Ch. 10 , 11

B cells are primarily associated with humoral immunity.

TRUE

T cells mature in the thymus and are active in cellular immunity.

TRUE

The innate immune system utilizes cytokines as part of its response.

TRUE Rationale: The innate and adaptive immune systems utilize cytokines. Cytokines are short-acting, soluble molecules that are used to communicate and initiate interactions of immune response. Cytokines include interleukins and interferons. They are also able to interact with different cell types.

In what area would you least expect to see surgical asepsis implemented? - The operating room - The labor and delivery unit - The cardiac catheterization lab - A long-term nursing care facility

A long-term nursing care facility Rationale: Surgical asepsis is least likely to be found in the long-term nursing care unit. It is most likely utilized in operating rooms, labor and delivery units, and on certain procedural units such as the cardiac catheterization lab.

Which is not a potential source of an infection that could cause sepsis? - Central venous access device - Atherosclerosis - COVID-19 - Stage 4 pressure injury

Atherosclerosis Rationale: Atherosclerosis does not cause sepsis. Central venous access devices, COVID-19, and a wound like a stage 4 pressure injury are all potential sources of infections that lead to sepsis.

___________ are low molecular weight regulatory proteins that are produced by cells of innate and adaptive immunity.

Cytokines

Lymphocytes are categorized as either granulocytes or agranulocytes.

FALSE

Humoral- and cell-mediated immunity are types of innate immunity.

FALSE Rationale: The responders of the innate immune system include phagocytic white blood cells (leukocytes), lymphocytes (specifically natural killer lymphocytes), and proteins of the complement system.

Which are interprofessional goals of treating sepsis? Select all that apply. - Prevent and treat infection. - Maintain tissue oxygenation. - Avoid nutritional support. - Support failing organs. - Keep mean arterial pressure (MAP) above 65 mm Hg.

Prevent and treat infection., Maintain tissue oxygenation., Support failing organs., Keep mean arterial pressure (MAP) above 65 mm Hg. Rationale: Interprofessional goals for treating sepsis are to prevent and treat infection, maintain tissue oxygenation, provide nutritional and metabolic support, support failing organs, and to keep the MAP above 65 mm Hg.

Toll-like receptors play a role in the pathogen sensation process of innate immunity.

TRUE

The __________ system is a contributor to both innate and humoral immunity that requires sequential activation.

complement

Antibodies are also known as __________.

Immunoglobulins

What is aseptic technique? - All activities to prevent infection or break the chain of infection - Strict sterile technique always - The proper way to make and maintain a bed - A way to safely administer medications to prevent infection

All activities to prevent infection or break the chain of infection Rationale: Aseptic technique includes all activities to prevent infection or break the chain of infection. It is not the same as strict sterile technique and encompasses more than making and maintaining a bed or safely administering medications.

Which statement is true regarding drawing blood cultures? - Always draw one blood culture before administering antibiotics. - Draw one set of blood cultures, administer antibiotics, and then draw second set of blood cultures. - Always draw both sets of blood cultures before administering antibiotics. - Drawing blood cultures and administering antibiotics can be done simultaneously.

Always draw both sets of blood cultures before administering antibiotics. Rationale: The nurse should always draw both sets of blood cultures before administering antibiotics to ensure that the best unaltered sample is obtained.

For a patient on any type of precautions, when is hand hygiene supposed to be completed? - Before entering or exiting the room - Only when hands are visibly soiled - Before getting report in the morning - When wearing sterile gloves

Before entering or exiting the room Rationale: For patients on any precautions, hand hygiene before entering the room and upon exiting the room is required. It should also be done when hands are visibly soiled. It is not necessary to wash hands in sterile gloves, and it is not required before getting report.

In what area is medical asepsis most likely utilized? - The operating room - A medical-surgical unit - An outpatient psychiatric unit - Every area of healthcare

Every area of healthcare Rationale: Medical asepsis is utilized in every area of healthcare at all times. It is not limited to one department or unit.

Components of the innate immune system can be physical, chemical, lymphocytes, and/or antibodies.

FALSE Rationale: Innate immunity is the first line of defense or protection against pathogenic microorganisms and includes physical barriers such as intact skin, chemical barriers such as tears, and cellular defenders such as neutrophils.

Passive immunity is achieved through immunization.

