Concepts II Week 2 Material

A male client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: 1. fluid resuscitation. 2. infection. 3. body image. 4. pain management.

4. pain management Explanation: With a superficial partial thickness burn such as a solar burn (sunburn), the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

Select all the organs from the following list that are part of the immune system. A. Adenoids B. Appendix C. Bone marrow D. Gallbladder E. Liver F. Thyroid gland

A B C The lymphoid organs of the immune system are the adenoids, appendix, and bone marrow. Other organs of the immune system include the lymph nodes, thymus gland, tonsils, and spleen. The gallbladder, liver, and thyroid gland are not part of the immune system

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to (Select all that apply): A. Wear sunglasses. B. Drink plenty of water. C. Eat plenty of foods high in vitamin K. D. Apply sunscreen 30 minutes prior to exposure.

A and D Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and has not been indicated.

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose of 136 mg/dL b. Oral temperature of 101° F (38.3° C) c. Separation of the proximal wound edges d. Patient complaint of increased incisional pain

ANS: C Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly. DIF: Cognitive Level: Analyze (analysis)

*When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?* 1) Necrotic tissue 2) Wound drainage 3) Wound circumference 4) Cleansed wound

*Answer: 4* Rationale: Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? 1. Walking without shoes 2. Sitting in Fowler's position 3. Lying supine in bed 4. Using a heating pad

2. Sitting in Fowler's position; None of the other movements or situations creates the combination of friction and pressure with downward movement seen in bedridden clients positioned in Fowler's position.

To reduce pressure points that may lead to pressure ulcers, the nurse should: 1. Position the client directly on the trochanter when side-lying 2. Use a donut device for the client when sitting up 3. Elevate the head of the bed as little as possible 4. Massage over the bony prominences

3. Elevate the head of the bed as little as possible Explanation: elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development form shearing forces.

An infant develops a fever secondary to a bacterial infection. Which of the following most likely triggered the fever? a. Interleukin-1 b. Interleukin-6 c. Interleukin-10 d. Interferons (INFs)

A

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient has had the heel ulcers for 6 months. b. The patient takes oral hypoglycemic agents daily. c. The patient states that the ulcers are very painful. d. The patient has several incisions that formed keloids.

ANS: B The use of oral hypoglycemics indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the past 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's pain will be implemented, but pain does not directly affect wound healing. DIF: Cognitive Level: Analyze (analysis) Apply

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a. Obtaining a complete blood count (CBC) b. Protection from excessive heat c. Protection from excessive ultraviolet (UV) exposure d. Instructing the patient to take their multivitamin prior to treatment

ANS: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis. REF: Page 267 OBJ: NCLEX® Client Needs Category: Safe and Effective Care Environment Safety: Safety and Infection Control

A patient's 4 x 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing c. Hydrocolloid dressing b. Nonadherent dressing d. Transparent film dressing

ANS: C The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for clean wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound. DIF: Cognitive Level: Apply (application)

A client who sustained burns to both lower extremities complains to the nurse about feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time? A) Ineffective Coping B) Powerlessness C) Anxiety D) Situational Low Self-Esteem

Answer: B Explanation: The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low-self-esteem, ineffective coping, or anxiety.

A patient is admitted to the medical unit with a 103.7*F temperature. Which of the following would be most effective in restoring normal body temperature? A. use a cooling blanket while the patient is febrile B. administer antipyretics on a round-the-clock schedule C. provide increased fluids and have the NAP give sponge baths D. give prescribed antibiotics and provide warm blankets for comfort.

B

A public health nurse is teaching the community about health promotion. Which information should the nurse include for innate immunity? Innate immunity is gained: a. Following an illness b. At birth c. Via injection of specific antibodies d. In adulthood

B

Passive acquired immunity in the baby is also provided by ______________ which crosses through the placenta and is present in the baby for at least 3 months A IgA B IgM C IgG D IgD

C IgG

A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action? 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. When administering immunotherapy, it is imperative to closely monitor the patient for any signs of an adverse reaction. The high risk and significant consequence of an adverse reaction supersede the need to assess the patient's fluid balance. Pain and changes in level of consciousness are not likely events when administering immunotherapy. Text Reference - p. 215

The function of monocytes in immunity is related to their ability to: A. stimulate the production of T and B lymphocytes B. produce antibodies on exposure to foreign substances C. bind antigens and stimulate natural killer cell activation D. capture antigens by phagocytosis and present them to lymphocytes

D Rationale: The mononuclear phagocyte system includes monocytes in the blood and macrophages found throughout the body. Mononuclear phagocytes have a critical role in the immune system. They are responsible for capturing, processing, and presenting the antigen to the lymphocytes.

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.

ANS: A The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well. DIF: Cognitive Level: Analyze (analysis)

*After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (select all that apply)* 1) Notify the surgeon 2) Allow the area to be exposed to air until all drainage has stopped 3) Place several cold packs over the area, protecting the skin around the wound 4) Cover the area with sterile, saline-soaked towels immediately 5) Cover the area with sterile gauze and apply an abdominal binder

*Answer: 1, 4* Rationale: If a patient has an opening in the surgical incision and a part of the small bowel is noted, this is evisceration. The small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

*Name the three important dimensions to consistently measure to determine wound healing*

*Answer: Width, length, depth* Rationale: Consistent measurement of the wound using the dimensions of width, length, and depth provide information on the overall change in wound size that indicates if the wound is moving toward healing.

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection?

A) Increased platelet count B) Increased blood urea nitrogen C) Increased number of band neutrophils D) Increased number of segmented myelocytes Answer: C The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse?

A) Notify the health care provider. B) Document the fistula formation. C) Assess the patient and vaginal drainage. D) Have the UAP apply a dressing to the vagina. Answer: C With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse should first assess the patient and drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care provided, describe interventions prescribed, and document the care and patient response.

The nurse assesses impaired skin integrity in this patient. How will the nurse document this?

A) Stage I B) Stage II C) Stage III D) Stage IV Answer: C Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage I ulcers have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage II ulcers are partial thickness with a red-pink wound bed. Stage IV ulcers involve extensive destruction of tissue with exposed bone, tendon, or muscle.

During the acute phase of a burn, the nurse in-charge should assess which of the following? 1. Client's lifestyle 2. Alcohol use 3. Tobacco use 4. Circulatory status

4. Circulatory status Explanation: During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.

On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action? 1. Documenting the findings 2. Loosening any dressings on the chest 3. Raising the head of the bed 4. Preparing for intubation

4. Preparing for intubation Explanation: Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway. The swelling usually precludes intubation.

An 85 year-old patient is assessed to have a score of 16 on the Braden scale.Based on this information, how should the nurse plan for this patient's care? A. implement a q2h turning schedule with skin assessment B. place a DuoDerm on the patient's sacrum to prevent breakdown C. elevate the head of the bed to 90* when the patient is supine D. continue weekly skin assessments with no extra precautions

A

To maintain a positive nitrogen balance in a major burn, the patient must: A) Eat a high-protein, low-fat, high-carbohydrate diet B) Increase normal caloric intake by about three times C) Eat at least 1500 calories/day in small, frequent meals D) Eat rice and whole wheat for the chemical effect on nitrogen balance

A

The most common cause of secondary immunodeficiencies is: A. drugs B. stress C. malnutrition D. human immunodeficiency virus

A Rationale: Drug-induced immunosuppression is the most common cause of secondary immunodeficiency disorders.

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

ANS: A Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition is also important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing. DIF: Cognitive Level: Analyze (analysis)

One function of cell-mediated immunity is: A. formation of antibodies B. activation of the complement system C. surveillance for malignant cell changes D. opsonization of antigens to allow phagocytosis by neutrophils

C Rationale: One role of cell-mediated immunity is immune surveillance to detect any malignant changes in cells and then destroy them.

After teaching the staff about the clotting system, which statement indicates teaching was successful? The end product of the clotting system is: a. Plasmin b. Fibrin c. Collagen d. Factor X

B

The nurse is monitoring a patient who has a past history of blood transfusion reactions. A transfusion reaction is an example of which of these hypersensitivity reactions? A. Type I: IgE-mediated B. Type II: Cytotoxic C. Type III: Immune-complex. D. Type IV: Delayed hypersensitivity.

B

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? A. The total 24-hour fluid requirement should be administered in the first 8 hours. B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

B Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours

When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient ()? (Select all that apply.) A. The exercises are the only way to prevent contractures. B. Active and passive ROM maintain function of body parts. C. ROM will show the patient that movement is still possible. D. Movement facilitates mobilization of leaked exudates back into the vascular bed. E. Active and passive ROM can only be done while the dressings are being changed.

B and C Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

After a successful organ transplant, a patient began receiving immunosuppressive therapy, specifically tacrolimus (Prograf), methylprednisolone (Solu-Medrol), and mycophenolate mofetil (CellCept). Which food should the nurse instruct the patient to avoid during this therapy? A. Jackfruit B. Grapefruit C. Dragon fruit D. Passion fruit

B. Grapefruit contains a chemical substance that interferes with the metabolism of tacrolimus, causing drug toxicity events. Jackfruit, dragon fruit, and passion fruit do not interfere with the metabolism of these medications. Text Reference - p. 223

The nurse creates a plan of care for a patient who has had an allergic reaction to a bee sting. What is the priority expected outcome for this patient? A. Verbalizing comfort B. Maintaining a clear and patent airway C. Being free of signs and symptoms of infection D. Demonstrating self-administration of epinephrine

B. This patient is at risk for development of an anaphylactic reaction. Maintaining a clear and patent airway is a priority outcome with a patient who has sustained a bee sting and has a known allergy to bees. Comfort and being free of signs and symptoms of infection are important after ensuring airway patency and breathing. Although the demonstration of self-administered epinephrine is likely valuable for the allergic patient, immediately after the bee sting is not the best time to engage in education because a delay in the administration of epinephrine could result. Text Reference - p. 214

A 5-year-old male is diagnosed with a bacterial infection. Cultures of the bacteria revealed lipopolysaccharides on the bacterial cell surface. Which of the complement pathways would be activated in this case? a. Classical pathway b. Lectin pathway c. Alternative pathway d. Kinin pathway

C

A 65-year-old female is diagnosed with metastatic breast cancer. She has developed muscle wasting. Which of the following substances would be produced in large quantities to eliminate the tumor cells and cause muscle wasting? a. Interleukin-6 b. Eosinophils c. Tumor necrosis factor d. Platelets

C

An 82 year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1cm x 2cm x 0.8cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? A. Stage I B. Stage II C. Stage III D. Stage IV

C

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? A. Full liquids only B. Whatever the patient requests C. High-protein and low-sodium foods D. High-calorie and high-protein foods

D A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

Using the Braden scale, which client is at highest risk for developing a pressure ulcer? 1. One with a score of 15 2. One with a score of 18 3. One with a score of 20 4. One with a score of 23

1. One with a score of 15 Explanation: clients with a score of less than 18 are at risk for developing a pressure ulcer. A maximum score is 23.

