NCLEX 10000 – Flashcards
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A physician orders gentamicin sulfate, 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least:
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30 min
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A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:
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autonomy
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A client with granulocytopenia has many visitors. The most important measure to prevent infection is for the visitors to:
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wash their hands
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A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I will not lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate?
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take a warm tub bath or shower
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A client has extreme fatigue and is malnourished, and laboratory tests reveal a hemoglobin level of 8.5 g/dL (85 g/L). The nurse should specifically ask the client about the intake of food high in which nutrients?
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B6 and B12, folate, iron, and copper
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The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use?
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contact the health care provider
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When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into her eyes. What should the nurse do next?
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rinse her eyes with water, report the incident and go to employee health
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The nurse is teaching the parents of a child with sickle cell disease. To instruct them on how to prevent sickle cell crisis, she should include which instruction?
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drink at least 2 quarts of fluids per dayadminster epinephrine
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A client with rheumatoid arthritis is being discharged with a prescription for aspirin, 600 mg P.O. every 6 hours. Which statement by the client indicates understanding of the adverse effects of the medication?
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ill call my physician if i have ringing in the ears
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Which symptom is an early indication that the client's serum potassium level is below normal?
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muscle weakness in the legs
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The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:
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stay with the client during the first 15 min of infusion
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A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain?
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hearing
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A multidisciplinary oncology team of physicians, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply.
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decreased white decreased plate decreased RBC
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The nurse is developing a plan of care for a client who has joint stiffness due to rheumatoid arthritis. Which measure will be the most effective in relieving stiffness?
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a warm shower before performing activities of daily living
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The teaching plan for the client with rheumatoid arthritis includes rest promotion. What position of the involved joints should the nurse tell the client to avoid when at rest?
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maintaining the joints in a flexed position
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Which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site?
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lying on the and with toes pointed inward
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A client with multiple sclerosis is taking baclofen. Which sign indicates the drug is having the intended outcome? The client:
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has relief from muscle spasms
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A young adult has been bitten by a human, and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client for:
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an injection of tetanus
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A client with aplastic anemia is instructed to eat foods rich in iron. The nurse should instruct the client to include which food in the diet to increase iron intake?
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dark green leafy veg
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A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used:
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to provide long term access to central veins
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On the fourth day after surgery, a client's incision is red and inflamed. There is moderate drainage from the incision. The client has a temperature of 102° F (38.9° C). The total white blood count (WBC) 10,000/mm3 (10 × 109/L). The nurse should first:
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notify the health care provider
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On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for:
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early morning stiffness
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Which statement indicates that the client with osteoarthritis understands the effects of capsaicin cream?
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i always wash my hands right after...
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The nurse is teaching a client about preventing toxic shock syndrome (TSS). Which action is a risk factor for toxic shock syndrome?
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using only tampons at night
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A client with human immunodeficiency virus (HIV) infection is taking zidovudine (AZT). The expected outcome of AZTis to:
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show replication of the veins
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Which type of white blood cell (WBC) is the most numerous?
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neutrophil
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A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
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risk for injury
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A client on the oncology floor is ordered a blood transfusion. The nurse explains the procedure and informs the client that an informed consent form must be signed before the blood may be administered. The client asks why consent is necessary. Which response by the nurse best explains why consent is necessary for blood transfusions?
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the consent allows you to make an informed decision about
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At which time should the nurse instruct the client to take ibuprofen, prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?
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immediately after a meal
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After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which activity observed by the nurse indicates the need for additional teaching?
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carrying a laundry basket with clinched fingers and fists
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While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
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platelet count, prothrombin time, and partial thrombo
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The nurse explains to the parents of a 1-year-old child admitted to the hospital in sickle cell crisis that the local tissue damage the child has on admission is caused by which factor?
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obstruction to circulation
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A client with iron deficiency anemia is taking iron supplements. The nurse emphasizes to the client that the drug will have increased absorption if taken with:
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Orange juice
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What should the nurse should teach the client with neutropenia and the family to avoid?
