exam 3

Which type of immunity is the result of contact with the antigen through infection and is the longest lasting type of immunity? a. artificial active acquired immunity b. artificial passive acquired immunity c. innate immunity d. natural active acquired immunity

d

what task can the rn not delegate to the technical partner? a. getting vital signs b. drawing a peripheral cbc c. checking a manual bp d. providing discharge information

d

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for cancers c. Screening for antibody deficiencies 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.

A patient with a family history of cystic fibrosis (CF) asks for information about genetic testing. Which response by the nurse is most appropriate? a. Refer the patient to a qualified genetic counselor. b. Ask the patient why genetic testing is so important. c. Remind the patient that genetic testing has many social implications. d. Tell the patient that cystic fibrosis is an autosomal recessive disorder.

ANS: A A genetic counselor is best qualified to address the multiple issues involved in genetic testing for a patient who is considering having children. Although genetic testing does have social implications, the woman will be better served by a genetic counselor who will have more expertise in this area. CF is an autosomal recessive disorder, but the patient might not understand the implications of this statement. Asking why the patient feels genetic testing is important may imply to the patient that the nurse is questioning her value system.

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.

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.

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.

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

When caring for a young adult patient who has abnormalities in the cytochrome P450 (CYP 450) gene, which action will the nurse include in the patients plan of care? a. Teach that some medications may not work as effectively. b. Teach about genetic risk for cystic fibrosis in any children. c. Suggest that the patient make heart healthy lifestyle choices. d. Discuss the need for screening mammograms starting at age 30.

ANS: A The CYP 450 gene affects the metabolism of many medications, and they may not work as effectively or may have unexpected toxic effects. The CYP 450 gene does not affect risk for breast cancer, cystic fibrosis, or coronary artery disease.

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.

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

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-associated 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.

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

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

ANS: B 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.

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 a different way to earn extra money." b."I will take oral antihistamines before going to work." c."I will get a prescription for epinephrine and learn to self-inject it." d."I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

ANS: B 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.

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.

Which example should the nurse use to explain an infant's "passive immunity" to a new mother?a.Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases

ANS: B Colostrum in breast milk 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. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy.

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."I need to be monitored closely for development of malignant tumors." b."After a couple of years I will be able to stop taking the cyclosporine." c."If I develop acute rejection episode, I will need additional types of drugs." d."The drugs are combined to inhibit different ways the kidney can be rejected."

ANS: B 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.

A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a.Monitor the patient's edema. b.Administer a dose of epinephrine. c.Provide a prescription for oral antihistamines d.Ask the patient about the use of new skin products.

ANS: B Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and assess for development of additional edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin products does not address the immediate concern of a possible anaphylactic reaction.

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

ANS: B 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 risk for decreased immune function? a."I had a chest x-ray 6 months ago." b."I had my spleen removed after a car accident." c."I take one baby aspirin every day to prevent stroke." d."I usually eat eggs or meat for at least two meals a day."

ANS: B 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.

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. b. Document the assessment. c. Notify the health care provider. 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.

A 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 expect to administer? a.Corticosteroids c.Hepatitis B vaccine b.Gamma globulin 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 taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a.Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b.Document the patient's history and teach about clinical manifestations of a type I latex allergy. c.Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d.Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

ANS: B The patient's allergy history and occupation indicate a risk of developing a latex allergy. The patient should be taught about symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Using latex gloves increases the chance of developing latex sensitivity. Oil-based creams will increase the exposure to latex from latex gloves.

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.

A patient tells the nurse, I would like to use a home genetic test to see if I will develop breast cancer. Which response by the nurse is best? a. Home genetic testing is very expensive. b. Are you concerned about developing breast cancer? c. Wont you be depressed if the testing shows a positive result? d. Genetic testing can only determine if you are at higher risk for breast cancer.

ANS: B This response uses the communication technique of clarifying to further assess the patients concerns. The other options accurately indicate information about genetic testing, but the initial response by the nurse should be focused on assessment.

When counseling a couple in which the man has an autosomal recessive disorder and the woman has no gen for the disorder, the nurse uses Punnett squares to show the couple the probability of their having a child with the disorder. Which statement by the nurse is most appropriate? a. You should consider adoption. b. Your children will be carriers of the disorder. c. Your female children will display characteristics of the disorder. d. Your first-born child will likely display characteristics of the disorder.

ANS: B When one parent has an autosomal recessive disorder and the other parent has no genes for the autosomal recessive disorder, the children will not display characteristics of the disorder. However, the children will be carriers of the autosomal recessive disorder.

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

ANS: C A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

Which information about intradermal skin testing should the nurse teach 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 sister of a patient diagnosed with BRCA generelated breast cancer asks the nurse, Do you think I should be tested for the gene? Which response by the nurse is most appropriate? a. In most cases, breast cancer is not caused by the BRCA gene. b. It depends on how you will feel if the test is positive for the BRCA gene. c. There are many things to consider before deciding to have genetic testing. d. You should decide first whether you are willing to have a bilateral mastectomy.

ANS: C Although presymptomatic testing for genetic disorders allows patients to take action (such as mastectomy) to prevent the development of some genetically caused disorders, patients also need to consider that test results in their medical record may affect insurance, employability, etc. Telling a patient that a decision about mastectomy should be made before testing implies that the nurse has made a judgment about what the patient should do if the test is positive. Although the patient may need to think about her reaction if the test is positive, other issues (e.g., insurance) also should be considered. Although most breast cancers are not related to BRCA gene mutations, the patient with a BRCA gene mutation has a markedly increased risk for breast cancer.

