Test II Practice Questions
Which functions would the nurse identify as part of the normal immune response? Select all that apply. Defense Deployment Mobilization Surveillance Homeostasis
Defense Surveillance Homeostasis
A patient's laboratory report reveals that the cells from the tumor biopsy are grade II. Which interpretation would the nurse make about the tumor cells? A) Abnormal and moderately differentiated B) Very abnormal and poorly differentiated C) Immature, primitive, and undifferentiated D) Differing slightly from normal cells, well differentiated
A) Abnormal and moderately differentiated *Grade II cells are more abnormal than grade I cells and are moderately differentiated. Grade III cells are very abnormal and poorly differentiated. Grade IV cells are immature, primitive, and undifferentiated; the cell origin is difficult to determine. Grade I cells differ slightly from normal cells and are well differentiated.
Cytokines provide instructions to cells to alter which processes? Select all that apply. Select all that apply A) Activity B) Secretion C) Proliferation D) Composition E) Differentiation
A) Activity B) Secretion C) Proliferation E) Differentiation
Allergic rhinitis is a common type I hypersensitivity, which is also known as which type of reaction? A) Atopic reaction B) Cytolytic reaction C) Immune-complex reaction D) Delayed-hypersensitivity reaction
A) Atopic reaction
The nurse is assessing an older adult patient, what age related disorder should the nurse assess for related to the increased immunologic response? A) Autoimmune response B) Cell-mediated immunity C) Hypersensitivity response D) Humoral immune response
A) Autoimmune response
A patient is suspected of having ovarian cancer. Which oncofetal antigen would the nurse anticipate seeing when the laboratory results return? A) Carbohydrate antigen-125 (CA-125) B) Carbohydrate antigen-15-3 (CA-15-3) C) Carbohydrate antigen-19-9 (CA-19-9) D) Carbohydrate antigen-27-29 (CA-27-29)
A) Carbohydrate antigen-125 (CA-125)
Which function does the complement system serve during an immune response? A) Cellular lysis B) Promoting clot formation C) Decrease in vascular permeability D) Cleaning the injured area before healing
A) Cellular lysis
The nurse identifies that a patient who takes cyclophosphamide is at risk for neutropenia. Which is the medication's primary mechanism of action? A) Cross-links DNA B) Inhibits purine synthesis C) Causes prolonged T-cell depletion D) Inhibits cytokine production
A) Cross-links DNA
Which coagulation factor converts prothrombin to thrombin?A) Factor X B) Factor XI C) Factor XII D) Factor XIII
A) Factor X
The patients diagnosed with anemia had laboratory tests done. Which results indicate a lack of nutrients needed to produce new red blood cells (RBCs)? A) Increased homocysteine B) Decreased reticulocyte count C) Decreased cobalamin (Vit B 12) D) Increased methylmalonic acid (MMA) E) Elevated erythrocyte sedimentation rate (ESR)
A) Increased homocysteine C) Decreased cobalamin (Vit B 12) D) Increased methylmalonic acid (MMA)
The nurse discusses the beneficial aspects of fever with a group of nursing students and will include which information? Select all that apply. A) Increased proliferation of T cells B) Increased release of epinephrine C) Enhancement of interferon activity D) Increased killing of microorganisms E) Impairment of the temperature control center
A) Increased proliferation of T cells C) Enhancement of interferon activity D) Increased killing of microorganisms
The nurse is reviewing the laboratory report of a patient who has been admitted to the hospital for a stab wound in the abdomen. Which finding is likely to be seen in the report? A) Leukocytosis B) Albuminuria C) Polycythemia D) Thrombocytopenia
A) Leukocytosis
A patient with chronic acquired immunodeficiency syndrome (AIDS) is taking antiretroviral therapy (ART) as well as medication for tuberculosis. Which laboratory data changes would the nurse anticipate? Select all that apply. A) Neutropenia B) Lymphopenia C) High platelet count D) Normal hemoglobin levels E) Abnormal liver function tests
A) Neutropenia E) Abnormal liver function tests
A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document the skin abnormality as: A) Petechiae B) Erythema C) Ecchymosis D) Telangiectasia
A) Petechiae
Which diagnostic test would the nurse prepare for the patient who is taking antiretroviral therapy (ART) for human immunodeficiency virus (HIV) and reports feeling like he or she did prior to starting ART? A) Phenotype assay B) Rapid HIV-antibody test C) Standard antibody assay test D) White blood cell count laboratory test
A) Phenotype assay
Which information would the nurse provide the patient with human immunodeficiency virus (HIV) who asks about factors determining progression to acquired immunodeficiency syndrome (AIDS)? Select all that apply. A) Progression of HIV can be assessed by your viral load. B) Your CD4 + T-cell count is one of several factors identified. C) Changes in your red blood cell count identifies progression of HIV. D) Testing for presence of the hepatitis B virus (HBV) assists in identifying progression. E) Your immunoglobulin M (IgM) antibody levels identify progression of HIV to AIDS.
