Immunity, Infection, & Inflammation PP1 EAQs

The nurse is preparing to insert an intravenous (IV) catheter in a thin, emaciated client who is scheduled to begin intravenous fluid therapy. Which interventions would the nurse follow to provide high-quality care? SATA a.) Insert an 18-gauge IV catheter b.) Change the IV line every 7 days c.) Flush the IV line with normal saline d.) Insert the IV catheter in the client's femur e.) Stop the insertion procedure when there is a break in technique

C & E

The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infections? a.) To the client from outside sources b.) From the clients to others c.) From the client by using special techniques to destroy infectious fluids and secretions d.) To the client by using special sterilization techniques for linens and personal items

a.) to the client from outside sources

Which therapeutic outcome is expected after administering ibuprofen? SATA a.) Diuresis b.) Pain relief c.) Temperature reduction d.) Bronchodilation e.) Anticoagulation f.) Reduced inflammation

B, C, & F

Which infection would the nurse monitor for in the toddler based on structural characteristics at this age? SATA a.) Bronchiolitis b.) Ear infection c.) Acute sinusitis d.) Laryngotracheobronchitis e.) Inflammation of the tonsils

B, C, D, & E

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse assesses the recorded vital signs. Which vital sign assessment requires reassessment? SATA a.) Respiratory rate of 14 breaths/minute b.) Blood pressure of 120/80 mm Hg c.) Oxygen saturation of 95% d.) Temporal temperature of 99.3°F (37.4°C) e.) Radial pulse rate of 72 and irregular

a.) respiratory rate of 14 breaths/minute b.) blood pressure of 120/80 mm Hg c.) oxygen saturation of 95%

Which is the correct response to a parent whose child is undergoing chemotherapy and is not up to date on required immunizations for school? a.) "By this time your child has developed sufficient antibodies to provide immunity" b.) "Maintaining current immunizations is critical. Make sure the series is completed" c.) "This isn't the best time to finish the immunizations, because your child's immune system is suppressed" d.) "It's important to complete the immunizations because your child needs to be protected from childhood diseases that could be fatal"

c.) "This isn't the best time to finish the immunizations, because your child's immune system is suppressed"

The nurse is caring for a client with chronic inflammation of the bowel. For which most serious complication would the nurse monitor in this client? a.) Ileus b.) Pain c.) Perforation d.) Obstruction

c.) perforation

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting for 5 days. Upon further assessment, the primary healthcare provider finds symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which foodborne disease would the provider suspect in this client? a.) Listeriosis b.) Shigellosis c.) Salmonellosis d.) Staphylococcus

c.) Salmonellosis

The nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media? a.) Complete the entire course of antibiotic therapy b.) Herbal fever remedies are highly discouraged c.) Administer the medication with meals d.) Stop the antibiotic therapy when the child no longer has a fever

a.) complete the entire course of antibiotic therapy

Which findings noted during assessment would lead the nurse to determine that a client is at an increased risk for infection? SATA a.) Surgical incision b.) Urinary catheter c.) Antibiotic therapy d.) Intravenous access e.) Diminished appetite

A, B, C, & D

Arrange the steps required to stimulate antibody-mediated immunity in the sequence they occur: a.) Neutralization or elimination of the antigen b.) Invasion of new antigens in the body c.) Production of antibodies by B lymphocytes d.) Sensitization of B lymphocyte to the new antigen e.) Interaction of the macrophage and helper T cells to recognize the antigen f.) Binding of antibodies to the antigen and formation of immune complex

b, e, d, c, f, a

A client who has rheumatoid arthritis participates in an individualized exercise program daily. Which statement from the client indicates to the nurse that the client understands the purpose of the program? a.) "I know the exercises are important, so I do them as many times as I can" b.) "I do my exercises when I go to physical therapy in the morning and afternoon" c.) "Because I'm stiff in the morning, I do most of my exercises then, so I'm done for the day" d.) "I do one set of exercises slowly after breakfast, then I space the rest of them throughout the day"

d.) "I do one set of exercises slowly after breakfast, then I space the rest of them throughout the day"