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using suppositories or enemas
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Which is least likely a danger associated with pancytopenia?
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hypothyrodisim
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A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client?
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you will feel a pulling type of discomfort for a few seconds
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When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which physiologic functions?
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bleeding tendencies
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A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety?
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place the walker directly in front of you
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During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and foul smelling diarrhea. Which priority order should the nurse anticipate from the health care provider?
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stool sample for C diff
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A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?
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stop the transfusion infuse normal saline solutions and call the physician
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The nurse teaches the client with iron deficiency anemia that food sources with high iron content include:
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beef
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A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). The client gets angry when the call bell isn't answered immediately. What is the nurse's most appropriate response?
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you seem angry would you like to talk
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Which dietary strategy best meets the nutritional needs of a client with acquired immunodeficiency syndrome (AIDS)?
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instruct the client to cook foods throughly
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A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
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use the smallest needle possible for injections
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A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?
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offer a face mask to the person with the cold and use this as an pop
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A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should wear gloves when:
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providing mouth care
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What nursing interventions should a nurse expect to implement when caring for a child in acute sickle cell crisis? Select all that apply.
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maintaining adequate hydration providing adequate pain frequently monitoring vital signs
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The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information is most important to communicate to the health care provider (HCP)?
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the clients daily record indicated a 3-kg weight gain over 2 days
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A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
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urine output of 29 ml/hr
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The nurse understands that the client who is undergoing induction therapy for leukemia needs additional instruction when the client makes which statement?
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i cannot wait to get home to my cat
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A nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
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following safer sex
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A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for her personal identification number (PIN) to log in. What is the nurse's best response?
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ill be happy to contact information services
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A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?
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dyspnea, tachcardia and pallor
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A client takes prednisone, as ordered, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as:
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fluid retention and weight gain
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Allopurinol is prescribed for a client who has chronic gout. Which comment indicates that the client understands how to take the allopurinol?
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i should drink plenty of fluids when taking allopurinol
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A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?
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intrinsic factor
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The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue?
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i schedule afternoon rest periods for myself in addition to
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A client with acute lymphocytic leukemia is receiving vincristine. Prior to infusing the drug, the nurse administers diphenhydramine. The nurse should inform the client that the expected outcome of using diphenhydramine in this situation is to:
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decrease incidence of a reaction to the vincristine
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The nurse assesses the mouth and oral cavity of a client with human immunodeficiency virus (HIV) infection because the most common opportunistic infection initially presents as:
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oral candidasis
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A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern?
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butterfly rash
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A parent asks the nurse if a child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which principle?
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children with iron def
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Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?
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lamb and peaches
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Which is an appropriate outcome for a client with rheumatoid arthritis?
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the client will manage joint pain and fatigue to perform
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The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns?
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your physician will continue to care for you
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A client diagnosed with metastatic cancer is preparing for discharge. The physician orders morphine sulfate controlled-release tablets 100 mg every 12 hours as needed after discharge. What legal rights and responsibilities should the nurse address when teaching the client about morphine sulfate use?
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federal law prevents refills
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The nurse is completing a health history review of a client who has received long term medical steroid therapy for Lupus. Which client data does the nurse recognize as potentially linked to the steroid use? Select all that apply.
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3 infections over the course acne noted on the forehead cheeks
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A client has been taking a decongestant for allergic rhinitis. Which finding suggests that the decongestant demonstrates maximum therapeutic effective?
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reduced sneezing
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During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?
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a bouquet of flowers
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A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?
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it will get better and worse again
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A client who had a splenectomy is being discharged. The nurse should instruct the client to:
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report early of infections
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The nurse is caring for a client who has a history of aplastic anemia. Which information from the nursing history indicates that the anemia is not being managed effectively?