A) Progression of HIV can be assessed by your viral load. B) Your CD4 + T-cell count is one of several factors identified.
Which action by the nurse is most helpful in treating a patient who is experiencing chills related to an infection? A) Providing a light blanket B) Encouraging a hot shower C) Monitoring the patient's body temperature every hour D) Increasing the temperature on the thermostat in the patient's room
A) Providing a light blanket
In a patient admitted with cellulitis of the left foot, which clinical manifestation would the nurse expect to find on assessment of the left foot? A) Redness and swelling B) Pallor and poor turgor C) Cyanosis and coolness D) Edema and brown skin discoloration
A) Redness and swelling
The nurse uses an Aquaform hydrogel dressing to cover a patient's necrotic wound. Which advantages does this type of dressing have when compared to other dressings? Select all that apply. Select all that apply A) Rehydrates wound tissue B) Maintains a moist environment C) Donates moisture to dry wound D) Holds large amount of exudates E) Allows visualization of the wound
A) Rehydrates wound tissue B) Maintains a moist environment C) Donates moisture to dry wound
The nurse is caring for a patient with multiple skin blisters on the chest after experiencing an adverse reaction to a medication. If the blisters rupture, which type of exudate will likely be present? A) Serous B) Fibrinous C) Hemorrhagic D) Serosanguineous
A) Serous
A healthy older adult patient requests a "flu shot" during an office visit. When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply.)? A. Shingles B. Pneumonia C. Meningococcal D. Haemophilus influenzae type b (Hib) E. Measles, mumps, and rubella (MMR)
A) Shingles B) Pneumonia
A patient with phlebitis due to prolonged IV cannulation develops a fever, chills, and an elevated white blood cell count. Blood cultures are drawn and reveal Staphylococcus aureus. Of which type of infection is this an example? A) Systemic B) Localized C) Contained D) Community-acquired
A) Systemic
The nurse provides education to staff about mycotic infections and includes which examples? Select all that apply. Select all that apply A) Thrush B) Hepatitis C C) Tinea pedis D) Tuberculosis E) Tinea corporis
A) Thrush C) Tinea pedis E) Tinea corporis
The nurse notes redness around a patient's infiltrated IV site. Which physiologic event occurred related to the assessment finding? A) Vasodilation B) Change in pH C) Shifting of fluid to interstitial spaces D) Increased metabolism at the inflammatory site
A) Vasodilation
A patient with systemic lupus erythematosus is receiving plasmapheresis to treat an acute attack. What symptoms will the nurse monitor to determine if the patient develops complications related to the procedure? A) hypotension, parasthesias and dizziness B) polyuria, decreased reflexes, and lethargy C) Intense thirst, flushed skin, and weight gain D) Abdominal cramping, diarrhea, and leg weakness
A) hypotension, parasthesias and dizziness
When teaching strategies to minimize the effects of a patient's seasonal allergic rhinitis, which statement will the nurse use? A) "What type of pets do you have? You will need to get rid of them." B) "You will need to begin sleeping in an air-conditioned room." C) "If you begin to stay indoors during the winter months, the rhinitis will decrease." D) "Begin having someone else (not you) dust your home with a dry feather duster twice a week."