Which of the following is an example of a wound or injury that heals from secondary intention? 1. Pressure ulcer 2. Fracture 3. Sprained ankle 4. Surgical incision

1. Pressure ulcer Explanation: a pressure ulcer heals by secondary intention. The ends of the ulcer cannot be approximated. The wound must heal from the inside first.

*When is an application of a warm compress to an ankle muscle sprain indicated? (select all that apply)* 1) To relieve edema 2) To reduce shivering 3) To improve blood flow to an injured part 4) To protect bony prominences from pressure ulcers 5) To immobilize area

*Answer: 1, 3* Rationale: Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

*What does the Braden Scale evaluate?* 1) Skin integrity at bony prominences, including any wounds 2) Risk factors that place the patient at risk for skin breakdown 3) The amount of repositioning that the patient can tolerate 4) The factors that place the patient at risk for poor healing

*Answer: 2* Rationale: The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

How often do you assess an individual for pressure ulcers in the following settings? 1. acute care 2. long-term care 3. home care

1. every 24 hours 2. weekly for the first 4 weeks after admission then monthly/quarterly 3. every nurses visit

Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict: 1. range of motion. 2. protein intake. 3. going outdoors. 4. fluid ingestion.

1. range of motion. Explanation: To prevent disruption of the artificial skin's adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn't be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

Why is a client with fever often predisposed to pressure ulcers? 1. Pain perception is diminished. 2. Medications given to relieve fever cause edema. 3. The client may be too weak to change position. 4. Increased metabolism causes increased oxygen needs that cannot be met.

4. Increased metabolism causes increased oxygen needs that cannot be met; Increased metabolism causes increased oxygen needs that cannot be met; therefore, a client with a fever is predisposed to pressure ulcers. Answers 1 and 2 are false statements. Answer 3 may be a cause of pressure ulcers and may occur in clients with fever, but it is not directly related.

The complement, clotting, and kinin systems share which of the following characteristics? a. Activation of a series of proenzymes b. Phagocytosis initiation c. Granulocyte production d. Activated by interferon

A

The directional migration of leukocytes along a chemical gradient is termed: a. Chemotaxis b. Endocytosis c. Margination d. Diapedesis

A

The injury that is least likely to result in a full-thickness burn is: A) Sunburn B) Scald injury C) Chemical burn D) Electrical injury

A

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way?

A) Local response B) Systemic response C) Infectious response D) Acute inflammatory response Answer: B The systemic response to inflammation includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in 2 to 3 weeks and usually leaves no residual damage.

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication?

A) Pain level B) Intake and output C) Oxygen saturation D) Level of consciousness Answer: B Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient.

The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse?

A) Provide a light blanket. B) Encourage a hot shower. C) Monitor temperature every hour. D) Turn up the thermostat in the patient's room. Answer: A Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.

A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

ANS: 2140 calories DIF: Cognitive Level: Apply (application)

*What is the removal of devitalized tissue from a wound called?* 1) Debridement 2) Pressure reduction 3) Negative pressure wound therapy 4) Sanitization

Answer: 1

A 10-year-old male is diagnosed with a parasite. Which lab result should the nurse check for a response to the parasite? a. Monocytes b. Eosinophils c. Neutrophils d. Macrophages

B

A 20-year-old male shoots his hand with a nail gun while replacing roofing shingles. Which of the following cell types would be the first to aid in killing bacteria to prevent infection in his hand? a. Eosinophils b. Neutrophils c. Leukotrienes d. Monocytes

B

The nurse is reviewing the lab data of a newly admitted patient. The nurse notes the patient had an erythrocyte sedimentation done, and the results are quite elevated. The nurse would focus the care plan on which of the following conditions? a. Anemia b. Infection c. Inflammation d. Electrolyte imbalance

C

When an aide asks the nurse what is a purpose of the inflammatory process, how should the nurse respond? a. To provide specific responses toward antigens b. To lyse cell membranes of microorganisms c. To prevent infection of the injured tissue d. To create immunity against subsequent tissue injury

C

A patient is admitted to the burn centre with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? A) Obtain vital signs and a STAT arterial blood gas B) Encourage the patient to cough and auscultate the lungs again C) document the findings and continue to monitor the patient's breathing D) Anticipate the need for endotracheal intubation and notify the physician

D

If a person is heterozygous for a given gene, it means that the person: A. is a carrier for a genetic disorder B. is affected by the genetic disorder C. has two identical allels for the gene D. has two different allels for the gene

D

Intact skin with nonblanchable redness of a localized area

Stage I: Nonblanchable Erythema

A female client is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 1. 18% 2. 27% 3. 30% 4. 36%

4. 36% Explanation: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first? a. Remind the patient to remain calm. b. Administer subcutaneous epinephrine. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site.

ANS: C Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action.

The nurse, who is reviewing a clinic patient's medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate? a. Schedule an additional dose that week. b. Administer the usual dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by "passive immunity." Which example should the nurse use to explain this type of immunity? a. Early immunization b. Bone marrow donation c. Breastfeeding her infant d. Exposure to communicable diseases

ANS: C Colostrum provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. It requires that the infant has an immune response after exposure to an antigen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active immunity.

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she states which of the following? a. "My body will treat the new kidney like my original kidney." b. "I will have to make sure that I avoid being around people." c. "The medications that I take will help prevent my body from attacking my new kidney." d. "My body will only have a problem with my new kidney if the donor is not directly related to me."

ANS: C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don't have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.

A client with a burn injury is prescribed mechanical debridement of the wounds. What will the nurse plan to do when performing mechanical debridement? Select all that apply. A) Schedule the client for a homograft. B) Apply a topical agent to dissolve necrotic tissue. C) Irrigate the burn wounds. D) Apply wet-to-dry gauze dressings. E) Schedule the client for hydrotherapy.

Answer: C, D, E Explanation: Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.

After a skin graft procedure to the leg, a client is returned to the burn care unit. How will the nurse position the client? A) Place the client flat with the affected extremity abducted. B) Elevate the head of bed 30°. C) Maintain the head of the bed flat. D) Elevate the affected extremity.

Answer: D Explanation: Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.

Healing by secondary intention would occur in which of the following patients? A patient with a: a. Sutured surgical wound b. Stage IV pressure ulcer c. Paper cut d. Sunburn

B

Biochemical secretions that trap and kill microorganisms include: a. Hormones b. Neurotransmitters c. Earwax d. Gastric acid

C

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include: A) Adherence of albumin to vascular walls B) Movement of potassium into the vascular space C) Sequestering of sodium and water in interstitial fluid D) Hemolysis of red blood cells from large volumes of rapidly administered fluid

C

The mature plasma cell secretes immunoglobulins. The nurse recalls that which immunoglobulin is found in plasma, and helps in the differentiation of B lymphocytes ? A IgA B IgM C IgG D IgD

D IgD

A nurse recalls the mast cell, a major activator of inflammation, initiates the inflammatory response through the process of: a. Chemotaxis b. Endocytosis c. Degranulation d. Opsonization

C

A nurse is preparing to teach on the subject of opsonins. Which information should the nurse include? Opsonins are molecules that: a. Are composed of fatty acids b. Regulate inflammation c. Degranulate mast cells d. Enhance phagocytosis

D

In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client? 1. A urine output consistently above 100 ml/hour 2. A weight gain of 4 lb (2 kg) in 24 hours 3. Body temperature readings all within normal limits 4. An electrocardiogram (ECG) showing no arrhythmias

1. A urine output consistently above 100 ml/hour Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

Which of the following orders should a nurse question as part of the plan of care for a patient with a stage III pressure ulcer? A. pack the ulcer with foam dressing B. turn and reposition the patient every 2 hours C. clean the ulcer every shift with Dakin's solution D. assess for pain and medicate before dressing change

C

Which statement indicates teaching was successful regarding collectins? Collectins are produced by the: a. Kidneys b. Bowel c. Lungs d. Integument

C

The predominant phagocyte of early inflammation is the: a. Eosinophil b. Neutrophil c. Lymphocyte d. Macrophage

B

The mature plasma cell secretes immunoglobulins. The nurse recalls that which immunoglobulin is found in plasma, and interstitial fluid. It is responsible for secondary immune response ? A IgA B IgM C IgG D IgD

C IgG

During inflammation, the liver is stimulated to release plasma proteins, collectively known as: a. Opsonins b. Acute phase reactants c. Antibodies d. Phagolysosome

B

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. No slough

Stage II: Partial Thickness

Which of the following individuals would be at greatest risk for an opportunistic infection? a. 18-year-old with diabetes b. 70-year-old with congestive heart failure c. 24-year-old who is immunocompromised d. 30-year-old with pneumonia

C

Full-thickness tissue loss. Subcutaneous fat may be visible but NO bone, tendon, or muscle. Slough may be present. May include undermining and tunneling

Stage III: Full-thickness Skin Loss

A 20-year-old male received a knife wound to the arm during an altercation. Which of the following types of immunity was compromised? a. Innate immunity b. Inflammatory response c. Adaptive immunity d. Specific immunity

A

A 3-year-old is making play cakes in a sandbox and is eating the play cakes. The sand was also being used by cats as a litter box and was contaminated with toxoplasmosis. Which of the following would most likely also be present? a. Granuloma formation b. Degranulation c. Blood clots d. Exudate production

A

A patient has researched bradykinin on the Internet. Which information indicates the patient understands the functions of bradykinin? Bradykinin is involved in: a. Increasing vascular permeability b. Vasoconstricting blood vessels c. Stimulating the clotting system d. Increasing degradation of prostaglandins

A

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is: A) apply pressure garments B) Repositioning the patient every 2 hours C) Performing active ROM at least every 4 hours D) massaging the new tissue with water-based moisturizers

A

An 8-year-old female presents with edema of the cutaneous and mucosal tissue layers. Her mother reports that the condition is recurrent and seems to occur more often during stressful situations. The child is diagnosed with hereditary angioedema. Which of the following is deficient in this child? a. C1 esterase inhibitor b. Carboxypeptidase c. Neutrophils d. Plasmin

A

When phagocytes begin to stick avidly to capillary walls, which process is occurring? a. Margination b. Exudation c. Integration d. Emigration

A

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change? A. Morphine sulfate B. Sertraline (Zoloft) C. Zolpidem (Ambien) D. Enoxaparin (Lovenox)

A Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.