False, active immunity

What is the proper order for donning personal protective equipment? - Gown, mask, goggles, gloves - Gloves, gown, goggles, mask - Mask, gown, gloves goggles - Goggles, mask, gown, gloves

Gown, mask, goggles, gloves Rationale: Per the Centers of Disease Control and Prevention (CDC), the nurse applies the gown, mask, goggles, then gloves. Think of this as going up the body with the gloves last.

The innate immune system is able to recognize and identify self from nonself as well as microbial organisms.

TRUE Rationale: One of the characteristics of the innate immune system is its ability to distinguish self from nonself and thereby rapidly identify pathogenic microorganisms as invaders (nonself) and begin to defend against these cells.

The innate immune system is a quickly reacting system.

TRUE Rationale: Part of the innate immune response involves the phagocytic neutrophils. This system and these cells can rapidly determine self from nonself and can mount defenses against penetrating microorganisms within minutes to hours. Other components of the innate immune system include physical and chemical barriers that are an immediate barrier or defense against microorganisms.

Which description best characterizes sepsis? - A localized infection - An infection that spread from the skin to the lymph nodes - The body's exaggerated response to infection - An infection that develops postoperatively

The body's exaggerated response to infection Rationale: Sepsis is the body's extreme response to infection. It affects the full body and is not localized. It affects more than the skin and lymph nodes and while it can develop postoperatively, it can also develop due to other reasons.

A patient on droplet precautions needs to leave their room for a computed tomography (CT) scan. How should the nurse address the droplet precautions? - The patient should not wear anything additional. - The patient must promise not to cough when outside the room. - The patient should hold a sheet over their mouth when talking to others outside the room. - The patient should don a surgical mask for the duration of time spent outside the room.

The patient should don a surgical mask for the duration of time spent outside the room. Rationale: The patient should don a surgical mask when outside of the room. Not wearing a mask will not prevent droplet transmission. The patient cannot promise not to cough and should not be asked to. The patient needs a mask to cover their mouth, not a sheet.

Why is it important to know surgical asepsis? - To know how to act around a sterile environment - To understand how to handle bed linens - To know why informed consent is essential - To know how to clean a patient for good hygiene

To know how to act around a sterile environment Rationale: Knowing how to act in a sterile environment is paramount for quality, safe care. Cleaning a patient and handling bed linens are more related to medical asepsis. Informed consent does not have anything to do with surgical asepsis.

What is the goal of clean technique? - To keep objects free of microorganisms - To provide information on a sterile field - To reduce the number and transfer of pathogens - To keep the operating room floor clean

To reduce the number and transfer of pathogens Rationale: The goal of clean technique (medical asepsis) is to reduce the number and transfer of pathogens. Keeping objects free of microorganisms and providing information on a sterile field are parts of sterile technique (surgical asepsis). Neither technique has specific indications regarding the floor of the operating room.

Which diagnoses warrant airborne precautions? - Influenza, rubella, diphtheria - Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant - Enterococci(VRE), extended spectrum beta-lactamase (ESBL) - Tuberculosis, measles, disseminated herpes zoster - Lung cancer, liver disease, stage IV pressure injuries

Tuberculosis, measles, disseminated herpes zoster Rationale: Tuberculosis, measles, and disseminated herpes zoster are indications for a patient to be on airborne precautions. Influenza, rubella, and diphtheria require droplet precautions. MRSA, VRE, and ESBL require contact precautions. Lung cancer, liver disease, and stage IV pressure injuries are not transmissible and do not indicate specific types of precautions.

Which patient is at the highest risk for developing sepsis? - A patient admitted for nephrolithiasis - A patient admitted for end-stage kidney disease - A patient admitted for vaginal delivery of a child - A patient who is newly nothing-by-mouth (NPO) status for a procedure in the morning

Which patient is at the highest risk for developing sepsis? Rationale: People who are immunocompromised, older adults, have chronic illnesses, or have undergone invasive procedures and emergent and/or multiple surgeries are at the highest risk for developing sepsis. In this group, the patient admitted for end-stage kidney disease is at a higher risk than the patient with nephrolithiasis, the patient giving birth, or the patient who is awaiting a procedure.

____________ immunity is mediated by secreted molecules and is the main defense against extracellular microbes.

humoral

The organ most closely associated with the maturation of T cells is the __________.

thymus