B) "You will need to begin sleeping in an air-conditioned room."
Which patient is statistically and medically at the highest risk of developing cancer? A) A 68 year old white woman who has BRCA-1 gene and is obese B) A 56 year old black man with hep C who drinks alcohol daily C) A 18 year old hispanic man who eats fast food once per week and drinks alcohol D) A 80 year old asian woman with coronary artery disease on blood pressure medication
B) A 56 year old black man with hep C who drinks alcohol daily
A newly diagnosed patient with human immunodeficiency virus (HIV) inquires as to the requirements for development of acquired immunodeficiency syndrome (AIDS). Which diagnostic criterion for AIDS would the nurse share with the patient? Select all that apply. A) The presence of HIV antibodies B) A CD4 + T-cell count below 200/µL C) The presence of an opportunistic infection D) A white blood cell (WBC) count below 5000/µL E) Presence of an opportunistic cancer F) Loss of 10% or more of ideal body mass
B) A CD4 + T-cell count below 200/µL C) The presence of an opportunistic infection E) Presence of an opportunistic cancer F) Loss of 10% or more of ideal body mass
A patient waiting for a kidney transplant asks the nurse to explain the difference between a negative and positive crossmatch. Which statement by the nurse would be the most accurate response? A) A negative crossmatch means that both the donor and recipient are Rh negative, and the transplant is safe B) A negative crossmatch means that no preformed antibodies are present, and the transplant would be safe C) A positive crossmatch means the blood type is the same between donor and recipient, and the transport is safe D) A positive crossmatch means that both the donor and the recipient have antigens that are similar, and the transplant would be safe
B) A negative crossmatch means that no preformed antibodies are present, and the transplant would be safe
A patient receiving allergy skin testing develops itching and swelling at the injection site. Which intervention would the nurse implement first? A) Assess for systemic rash. B) Administer epinephrine (Adrenalin). C) Establish IV access. D) Apply a topical antihistamine to the injection site.
B) Administer epinephrine (Adrenalin).
The nurse performs a dressing change for a wound that is irregularly shaped and draining. Which type of dressing does the nurse apply that forms a nonsticky gel? A) Foam B) Alginate C) Hydrogel D) Semipermeable transparent film
B) Alginate
The nurse is administering medications to a patient. What medication taken by the patient is most likely to have an effect on the integumentary system? A) Diuretic B) Corticosteroid C) Benzodiazepine D) Calcium Channel Blocker
B) Corticosteroid
During the promotion stage of cancer development, which statement by the nurse most facilitates patient cancer prevention? A) Exercise every day for 30 mins B) Follow smoking cessation recommendations C) Following a vitamin regime is highly recommended D) I recommend excision of the cancer as soon as possible
B) Follow smoking cessation recommendations
Which medication may be prescribed for a patient who has peripheral neuropathy after taking chemotherapy? A) Furosemide B) Gabapentin C) Metoclopramide D) Morphine sulfate
B) Gabapentin
During a patient's postoperative follow-up visit, the nurse notes that the patient's wound is pink and vascular with numerous red granules. In which stage of healing is the wound? A) Initial phase B) Granulation phase C) Maturation phase D) Scar contraction
B) Granulation phase
A nursing instructor is providing education about immunology and includes information about which immunoglobulin that is found in tears and colostrum? A) IgE B) IgA C) IgG D) IgM
B) IgA
A patient had a splenectomy for injuries sustained in a motor vehicle accident. Which phenomena are likely to result from the absence the patient's spleen? SATA A) Impaired fibrinolysis B) Increased platelet levels C) Increased eosinophil levels D) Fatigue and cold intolerance E) Impaired immunologic function
B) Increased platelet levels E) Impaired immunologic function
Which type of immunity is present at birth? A) Active B) Innate C) Passive D) Acquired
B) Innate
Which stem cell differentiates to form neutrophils? A) Monoblast B) Myeloblast C) Erythroblast D) Megakaryoblast
B) Myeloblast
The nurse is conducting an integumentary assessment of a black patient who has darkly pigmented skin and a history of COPD. Which locations should the nurse inspect for cyanosis? SATA A) Sclera B) Nail beds C) Soles of feet D) Palms of hands E) Conjunctiva of the eyes
B) Nail beds E) Conjunctiva of the eyes
A nursing professor, teaching about cellular response after tissue injury, asks a nursing student about the role of neutrophils. Which student response indicates that the student understands the information? A) Neutrophils are the last to arrive at the injury site. B) Neutrophils phagocytize bacteria and damaged cells. C) Neutrophils are primarily involved in humoral immunity. D) Neutrophils transform into macrophages after entering the tissue spaces.