*Which of the following describes a hydrocolloid dressing?* 1) A seaweed derivative that is highly absorptive 2) Premoistened gauze placed over a granulating wound 3) A debriding enzyme that is used to remove neurotic tissue 4) A dressing that forms a gel that interacts with the wound surface

*Answer: 4* Rationale: A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

*Which of the following are measures to reduce tissue damage from shear? (select all that apply)* 1) Use a transfer device (e.g., transfer board) 2) Have head of bed elevated when transferring patient 3) Have head of bed flat when repositioning patient 4) Raise head of bed 60 degrees when patient positioned supine 5) Raise head of bed 30 degrees when patient positioned supine

*Answer: 1, 3, 5* Rationale: A transfer device can pick up a patient and prevent his or her skin from sticking to the bedsheet as he or she is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position causes patient to slide down, causing shear.

*Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (select all that apply)* 1) Frequent position changes 2) Keeping the buttocks exposed to air at all times 3) Using a large absorbent diaper, changing when saturated 4) Using an incontinence cleaner 5) Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6) Applying a moisture barrier ointment

*Answer: 1, 4, 6* Rationale: Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin-care and moisture barriers must also be used with frequent position changes to help reduce the risk for pressure ulcers.

*Match the pressure ulcer categories/stages with the correct definition:* 1) Category/stage I 2) Category/stage II 3)Category/stage III 4)Category/stage IV a) Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b) Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c) Full thickness tissue loss; muscle and bone visible. May include undermining. d) Partial-thickness skin loss or intact blister with serosanguinous fluid.

*Answer: 1a, 2d, 3b, 4c* Rationale: Category/stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Category/stage II ulcer has a shallow open ulcer (partial-thickness wound). It may also have an intact fluid-filled blister. Category/ stage III is full-thickness damage without visible fat; however, bone, tendon, and muscle are not exposed. Category/stage IV has full-thickness damage with visible bone, tendon, or muscle exposed.

*For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part?* 1) Binder 2) Ice bag 3) Elastic bandage 4) Absorptive dressing

*Answer: 2* Rationale: An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

*Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (select all that apply)* 1) Collection of wound drainage 2) Providing support to abdominal tissues when coughing or walking 3) Reduction of abdominal swelling 4) Reduction of stress on the abdominal incision 5) Stimulation of peristalsis (return of bowel function) from direct pressure

*Answer: 2, 4* Rationale: A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

*On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer?* 1) Category/stage II 2) Category/stage IV 3) Unstageable 4) Suspected deep-tissue damage

*Answer: 3* Rationale: To determine the category/stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

*When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?* 1) A local skin infection requiring antibiotics 2) Sensitive skin that requires special bed linen 3) A stage III pressure ulcer needing the appropriate dressing 4) Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

*Answer: 4* Rationale: When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed

1, 3, & 4; Risk factors for pressure ulcers include a low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chance of skin breakdown.

A client has an ischemic wound. This means that there has been: 1. A deficient blood supply to the tissue 2. Damage to the small blood vessels 3. Compression of the tissue 4. A combination of friction and pressure

1. A deficient blood supply to the tissue Explanation: insufficient blood supply to the tissue is ischemia. It is the cause of pressure ulcer formation.

When assessing a lesion diagnosed as malignant melanoma, the nurse in-charge most likely expects to note which of the following? 1. An irregular shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border

1. An irregular shaped lesion Explanation: A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment? 1. Lips 2. Sacrum 3. Earlobes 4. Back of the hands

1. Lips Explanation: In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge.

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? 1. Begin intravenous fluids 2. Check the pulses with a Doppler device 3. Obtain a complete blood count (CBC) 4. Obtain an electrocardiogram (ECG)

1. Begin intravenous fluids Explanation: Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Fluids can treat this problem. An ECG and CBC will be taken to ascertain if a cardiac or bleeding problem is causing these vital signs. However these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery but this is not an immediate nursing action.

When turning a client the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? 1. Clean area with mild soap, and dry. 2. Apply a dilute hydrogen peroxide and water mixture, and use a heat lamp on the area 3. Soak the area in normal saline solution 4. Wash the area with an astringent

1. Clean area with mild soap, and dry. Explanation: The skin should be cleansed and completely dried. B. Hydrogen peroxide can be irritating to the tissue and should not be used. A heat lamp is not necessary and would increase the client's risk of an accidental burn. C. The area should not be soaked, as this may lead to maceration of the skin. D. The area should not be cleansed with an astringent. An astringent may cause excessive drying of the tissue.

The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a "small amount of pain." How will the nurse categorize this injury? 1. Full-thickness 2. Partial-thickness superficial 3. Partial-thickness deep 4. Superficial

1. Full-thickness. Explanation: The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white in color with pain, and superficial burn color is pink to red, with pain.

Common Nursing diagnosis for pressure ulcers

1. Impaired skin integrity related to mechanical factors and physical immobilization 2. Impaired tissue integrity related to impaired circulation and imbalanced nutritional state

A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should: 1. turn him frequently. 2. perform passive range-of-motion (ROM) exercises. 3. reduce the client's fluid intake. 4. encourage the client to use a footboard.

1. turn him frequently. Explanation: The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? 1. Avoiding sharing equipment such as blood pressure cuffs between clients 2. Changing gloves between wound care on different parts of the client's body 3. Using the closed method of burn wound management 4. Using proper and consistent handwashing

2. Changing gloves between wound care on different parts of the client's body. Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client's body can prevent autocontamination.

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client? 1. Current range of motion in all extremities 2. Heart rate and rhythm 3. Respiratory rate and pulse oximetry reading 4. Orientation to time, place, and person

2. Heart rate and rhythm Explanation: The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. Range of motion and neurologic assessments are important. However the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.

Which of the following clients would least likely be at risk of developing skin breakdown? 1. A client incontinent of urine feces 2. A client with chronic nutritional deficiencies 3. A client with decreased sensory perception 4. A client who is unable to move about and is confined to bed

3. A client with decreased sensory perception Explanation: Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk, as presented in the options, is the decreased sensory perception. Options 1, 2, and 4 identify physiological conditions, which are the risk priorities.

Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is at increased risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.

2. Implement a turning schedule; the client is at increased risk for skin breakdown; A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.

The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury? 1. Full-thickness 2. Partial-thickness superficial 3. Partial-thickness deep 4. Superficial

2. Partial-thickness superficial Explanation: The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and superficial burns, and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns are red to white in color.

The nurse notes a client's skin is reddened, with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2. Stage 2 Explanation: This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and appears as an abrasion, blister, or shallow crater. 1. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. The description is not consistent with a stage I pressure ulcer. 3. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through the muscle. The description is not consistent with a stage III pressure ulcer. 4. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. The description is not consistent with a stage IV pressure ulcer.

A male client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction would best prevent skin damage? 1. "Minimize sun exposure from 1 to 4 p.m. when the sun is strongest." 2. "Use a sunscreen with a sun protection factor of 6 or higher." 3. "Apply sunscreen even on overcast days." 4. "When at the beach, sit in the shade to prevent sunburn."

3. "Apply sunscreen even on overcast days." Explanation: Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn't guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun's rays onto the skin.

The client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide? 1. "With reconstructive surgery, you can look the same." 2. "We can remove the scars with the use of a pressure dressing." 3. "You will not look exactly the same." 4. "You shouldn't start worrying about your appearance right now."

3. "You will not look exactly the same." Explanation: Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. Pressure dressings prevent further scarring. They cannot remove scars. The client and family should be taught the expected cosmetic outcomes.

A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? 1. How to maintain home smoke detectors 2. Joining a community reintegration program 3. Learning to perform dressing changes 4. Options available for scar removal

3. Learning to perform dressing changes Explanation: Critical for the goal of progression toward independence for the client is teaching clients and family members to perform care tasks such as dressing changes. All the other distractors are important in the rehabilitation stage. However, dressing changes have priority.

Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? 1. Turn and reposition the client at least once every 8 hours. 2. Vigorously massage lotion into bony prominences. 3. Post a turning schedule at the client's bedside. 4. Slide the client, rather than lifting, when turning.

3. Post a turning schedule at the client's bedside. Explanation: A turning schedule with a signing sheet will help ensure that the client gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing.

A client has been lying on her back for two hours. When the nurse turns her, the nurse notices the skin over her sacrum is very white. By the time the nurse finishes repositioning her, the spot has turned bright red. The nurse should: 1. Massage the spot with lotion 2. Apply a warm compress for 30 minutes 3. Return in 30-45 minutes to see if the redness has disappeared 4. Wash the area with soap and water and notify the physician

3. Return in 30-45 minutes to see if the redness has disappeared Explanation: the nurse would return to see if the skin has returned to its normal color. If not, it is a sign of damage to the tissue. 1: Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue and pressure ulcer formation. 2: A warm compress will increase circulation to the area. However the nurse would want to assess the area prior to application of the compress. 4: The nurse would make sure the area is clean but it is not the first nursing action. In some situations the physician would be notified.

