⭐️CM1 test THREE = immunity & inflammation

which bacterial infection displays as hot, tender, erythematous, and edematous area with a diffusion boarder?

cellulitis

which condition would the nurse suspect in a client reporting fever, redness, skin breakdown, and inflammation on the leg with an area that is tender and edematous with diffused border? a. shingles b. cellulitis c. folliculitis d. onychomycosis

cellulitis

which action will the nurse take when caring for a client whose IV site is tender with erythema, warmth, and mild edema? a. irrigate IV tubing b. change IV site c. slow infusion rate d. obtain a prescription for an analgesic

change IV site

when teaching a health promotion class at a retirement home, which info would you include about ways to decrease infection? a. use handkerchiefs b. get the flu vaccine c. decrease dietary protein d. limit daily activity

get the flu vaccine

which assessment finding would the nurse expect to increase in a client with Cushing's syndrome? a. urine output b. glucose level c. serum potassium d. fever

glucose level

which example illustrates health promotion activities? select all that apply a. good nutrition b. regular exercise c. physical awareness d. immunization against measles e. education about stress management

good nutrition regular exercise

Which client statement indicates that the client understands the nurse's instructions about long-term steroid therapy? a. my urine may become discolored b. i should avoid crowds in enclosed areas c. weight loss can occur with this med d. the med should be taken between meals

i should avoid crowds in enclosed areas

which statement by the nursing student indicates understanding of the precautions needed in the provision of care to a child who's HIV positive? a. "ill put on a mask" b. "ill wear an N-95" c. "ill wear a gown & gloves" d. "ill wear gloves if i'm in contact with body fluids"

i'll wear gloves if i'm in contact with body fluids

which factor is the cause of frequent upper respiratory tract infections in toddlers? a. stress b. unhealthy diet c. lack of exercise d. immature immune system

immature immune system

which potential complication is important for the nurse to include when teaching prevention strategies to clients with HIV? a. infection b. depression c. social isolation d. kaposi sarcoma

infection

Hgb and Hct are used to determine the presence of ____________

inflammation

what does an elevated ESR lab test indicate?

inflammation or infection somewhere in the body

which cause would you suspect is responsible for warmth, redness, and tenderness at the pt's IV site? a. rapid fluid delivery b. phlebitis c. allergic response d. infiltration

phlebitis

which statement indicates effective teaching regarding the most effective measure to prevent the spread of infection? a. wear gloves when in contact with patients b. cover your mouth when you cough or sneeze c. proper hand washing can stop the spread of infection d. use sterile technique to stop infection when changing a dressing

proper hand washing can stop the spread of infection

which lab test will be evaluated in a client with inflammatory arthritis? a. leukocyte count b. Hgb Hct c. BUN and creatinine d. Erythrocyte sedimentation rate (ESR)

ESR

which potential immunological reaction may occur in a client who experiences localized edema & itching from an insect bite? a. anaphylaxis b. atopic reaction c. good pasture syndrome d. systemic lupus erythematosus

anaphylaxis

which action would you implement when a client has an anaphylactic reaction? select all apply O2 at 90-100% NC call rapid response elevate HOB to 45 degrees assign UAP to stay with client ensure emergency airway equipment is at bedside intubate client and initiate CPR

apply O2 at 90-100% NC call rapid response elevate HOB to 45 degrees ensure emergency airway equipment is at bedside

which action would the nurse implement when caring for a client reporting a recent bee sting presenting with localized redness, swelling, intense local pain, and itching? a. apply cool compressed to the area b. ensure client keeps skin clean & dry c. monitor for neurological and cardiac symptoms d. advise client to launder all clothes

apply cool compressed to the area

which priority action would the nurse perform when caring for a client with suspected anaphylaxis? a. obtain full vitals b. assess airway and oxygenation c. determin LOC d. notify the client's HC provider

assess airway and oxygenation

which action would you take after stoping the antibiotics infusion in a client who became restless and flushed and began to wheeze during administration? a. check their temp b. take their BP c. obtain SpO2 d. assess their RR and status

assess their RR and status

which nursing action is priority when admitting a child to the ED who was bitten by a dog? a. asking if they're allergic to horse serum b. assessing injury, VS, and health history c. inoculating the child with human rabies immunoglobulin d. notify the police to capture the dog

assessing injury, VS, and health history

what does an elevated leukocyte level indicate?

bacterial infection

Which info would the nurse teach the parent of an infant who is at risk for infection? a. you must avoid placing the infant in bright sunlight b. breast-feeding will provide protection against bacteria c. use soy-based infant formulas to help prevent infection d. the infant

breast-feeding will provide protection against bacteria

the nurse is preparing to administer a diphtheria, tetanus, and pertussis vaccine to a kid. After assessing she conclude that she can't give it safely. Which assessment finding supports that conclusion? a. fever has developed within 48 hr of previous vaccines b. child went into a shock-like state after previous vaccine c. child has a hx of anaphylaxis to vaccines d. child has an upper respiratory infection

child has a hx of anaphylaxis to vaccines

Which intervention would be an effective first-aid treatment for the nurse to implement for a client in the ED who states "I was bitten by a raccoon while working under my house" a. administer antivenin b. maintain a pressure dressing c. cleanse the wound with soap and water d. apply a tourniquet proximal to the wound

cleanse the wound with soap and water

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

client will be free of s/s of infection by discharge

which category of isolation would the nurse implement for a client with CDiff? a. airborne b. droplet c. contact d. protective environment

contact

which clinical finding leads the nurse to conclude that an IV has infiltrated rather than caused inflammation? a. pain b. coolness c. localized swelling d. cessation in flow of solution

coolness

Steroids decreased lymphocytes, resulting in a _______________

decreased immunity

which nursing action will be most helpful in preventing transmission of the flu in crowds? a. teaching proper hand washing b. demonstrating how to cover mouth c. educate on annual vaccinations d. give antiviral meds within 48 hours of symptom development

educate on annual vaccinations

What is the priority teaching point at discharge of a child who just finished a cycle of chemo? a. purchase a wig b. ensure adequate rest c. offer sufficient fluids d. perform thorough hand washing

perform thorough hand washing

which finding would the nurse identify as normal inflammation vs. an infection when assessing a client's wound from 72 hrs ago? a. increasing pain reported b. temp of 101 c. small amount of purulent drainage d. slight red border

slight red border

why does an IV infiltration feel cool?

the IV solution is room temp whereas the body temp is hot

The nurse places a school aged child with bacterial meningitis in isolation with droplet precautions. Which is the purpose of these precautions? a. they keep them away from uninfected people b. the infectious process is interrupted asap c. they're protected from contracting a secondary infection d. they prevent the development of a HAI

they keep them away from uninfected people

which response would be given to an elderly client brought in with partial-thickness burns a protests being in the hospital stating "why can't I just go home and let my wife take care of me?" a. "you sound upset but your doctor knows best" b. "your wife is capable but if your burns get infected they can't give you the injections you need" c. "your burns are more serious than you think and we have specially trained people here" d. "you may heal more slowly bc of your age and might need the specia

you may heal more slowly bc of your age and might need the special care & equipment here"