B) Neutrophils phagocytize bacteria and damaged cells.
Which term is used for a malignant bone tumor? A) Carcinoma B) Osteosarcoma C) Neuroblastoma D) Chondrosarcoma
B) Osteosarcoma
At the allergist's office visit, the patient, who is employed as a visiting home health nurse, reports anxiety related to triggering an asthma attack when entering patient homes on a regular basis. About which contributory factors would the visiting nurse be concerned? Select all that apply. A) Nutritional needs B) Pets in the homes C) Reaction to medications D) Over-the-counter medications E) Patient lifestyle and stress level F) The need to wear medical alert identification
B) Pets in the homes C) Reaction to medications D) Over-the-counter medications E) Patient lifestyle and stress level
A patient has been prescribed antiretroviral therapy (ART), and the nurse is monitoring the assessment of growth of human immunodeficiency virus (HIV) in the concentrations of prescribed antiretroviral drugs. The nurse anticipates that what test will be advised for the patient? A) Genotype assay B) Phenotype assay C) Enzyme immunoassay D) Immunofluorescence assay
B) Phenotype assay
A patient presents to the allergy clinic with recurrent symptoms of an allergy, specifically hives and rashes. Which type of diagnostic testing would identify the patient's allergy? A) Enzyme-linked immunosorbent assay (ELISA) B) Skin testing C) Complete blood count (CBC) with differential D) Testing bronchial secretions
B) Skin testing
In the early stages of human immunodeficiency virus (HIV) infection, which cells protect the human body from infections? A) Platelets B) T cells C) Red blood cells D) Immunoglobulins
B) T cells
To cope with the side effects of receiving efavirenz (Sustiva) once a day, which instruction would the nurse provide the patient? A) Use electronic reminders, timers, and beepers. B) Take the dose at bedtime. C) Have tests performed regularly to assess viral load in the body. D) Inform the health care provider about other drugs being taken.
B) Take the dose at bedtime.
A patient receiving long-term corticosteroid therapy for an autoimmune disorder is hospitalized with a wound of an extremity. The nurse identifies that the patient may experience which complications related to the use of the medication? Select all that apply. A) The patient is at risk of hypoglycemia. B) The wound of this patient will heal slowly. C) There will be reduced bleeding from the wound. D) The patient is at a risk of developing bone infection. E) The symptom of fever may be blunted in this patient.
B) The wound of this patient will heal slowly. E) The symptom of fever may be blunted in this patient.
Which is the primary function of red blood cells (RBCs)? A) Initiating the blood coagulation process B) Transporting oxygen and carbon dioxide C) Ingesting and destroying unwanted organisms D) Protecting the body against infections and foreign invaders
B) Transporting oxygen and carbon dioxide
A patient asks the nurse what the health care provider meant by "the wound will be allowed to heal by secondary intention." How does the nurse respond? A) "The wound will be stapled together until it heals." B) "The healing will contract the area to close the wound." C) "The wound will be left open and heal from the edges inward." D) "The wound will be sutured after the current infection is controlled."