When cleaning a wound, the nurse should: 1. Go over the wound twice and discard that swab 2. Move from the outer region of the wound toward the center 3. Start at the drainage site and move outward with circular motions 4. Cleanse the area around the drain and then clean the incision

3. Start at the drainage site and move outward with circular motions Explanation: To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in circular rotations outward from a point closest to the drain. A. The nurse never uses the same piece of gauze or swab to cleanse across an incision or wound twice. B. The wound should be cleansed in a direction from the least contaminated area, such as from the wound to the surrounding skin. The wound is cleaned from the center region to the outer region. D. The incision is cleansed first followed by the area around the drain

The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching? 1. "I'll limit my intake of protein." 2. "I'll make sure that the bandage is wrapped tightly." 3. "My foot should feel cold." 4. "I'll eat plenty of fruits and vegetables."

4. "I'll eat plenty of fruits and vegetables." Explanation: For effective tissue healing, adequate intake of protein, vitamin A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high protein diet with plenty of fruits and vegetables to provide these nutrients. The bandage should be secure but not too tight to impede circulation to the area (needed for tissue repair). If the client's foot feels cold, circulation is impaired, thus inhibiting wound healing.

The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse's best response? 1. "As soon as he finishes his antibiotic prescription." 2. "As soon as his albumin level returns to normal." 3. "When fluid remobilization has started." 4. "When the burn wounds are closed."

4. "When the burn wounds are closed." Explanation: Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open.

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss of the dermis

4. Partial-thickness skin loss of the dermis Explanation: In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.

Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition? 1. Acute phase of the injury 2. Autodigestion of collagen 3. Granulation of burned tissue 4. Wound infection

4. Wound infection Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. These symptoms will not be seen in the acute phase of the injury. Autodigestion of collagen and granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge.

The nurse cares for a patient that had an asthma attack due to an unknown allergen. Which immunoglobulin is primarily responsible for allergic reactions? A. IgE B. IgG C. IgM D. IgA

A Allergic reactions are IgE-mediated and happen only in individuals who are susceptible to specific allergens. IgG, IgM, and IgA are other immunoglobulins that are responsible for various immune mechanisms other than allergy. IgG is the primary antibody found in a secondary immune response. It can move from the intravascular space to extra vascular space. IgM is a large molecule. It is the first type of antibody formed, and remains confined to the intravascular space. IgA are immunoglobulins found in breast milk; they render passive immunity. Text Reference - p. 209

The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (Select all that apply.) A. Urine output is 80 mL/hour. B. Heart rate is 86 beats/minute. C. Urine specific gravity is 1.025. D. Mean arterial pressure is 54 mm Hg. E. Systolic blood pressure is 88 mm Hg.

A Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be at least 0.5 to 1 mL/kg/hr. Cardiac factors include a mean arterial pressure (MAP) > 65 mm Hg, systolic blood pressure (BP) > 90 mm Hg, heart rate < 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030.

The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Administer 100% humidified oxygen. B. Teach the patient deep breathing exercises. C. Encourage the patient to express his feelings. D. Assist the patient to a high Fowler's position.

A Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.

The mature plasma cell secretes immunoglobulins. The nurse recalls that which immunoglobulin is found in breast milk and colostrum? A IgA B IgM C IgG D IgD

A IgA is found in breast milk and colostrum. It lines mucous membranes and protects body surfaces. IgM is found in plasma, and is responsible for the primary immune response. It also produces antibodies against ABO blood antigens. IgG is found in plasma and interstitial fluid. It is responsible for secondary immune response. IgD is found in plasma. It helps in the differentiation of B lymphocytes. Text Reference - p. 206

The reason newborns are protected for the first 6 months of life from bacterial infection is because of the maternal transmission of: A. IgG B. IgA C. IgM D. IgE

A Rationale: Immunoglobulin G (IgG) crosses the placental membrane and provides the newborn with passive acquired immunity for at least 3 months. Infants also may obtain some passive immunity from immunoglobulin A (IgA) in breast milk and colostrum.

The nurse is alerted to possible anaphylactic shock immediately after a patient has received intramuscular penicillin by the development of: A. edema and itching at the injection site B. sneezing and itching of the nose and eyes C. a wheal-and-flare reaction at the injection site D. chest tightness and production of thick sputum

A Rationale: Initial symptoms include edema and itching at the site of the exposure to the allergen.

On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age? A Autoimmune response B Cell-mediated immunity C Hypersensitivity response D Humoral immune response

A With aging, autoantibodies increase, which lead to autoimmune diseases (e.g., systemic lupus erythematosis, acute glomerulonephritis, rheumatoid arthritis, hypothyroidism). Cell-mediated immunity decreases with decreased thymic output of T cells and decreased activation of both T and B cells. There is a decreased or absent delayed hypersensitivity reaction. Immunoglobulin levels decrease and lead to a suppressed humoral immune response in older adults. Text Reference - p. 208

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? (Select all that apply): A. Cleansing the wound. B. Managing pain. C. Applying a dry sterile dressing. D. Using cold water in the bath.

A and B Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

The nurse would explain to a patient that effective treatments for atopic pruritus include (Select all that apply): A. Oral steroids. B. Topical steroids. C. Oral antihistamines. D. Topical antihistamines. E. Topical petroleum ointment.

A and B Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical antihistamines are not usually given, because they are ineffective and may cause further irritation. Petroleum is also ineffective.

To which patient should the nurse plan to administer round-the-clock antipyretic drugs?

A) A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F B) An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F C) A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F D) A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F Answer: A Moderate fevers (up to 103°F) usually produce few problems in most patients and do not require antipyretic therapy. If the patient is very young or very old, is extremely uncomfortable, or has a significant medical problem (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. High fevers (above 104°F) should be treated with antipyretics. High fevers can damage body cells and cause delirium and seizures.

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be?

A) Adhesion B) Contractions C) Keloid formation D) Excess granulation tissue Answer: D Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable.

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state?

A) Administer aspirin on a scheduled basis around the clock. B) Provide acetaminophen every 4 hours to maintain consistent blood levels. C) Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. D) Provide drug interventions if complementary and alternative therapies have failed. Answer: B Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.

Which patient is most at risk for the development of a pressure ulcer?

A) An older patient who is septic, bedridden, and incontinent B) An obese woman with leukemia who is receiving chemotherapy C) A middle-aged thin man in a halo cast after a motor vehicle accident D) An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis Answer: A ndividuals at risk for the development of pressure ulcers include those who are older, incontinent, bed or wheelchair bound, or recovering from spinal cord injuries. Other examples of risk factors include diabetes mellitus, elevated body temperature, immobility, and anemia.

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing?

A) Apple B) Custard C) Popsicle D) Potato chips Answer: B Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. The other snacks do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid that are also needed for healing.

An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient?

A) Dress it with an absorbent dressing for exudate. B) Handle the wound gently and let it dry out to heal. C) Debride the nonviable, eschar tissue to allow healing. D) Use negative-pressure wound (vacuum) therapy to facilitate healing. Answer: C With a black wound, the immediate therapy should be debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first. The red wound is handled gently because it is granulating and re-epithelializing, but it must be kept slightly moist to heal. The negative-pressure wound (vacuum) therapy is used to remove drainage and is more likely to be used after debridement.

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection?

A) Fever and chills B) Increased blood pressure C) Increased respiratory rate D) General malaise and fatigue Answer: D An immunosuppressed individual may have the classic symptoms of inflammation or infection masked by the inability to launch a normal immune response. Therefore, in this person, early symptoms may be malaise, fatigue, or "just not feeling well."

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer?

A) Keep the pressure ulcer clean and dry. B) Maintain protein intake of at least 1.25 g/kg/day. C) Use a 10-mL syringe to irrigate the pressure ulcer. D) Irrigate the pressure ulcer with hydrogen peroxide. Answer:B Adequate protein intake (between 1.25 and 1.50 g/kg/day) is needed to promote healing of pressure ulcers. Hydrogen peroxide is cytotoxic and should not be used to clean pressure ulcers. A 30-mL syringe with a 19-gauge needle will provide optimal pressure (4 to 15 psi) without causing tissue trauma or damage. The pressure ulcer should be kept moist to aid in healing.

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care?

A) Reposition every 2 hours. B) Measure the size of the reddened area. C) Massage the area to increase blood flow. D) Evaluate the area later to see if it is better. Answer: A The most important thing to do for this patient is to prevent deterioration of the ulcer and eliminate factors that led to pressure ulcers. This would include eliminating pressure on the reddened area with repositioning every 2 hours in bed and every hour while up in the chair. The nurse must complete the assessment of the new reddened area as well as evaluation of the area. Massage is not used when there is the possibility of damaged blood vessels or fragile skin, so the RN cannot advise the UAP to do this until the RN has assessed the patient and the area.

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage?

A) Serous B) Purulent C) Fibrinous D) Catarrhal Answer: B Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)?

A) Take the antibiotic until the wound feels better. B)Take the analgesic every day to promote adequate rest for healing. C) Be sure to wash hands after changing the dressing to avoid infection. D) Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. E) Notify the health care provider of redness, swelling, and increased drainage. Answer: C, D Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing.

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process?

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. Answer: C With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled.

A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury?

A) Warm, moist heat and massage B) Rest, ice, compression, and elevation C) Antipyretic and antibiotic drug therapy D) Active movement and exercise to prevent stiffness Answer: B Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation. Heat may be applied 24 to 48 hours after the injury.

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective?

A) White blood cell (WBC) count of 8000/ìL; temperature of 101 F B) White blood cell (WBC) count of 4000/ìL; temperature of 100 F C) White blood cell (WBC) count of 8500/ìL; temperature of 98.4 F D) White blood cell (WBC) count of 16,500/ìL; temperature of 98.8 F Answer: C This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/ìL. An elevated WBC count and elevated temperature are indicators of infection.

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment?

A)Frequent examination of the character and quantity of exudate B) Monitoring for signs and symptoms of local or systemic infections C) Assessment of the patient's circulation distal to the location of the dressing D) Assessment of the range of motion of the ankle and the patient's activity tolerance Answer: C Any compression dressing requires vigilant assessment of the circulation distal to the dressing site because tissue and nerve damage is a significant risk. This supersedes the importance of assessing the patient's mobility. Exudate and infection would not normally accompany a soft tissue injury such as a sprain.

