N324/327 GSS Week One GSS

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/minute. The label on the infusion bag states: dobutamine 250 mg in 250 mL normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many mL per hour?

27 mL/hr

The directional migration of leukocytes along a chemical gradient is termed: A. Chemotaxis B. Endocytosis C. Margination D. Diapedesis

A. Chemotaxis

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate? A. Elevate the ankle above heart level. B. Remove the patients shoe and sock. C. Apply a warm moist pack to the ankle. D. Assess the ankles range of motion (ROM).

A. Elevate the ankle above heart level.

A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? A. Give PRN furosemide (Lasix) 40 mg IV. B. Increase normal saline infusion to 250 mL/hr. C. Administer hydrocortisone (Solu-Cortef) 100 mg IV. D. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.

A. Give PRN furosemide (Lasix) 40 mg IV. Furosemide will lower the filling pressures and renal perfusion further

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patients human immunodeficiency virus (HIV) status is unknown? A. Needle stick with a needle and syringe used to draw blood B. Splash into the eyes when emptying a bedpan containing stool C. Contamination of open skin lesions with patient vaginal secretions D. Needle stick injury with a suture needle during a surgical procedure

A. Needle stick with a needle and syringe used to draw blood

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? A. Use aseptic technique when caring for invasive lines or devices. B. Ambulate postoperative patients as soon as possible after surgery. C. Remove indwelling urinary catheters as soon as possible after surgery. D. Advocate for parenteral nutrition for patients who cannot take oral feedings. E. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

A. Use aseptic technique when caring for invasive lines or devices. B. Ambulate postoperative patients as soon as possible after surgery. C. Remove indwelling urinary catheters as soon as possible after surgery. E. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

Which options have the highest risk for HIV transmission? A. Women during heterosexual intercourse B. Hollow-bore needle used for vascular access C. Perinatal transmission from HIV-infected mothers taking ART D. A splash exposure of HIV-infected blood on skin with an open lesion

A. Women during heterosexual intercourse B. Hollow-bore needle used for vascular access Women are at risk due to contact with semen and vaginal interaction

A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to: A. obtain wound cultures. B. start antibiotic therapy. C. redress the wound with wet-to-dry dressings. D. continue to monitor the wound for purulent drainage.

A. obtain wound cultures. don't want to affect what we find

The health care provider orders a clean-catch urine specimen for culture and sensitivity testing for a patient with a suspected urinary tract infection (UTI). To obtain the specimen, the nurse will plan to A. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. B. have the patient empty the bladder completely, and then obtain the next urine specimen that the patient is able to void. C. insert a short, small mini catheter attached to a collecting container into the urethra and bladder to obtain the specimen. D. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.

A. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.

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. At birth

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 (Vitamin C) C. Melanin D. Cholesterol

B. Ascorbic Acid (Vitamin C)

The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? A. Obtain wound cultures. B. Document the assessment. C. Notify the health care provider. D. Assess the wound every 2 hours.

B. Document the assessment. normal finding bc pt is post op after a day

An 82 yr-old male patient with cardiac disease who is in the ICU is beginning to have decreased cognitive function. What should the nurse first suspect as a potential cause of this change? A. Fatigue B. Infection C. ICU psychosis D. Medication allergy

B. Infection

A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, I am very nervous about making my baby sick. Which information will the nurse include when teaching the patient? A. The antiretroviral medications used to treat HIV infection are teratogenic. B. Most infants born to HIV-positive mothers are not infected with the virus. C. Because she is at an early stage of HIV infection, the infant will not contract HIV. D. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART).

B. Most infants born to HIV-positive mothers are not infected with the virus. If she were to take ART,...

When administering any vasoactive drug during the treatment of shock, the nurse should know that what is the goal of the therapy? A. Increasing urine output to 50 mL/hr B. Constriction of vessels to maintain BP C. Maintaining a MAP of at least 65 mmHg D. Dilating vessels to improve tissue perfusion

C. Maintaining a MAP of at least 65 mmHg

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? A. The patient meets the criteria for a diagnosis of an acute HIV infection. B. The patient will be diagnosed with asymptomatic chronic HIV infection. C. The patient has developed acquired immunodeficiency syndrome (AIDS). D. The patient will develop symptomatic chronic HIV infection in less than a year.

C. The patient has developed acquired immunodeficiency syndrome (AIDS).

What is one of the most significant factors in determining when to start ART in a patient with HIV infection? A. Whether the patient has high levels of HIV antibodies B. Confirmation that the patient has contracted HIV infection C. The patient's readiness to commit to a complex, lifelong, uncomfortable drug regimen D. Whether the patient has a support system to help manage the treatment regimen and costs

C. The patient's readiness to commit to a complex, lifelong, uncomfortable drug regimen ART is very complex

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. To prevent infection of the injured tissue

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. Edema at injured site vasodilation

A 25-year-old female presents with burning urination. She was diagnosed with a urinary tract infection. When the nurse checks the culture results, which of the following organisms is most likely infecting her urinary tract? A. Streptococcus B. Candida albicans C. Chlamydia D. Escherichia coli

D. Escherichia coli