Fresno City College BIO 102 Medical-Surgical Nursing Critical Thinking in Client Care4th CHAPTER 13

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER 13

Chapter 13

1. A client with a history of latex allergies develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which of the following would the nurse perform initially?

1. Administer epinephrine 1:100,000 IV per MD orders.
2. Collect a detailed history from the client regarding the history of latex allergies.
3. Teach the client regarding using a kit that contains treatment for allergic reactions.
4. Administer diphenhydramine (Benadryl) by mouth every four hours per physician’s orders.

2. A client who is a bone marrow transplant recipient develops a maculopapular rash on the palms of both hands and the soles of the feet. The client complains of severe abdominal pain with bloody diarrhea. The nurse would suspect that the client is experiencing:

1. Chronic tissue rejection.
2. Graft-versus-host disease.
3. Acute tissue rejection.
4. Hyperacute tissue rejection.

3. A client with AIDS is taking an antiretroviral medication. The client complains of nausea, fever, severe diarrhea, and anorexia. Which of the following medications would be the most effective to relieve the anorexia, as well as to stimulate the client’s appetite?

1. Megestrol (Megace)
2. Ciprofloxacin (Cipro)
3. Zidovudine (Retrovir, AZT)
4. Abacavir (Ziagen)

Question #4

4. Which statement made by the client taking an immunosuppressive agent would require further teaching?

1. “I know to call the physician if I start experiencing a lot of bruising.”
2. “I should drink plenty of water to keep me from getting dehydrated.”
3. “I should drink a lot of fruit juices, such as grapefruit juice.”
4. “If I experience any joint pain, I should take ibuprofen for the pain as needed every four hours.”

5. A client is suspected of having a reaction. Which lab test would alert the nurse regarding the possibility of a hypersensitivity reaction?

1. Eosinophils of 2% of the total WBC
2. Indirect Coombs’ showing no agglutination
3. Patch test with a one-inch area of erythema
4. Rh antigen with negative results

6. A client has a diagnosis of AIDS. The nurse is teaching the client regarding a diet with increased kilocalories. Which of the following diets would indicate that the client has an understanding of the appropriate diet?

1. Spaghetti and meat sauce, raisin salad, whole grain roll with butter, vanilla

milkshake (with Ensure), and a piece of pecan pie

1. Baked chicken (thigh), cabbage, small green salad, slice of white bread, dried prunes, and a soda
2. Red beans and rice, slaw, tomato, crackers, chocolate pudding, and iced tea
3. Vegetable soup, small piece of cornbread, banana pudding, and water

7. Which of the following statements by the client who has HIV would require further teaching by the healthcare professional?

1. “I know I have to practice safe sex with my partner.”
2. “I will not share my toothbrush or razor with my partner.”
3. “I know I can’t donate blood anymore since I have HIV.”
4. “I know to use an oil-based lubricant to prevent spread of the disease to my partner.”

8. The home health nurse is planning the day. Which of the following clients should the nurse see first?

1. A client with wasting syndrome who has end-stage AIDS who needs modifications and education regarding dietary changes
2. A client with a long history of AIDS who is receiving IV antibiotics

        daily for toxoplasmosis

1. A client with PCP (Pneumocystis carinii pneumonia) who called the office to report a new onset of fever, cough, and SOB this AM
2. A client with AIDS who is receiving Epivir (lamivudine) because of a diagnosis of a low CD4 cell count.

9. A nurse is performing an admission assessment on a client with AIDS. Which of the following questions would be inappropriate for the nurse to ask the client in the interview process?

1. “Have you ever experimented with recreational drugs?”
2. “How long have you had AIDS?”
3. “Does your partner have AIDS?”
4. “Have you had any fever, diarrhea, or chills over the last 48 hours?”

10. A client with HIV states “I don’t think I am going to live much longer. I feel so bad.” The nurse determines that which of the following would be the best response?

1. “You will be fine; you just need to let the medication have a chance to work.”
2. “It must be very difficult for you right now dealing with your diagnosis.”
3. “You need to be more positive about your diagnosis because it will improve

        your chances of surviving this disease.”

1. “Try not to be negative. You need to give yourself some time to feel better about

        your diagnosis.”

11. A nurse is monitoring a client who is receiving a unit of packed red blood cells. The client suddenly develops chest pains, hives, chills, and hypotension. Number the action that the nurse would take in order of priority.

_____   1.            Start normal saline at KVO (keep vein open).

_____   2.            Stop the transfusion.

__ ___ 3.             Notify the physician and blood bank.

_____   4.            Remove the blood bag and the tubing with the blood in it.

_____   5.            Obtain a urine specimen and send to the lab.

12. The nurse has admitted a client who has a diagnosis of Crytosporidium. Which care activity would be appropriate to delegate to the UAP (unlicensed assistive personnel)?

Select all that apply.

1. Obtain a detailed history regarding the client’s history.
2. Obtain the client’s admitting height and weight.
3. Review the client’s home medications, and complete the medication reconciliation sheet.
4. Obtain the client’s admitting vital signs.
5. Educate the client regarding the diet that the physician has ordered.

13. The nurse would report to the physician which of the following laboratory values for a client newly diagnosed with AIDS? Select all that apply.

1. CD4 cell count 344/mm³
2. T₄ cell count 150
3. WBC 6,500
4. CD4 lymphocytes 12%
5. Viral load 11,500 copies/mL