C) "The wound will be left open and heal from the edges inward."
A patient with pruritus and a rash over the trunk and arms develops audible wheezes and difficulty breathing. Per the facility's protocol, which action would the nurse implement? A) Administer an antihistamine B) Administer cromolyn (Nedocromil) C) Administer epinephrine (Adrenaline) D) Begin cardiopulmonary resuscitation (CPR)
C) Administer epinephrine (Adrenaline)
Which cells are involved in humoral immunity? A) Neutrophils B) T lymphocytes C) B lymphocytes D) Natural killer cells
C) B lymphocytes
The nurse is caring for a patient with active hepatitis C and recalls that the disease is spread by which route? A) Feces B) Semen C) Blood D) Inhalation
C) Blood
Where are lymphocytes produced? A) Spleen B) Tonsils C) Bone marrow D) Thymus gland
C) Bone marrow
A newly admitted patient reports allergies to eggs, nuts, and latex during the nurse's admission assessment. Which intervention would the nurse implement upon receiving this information? A) Place epinephrine (Epi-Pen) at the patient's bedside. B) Obtain an order for a consult with the dietitian. C) Document allergies in the patient's medical record and in the room. D) Notify the health care provider of the patient's allergies.
C) Document allergies in the patient's medical record and in the room.
A patient has taken amoxicillin once as a child for an ear infection. When given an injection of penicillin V, the patient develops a systemic anaphylactic reaction. Which manifestation would be seen first? A) Dyspnea B) Dilated pupils C) Edema D) Wheal-and-flare reaction
C) Edema
Which role does an antigen serve in the immune system? A) Provide immunity B) Promote homeostasis C) Elicit an immune response D) Protect the body against microorganisms
C) Elicit an immune response
The nurse assesses that there is fecal material drainage coming from an abscess in the perianal area. Which complication of wound healing does the nurse suspect has occurred? A) Evisceration B) Keloid formation C) Fistula formation D) Hypertrophic scars
C) Fistula formation
The nurse determines that a patient's abdominal surgical wound is healing by primary intention. Which phase best describes the migration of fibroblasts? A) Initial phase B) Maturation phase C) Granulation phase D) Regeneration phase
C) Granulation Phase
The nurse determines that a patient's abdominal surgical wound is healing by primary intention. Which phase best describes the migration of fibroblasts? A) Initial phase B) Maturation phase C) Granulation phase D) Regeneration phase
C) Granulation phase
Which type of immune response is an autoimmune disorder? A) Anaphylaxis B) Atopic reaction C) Hypersensitivity D) Contact dermatitis
C) Hypersensitivity
Which physiologic change is associated with fever during inflammatory conditions? A) Increased blood flow rate B) Decreased neutrophil action C) Increased proliferation of T cells D) Suppressed activity of interferon
C) Increased proliferation of T cells
The patient is told that an adenoma tumor is not encapsulated but has normally differentiated cells and surgery will be needed. The patient asks the nurse what this means. What should the nurse's response be to the patient? A) It will recur B) It has metastasized C) It is probably benign D) It is probably malignant
C) It is probably benign
A patient received penicillin V potassium intramuscular (IM) causing a systemic anaphylactic reaction. What manifestations does the nurse observe initially? A) Dyspnea B) Dilated pupils C) Itching and edema D) Wheal-and-flare reaction
C) Itching and edema
The nurse assesses a patient who has a tumorlike mass of scar tissue that extends beyond the edges of an abdominal scar. The scar is from a surgery that occurred several years prior to the patient's current visit. Which term does the nurse use to document the assessment finding? A) Adhesion B) Evisceration C) Keloid formation D) Fistula formation
C) Keloid formation
Which term refers to the resident macrophages in the liver? A) Mast cells B) Osteoclasts C) Kupffer cells D) Megakaryocyte
C) Kupffer cells
When administering the patient's initial dose of subcutaneous immunotherapy for treatment of intractable environmental allergies, which action would the nurse implement? A) Monitor the patient's fluid balance. B) Assess the patient's need for analgesia. C) Monitor for signs and symptoms of an adverse reaction. D) Assess the patient for changes in level of consciousness.