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply): A. Applying over-the-counter lotions to skin that is not broken. B. Assisting the client with frequent turning to prevent pressure ulcers. C. Covering the client who complains of being cold with more blankets. D. Placing a sterile gauze pad over broken skin to contain drainage. E. Assessing a patient complaining of an itching rash.

A, B, C, and D All the above options can be delegated to an unlicensed assistive personnel employee except for assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury ()? (Select all that apply.) A. Singed nasal hair B. Generalized pallor C. Painful swallowing D. Burns on the upper extremities E. History of being involved in a large fire

A, B, C, and E Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color

Pain management for burn patient is most effective when (Select all that apply): A) A pain rating tool is used to monitor the patient's level of pain B) Painful dressing changes are delayed until the patient;s pain is completely relieved C) the patient is informed about and has some control over the management of the pain D) A multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics) E) Nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabiltiation phase of a burn injury

A, C, D

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care ()? (Select all that apply.) A. Escharotomy B. Administration of diuretics C. IV and oral pain medications D. Daily cleansing and debridement E. Application of topical antimicrobial agent

A, C, D, and E An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply): A) Blisters B) Exposed fascia C) Exposed muscles D) intact nerve endings E) red, shiny, wet appearance

A, D, and E

A nurse is preparing the discharge plan of a patient who is allergic to latex. What foods should the nurse ask the patient to avoid? Select all that apply. A. Tomatoes B. Leafy vegetables C. Avocados D. Potatoes E. Milk

A,C, D Some of the proteins in rubber latex are similar to food proteins. The patient who is allergic to latex may also be allergic to foods that contain similar food proteins. Tomatoes, potatoes, and avocados should be avoided. Milk and leafy vegetables do not contain proteins similar to those found in latex. Text Reference - p. 216

A patient allergic to insect stings is going on a jungle trek. How will you instruct the patient to take precautionary measures? Select all that apply. A. Carry preinjectable epinephrine and a tourniquet. B. Take methdilazine (Tacaryl) orally as a preventive measure. C. Wear a Medic Alert bracelet. D. Learn how to self-inject epinephrine. E. Apply calamine lotion topically as a preventive measure.

A,C,D Wearing a Medic Alert bracelet is important because it gives an indication to the health care provider about the patient's medical history. The patient should carry preinjectable epinephrine and a tourniquet. The patient should be taught the technique of applying a tourniquet and the method of self-injecting epinephrine in case of emergency. Methdilazine is an antipruritic agent that requires a prescription, and it should be used with great caution. Also, as it is antipruritic, it will not protect against insect sting. Calamine lotion is also antipruritic. It will help to relieve itching but will not act as a preventive measure for insect stings. Text Reference - p. 214

The nurse is caring for a patient experiencing an immune response. She assesses the patient for development of a hyperimmune response while knowing that cytotoxic T cells are responsible for which action? A May kill healthy cells along with foreign antigens. B Are the most prevalent type of T lymphocyte. C Can suppress the immune response. D Diminish dendritic cell function.

A. Cytotoxic T lymphocytes can kill healthy tissue along with antigens. Suppressor T cells help to keep cytotoxic T cells in check. Helper T cells are the most prevalent type of T lymphocyte, not cytotoxic cells. Cytotoxic T lymphocytes do not suppress the immune response but are a factor in optimal immune functioning. Suppressor T lymphocytes help to suppress the function of cytotoxic cells. Dendritic cell function enhances cytotoxic T lymphocyte functioning.

The nurse is teaching a patient with a new diagnosis of systemic lupus erythematosus (SLE) about her disease. The nurse recognizes that the patient understands the information when making which statement? A. "I need to avoid getting infections because they will increase the immune response in my body, which can make my SLE worse." B. "I need to be sure to take all the available immunizations to keep me from getting sick." C. "Because of my SLE, my immune system is already diminished, so I need to avoid people with the flu." D. "As long as I take all my prescribed medications, I won't have to make any lifestyle changes as a result of my SLE.

A. SLE is a hyperimmunity problem. Pathogens trigger the immune response in the body, which can exacerbate the SLE. Immunizations trigger the immune response in the body to help create antibodies. In patients with autoimmune diseases such as SLE, immunizations can exacerbate the disease. SLE is not the result of immunosuppression. Lifestyle changes are required with most chronic illnesses such as SLE. Patients cannot depend on medications alone

The nurse recalls that interferons may be used in the treatment of certain diseases. What is the clinical use of β-Interferon? A. As a treatment for multiple sclerosis B. As a treatment for multiple myeloma C. As a treatment for hairy cell leukemia D. As a treatment for renal cell carcinoma

A. β-Interferon is used in treating multiple sclerosis. Cytokines instruct cells to alter their proliferation, differentiation, secretion, or activity. Cytokines play an important role in hematopoiesis. α-interferon is used to treat multiple myeloma, hairy cell leukemia, and renal cell carcinoma. Text Reference - p. 208

A nurse is caring for a patient with systemic lupus erythematosus. The nurse understands that this disease is caused when the body identifies self proteins as foreign substances, triggering an immune response. What is this pathophysiological condition called? A. Autoimmunity B. Hypersensitivity C. Immunodeficiency D. Delayed hypersensitivity

A. Autoimmunity occurs when the body identifies self proteins as foreign substances, it causes cellular and tissue damage. Hypersensitivity is an exaggerated immune response to specific products. Immunodeficiency results from an incompetent immune system, which can be caused by pathogens, medications, and many other factors. Delayed hypersensitivity is a type of hypersensitivity reaction that takes 24 to 48 hours to occur. Text Reference - p. 217

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

ANS: A, D, B, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last. DIF: Cognitive Level: Analyze (analysis)

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matching

ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing.

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "After a couple of years, it is likely that I will be able to stop taking the cyclosporine." b. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." c. "I need to be monitored closely because I have a greater chance of developing malignant tumors." d. "The drugs are given in combination because they inhibit different ways the kidney can be rejected."

ANS: A Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Administer prescribed PRN hydrocodone 30 minutes before the change. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Soak the old dressings with sterile saline 30 minutes before the dressing change

ANS: A Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound but not soaked after packing. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing. DIF: Cognitive Level: Apply (application)

A nurse is conducting community education classes on skin cancer. One participant says to the nurse: "I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?" The nurse's most helpful response would be which of the following? a. "That is not correct. Melanoma is more commonly found on the torso or the lower legs of women." b. "That is correct, because the face and arms are exposed more often to the sun." c. "That is not correct. Melanoma occurs on the top of the head in men but is rare in women." d. "That is incorrect. Melanoma is most commonly seen in dark-skinned individuals."

ANS: A Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma. REF: Page 264

A nurse is conducting community education classes on skin cancer. One participant says to the nurse: "I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?" The nurse's most helpful response would be which of the following? a. "That is not correct. Melanoma is more commonly found on the torso or the lower legs of women." b. "That is correct, because the face and arms are exposed more often to the sun." c. "That is not correct. Melanoma occurs on the top of the head in men but is rare in women." d. "That is incorrect. Melanoma is most commonly seen in dark-skinned individuals."

ANS: A Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma. REF: Page 264 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse cleans the ulcer with half-strength peroxide. b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer. c. The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe. d. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.

ANS: A Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate. DIF: Cognitive Level: Apply (application)

An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for a. primary immunodeficiency. b. secondary immunodeficiency. c. cancer. d. autoimmunity.

ANS: A Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils

ANS: A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive range of motion (ROM).

ANS: A Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues. DIF: Cognitive Level: Apply (application)

A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? a. Administer epinephrine. b. Apply topical hydrocortisone. c. Monitor the patient for lower extremity edema. d. Ask the patient about exposure to any new lotions or soaps.

ANS: A The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction. Exposure to lotions and soaps does not address the immediate concern of a possible anaphylactic reaction. The nurse should not wait and observe for edema. The nurse should act immediately in order to prevent progression to anaphylaxis.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patient's skin rash? a. The donor T cells are attacking the patient's skin cells. b. The patient's antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity

An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-stimulating infections in older individuals

ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation if a. his immune system is functioning properly. b. he is properly vaccinated. c. he has an infection. d. the suppressor T-cells in his body are activated.

ANS: A Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body's response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound

ANS: A With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing. DIF: Cognitive Level: Analyze (analysis)

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple leg wounds with eschar to be debrided b. The patient receiving chemotherapy who has a temperature of 102° F c. The patient who requires analgesics before a scheduled dressing change d. The newly admitted patient with a stage IV pressure ulcer on the coccyx

ANS: B Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient. DIF: Cognitive Level: Analyze (analysis)

The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan? a. Plasmapheresis will eliminate eosinophils and basophils from blood. b. Plasmapheresis will remove antibody-antigen complexes from circulation. c. Plasmapheresis will prevent foreign antibodies from damaging various body tissues. d. Plasmapheresis will decrease the damage to organs caused by attacking T lymphocytes.

ANS: B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions

ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring. REF: Page 267

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions

ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring. REF: Page 267 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. c. Notify the health care provider. b. Document the assessment. d. Assess the wound every 2 hours.

ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally. DIF: Cognitive Level: Apply (application)

A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurse's priority action? a. Have the patient lie down. b. Assess the patient's airway. c. Administer high-flow oxygen. d. Remove the stinger from the site.

ANS: B The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance.

An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population

ANS: B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for further teaching? a. "I wear a hat and sit under the umbrella when not in the water." b. "I don't bother with sunscreen on overcast days." c."I use a sunscreen with the highest SPF number." d. "I wear a UV shirt and limit exposure to the sun by covering up."

ANS: B The sun's rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer. REF: Page 266

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for further teaching? a. "I wear a hat and sit under the umbrella when not in the water." b. "I don't bother with sunscreen on overcast days." c. "I use a sunscreen with the highest SPF number." d. "I wear a UV shirt and limit exposure to the sun by covering up."