Which instruction indicates a lack of understanding of a nurse teaching a human immunodeficiency virus (HIV)-positive client about strategies to prevent opportunistic infections? a.) "Reuse cups after washing them with warm soapy water" b.) "Rinse your toothbrush in liquid laundry bleach every week" c.) "Wash your armpits, groin, and genitals with antimicrobial soap twice a day" d.) "Purchase organic, unpasteurized apple cider for your vitamin C requirements"

d.) "Purchase organic, unpasteurized apple cider for your vitamin C requirements"

The nurses in a healthcare facility have developed a new care plan to prevent the risk of infection in clients with indwelling catheter in place. To determine if the changes prevent infections, the nurse manager uses the pan-do-study-act (PDSA). Place in order the steps that the nurse manager would follow to evaluate the changes. a.) Try out the change b.) Plan to test the change c.) Determine what was learned d.) Analyze what happened from the change

B, A, D, C

Which condition triggers humoral immunity? SATA a.) Tuberculosis b.) Atopic diseases c.) Bacterial infection d.) Anaphylactic shock e.) Contact dermatitis

B, C, D

Which scenario would the nurse consider an output component of the nursing process? SATA a.) While assessing a client, the nurse finds a history of mental illness b.) While assessing a client who is obese, the nurse finds a history of asthma c.) The nurse notices the client's wounds healed after performing regular wound debridement d.) When changing the surgical site dressing, the nurse notices the client developing an infection e.) The nurse finds the client's blood pressure increased, even with timely medication administration

C, D, & E

Which client would the nurse suspect as having a type IV hypersensitive reaction when providing care for four clients with hypersensitivity reactions? Client A: IgE antibody, wheal and flare result Client B: IgM antibody, no skin test result Client C: IgG antibody, erythema & edema after 4 hours Client D: No antibody, erythema & edema after 24 hours

Client D Type IV or delayed hypersensitive reactions are cell-mediated immune responses that involve T lymphocytes, not antibodies. These cause erythema and edema in client D within 24-48hours after a skin test.

Arrange the steps involved in skin testing for an allergen causing a type I allergic reaction in their correct sequence. a.) Use a skin testing needle to scratch the surface of the skin b.) Apply topical steroid on the skin c.) Observe for a wheal formation on the skin d.) Discontinue corticosteroid medications e.) Clean the inner side of the forearm with soap and water f.) Place drops of sera containing the known allergen on skin

D, E, F, A, C, B

Which action would the nurse instruct an older client to implement to ensure antibody-mediated immunity? SATA a.) Obtain a shingles vaccination b.) Receive a tetanus booster injection c.) Obtain the pneumococcal vaccination d.) Receive annual testing for tuberculosis e.) Receive an annual influenza vaccination f.) Avoid obtaining the pertussis vaccination

A, B, C, & E

Which option is an example of actively acquired specific immunity? SATA a.) Recovery from measles b.) Recovery from chickenpox c.) Maternal immunoglobulin in the neonate d.) Immunization with live or killed vaccines e.) Injection of human gamma immunoglobulin

A, B, D

Identify the clinical manifestation associated with the release of histamine during a type I rapid hypersensitivity reaction. SATA a.) Pruritus b.) Erythema c.) Fibrotic changes d.) Nasal mucus secretion e.) Conjunctival mucus secretion f.) Hematuria

A, B, D, & E

Which information is appropriate for the nurse to include in the education for a group of nursing students regarding near-miss events? SATA a.) No actual harm is caused to the clients b.) Moderate-harm may be caused c.) They are caused by a variation in standard care d.) They are caused by impaired immune functioning e.) The cause may be analyzed by a failure modes effects analysis (FMEA).