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pallor of the skin and mucous membranes
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The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client says:
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ecchymoses are large
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A nurse is to give a client heparin 8,000 units subcutaneously. The available vial is 10,000 units/mL. How many milliliters should the nurse draw up into the syringe? Record your answer using one decimal place
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0.8
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The parent brings a child to the clinic after discharge from the hospital for Guillain-Barré syndrome. Which statement by the parent indicates that the discharge plan is being followed?
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i take her to the pool where she can
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A client is having a blood transfusion reaction. What must the nurse do in order of priority from first to last? All options must be used.
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stop keep notify complete
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A client with a history of type 1 diabetes mellitus and chronic obstructive pulmonary disease should have which immunization?
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influenza
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A client is receiving a unit of packed red blood cells. Before the transfusion started, the client's blood pressure was 90/50 mm Hg, pulse rate 100 bpm, respirations 20 breaths/minute, and temperature 98° F (36.7° C). Fifteen minutes after the transfusion starts, the client's blood pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18 breaths/minute, and temperature is 101.4° F (38.6° C). The nurse should first:
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stop the transfusion
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A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement?
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i will need to take an iron supplement even if my lab
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The nurse devises a teaching plan for the client with aplastic anemia. Which directive is the most important to include in the plan?
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avoid exposure to others with acute infections
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A home care nurse is making the initial home visit to a client with lung cancer who had a peripherally inserted central catheter placed during hospitalization for an upper respiratory infection. During the visit, the nurse must administer an antibiotic, teach the client how to care for the catheter, and provide information about when to notify the home care agency and physician. When the nurse arrives at the client's home, the client's face is flushed and he complains of feeling tired. Which actions should the nurse take first?
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obtain the clients vital signs and assess breath sounds
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A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
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abnormally low HCT and Hb
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A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?
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i can eat whatever i want as ling as its low in fat
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A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response?
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the reason for your it def is an inability to absorb
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The family of a client, stung by a bee, is rushed the client to the emergency room. The client is experiencing hives and redness at the site. Upon arrival, the client states, "I feel a lump in my throat and I am sweating. I can't breathe! I think I am going to die!" The nurse anticipates which emergency treatment next?
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administer an injection of epinephrine stat
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A client is admitted with fatigue, shortness of breath, pale skin, and dried, cracked lips, tongue, and mouth. The hemoglobin is 9 g/dL (90 g/L), and red blood cell count is 3.5 million cells/mm3 (3.5 × 1012/L). The nurse should instruct the client to:
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eat foods with good sources of iron
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A client is receiving a transfusion of packed red blood cells. To safely administer the blood, the nurse should:
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stay with the client during the first 15 min
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A client's arterial blood gas values are as shown on the accompanying chart. These findings indicate which of the following acid-base imbalances?
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metabolic acidosis
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A client with mild dementia related to end-stage acquired immunodeficiency syndrome is preparing for discharge. He has decided against further curative treatment and wishes to return home. Before discharge, he develops ocular cytomegalovirus (CMV). His physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's partner feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which answer from the nurse best answers the partner's question reflecting client advocacy?
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the impact won't cure the virus but it may help
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A client is taking nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain from rheumatoid arthritis. What instruction should the nurse give the client about NSAIDs?
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take the prescribed meds with food and fluids
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A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
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discontinue the transfusion
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A client is in the acute phase of rheumatoid arthritis. In which order of priority from first to last should the nurse establish the goals? All options must be used.
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relieve pain perserve joint function perserve joint deformity maintain usual ways of accomplish
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A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. What should the nurse make sure that personnel involved with the procedure do?
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maintain sterile tech
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A nurse is administering an IV antineoplastic agent when the client says, "My arm is burning by the IV site." What should the nurse do first?
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stop infusing the medication
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A client with macrocytic anemia has a burn on her foot and reports watching television while lying on a heating pad. Which action should be the nurse's first response?
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check for diminished sensations
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A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse?