ANS: B The sun's rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer. REF: Page 266 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC)

ANS: B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won't get the disease, but it decreases the potential to contract the illness. No medication is risk free.

Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Ask the patient about any clear nasal discharge. b. Obtain the patient's blood pressure and heart rate. c. Check for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find another way to earn extra money." b. "I will get a prescription for epinephrine and learn to self-inject it." c. "I will plan to take oral antihistamines daily before going to work." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

ANS: C Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse explains to the patient that the goal of medication treatments for RA is to a. eradicate the disease. b. enhance immune response. c. control inflammation. d. manage pain.

ANS: C Medications for RA are intended to control the inflammation that results from the body's hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Check the patient's temperature again in 4 hours. d. Give acetaminophen (Tylenol) prescribed PRN for pain.

ANS: C Mild to moderate temperature elevations (<103° F) do not harm young adult patients and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms, and the patient does not require analgesics if not reporting discomfort. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation. DIF: Cognitive Level: Apply (application)

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is low

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag.

ANS: C Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care. DIF: Cognitive Level: Apply (application)

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a. Obtaining a complete blood count (CBC) b. Protection from excessive heat c. Protection from excessive ultraviolet (UV) exposure d. Instructing the patient to take their multivitamin prior to treatment

ANS: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis. REF: Page 267

Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness

ANS: C Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.

Which statement by a patient would alert the nurse to a possible immunodeficiency disorder? a. "I take one baby aspirin every day to prevent stroke." b. "I usually eat eggs or meat for at least 2 meals a day." c. "I had my spleen removed many years ago after a car accident." d. "I had a chest x-ray 6 months ago when I had walking pneumonia."

ANS: C Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function.

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism? a. Candida albicans b. Group A beta-hemolytic streptococci c. Staphylococcus aureus d. E. Coli

ANS: C Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues. REF: Page 268

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism? a. Candida albicans b. Group A beta-hemolytic streptococci c. Staphylococcus aureus d. E. Coli

ANS: C Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues. REF: Page 268 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying."

ANS: C The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer. REF: Page 266

An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying."

ANS: C The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer. REF: Page 266 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? a. Change the patient's bedding frequently. b. Apply a hydrocolloid dressing over the ulcer. c. Change the patient's position every 1 to 2 hours. d. Record the size and appearance of the ulcer weekly.

ANS: C The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching. DIF: Cognitive Level: Analyze (analysis)

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas, especially the face. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

ANS: C The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized. REF: Pages 266-267

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas, especially the face. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

ANS: C The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized. REF: Pages 266-267 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation

While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate? a. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.

ANS: C The patient's allergy history and occupation indicate a risk of developing a latex allergy. The nurse should be prepared to manage any symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing c. Rising body temperature b. Muscle cramps d. Decreasing blood pressure

ANS: C The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature. DIF: Cognitive Level: Apply (application)

The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient who had an anaphylactic reaction.

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's allergy symptoms have not improved. d. There is a 2-cm wheal at the site of the allergen injection.

ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

ANS: D Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patient's many concerns should be addressed, but these are not potentially life-threatening problems.

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who reports increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

ANS: D LPN/LVN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application)

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.

ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching.

The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation? a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Numbness and tingling

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

A patient asks the nurse what the purpose of the Wood's light is. Which response by the nurse is accurate? a. "We will put an anesthetic on your skin to prevent pain." b. "The lamp can help detect skin cancers." c. "Some patients feel a pressure-like sensation." d. "It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."

ANS: D The Wood's light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort. REF: Page 265

A patient asks the nurse what the purpose of the Wood's light is. Which response by the nurse is accurate? a. "We will put an anesthetic on your skin to prevent pain." b. "The lamp can help detect skin cancers." c. "Some patients feel a pressure-like sensation." d. "It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."

ANS: D The Wood's light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort. REF: Page 265 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise.

ANS: D The earliest manifestation of an infection may be "just not feeling well." Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. DIF: Cognitive Level: Analyze (analysis)

The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with pulse 112 beats/min and weak. The nurse suspects that the patient is experiencing a(n) a. suppressed immune response. b. hyperimmune response. c. allergic reaction. d. anaphylactic reaction.

ANS: D The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching? a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours

ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline. REF: Page 164

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching? a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours

ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline. REF: Page 164 OBJ: NCLEX® Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn. REF: Page 266

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn. REF: Page 266 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas

ANS: D Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue. DIF: Cognitive Level: Apply (application)

*What is the correct sequence of steps when performing wound irrigation to a large open wound?* 1) Use slow, continuous pressure to irrigate wound 2) Attach 19-gauge angiocatheter to syringe 3) Fill syringe with irrigation fluid 4) Place waterproof bag near bed 5) Position angiocatheter over wound

Answer: 4, 3, 2, 5, 1

The nurse is planning care for a client in the acute stage of a burn injury. Which areas will be included in the plan of care? Select all that apply. A) Nutrition B) Psychosocial support C) Pain management D) Fluid resuscitation E) Wound care

Answer: A, C, E Explanation: Nursing care for the client during the acute stage of burn injuries will include wound care, nutritional therapy, and pain management. Fluid resuscitation occurs during the emergency phase of burn care. Psychosocial support will be needed once the client has stabilized.

A nurse working in the pediatric intensive care unit (PICU) is planning care for a pediatric client who is being admitted with a partial-thickness thermal burn. What is true regarding this type of burn? A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only. B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn.

Answer: B Explanation: A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.

An older client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, what should be taken into consideration? A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase. C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins. D) The amount of urine output will be greatest in the first 24 hours after the burn injury.

Answer: B Explanation: The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.

A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified? A) Minor B) Moderate C) Major D) Significant

Answer: C Explanation: According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.

The nurse is concerned that a client is at a high risk for a burn injury. What did the nurse assess in this client? Select all that apply. A) Part-time employment at a convenience store B) Diagnosis of hypertension C) Age 71 years D) Utilizes public transportation for grocery shopping E) Currently smokes 1 pack per day of cigarettes

Answer: C, E Explanation: Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, sense of smell, and hearing, and impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Careless smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.

The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status? A) Creatine phosphokinase (CPK) B) BUN levels C) Hemoglobin D) Albumin level

Answer: D Explanation: Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent upon the fluid status.

A client is being evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. What best describes the underlying cause for this manifestation? A) Decreased osmotic pressure in the burned tissue B) Reduced vascular permeability at the site of the burned area C) Increased fluids in the extracellular compartment D) Inability of the damaged capillaries to maintain fluids in the cell walls

Answer: D Explanation: Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments.

A 25-year-old female presents to her primary care provider reporting vaginal discharge of a white, viscous, and foul-smelling substance. She reports that she has been taking antibiotics for the past 6 months. Which finding will the nurse most likely see on the microorganism report? a. Clostridium difficile overgrowth b. Decreased Lactobacillus c. Streptococcus overgrowth d. Decreased Candida albicans

B

A 25-year-old male is in a car accident and sustains a fracture to his left femur with extensive soft tissue injury. The pain associated with the injury is related to: a. Histamine and serotonin b. Kinins and prostaglandins c. Vasoconstriction d. Immune complex formation

B

A 30-year-old male was involved in a motor vehicle accident. The glass from the shattered window cut his face and neck. The scar, however, was raised and extended beyond the original boundaries of the wound. This pattern of scarring is caused by impaired: a. Nutritional status b. Collagen synthesis c. Epithelialization d. Contraction

B

A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? A. tertiary intention B. secondary intention C. regeneration of cells D. remodeling of tissue

B

A nurse is caring for a patient with diabetes and a necrotic left greater toe who is scheduled for amputation of the affected toe. The patient's WBC count is 15x10^6/uL, and he has coolness of the lower extremities, weighs 75 lbs more than his ideal body weight, and smokes 2 packs of cigarettes a day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? A. imbalanced nutrition: more than body requirements related to high-fat foods B. impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking C. ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking D. ineffective individual coping related to lack of regard and denial of the long-term effects of diabetes and smoking

B

A patient has 25% TBSA burned from a car fire. His wounds have been derided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to: A) Reapply a new dressing without disturbing the wound bed B) Observe the wound for signs of infection during dressing changes C) Apply cool compresses for pain relief in between dressing changes D) Wash the wound aggressively with soap and water three times a day

B

A patient is 1 day postoperative after having abdominal surgery, she has incisional pain, a 99.5*F temp, slight erythema at the incision margins, and 30mL of serous sanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make? A. the abdominal incision is showing signs of infection B. the patient is experiencing a normal inflammatory response C. the abdominal incision is showing signs of impending dehiscence D. the patient's physician needs to be notified of the patient's condition

B

The mature plasma cell secretes immunoglobulins. The nurse recalls that which immunoglobulin is found in plasma, and is responsible for the primary immune response ? A IgA B IgM C IgG D IgD

B IgM

A patient is admitted with a chronic leg wound. The nurse assess local manifestations of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? A. serum protein analysis B. WBC count with differential C. punch biopsy of center of wound D. culture and sensitivity of the wound

B

The post-surgical patient is experiencing delayed wound healing. The dietician believes the delay is related to nutritional intake. A deficiency in which of the following substances could directly affect healing? a. Vitamin D b. Ascorbic acid c. Melanin d. Cholesterol

B

Which statement indicates teaching was successful regarding the classic pathway of the complement system? The classic pathway of the complement system is activated by: a. Histamine b. Antigen-antibody complexes c. Leukotrienes d. Prostaglandins

B

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? A. GI distress B. Tachycardia C. Restlessness D. Hypokalemia

B Albuterol (Ventolin) stimulates μ-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the μ-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? A. SQ tetanus toxoid B. IV morphine sulfate C. IM hydromorphone (Dilaudid) D. PO oxycodone and acetaminophen (Percocet)

B IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired due to shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

B The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? A. 18% B. 22.5% C. 27% D. 36%

B Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? A. Skin is hard with a dry, waxy white appearance. B. Skin is shiny and red with clear, fluid-filled blisters. C. Skin is red and blanches when slight pressure is applied D. Skin is leathery with visible muscles, tendons, and bones.