A, C, & E

After a client experiences a cardiac arrest, the client is transferred to the intensive care unit (ICU). Which nursing intervention is the major attribute that affects the quality of care provided to the client? SATA a.) Develop a diet plan according to the client's food preference b.) Coordinate with the members of the ICU while transferring the client c.) Provide cardiopulmonary resuscitation before transferring the client d.) Encourage the client's family members to visit the client frequently e.) Administer digoxin to the client according to the prescription

B, C, & E

The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? a.) Hand washing before and after providing client care b.) Cleaning all equipment with an approved disinfectant after use c.) Wearing personal protective equipment (PPE) when providing client care d.) Using medical and surgical aseptic techniques at all times

a.) Hand washing before and after providing client care

The nurse is changing the dressing of a postoperative client. Another client has fallen near the nursing station and is unconscious. Which is the priority nursing action in this situation? a.) Attend to the client who lost consciousness b.) Delegate the dressing change to the nursing assistant c.) Delegate the care of the unconscious client to the nursing assistant d.) Complete the dressing because the open wound may increase infection risk

a.) attend to the client who lost consciousness

Which tasks should the nurse perform to comply with public health laws? SATA a.) Report cases of communicable diseases b.) Report incidences of domestic violence c.) Provide emergency assistance at an accident scene d.) Notify the primary healthcare provider of any client-related problems e.) Ensure that clients in a community have received necessary immunizations

a.) report cases of communicable diseases b.) report incidences of domestic violence e.) ensure that clients in a community have received necessary immunizations

While assessing a client, the nurse finds the inflammation of the skin at the bases of the client's nails. Which event or disorder would the nurse associate with the reason behind this condition? a.) Trauma b.) Trichinosis c.) Pulmonary disease d.) Iron-deficiency anemia

a.) trauma

Which complication would the nurse monitor for in a client on strict bed rest for 3 days? SATA a.) Atelectasis b.) Hypotension c.) Constipation d.) Pressure injuries e.) Urinary tract infection

all are correct clients on bedrest are at risk for complications secondary to mobility

A client with a methicillin-resistant Staphylococcus aureus (MRSA) infected wound is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse would implement which precaution? a.) No special precautions are required b.) Cover the infected site with a dressing c.) Drape the client with a covering labeled biohazardous d.) Place a surgical mask on the client

b.) cover the infected site with a dressing

Which assessment findings would the nurse identify in a client with clinical manifestations of rheumatoid arthritis? SATA a.) Obesity and asymmetric joint disease b.) Development of antinuclear antibodies c.) Inflammatory disease pattern d.) Bilateral involvement of metacarpophalangeal joints e.) Disease process involving the distal interphalangeal joints f.) Disease in the weight-bearing joints and hands

b.) development of antinuclear antibodies c.) inflammatory disease pattern d.) bilateral involvement of metacarpophalangeal joints

Which factor explains why a client who experiences an acute episode of rheumatoid arthritis has swollen finger joints? a.) Urate crystals in the synovial tissue b.) Inflammation in the joint's synovial lining c.) Formation of bony spurs on the joint surfaces d.) Deterioration and loss of articular cartilage joints

b.) inflammation in the joint's synovial lining

The nurse is preparing discharge instructions for a client who acquired a nosocomial Clostridium difficile infection. Which would the nurse include in the instructions? a.) Anticipate that nausea and vomiting will continue until the infection is no longer present b.) The infection causes diarrhea accompanied by flatus and abdominal discomfort c.) Consume a diet that is high in fiber and low in fat d.) Other than routine hand washing, it isn't necessary to perform special disinfection procedures

b.) the infection causes diarrhea accompanied by flatus and abdominal discomfort

A client arriving at a health clinic reports, "I am here to have my tuberculin skin test read." The nurse notes a 7-mm indurated area at the injection site. Which nurse's statement describes this result? a.) "The result indicates that you have active tuberculosis" b.) "The result indicates you are infected with the tuberculosis organism" c.) "The result indicates there are no tuberculin antibodies in your system" d.) "The result indicates you have a secondary infection related to the tuberculin organism"

b.) the result indicates you are infected with the tuberculosis organism

After instructing an older client's adult child about age-related immune system changes and associated care measures, which statement indicates a need for further instruction? a.) "My parent has a private room at home" b.) "My parent has received the pneumococcal vaccination recently" c.) "My parent comes in for checkups only when experiencing a fever" d.) "My parent has been given a second dose of the pertussis vaccination"

c.) "my parent comes in for checkups only when experiencing a fever"

