NUR 2530 EXAM 2 practice Questions and Answers 100% Solved correctly
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Course
NUR 2530
Institution
NUR 2530
The nurse is conducting a teaching session with a client on their diagnosis of
pemphigus. Which statement by the client indicates that the client understands the
diagnosis?
A. "My skin will have tiny red vessels"
B. "The presence of the skin vesicles is caused by a virus."
C. "I have an autoim...
NUR 2530 EXAM 2 practice questions
The nurse is conducting a teaching session with a client on their diagnosis of
pemphigus. Which statement by the client indicates that the client understands the
diagnosis?
A. "My skin will have tiny red vessels"
B. "The presence of the skin vesicles is caused by a virus."
C. "I have an autoimmune disease that causes blistering in the skin."
D. "Red, raised papule and large plaques covered by silvery scales will be present on
my skin." - ✔️✔️C - "I have an autoimmune disease that causes blistering in the skin."
Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis.
The client has large flaccid blisters (bullae). Because the blisters are in the epidermis,
they have a thin covering of the skin and break easily, leaving denuded areas of skin.
On initial examination, clients may have crusting areas instead of intact blisters.
The nurse prepares to give a bath and change the bed linens of a client with cutaneous
Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous
fluid. Which would the nurse incorporate into the plan during the bathing of this client?
A. wearing gloves
B. wearing a gown and gloves
C. wearing a gown, gloves, and a mask
D. wearing a gown and gloves to change the bed linens, and gloves only for the bath -
✔️✔️B. wearing a gown and gloves
Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled
items such as those with wound drainage or is caring for a client who is incontinent with
diarrhea or a client who has an ileostomy or colostomy. Regardless of the amount of
wound drainage, a gown and gloves must be worn.
The nurse provides home care instructions to a client with systemic lupus
erthyematosus and tells the client about methods to manage fatigue. Which statement
by the client indicates a need for further instruction?
A. "I should take hot baths because they are relaxing."
B. "I should sit whenever possible to conserve my energy."
C. "I should avoid long periods of rest because it causes joint stiffness."
D. "I should do some exercises, such as walking, when I am not fatigued." - ✔️✔️A. "I
should take hot baths because they are relaxing"
Rationale: To help reduce fatigue in the client with lupus, the nurse should instruct the
client to sit whenever possible, avoid hot baths (they exacerbate fatigue), schedule low-
impact exercises when not fatigued, and maintain a balanced diet.
A client develops an anaphylactic reaction after receiving morphine. The nurse should
plan to institute which actions? Select all that apply.
A. Administer oxygen
B. Quickly assess the clients respiratory status.
C. Document the event, interventions, and client's response.
, D. Leave the client briefly to contact a primary health care provider (HCP).
E. Keep the client supine regardless of the blood pressure readings.
F. Start an intravenous (IV) infusion of D5W and administer a 500ml bolus. - ✔️✔️A, B,
C. - administer oxygen, assess respiratory status, and documentation.
Rationale: An anaphylactic reaction requires immediate action starting with quickly
assessing the clients respiratory status. Although the PHCP and RRT team must be
notified immediately, the nurse must stay with the client. Oxygen is administered and an
IV of normal saline is started and infused per PHCP prescription. Documentation of the
event, actions taken, and client outcomes needs to be performed. The HOB should be
elevated if the client's blood pressure is normal.
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency
and should incorporate which action as a priority in the plan?
A. Protecting the client from infection
B. Providing emotional support to decrease fear
C. Encouraging discussion about lifestyle changes
D. Identifying factors that decreased the immune function - ✔️✔️A - protecting the
client from infection
Rationale: The client with immunodeficiency has inadequate or absence of immune
bodies and is at risk for infection. The priority nursing intervention would be infection
prevention.
The community health nurse is conducting a research study and is identifying clients in
the community at risk for latex allergy. Which client population is most at risk for
developing this type of allergy?
A. hairdressers
B. the homeless
C. children in day care centers
D. individuals living in a group home - ✔️✔️A - hairdressers
Rationale: Individuals most at risk for developing a latex allergy include health care
workers; individuals who work in the rubber industry; or those who have had multiple
surgeries, have spina bifida, wear gloves frequently (such as food handlers,
hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples,
tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.
Which interventions apply in the care of a client at high risk for allergic response to a
latex allergy? Select all that apply.
A. use non latex gloves
B. use medications from glass ampules.
C. place the client in a private room only
D. keep a latex-safe supply cart available in the clients area.
E. Avoid the use of medication vials that have rubber stoppers
F. Use a blood pressure cuff from an electronic device only to measure the blood
pressure - ✔️✔️A, B, D, E - use nonlatex gloves, use medications from glass ampules,
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