B Deep partial thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? A. Begin IV fluid replacement. B. Monitor for signs of complications. C. Assess and manage pain and anxiety. D. Discuss possible reconstructive surgery.

B Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? A "You will need to get rid of your pets." B "You should sleep in an air-conditioned room." C "You would do best to stay indoors during the winter months." D "You will need to dust your house with a dry feather duster twice a week."

B Seasonal allergic rhinitis most commonly is caused by pollens from trees, weeds, and grasses. Airborne allergies can be controlled by sleeping in an air-conditioned room, daily damp dusting, covering the mattress and pillows with hypoallergenic covers, and wearing a mask outdoors. It is not necessary to get rid of pets because pet dander does not contribute to seasonal allergies. It is not necessary to stay indoors during the winter. Daily damp dusting is recommended, not dry feather dusting. Text Reference - p. 209

The mature plasma cell secretes immunoglobulins. The nurse recalls that which immunoglobulin is found in plasma, and is responsible for produces antibodies against ABO blood antigens ? A IgA B IgM C IgG D IgD

B IgM

A 65 year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which of the following nursing diagnoses are appropriate (select all that apply): A. acute pain related to tissue damage and inflammation B. impaired skin integrity related to immobility and decreased sensation C. impaired tissue integrity related to inadequate circulation secondary to pressure D. risk for infection related to loss of tissue integrity and undernutrition secondary to stroke

B, C

On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response decrease with age? A. Autoimmune response B. Cell-mediated immunity C. Hypersensitivity response D. Humoral immune response

B, Cell-mediated immunity C Hypersensitivity response D Humoral immune response

In a person having an acute rejection of a transplanted kidney, which of the following would help the nurse understand the course of events (select all that apply): A. a new transplant could be considered B. acute rejection can be treated with OKT3 C. acute rejection usually leads to chronic rejection D. corticosteroids are the most successful drug used to treat acute rejection E. Acute rejection is common after a transplant and can be treated with drug therapy

B, E Rationale: Acute rejection is treatable and does not usually necessitate replacement transplantation. Monoclonal antibodies such as muromonab-CD3 (Orthoclone OKT3) are used for preventing and treating acute rejection episodes. Calcineurin inhibitors are the most effective immunosuppressants available to treat organ rejection. It is not uncommon to have at least one acute rejection episode, especially with organs from deceased donors. These episodes are usually reversible with additional immunosuppressive therapy that may include increased corticosteroid doses or polyclonal or monoclonal antibodies.

A patient presents to the clinic with observable edema and erythema of the left forearm. A brief history reveals no exposure to potential irritating agents. On palpation, the nurse finds the area very warm and tender. What is the most likely cause of the patient's symptoms? A An allergic reaction B A complement cascade C IgE reactions D Clonal diversity

B. A complement cascade is responsible for the dilation of blood vessels and leaking of fluid from the vascular system to the area of insult, resulting in the swelling and redness associated with an inflammatory response. An allergic reaction can cause edema and erythema, but the question does not provide enough information to determine the specific cause of the swelling and redness. IgE is a specific immunoglobulin associated with signs and symptoms of allergic rhinitis. Clonal diversity refers to the maturation process of cells

A nurse is teaching a new mother about the advantages of breast-feeding in protecting the baby against infections. Which immunoglobulin is present in breast milk that provides immunity against infections in the baby? A. IgG B. IgA C. IgM D. IgE

B. IgA is the only immunoglobulin found in breast milk and colostrum. It provides passive acquired immunity to the baby. No other immunoglobulins are present in the breast milk. Passive acquired immunity in the baby is also provided by IgG, which crosses through the placenta and is present in the baby for at least 3 months. IgM and IgE are not present in the breast milk. Text Reference - p. 206

A patient presents with recurrent symptoms of allergy, specifically hives and rashes. What type of allergy test would the nurse expect to be performed on this patient? A. ELISA B. Skin testing C. CBC with differential D. Testing bronchial secretions

B. Skin testing is the preferred method for specific allergy testing. Enzyme linked-immunosorbent assay (ELISA) is performed in specific conditions when the patient cannot undergo skin allergy testing. A complete blood count (CBC) with differential helps determine the level of eosinophils, which are elevated in type I hypersensitivity reactions. However, CBC with differential does not help to identify the allergens. Testing bronchial secretions does not help in allergy testing, as bronchial secretions are not highly specific. Text Reference - p. 214

A nurse has just been asked by a friend to administer allergy shots at home to save money by avoiding office visits. Which response by the nurse is most appropriate? A. "I would, but it is illegal for nurses to administer injections outside of a medical setting." B. "These injections should only be administered in a setting where emergency equipment and drugs are available." C. "Just make sure you have epinephrine in an injectable syringe provided along with the allergy injections." D. "Allergy shots are not usually effective; it is safer and more effective to control allergies by avoiding allergens."

B. Anaphylactic reactions occur suddenly in hypersensitive patients after exposure to the offending allergen. They may occur after parenteral injection of drugs (especially antibiotics) or blood products, and after insect stings. The cardinal principle in management is speed in recognition of signs and symptoms of an anaphylactic reaction, maintenance of a patent airway, prevention of spread of the allergen by using a tourniquet, administration of drugs, and treatment for shock. Text Reference - p. 210

A 12-year-old male is fighting with another child when he receives a puncture wound from a pencil. The school nurse cleans and bandages the wound. After about 1 week, the wound would be in which phase of healing? a. Debridement b. Primary intention c. Resolution d. Maturation

C

A 25-year-old female experiences a headache and takes aspirin for relief. A nurse recalls aspirin relieves the headache by: a. Decreasing leukotriene production b. Increasing histamine release c. Decreasing prostaglandin production d. Increasing platelet-activating factor

C

A father who has an X-linked recessive disorder and a wife with a normal genotype will: A. pass the carrier state to his make child B. pass the carrier state to all of his children C. pass the carrier state to his female child D. not pass on the genetic mutation to any of is children

C

A patient is recovering fro ,second and third degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to: A) Arrange a return-to-clinic appointment and prescription for pain medications B) Teach the patient and the caregiver proper wound care to be performed at home C) Review the patient's current health care status and readiness for discharge to home D) Give the patient written discharge information and websites for additional information for burn survivors

C

Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? A) Set hot water temperature at 140F (60C) B) Use only hardwired smoke detectors C) Encourage regular home fire exit drills D) Never permit older adults to cook unattended

C

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? A. Sit or lay in the position of comfort. B. Wear a pressure garment for 8 hours each day. C. Refer the patient to a counselor for psychosocial support. D. Use the sun to increase the skin color on the healed areas.

C In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way they looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in her new home? A. Cook for her. B. Stop her from smoking. C. Install tap water anti-scald devices. D. Be sure she uses an open space heater.

C Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.

The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? A. Replace the blood lost. B. Maintain a neutral pH. C. Maintain fluid balance. D. Replace serum potassium.

C This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities

A parent arrives at the pediatrician's office with a young patient who is to receive vaccines. The nurse would explain that the type of immunity rendered through the vaccination is what? A. Artificially acquired passive immunity B. Naturally acquired active immunity C. Artificially acquired active immunity D. Naturally acquired passive immunity

C Artificially acquired active immunity is the response to antigens that are artificially acquired by the body through vaccination. If the antigens are naturally introduced in the body, it is called naturally acquired active immunity. In passive immunity, the body receives antigens rather than synthesizing them. Text Reference - p. 204

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? A. Mannitol 75 gm IV B. Urine for myoglobulin C. Lactated Ringer's at 25 mL/hr D. Sodium bicarbonate 24 mEq every 4 hours

C Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2-4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in her treatment to: A. remove T lymphocytes in her blood that are producing antinuclear antibodies B. remove normal particles in her blood that are being damaged by autoantibodies C. exchange her plasma that contains antinuclear antibodies with a substitute fluid D. replace viral-damaged cellular components of her blood with replacement whole blood

C Rationale: The rationale for performing therapeutic plasmapheresis in patients with autoimmune disorders such as SLE is to remove pathologic substances (i.e., antinuclear antibodies) from plasma.

Which patient should the nurse prepare to transfer to a regional burn center? A. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% B. A 39-year-old patient with a partial-thickness burn to the right upper arm C. A 53-year-old patient with a chemical burn to the anterior chest and neck D. A 42-year-old patient who is scheduled for skin grafting of a burn wound

C The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to (Select all that apply): A. Bathe and dry the skin vigorously to stimulate circulation. B. Keep the head of the bed elevated 30 degrees. C. Offer nutritional supplements and frequent snacks. D. Turn the patient at least every 2 hours.

C and D The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline.

While undergoing a cerebral computed tomography (CT) scan, a contrast dye is injected. After administering a few mL of contrast media, the health care provider assesses the patient and immediately stops the infusion. What reasons could have led the health care provider to discontinue the contrast dye? Select all that apply. A. Nasal discharge B. Sneezing C. Dyspnea D. Rapid, weak pulse E. Hypotension

C,D,E Anaphylaxis is a significant adverse reaction that is life threatening in response to the iodinated dye that was used as a contrast. As anaphylaxis is manifested by respiratory distress, a rapid weak pulse, hypotension, and shock, counteractive measures must be implemented immediately. Nasal discharge and sneezing are not associated with contrast dye-related complications; these are minor manifestations of atopic reactions. Text Reference - p. 214

A patient undergoes ABO compatibility tests. When administering the patient a prescribed blood transfusion, the nurse monitors for what type of hypersensitivity reaction? A. Type I: IgE-mediated B. Type III: Immune-complex C. Type II: Cytotoxic and cytolytic D. Type IV: Delayed hypersensitivity

C. In type II hypersensitivity reactions, cellular structures are destroyed. These reactions mostly involve the destruction of red blood cells, platelets, and leukocytes. When incompatible blood types are mixed, agglutination occurs. As a result, hemoglobin may be released into the urine and plasma, causing acute kidney failure. Type I, III, and IV are not responsible for ABO incompatibility reactions. Type I hypersensitivity reactions occur during allergic rhinitis and asthma. Type III hypersensitivity reactions occur in disease conditions like rheumatoid arthritis. Type IV reactions occur in contact dermatitis. Text Reference - p. 211

