dietary staff.
- Document the information in the client’s chart.
- Ensure the information is relayed to the surgical team.
A: Ensure the information is relayed to the surgical team.
If right: A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the client’s NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority.
If wrong: A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the client’s NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority.

Q: A client is receiving plasmapheresis as treatment for Goodpasture’s syndrome. When planning care, the nurse places highest priority on interventions for which client problem?
- Reduced physical activity related to the disease’s effects on the lungs
- Inadequate family coping related to the client’s hospitalization
- Inadequate knowledge related to the plasmapheresis process
- Potential for infection related to the site for organism invasion
A: Potential for infection related to the site for organism invasion
If right: Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasive procedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity.
If wrong: Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasive procedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity.

Q: A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the client’s lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer?<br><i><span style="font-size:11pt">(Click the media button to hear the audio clip.)</span></i>
- Albuterol (Proventil) via nebulizer
- Diphenhydramine (Benadryl) IM
- Epinephrine 1:10,000 5 mg IV push
- Methylprednisolone (Solu-Medrol) IV push
A: Albuterol (Proventil) via nebulizer
If right: The nurse has auscultated wheezing in the client’s lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.
If wrong: The nurse has auscultated wheezing in the client’s lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.

Q: A client with Sjögren’s syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?
- Frequent eyedrops
- Home humidifier
- Strong moisturizer
- Tear duct plugs
A: Home humidifier
If right: A humidifier will help relieve many of the client’s Sjögren’s syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.
If wrong: A humidifier will help relieve many of the client’s Sjögren’s syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.

Q: A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
- “I don’t need to go to the hospital after using it.”
- “I must carry two EpiPens with me at all times.”
- “I will write the expiration date on my calendar.”
- “This can be injected right through my clothes.”
A: “I don’t need to go to the hospital after using it.”
If right: Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.
If wrong: Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.

Q: A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best?
- Assess the client frequently for worsening of his or her condition.
- Delegate comfort measures to unlicensed assistive personnel.
- Ensure the client is placed on Contact Precautions.
- Restrict visitors to the immediate family only.
A: Assess the client frequently for worsening of his or her condition.
If right: Meningitis is a disease caused by endotoxins, which are released with cell lysis. Antibiotics often work by lysing cell membranes, which would increase the amount of endotoxin present in the client’s body. The nurse should carefully monitor this client for a worsening of his or her condition. Delegating comfort measures is appropriate for any client. Clients with meningitis are placed on Droplet Precautions, and initiating isolation should have been done on admission. The client does not need to have visitors restricted.
If wrong: Meningitis is a disease caused by endotoxins, which are released with cell lysis. Antibiotics often work by lysing cell membranes, which would increase the amount of endotoxin present in the client’s body. The nurse should carefully monitor this client for a worsening of his or her condition. Delegating comfort measures is appropriate for any client. Clients with meningitis are placed on Droplet Precautions, and initiating isolation should have been done on admission. The client does not need to have visitors restricted.

Q: A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client’s partner is listed as the emergency contact, but the client’s mother insists that she should be listed instead. What action by the nurse is best?
- Contact the social worker to assist the client with advance directives.
- Ignore the mother; the client does not want her to be involved.
- Let the client know, gently, that nurses cannot be involved in these disputes.
- Tell the client that, legally, the mother is the emergency contact.
A: Contact the social worker to assist the client with advance directives.
If right: 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.
If wrong: 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.

Q: A client has been placed on Contact Precautions. The client’s family is very afraid to visit for fear of being “contaminated” by the client. What action by the nurse is best?
- Explain to them that these precautions are mandated by law.
- Inform them that the infection is the issue, not the client.
- Reassure the family that they will not get the infection.
- Tell the family it is important that they visit the client.
A: Inform them that the infection is the issue, not the client.
If right: Families and clients often have negative reactions to isolation precautions. The nurse can explain that the infection is the problem, not the client, and encourage them to visit because following the precautions will prevent them from acquiring the infection. The other options do not give the family useful information to help them make an informed decision.
If wrong: Families and clients often have negative reactions to isolation precautions. The nurse can explain that the infection is the problem, not the client, and encourage them to visit because following the precautions will prevent them from acquiring the infection. The other options do not give the family useful information to help them make an informed decision.

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?
- Assess the client for support systems.
- Determine if a clergy member would help.
- Explain legal requirements to tell sex partners.
- Offer to tell the family for the client.
A: Assess the client for support systems.
If right: 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.
If wrong: 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.

Q: A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?
- Obtain cultures of the lesions.
- Place the client on Airborne Precautions.
- Prepare to administer antibiotics.
- Provide comfort measures for the rash.
A: Place the client on Airborne Precautions.
If right: This client has manifestations of smallpox, a public health emergency, and should be placed on Airborne Precautions first before other care measures are implemented.
If wrong: This client has manifestations of smallpox, a public health emergency, and should be placed on Airborne Precautions first before other care measures are implemented.

Q: A client is admitted with possible sepsis. Which action should the nurse perform first?
- Administer antibiotics.
- Give an antipyretic.
- Place the client in isolation.
- Obtain specified cultures.
A: Obtain specified cultures.
If right: Prior to administering antibiotics, the nurse obtains the ordered cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The client may or may not need isolation.
If wrong: Prior to administering antibiotics, the nurse obtains the ordered cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The client may or may not need isolation.

Q: A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? <b>(Select all that apply.)</b>
- Admit the client to a negative-airflow room.
- Maintain a distance of 3 feet from the client at all times.
- Order specialized masks/respirators for caregiving.
- Other than wearing gloves, no special actions are needed.
- Wash hands with chlorhexidine after providing care.
A: Admit the client to a negative-airflow room.; Order specialized masks/respirators for caregiving.
If right: A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot distance is required for Droplet Precautions. Chlorhexidine is used for clients with a high risk of infection.
If wrong: A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot distance is required for Droplet Precautions. Chlorhexidine is used for clients with a high risk of infection.