Which education would the nurse provide the parent of a 2-month-old infant about home care in the event of an immunization reaction? a.) Give aspirin for pain; if swelling at the injection site develops, call the healthcare provider b.) Apply heat to the injection site for the first day after the injection; apply ice if the arm is inflamed c.) Give acetaminophen for fever; call the healthcare provider if the child exhibits marked drowsiness or seizures d.) Apply ice to the injection site if soreness develops; call the healthcare provider if the child comes down with a fever

c.) give acetaminophen for fever; call the healthcare provider if the child exhibits marked drowsiness or seizures

A 5-month-old infant is brought to the pediatric clinic because of exposure to an adolescent sibling with measles. Which factor would the nurse consider when determining the infant's risk of infection? a.) The infant's immunizations b.) The infant's previous viral illnesses c.) Maternal diseases and immunizations d.) Maternal exposure to tuberculosis and herpes genitalis

c.) maternal diseases and immunizations

The nurse is collecting case reports that can be analyzed using the failure mode effective analysis (FMEA) tool. Which case files would the nurse select? SATA a.) A coma due to severe hemolytic transfusion reaction b.) Depression committed suicide by falling off the terrace of the hospital c.) Retained foreign body left during surgery that was removed immediately d.) Wheelchair-bound client rescued from falling in the corridor of the hospital e.) Urinary tract infection after 4 days of continuous catheterization

c.) retained foreign body left during surgery that was removed immediately d.) wheelchair-bound client rescued from falling in the corridor of the hospital e.) urinary tract infection after 4 days of continuous catheterization

The patient of a newborn asks the nurse why, except for the hepatitis B vaccine, the immunization schedule doesn't start until the infant is 2 months old. Which response would the nurse provide? a.) "A newborn's spleen can't produce efficient antibodies" b.) "Infants younger than 2 months are rarely exposed to infectious disease" c.) "The immunization will attack the infant's immature immune system and cause the disease" d.) "Maternal antibodies interfere with the development of active antibodies by the infant when immunized."

d.) "maternal antibodies interfere with the development of active antibodies by the infant when immunized"

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Which statement describes the nurse's responsibility in this situation? a.) The nurse's judgement was adequate, and the client was treated accordingly b.) The possibility of tetanus was not foreseen because the client was immunized c.) Nurses would routinely administer immunization against tetanus after such an injury d.) Assessment by the nurse was incomplete and, as a result, the treatment was insufficient

d.) assessment by the nurse was incomplete and, as a result, the treatment was insufficient

Which recommendation would the nurse make to the family of a child with juvenile idiopathic arthritis who has difficulty getting ready for school in the morning due to joint pain and stiffness? a.) Administer acetaminophen before bedtime b.) Ice the joints that are painful in the evening c.) Encourage a program of active exercise after awakening d.) Provide warm, moist heat to the affected joints before arising

d.) provide warm, moist heat to the affected joints before arising

The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client? a.) All nursing functions will be completed by discharge b.) All invasive intravenous lines will remain patent c.) The client will remain awake, alert, and oriented at all times d.) The client will be free of signs and symptoms of infection by discharge

d.) the client will be free of signs and symptoms of infection by discharge

Which function of leukocytes is involved in the inflammation process? SATA a.) Destruction of bacteria and cellular debris b.) Selective attack and destruction of non-self cells c.) Release of vasoactive amines during allergic reactions d.) Secretion of immunoglobulins in response to a specific antigen e.) Enhancement of immune activity through secretion of various factors, cytokines, and lymphokines

A & C

Which leukocyte would the nurse include when teaching about antibody-mediated immunity? SATA a.) Monocyte b.) Memory cell c.) Helper T cell d.) B-lymphocyte e.) Cytotoxic T cell