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well need more generic counseling in the future
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The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. The most appropriate goal for this client is to:
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gradually increase activity tolerance
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The nurse is developing a care plan for a client who has had radiation therapy for Hodgkin's lymphoma. What is the primary goal of care for this client?
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prevent infection
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When starting the client's intravenous infusion line, the nurse applies a tourniquet and selects the site for inserting the needle. When should the nurse remove the tourniquet?
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as soon as the needle in in the vein
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A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?
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normal saline solution as this is considered an isotonic
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A client with rheumatoid arthritis reports GI irritation after taking piroxicam. To prevent GI upset, the nurse should provide which instruction?
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take piroxicam with food or an antacid
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A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
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i won't donate blood because i don't want to get AIDS
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A client is experiencing an allergic response. The nurse should perform the actions in which order from first to last? All options must be used
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assess the airway and breathing pattern assess for urticaria active the rapid response notify the HCP
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The client diagnosed with osteoarthritis tells the nurse, "My friend takes steroid pills for her rheumatoid arthritis. Should I be taking steroids, too?" What should the nurse explain to the client?
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INtra articular corticosteroid injections
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When teaching a client about human immunodeficiency virus (HIV), the nurse should take into account the fact that the most effective method known to control the spread of HIV infection is:
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ongoing sex education about preventive
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Several clients who work in the same building are brought to the emergency department. They all have fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate?
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contact isolation with double gloving and shoe covers
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After teaching the parents of a child newly diagnosed with leukemia about the disease, which description if given by the mother best indicates that she understands the nature of leukemia?
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the sides is a type of cancer characterized by an increase
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A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
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i will receive parenteral bit B12 therapy
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A nurse on the hematology floor feels the charge nurse has been unfairly assigning complex clients to her by not dividing enough of the workload among the rest of the staff. This nurse is creating tension among the staff. What is the charge nurse's best approach?
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meet with this nurse privately and give her an opportunity
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The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
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obtian adequate bed rest
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A nurse is planning care for a client with human immunodeficiency virus (HIV). The registered nurse (RN) is delegating responsibilities to a licensed practical/vocational nurse (LPN/VN). Which statements by the LPN/VN indicates understanding of HIV transmission? Select all that apply.
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i will ear a mask gown and gloves when splashing of body i will wash my hands after client care
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On the fourth day after surgery, a client's incision is red and inflamed. There is moderate drainage from the incision. The client has a temperature of 102° F (38.9° C). The total white blood count (WBC) 10,000/mm3 (10 × 109/L). The nurse should first:
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notify HCP
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Which step must be done first when administering a blood transfusion?
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verify the physicians order
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A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
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listen and show interest as the client
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The nurse in the emergency department reports there is a possibility of having had direct contact with blood of a client who is suspected of having HIV/AIDS. The nurse requests that the client have a blood test. Consent for human immunodeficiency virus (HIV) testing can only be completed when which circumstances are present? Select all that apply.
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an emergency medical provider testing is prescribed by health care testing is ordered by a court trsting is done on blood collected
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A client with lymphoma tells the nurse that he's found an overseas holistic physician who can cure him with coffee enemas. What should the nurse say?
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you should ask you physician if this is a helpful approach
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the nurse is planning to initiate a blood transfusion. Which solution should the nurse select to prime the tubing when preparing to administer the blood?
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normal saline
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After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?
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administer epinephrone as ordered and prepare to intubate
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A client undergoing antineoplastic therapy is prescribed subcutaneous epoetin. The nurse evaluates that the drug is effective when:
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hemoglobin levels rise
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Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis?
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acute pain related to sickle cell crisis
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A client is to receive a blood transfusion of packed RBCs for severe anemia. Place the following steps in the order a nurse would follow to administer this product. All options must be used.
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record check verify put flush remain
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Which foods should the nurse encourage the mother to offer to her child with iron-deficiency anemia?