C) Monitor for signs and symptoms of an adverse reaction.
The nurse is planning health promotion teaching for a group of healthy older adults in a residential community. Which statement accurately describes expected hematologic affects of aging? A) Platelet production increases with age and leads to easy bruising B) Anemia is common with aging because iron absorption is impaired C) Older adults with infections may have only a mild white blood cell count elevation D) Older adults often have poor immune function with a decreased number of lymphocytes
C) Older adults with infections may have only a mild white blood cell count elevation
A patient who is being treated for an inflammation receives a medication that promotes healing by preventing the liberation of lysosomes. The nurse recognizes that which drug has this mechanism of action? A) Ibuprofen B) Piroxicam C) Prednisone D) Acetaminophen
C) Prednisone
When teaching a group of adults about immunoglobulins, which function would the nurse present for IgG? A) Primary immune response B) Lining mucous membranes C) Secondary immune response D) Causing an allergic response
C) Secondary immune response
Which condition is indicated by a grade III histologic classification? A) Anaplasia B) Mild dysplasia C) Severe dysplasia D) Moderate dysplasia
C) Severe dysplasia
A patient being treated for a large pressure ulcer on the heel reports new inflammation in the surrounding subcutaneous tissue. Which term describes the condition the patient is experiencing?
Cellulitis
Which term refers to the directional migration of white blood cells to the site of a cellular injury?
Chemotaxis
Which patient is at risk for developing graft-versus-host disease (GVHD)? A) A 65 year old man who received an autologous blood transfusion B) A 40 year old man who received a kidney transplant from a living donor C) A 65 year old woman who received a pancreas and kidney from a deceased donor D) A 40 year old woman received a bone marrow transplant from a close relative
D) A 40 year old woman received a bone marrow transplant from a close relative
The nurse recognizes that which patient is likely to the poorest prognosis? A) A patient with nodular ulcerative basal cell cancer B) A patient who has been diagnosed with late squamous cell cancer C) A patient whose is being treated for superficial squamous cell cancer D) A patient who is newly diagnosed with stage IV malignant melanoma
D) A patient who is newly diagnosed with stage IV malignant melanoma
Which is the primary function of beta interferon (β-IFN)? A) Proliferation and differentiation of monocytes B) Proliferation and differentiation of neutrophils C) Production of red blood cells in the bone marrow D) Activation of natural killer cells and macrophages
D) Activation of natural killer cells and macrophages
Which intervention would the nurse implement first for a patient who develops severe symptoms of an anaphylactic reaction during intradermal skin testing? A) Elevate the legs of the patient. B) Move the patient to a supine position. C) Notify the health care provider. D) Apply a tourniquet above the site of the test.
D) Apply a tourniquet above the site of the test.
The nursing instructor asks a nursing student to identify the central lymphoid organs. Which examples provided by the student are correct? Select all that apply. Select all that apply A) Spleen B) Tonsils C) Lymph nodes D) Bone marrow E) Thymus gland
D) Bone marrow E) Thymus gland
Which response does the immune system normally make to antigens of malignant cells? A) Metastasis B) Tumor angiogenesis C) Immunologic escape D) Immunologic surveillance
D) Immunologic surveillance
The nurse plans which intervention for an older adult patient who is assessed to have a score of 16 on the Braden scale? A) Massage the pressure points every shift. B) Apply moist gauze dressings over the bony prominences. C) Elevate the head of bed to 90 degrees when the patient is supine. D) Implement a one-hour turning schedule with skin assessment.
D) Implement a one-hour turning schedule with skin assessment.