B & D

Arrange the pathophysiological events of acne in the correct sequence. a.) Immune response and inflammation b.) Excessive sebum production c.) Alterations in follicular growth and differentiation d.) Colonization of Propionibacterium acnes

B, C, D, A

The nurse caring for a client post-surgery takes necessary steps to achieve quality client care. Which nursing action satisfies the Quality and Safety Education for Nurses (QSEN) competency called informatics? SATA a.) Washing the hands before handling the client's incision site b.) Implementing a new method of monitoring the client's incision site for infection c.) Documenting in the electronic health record (EHR) after performing wound debridement d.) Locking the electronic health record (EHR) after every entrance of necessary information e.) Using a computer-assisted instruction (CAI) program to provide better quality of care to the client

C, D, & E

Which response would the nurse provide during an education session at the local community center to a question asking why influenza vaccines are needed annually? A.) "The influenza virus has a high level of infectivity, thus requiring an annual booster to keep rates of influenza low" B.) "Because influenza is seasonal and has never been eradicated, the need for a vaccine is also seasonal annually" C.) "The nature of the virus changes every year; the vaccine is developed based on the most prevalent type and variant being seen" D.) "There are several types of influenza viruses with differing levels of virulence, making it difficult to develop a vaccine that will be effective against all types of influenza"

C.) "The nature of the virus changes every year; the vaccine is developed based on the most prevalent type and variant being seen"

Which client condition is an example of cell-mediated immunity? SATA a.) Tuberculosis (TB) b.) Graft rejection c.) Allergic rhinitis d.) Contact dermatitis e.) Anaphylactic shock

A, B, & D

Which information will the nurse consider when planning care for a client with human immunodeficiency virus (HIV) who has been diagnosed with class 3 tuberculosis? SATA a.) Class 3 tuberculosis is a clinically active disease, which is contagious b.) Tuberculosis is the leading cause of mortality in clients infected with HIV c.) HIV-positive clients are more likely to have multidrug resistant tuberculosis d.) Individuals with HIV usually have high fevers with active tuberculosis infection e.) Persons with active tuberculosis are usually treated on an outpatient basis

A, B, & E

Which disease process places a client at increased risk for infection? SATA a.) Leukemia b.) Lymphoma c.) Emphysema d.) Schizophrenia e.) Osteoarthritis

A, B, C

Which strategies would the nurse apply when vaccinating a child to decrease pain and anxiety? SATA a.) Applying a topical anesthetic b.) Injecting the most painful vaccine last c.) Holding the child upright during the vaccination d.) Administering intramuscular injections rapidly without prior aspiration e.) Administering acetaminophen or ibuprofen after vaccination

A, B, C, & D are correct

According to Maslow's hierarchy, which example belongs to the third level of needs? SATA a.) "A client is depressed because their significant other passed away" b.) "A client is constipated due to excess loss of fluids from the body" c.) "A client wants to reconnect with old friends after being diagnosed with cancer" d.) "A client has to live in a rat-infested apartment due to a lack of financial resources" e.) "A client never goes to family gatherings because the family members don't accept the client"

A, C, & E

Which intervention would the nurse anticipate incorporating into the plan of care for a client with bursitis of the left knee? SATA a.) Rest the affected joint b.) Apply a heat pack c.) Use a compression splint d.) Do gentle range-of-motion exercises e.) Take nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for pain

A, C, & E

The nurse instructs a client who avoids bathing to take a bath or shower each day as a means of maintaining hygiene and preventing infection. Which of these reactions would the nurse expect if the client is in the action stage? SATA a.) "I only take a bath once a week, but I don't see any infections on my skin" b.) "I try to take a shower every day, but I skip it sometimes because of my tight work schedule" c.) "I understand that bathing regularly is a good habit, but my bathroom is very cold in the mornings" d.) "Please tell me how to get into the habit of taking a bath daily so that I can keep myself clean and healthy" e.) "I want to take a bath regularly, but I don't have time because I need to look after my kids and my parents"