The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? A. It will gather platelets for use later when needed. B. It will cause anemia because it removes whole blood and red blood cells (RBCs) that are damaged. C. It will remove the immunoglobulin G (IgG) autoantibodies and antigen complexes from the plasma. D. It will remove the peripheral stem cells to cure the autoimmune disease

C. Plasmapheresis removes plasma that contains autoantibodies (usually IgG class) and antigen-antibody complexes to remove the pathologic substances in the plasma without causing anemia. Plateletpheresis removes platelets from normal individuals for use by patients with low platelet counts. Apheresis is used to collect stem cells from peripheral blood that does not cure autoimmune disease. Text Reference - p. 217

During a preoperative assessment, the nurse would assess for latex allergy by asking the patient about allergy to which substance? A. Penicillin B. Sulfa C. Avocados D. Shellfish

C. When trying to determine whether a patient is at risk for latex allergy, the nurse can inquire about a history of allergy to avocados or bananas, which are both plant-based substances. Sulfa, penicillin, and shellfish are not associated with latex allergies. Text Reference - p. 216

A 35-year-old male is diagnosed with lobar pneumonia (lung infection). Which of the following exudates would be present in highest concentration at the site of this advanced inflammatory response? a. Serous b. Purulent c. Hemorrhagic d. Fibrinous

D

A 54-year-old male intravenous (IV) drug user is diagnosed with chronic hepatitis C. Testing revealed that he is a candidate for treatment. Which of the following could be used to treat his condition? a. Interleukin-1 b. Interleukin-6 c. Interleukin-10 d. INFs

D

A child fell off the swing and scraped the right knee. The injured area becomes painful. What else will the nurse observe upon assessment? a. Vasoconstriction at injured site b. Decreased RBC concentration at injured site c. Pale skin at injured site d. Edema at injured site

D

The macrophage secretion that stimulates procollagen synthesis and secretion is: a. Angiogenesis factor b. Matrix metalloproteinase c. Vascular endothelial growth factor d. Transforming growth factor-beta

D

Which factor will help the nurse differentiate leukotrienes from histamine? a. Site of production b. Vascular effect c. Chemotactic ability d. Time of release

D

The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? A. Severe pain, blisters, and blanching with pressure B. Pain, minimal edema, and blanching with pressure C. Redness, evidence of inhalation injury, and charred skin D. No pain, waxy white skin, and no blanching with pressure

D With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications? A. "My drug dosages will be lower because the medications enhance each other." B. "Taking more than one medication will put me at risk for developing allergies." C. "I will be more prone to malignancies because I will be taking more than one drug." D. "The lower doses of my medications can prevent rejection and minimize the side effects."

D Because immunosuppressants work at different phases of the immune response, lower doses of each drug can be used to produce effective immunosuppression while minimizing side effects. The use of several medications is not because they enhance each other, and does not increase the risk of allergies or malignancies. Text Reference - p. 221

The nurse recognizes that a patient is demonstrating signs of a transplant rejection after a renal transplant. Which phenomenon is responsible for the rejection of donor organs and tissue? A Innate immunity B Passive immunity C Humoral immunity D Cell-mediated immunity

D Cell-mediated immunity involves various cells, including natural killer cells. The natural killer cells are responsible for identifying "self" and "non-self" tissues, which sometimes results in rejection of grafts and transplants. Innate immunity is present after birth. It involves a non-specific response through neutrophils and monocytes and is not responsible for graft rejections. Passive immunity results when antibodies are acquired by the body and not produced within. Humoral immunity involves immunoglobulin production and is responsible for allergic reactions. Text Reference - p. 208

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? A. Serum sodium and potassium increase. B. Serum sodium and potassium decrease. C. Edema and arterial blood gases improve. D. Diuresis occurs and hematocrit decreases.

D In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of RBCs and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

Which of the following accurately describes rejection following transplantation? A. hyperacute rejection can be treated with OKT3 B. acute rejections can be treated with sirolimus or tacrolimus C. chronic rejection can be treated with tacrolimus or cyclosporine D. hyperacute rejection can usually be avoided is crossmatching if done before the transplantation

D Rationale: A positive crossmatch indicates that the recipient has cytotoxic antibodies to the donor's antigens and is an absolute contraindication to transplantation. If transplanted, the organ would undergo hyperacute rejection.

The nurse advises a friend who asks him to administer his allergy shots that: A. it is illegal for nurses to administer injections outside of a medical setting B. he is qualified to do it if the friend has epinephrine in an injectible syringe provided with his extract C. avoiding the allergens is a much more effective way of controlling allergens, and allergy shots are not usually effective D. immunotherapy should only be administered in a setting where emergency equipment and drugs are available

D Rationale: Anaphylactic reactions occur suddenly in hypersensitive patients after exposure to the offending allergen. They may occur after an allergy shot (i.e., parenteral injection). The cardinal principle in therapeutic management is speed in (1) recognition of signs and symptoms of an anaphylactic reaction, (2) maintenance of a patent airway, (3) prevention of spread of the allergen by use of a tourniquet, (4) administration of drugs, and (5) treatment for shock.

Association between HLA antigens and disease is most commonly found in what disease condition? A. malignancies B. infectious disease C. neurologic diseases D. autoimmune disorders

D Rationale: Most of the human leukocyte antigen (HLA)-associated diseases are classified as autoimmune disorders. Examples of associations between HLA types and disease include (1) that of HLA-B27 with ankylosing spondylitis, (2) those of HLA-DR2 and HLA-DR3 with systemic lupus erythematosus (SLE), and (3) those of HLA-DR3 and HLA-DR4 with diabetes mellitus.

In a type 1 hypersensitivity reaction, the primary immunologic disorder appears to be: A. binding of IgG to an antigen on the cell surface B. deposit of antigen-antibody complexes in small vessels C. release of cytokines to interact with specific antigens D. release of chemical mediators from IgE-bound mast cells and basophils

D Rationale: Type I hypersensitivity reactions occur only in susceptible persons who are highly sensitized to specific allergens. Immunoglobulin E (IgE) antibodies, produced in response to the allergen, have a characteristic property of attaching to mast cells and basophils.

A patient has developed multiple chemical sensitivities. What line of treatment would be appropriate for this patient? Select all that apply. A. Start narcotic drugs. B. Start anti-anxiety drugs. C. Start antidepressants. D. Avoid chemicals that may trigger symptoms. E. Create an odor-free and chemical-free home and workplace.

D, E The patient should be instructed to avoid chemicals known to trigger symptoms. Creating a chemical- and odor-free environment is the most appropriate treatment to prevent symptoms related to chemical sensitivity. Narcotic drugs, anti-anxiety drugs, and antidepressant drugs are used only to treat the symptoms temporarily. These drugs do not desensitize the patient toward the chemicals. TEST-TAKING TIP: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option. Text Reference - p. 216

healthy 65-year-old man who lives at home is at the clinic requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving? Select all that apply. A. Haemophilus influenzae type b (Hib) B. Measles, mumps, and rubella (MMR) C. Meningococcal D. Shingles E. Pneumonia

D, E The patient should receive the shingles (herpes zoster) vaccine, Pneumovax, and influenza. Meningococcal, Hib, and MMR vaccinations do not apply to this patient. Meningococcal vaccination is recommended for adults at risk (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). Adults born before 1957 generally are considered immune to measles and mumps. Hib vaccination is considered only for adults with selected conditions (e.g., sickle cell disease, leukemia, human immunodeficiency virus [HIV] infection, or for those who have anatomic or functional asplenia) if they have not been vaccinated previously. Text Reference - p. 208

The nurse is caring for a patient with a diagnosis of multiple sclerosis (MS). The nurse should be aware of which associated response? A Primary immunodeficiency B Secondary immunodeficiency C Optimal immune response D Exaggerated immune response

D. MS is an autoimmune disease, which is a form of exaggerated immune response. MS is not a problem of immunodeficiency, nor is it an optimal immune response.

A patient who has been receiving immunotherapy for the control of allergy symptoms requests a dose that can be taken at home. What is the most appropriate nursing response? A. Give immunotherapy to the patient that can be taken at home as requested. B. Give immunotherapy to the patient at home but explain that the patient will need to visit the hospital immediately afterward for testing. C. Give immunotherapy at the hospital and let the patient go home. D. Give immunotherapy at the hospital and closely monitor the patient.

D. The nurse should give immunotherapy at the hospital and closely monitor the patient for any adverse reactions. Immunotherapy may cause a severe anaphylactic reaction; therefore, the nurse should give immunotherapy only when emergency equipment is available. Immunotherapy should never be given in the home as anaphylactic shock cannot be adequately treated at home. The patient should never be left alone after immunotherapy, as systemic reactions may occur. TEST-TAKING TIP: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. Text Reference - p. 216

A student nurse learns that dendritic cells are an important component of the immune system and are found in the skin and the lining of the nose, the lungs, the stomach, and the intestine. What is the function of dendritic cells? A. They promote growth of T and B cells. B. They enhance T cell survival and mast cell activation. C. They cause chemotaxis of neutrophils and T cells. D. They capture antigens at the sites of contact with the external environment.

D. Dendritic cells capture antigens at the sites of contact with the external environment. Dendritic cells transport an antigen until it encounters a T cell with specificity for the antigen. Dendritic cells activate the immune response. IL-7 promotes growth of T and B cells. IL- 9 enhances T cell survival and mast cell activation. IL-8 facilitates chemotaxis of neutrophils and T cells. Text Reference - p. 206

When the nurse changes the dressing and documents that there is serosanguineous drainage, which type of drainage did she see on the dressing? (Images from Potter PA, Perry AG: Fundamentals of nursing, ed 7, St Louis, 2009, Mosby.)

Image C Serosanguineous drainage is frequently seen postoperatively and is composed of RBCs and serous fluid so it is a semiclear pink drainage. Serous drainage is a thin, watery drainage. Hemorrhagic drainage is bloody drainage. Purulent drainage consists of WBCs, microorganisms, and other debris that signal an infection.

Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present

Stage IV: Full-thickness Tissue Loss