Q: A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?
- Consult with the provider about obtaining stool cultures.
- Delegate frequent perianal care to unlicensed assistive personnel.
- Place the client on NPO status until the diarrhea resolves.
- Request a prescription for an anti-diarrheal medication.
A: Consult with the provider about obtaining stool cultures.
If right: Hospitalized clients who have three or more stools a day for 2 or more days are suspected of having infection with <i>Clostridium difficile. </i>The nurse should inform the practitioner and request stool cultures. Frequent perianal care is important and can be delegated but is not the priority. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Anti-diarrheal medication may or may not be appropriate, and the diarrhea serves as the portal of exit for the infection.
If wrong: Hospitalized clients who have three or more stools a day for 2 or more days are suspected of having infection with <i>Clostridium difficile. </i>The nurse should inform the practitioner and request stool cultures. Frequent perianal care is important and can be delegated but is not the priority. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Anti-diarrheal medication may or may not be appropriate, and the diarrhea serves as the portal of exit for the infection.

Q: A client is hospitalized with <i>Pneumocystis jiroveci </i>pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?
- Administer sleeping medication.
- Perform most activities for the client.
- Increase the client’s oxygen during activity.
- Pace activities, allowing for adequate rest.
A: Pace activities, allowing for adequate rest.
If right: 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 client’s activity.
If wrong: 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 client’s activity.

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?
- Chooses high-protein food
- Has decreased oral discomfort
- Eats 90% of meals and snacks
- Has a weight gain of 2 pounds/1 month
A: Has a weight gain of 2 pounds/1 month
If right: 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.
If wrong: 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.

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?
- “Gabapentin can be used as an antidepressant too.”
- “I have no idea why you should be taking this drug.”
- “This drug helps treat the pain from nerve irritation.”
- “You are at risk for seizures due to fungal infections.”
A: “This drug helps treat the pain from nerve irritation.”
If right: 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.
If wrong: 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.

Q: A client with acquired immune deficiency syndrome (AIDS) is hospitalized with <i>Pneumocystis jiroveci</i> 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?<i> </i><b>(Select all that apply.)</b>
- Aspartate transaminase, alanine transaminase: elevated
- CD4+ cell count: 180/mm<sup>3</sup>
- Creatinine: 1.0 mg/dL
- Platelet count: 80,000/mm<sup>3</sup>
- Serum sodium: 120 mEq/L
A: Aspartate transaminase, alanine transaminase: elevated; Platelet count: 80,000/mm<sup>3</sup>; Serum sodium: 120 mEq/L
If right: The drug of choice to treat <i>Pneumocystis jiroveci</i> 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.
If wrong: The drug of choice to treat <i>Pneumocystis jiroveci</i> 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.

Q: A client with acquired immune deficiency syndrome and esophagitis due to <i>Candida</i> fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? <b>(Select all that apply.)</b>
- Assess the client’s mouth and throat.
- Determine if the client has a stiff neck.
- Ensure that the consent form is on the chart.
- Maintain NPO status as prescribed.
- Percuss the client’s abdomen.
A: Assess the client’s mouth and throat.; Ensure that the consent form is on the chart.; Maintain NPO status as prescribed.
If right: Oral <i>Candida</i> fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client’s 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.
If wrong: Oral <i>Candida</i> fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client’s 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.

Q: A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?
- Auscultating the lungs
- Assessing mucous membranes
- Listening to bowel sounds
- Performing a neurologic examination
A: Assessing mucous membranes
If right: 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 client’s mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.
If wrong: 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 client’s mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.

Q: 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)? <b>(Select all that apply.)</b>
- Apply oral anesthetic gels before meals.
- Assist the client with oral care every 2 hours.
- Offer the client frequent sips of cool drinks.
- Provide the client with alcohol-based mouthwash.
- Remind the client to use only a soft toothbrush.
A: Assist the client with oral care every 2 hours.; Offer the client frequent sips of cool drinks.; Remind the client to use only a soft toothbrush.
If right: 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.
If wrong: 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.

Q: A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi’s sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?
- Adhering to Standard Precautions
- Assessing tolerance to dressing changes
- Performing hand hygiene before and after care
- Disposing of soiled dressings properly
A: Disposing of soiled dressings properly
If right: All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.
If wrong: All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.

Q: 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)? <b>(Select all that apply.)</b>
- Assessing the client’s fluid and electrolyte status
- Assisting the client to get out of bed to prevent falls
- Obtaining a bedside commode if the client is weak
- Providing gentle perianal cleansing after stools
- Reporting any perianal abnormalities
A: Assisting the client to get out of bed to prevent falls; Obtaining a bedside commode if the client is weak; Providing gentle perianal cleansing after stools; Reporting any perianal abnormalities
If right: The UAP can assist the client with getting out of bed, obtain a bedside commode for the client’s use, cleanse the client’s perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.
If wrong: The UAP can assist the client with getting out of bed, obtain a bedside commode for the client’s use, cleanse the client’s perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

Q: A client with an infection has a fever. What actions by the nurse help increase the client’s comfort? <b>(Select all that apply.)</b>
- Administer antipyretics around the clock.
- Change the client’s gown and linens when damp.
- Offer cool fluids to the client frequently.
- Place ice bags in the armpits and groin.
- Provide a fan to help cool the client.
A: Change the client’s gown and linens when damp.; Offer cool fluids to the client frequently.
If right: Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.
If wrong: Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.