B, C, & E are correct

Place in order the steps the nurse would follow when developing a protocol in the electronic health record for clients with indwelling urinary catheters to decrease the risk of urinary tract infections. a.) Selects an assessment tool b.) Adds a decision support rule c.) Interviews the nursing staff d.) Meets with the nursing staff e.) Evaluates and determines data f.) Selects a standardized language g.) Designs the assessment screens

D, A, C, G, E, F, B

When assessing risk factors, which question would the nurse ask a client who has developed pneumonia? a.) "Are you diabetic?" b.) "Have you ever had pneumonia?" c.) "What do you use for contraception?" d.) "Do you have a history of intravenous (IV) drug abuse?"

a.) "Are you diabetic?"

Which type of immunity would a 4-year-old child develop during the course of an infection with varicella? a.) Active natural immunity b.) Active artificial immunity c.) Passive natural immunity d.) Passive artificial immunity

a.) Active natural immunity

The nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which clinical findings to this disease would the nurse expect the client to exhibit? SATA a.) butterfly facial rash b.) firm skin fixed to tissue c.) inflammation of the joints d.) muscle mass degeneration e.) inflammation of small arteries

a.) butterfly facial rash c.) inflammation of the joints

Which nursing intervention is the priority when a client receiving chemotherapy develops a temperature of 102.2°F (39°C) when the temperature 6 hours ago was 99.2°F (37.3°C)? a.) Assess the amount and color of urine; obtain a specimen for a urinalysis and culture b.) Administer the prescribed antipyretic and notify the primary healthcare provider of this change c.) Note the consistency of respiratory secretions and obtain a specimen for culture and sensitivity d.) Obtain the respirations, pulse, and blood pressure when rechecking the temperature in 1 hour

b.) Administer the prescribed antipyretic and notify the primary healthcare provider of this change

The nurse is caring for a client who had an above-the-knee amputation 1 week ago. Which action would the nurse take to control edema of the residual limb? a.) Administer a diuretic as needed b.) Restrict the client's oral fluid intake c.) Rewrap the elastic bandage as necessary d.) Keep the residual limb elevated on a pillow

c.) rewrap the elastic bandage as necessary

Which describes the purpose of preoperative antibiotics for a client scheduled for a surgical resection of the colon and creation of a colostomy? a.) To decrease peristalsis b.) To minimize electrolyte imbalance c.) To decrease bacteria in the intestines d.) To treat inflammation caused by the malignancy

c.) to decrease bacteria in the intestines

Which nursing intervention would prevent septic shock in the hospitalized client? a.) Maintain the client in a normothermic state b.) Administer blood products to replace fluid losses c.) Use aseptic technique during all invasive procedures d.) Keep the critically ill client immobilized to reduce metabolic demands

c.) use aseptic technique during all invasive procedures

After teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STIs), which client statement indicates effective learning? a.) "I will use condoms when having sex with an infected partner" b.) "I will perform a self-examination of my genitals every month before bathing" c.) "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years" d.) "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia"

d.) "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia"

Which response would the nurse give to a client taking ibuprofen for rheumatoid arthritis who asks the nurse if acetaminophen can be substituted? a.) "Yes, both are antipyretics and have the same effect" b.) "Acetaminophen irritates the stomach more than ibuprofen does" c.) "Acetaminophen is the preferred treatment for rheumatoid arthritis" d.) "Ibuprofen has anti-inflammatory properties, and acetaminophen does not"

d.) "Ibuprofen has anti-inflammatory properties, and acetaminophen does not"

Which meal is most appropriate for a client with a large pressure injury? a.) Hamburger with French fries b.) Turkey meatloaf with brown rice c.) Pasta and tomato sauce with a side salad d.) Grilled chicken, steamed spinach, and a side of orange slices

d.) grilled chicken, steamed spinach, and a side of orange slices

Which type of delayed hypersensitivity reaction does the client pictured in the image likely have? a.) Type I b.) Type II c.) Type III d.) Type IV (Contact dermatitis of the skin to rubber boots)

d.) type IV