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potato, peas and chicken
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A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which should be the primary focus of nursing care for this client?
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decrease cardiac demands by promoting rest
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A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
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pallor, tachycardia, sore tongue
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A parent of a child with acute poststreptococcal glomerulonephritis (APSCN) asks how streptococcal infection caused the child to have a kidney problem. What is the nurse's best response?
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by products of immure complexes that fought the infections
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Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
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infuse a unit of PRBC stop transfusion if reaction inspect the blood bag
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A client being treated for iron deficiency anemia with ferrous sulfate continues to be anemic despite treatment. The nurse should assess the client for use of which medication?
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aluminum hydroxide
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The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?
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droplet
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A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?
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hypercalcemia
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The nurse is caring for a client admitted with trauma from a motor vehicle crash. Which of the following assessment information would indicate the client may have disseminated intravascular clotting (DIC)?
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hematemesis, melena, increase prothrombin time
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A client with toxic shock has been receiving ceftriaxone sodium, 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory finding does the nurse monitor?
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serum creatinine
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The nurse is assessing a client experiencing a sickle cell crisis who continues to rate the pain at 10 on a scale of 1 to 10. Which is true about pain?
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expression and precipitation of pain vary widely
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The nurse should remind the unlicensed assistive personnel (UAP) that the most important goal in the care of the neutropenic client in isolation is:
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instructing the client to dispose the tissue after blowing
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A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?
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place a pressure reducing mattress on the clients bed
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A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address?
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the client is at risk for heparin induced thrombocyopenis
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The family of a client, stung by a bee, is rushed the client to the emergency room. The client is experiencing hives and redness at the site. Upon arrival, the client states, "I feel a lump in my throat and I am sweating. I can't breathe! I think I am going to die!" The nurse anticipates which emergency treatment next?
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administer an injection of epinephrine stat
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A physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?
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an above normal DNA test
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The nurse is administering didanosine to a client with HIV. Before administering this medication, the nurse should check which lab test results? Select all that apply.
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AST ALT elevated serum amylase
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The skin tone of a client of Vietnamese descent with dark skin who has early signs of iron deficiency anemia appears:
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yellowish brown
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A nurse is caring for a child in acute sickle cell crisis. Which laboratory values does the nurse expect to see? Select all that apply.
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low mean positive metabisulfate positive Hb SS
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The client who does not respond adequately to fluid replacement has an order for an IV infusion of dopamine hydrochloride at 5 mcg/kg/minute. To determine that the drug is having the desired effect, the nurse should assess the client for:
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increased cardiac output
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After teaching the client with severe rheumatoid arthritis about prescribed methotrexate, which statements indicate the need for further teaching?
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i will take my it while i am on this drug
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In addition to teaching regarding medications, what would the nurse include to reinforce health promotion and illness prevention for a client with acquired immunodeficiency syndrome (AIDS)?
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measeures to prevent transmission, maintain optimal nutrition
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When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching and there is a rise in the client's temperature. The nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction with a blood transfusion?
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type II hyersensitivity reaction
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The daily white blood cell (WBC) count in a client with aplastic anemia drops overnight from 3,900 to 2,900/µl (3.9 to 2.9 X 109/L). Which is the appropriate nursing intervention?
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call the primary care provider and request that the client be placed
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A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client?
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hemodilution
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A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving:
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A positive blood to and A negative client
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The nurse is evaluating the laboratory results of a client who was recently admitted to the hospital. Which result indicates the presence of inflammation?
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leukocytosis
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The nurse is preparing to administer platelets. The nurse should:
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gently rotate the bag
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A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:
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10,000
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A client has back pain 10 minutes after a unit of packed red blood cells (RBCs) was started. The client's pulse, blood pressure, and respirations are stable, and similar to vital signs obtained before infusing the RBCs. What should the nurse do? Select all that apply.
answer
turn off spend the remaining prepare for cardio obtain a urine
