Page 2193 - Saunders Comprehensive Review For NCLEX-RN

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?
1. Wearing gloves
2. Wearing a gown and gloves
3. Wearing a gown, gloves, and a mask
4. Wearing a gown and gloves to change the bed linens, and gloves
only for the bath
764. The nurse provides home care instructions to a client with systemic lupus
erythematosus and tells the client about methods to manage fatigue. Which
statement by the client indicates a need for further instruction?
1. “I should take hot baths because they are relaxing.”
2. “I should sit whenever possible to conserve my energy.”
3. “I should avoid long periods of rest because it causes joint
stiffness.”
4. “I should do some exercises, such as walking, when I am not
fatigued.”
765. A client develops an anaphylactic reaction after receiving morphine. The
nurse should plan to institute which actions? Select all that apply.
1. Administer oxygen.

2. Quickly assess the client’s respiratory status.

3. Document the event, interventions, and client’s response.
4. Leave the client briefly to contact a primary health care

provider (PHCP).
5. Keep the client supine regardless of the blood pressure

readings.
6. Start an intravenous (IV) infusion of D5W and administer a
500-mL bolus.
766. 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?
1. “My skin will have tiny red vesicles.”
2. “The presence of the skin vesicles is caused by a virus.”
3. “I have an autoimmune disease that causes blistering in the skin.”
4. “Red, raised papules and large plaques covered by silvery scales
will be present on my skin.”
767. 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?
1. Protecting the client from infection
2. Providing emotional support to decrease fear
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function
768. A client calls the nurse in the emergency department and states that he was

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