Which would the nurse include when teaching a patient about how to promote healing following abdominal surgery? Select all that apply. A) Take the prescribed antibiotic until the pain associated with the wound is lessened. B) Wound healing may not be complete for one to two weeks. C) Take an analgesic each day to promote adequate rest for healing. D) Increase the intake of protein and vitamins C, B, and A to facilitate healing. E) Notify the health care provider of redness, swelling, and increased drainage.
D) Increase the intake of protein and vitamins C, B, and A to facilitate healing. E) Notify the health care provider of redness, swelling, and increased drainage.
A patient with an arm sprain asks the nurse about the benefit of heat application. Which rationale does the nurse provide? A) It decreases congestion. B) It promotes vasoconstriction. C) It prevents further tissue injury. D) It localizes the inflammatory agents.
D) It localizes the inflammatory agents.
Which side effects would the nurse teach the patient with human immunodeficiency virus (HIV) to monitor when receiving antiretroviral therapy (ART) for a long time? A) Nausea B) Vomiting C) Diarrhea D) Lipodystrophy
D) Lipodystrophy
Which cells play a critical role in capturing, processing, and presenting an antigen to lymphocytes? A) Cytokines B) T lymphocytes C) B lymphocytes D) Mononuclear phagocytes
D) Mononuclear phagocytes
A patient who is receiving radiation to the head and neck as treatment for an invasive cancer reports mouth sores and pain. Which intervention should the nurse add to the plan of care? A) Provide ice chips to soothe the irritation B) Weigh the patient every month to monitor for weigh loss C) Cleanse the mouth every 2-4 hrs with hydrogen peroxide D) Provide high-protein and high-calorie, soft foods every 2 hrs
D) Provide high-protein and high-calorie, soft foods every 2 hrs
A patient with urticaria is receiving an albuterol treatment. Development of which clinical manifestation requires the nurse to contact the health care provider regarding an order for epinephrine (Adrenalin)? A) Manifestations of inflammation are present. B) The patient has persistent pruritus. C) Edema of the neck tissue is identified. D) Respiratory assessment indicates bronchoconstriction.
D) Respiratory assessment indicates bronchoconstriction.
The nurse pays close attention to which most common site for pressure ulcers when assessing a patient? A) Heels B) Ankles C) Elbows D) Sacrum
D) Sacrum
A patient developed a latex allergy caused by chemicals used in manufacturing of gloves used in hospitals. Which type of allergy would the nurse provide the patient information about? A) Type I B) Type II C) Type III D) Type IV
D) Type IV
The nurse differentiates between the types of hypersensitivity reactions and recognizes that which type is related to cell-mediated immunity? A) Type I B) Type II C) Type III D) Type IV
D) Type IV Type I-III are humoral immunity
The nurse evaluates wound healing for a patient with an arm laceration. The nurse recalls that which deficiency may cause insufficient collagen production by fibroblasts? A) Zinc deficiency B) Protein deficiency C) Vitamin B deficiency D) Vitamin C deficiency
D) Vitamin C deficiency
Which treatment options would the nurse describe to a patient who is to undergo mechanical debridement of a wound? Select all that apply A) Semi-occlusive dressing application B) Topical application of collagenase C) Surgical removal of eschar D) Wound irrigation E) Wet-to-dry dressing
D) Wound irrigation E) Wet-to-dry dressing
What indicates a bacterial infection?
Increased number of band neutrophils
During the repair of a patient's surgical incision, which cells release growth factors to initiate the healing process?
Platelets
When providing educational content for parents preparing their children for school, which infection would the nurse teach is preventable with vaccines?
Poliomyelitis
What is thick, white, malodorous drainage?
Purulent
Impaired skin integrity would be which stage?
Stage 3
Grade II Biopsy
abnormal and moderately differentiated
If a patient becomes hypotensive...
elevate the legs and put patient in a recumbent position
For immunocompromised patients, first signs of infection may be..
general malaise or fatigue. "Im just not feeling well"
A patient with pneumonia has a fever of 103.5 fever. What nursing actions will assist in managing the patients febrile state?
provide acetaminophen q4hrs to maintain consistent blood levels