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a.Obtain the patient's blood pressure and heart rate. b.Question the patient about any clear nasal discharge. c.Observe 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.

The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a.Schedule an additional dose the following week. b.Administer the scheduled 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.

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the medication at this time? a.The patient restricts salt to 2 grams per day. b.The patient eats green leafy vegetables daily. c.The patient drinks grapefruit juice every day. d.The patient drinks 3 to 4 quarts of fluid each day.

ANS: C Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function.

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.

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a.Plasmapheresis eliminates eosinophils and basophils from blood. b.Plasmapheresis decreases the damage to organs from T lymphocytes C. Plasmapheresis prevents inflammatory mediators from injuring tissues d.Plasmapheresis counteracts recovery of igG production

ANS: C 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 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 crossmatching are positive d.Panel of reactive antibodies (PRA) percentage is low

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation because 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.

The nurse in the outpatient clinic has obtained health histories for these new patients. Which patient may need referral for genetic testing? a. 20-year-old patient whose maternal grandparents died after strokes at ages 90 and 96 b. 20-year-old patient with a positive pregnancy test whose first child has cerebral palsy c. 30-year-old patient who has a sibling with newly diagnosed polycystic kidney disease d. 30-year-old patient with a history of cigarette smoking who is complaining of dyspnea

ANS: C The adult form of polycystic kidney disease is an autosomal dominant disorder and frequently it is asymptomatic until the patient is older. Presymptomatic testing will give the patient information that will be useful in guiding lifestyle and childbearing choices. The other patients do not have any indication of genetic disorders or need for genetic testing.

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? a.Provide high-flow oxygen. c.Assess the patient's airway. b.Administer antihistamines. d.Remove the stinger from the site.

ANS: C The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient's symptoms of anxiety and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part of the emergency management protocol for anaphylaxis, but the priority is airway assessment 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.

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 b. Muscle cramps c. Rising body temperature 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.

A patient's 4x3-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 b. Nonadherent dressing c. Hydrocolloid 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.

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a 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 There is no increased exposure to infection from a patient who had an anaphylactic reaction. 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.

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

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 symptoms did not improve in 2 months. 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.

A male patient with hemophilia asks the nurse if his children will be hemophiliacs. Which response by the nurse is appropriate? a. All of your children will be at risk for hemophilia. b. Hemophilia is a multifactorial inherited condition. c. Only your male children are at risk for hemophilia. d. Your female children will be carriers for hemophilia.

ANS: D Because hemophilia is caused by a mutation of the X chromosome, all female children of a man with hemophilia are carriers of the disorder and can transmit the mutated gene to their offspring. Sons of a man with hemophilia will not have the disorder. Hemophilia is caused by a single genetic mutation and is not a multifactorial inherited condition.

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 requires teaching about home care for a draining abdominal wound d. The patient who needs 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).

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is 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 a skin test 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 should assess the patient undergoing plasmapheresis for which clinical manifestation? a.Shortness of breath c.Transfusion reaction b.High blood pressure d.Extremity numbness

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 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.

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a. Eschar b. Slough c. Maceration d. Undermining

ANS: D Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narrower "lip" around the wound, which widens as the wound deepens. Eschar is a crusted cover over a wound. Slough and maceration refer to loosening friable tissue

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.

before giving digoxin, the priority nursing would be to check A. Pt sbp is >90 B. Hr is >60 C. Sbp is >100 D. Pt is voiding properly

B

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.

Correct answer: aRationale: Initial symptoms include edema and itching at the site of the exposure to the allergen.

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 injectable syringe provided with his extract. c. avoiding the allergens is a more effective way of controlling allergies, and allergy shots are not usually effective. d. immunotherapy should only be administered in a setting where emergency equipment and drugs are available.

Correct answer: 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.

The patient's wound is not healing, so the healthcare provider (HCP) is going to send the patient home with negative pressure wound therapy. What will the caregiver need to understand about the use of this device? a. The wound must be cleaned daily. b. The patient will be placed in a hyperbaric chamber. c. The occlusive dressing must be sealed tightly to the skin. d. The diet will not be as important with this sort of treatment.

c

Which patient is at the greatest risk for developing a pressure injury? a. A 42-year-old obese woman with type 2 diabetes b. A 78-year-old man who is confused and malnourished c. A 30-year-old man who is comatose after a head injury d. A 65-year-old woman who has urge and stress incontinence

c

A couple who recently had a son with hemophilia A is consulting with a nurse. They want to know if their next child will have hemophilia A. The nurse can tell the parents that if their child is a a. boy, he will have hemophilia A. b. boy, he will be a carrier of hemophilia A. c. girl, she will be a carrier of hemophilia A. d. girl, there is a 50% chance she will be a carrier of hemophilia A.

d

The patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure injury does the nurse expect to see on admission? a. stage 1 b. stage 2 c. stage 3 d. stage 4

d

A patient one day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight erythema at the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? A) The patient has a normal inflammatory response B) The abdominal incision show signs of an infection C) The abdominal incision show signs of impending dehiscence D) The patient's healthcare provider must be notified about her condition

a

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, calculate the total calories the patient should receive each day. a. 2140 b. 2007 c. 2020 d. 2700

a

Which patient has the greatest risk for experiencing delayed wound healing? A) A 65-year-old woman with stress incontinence B) a 52-year-old obese woman with type two diabetes C) a 78-year-old man who has a history of hypertension D) a 30-year-old man who drinks to alcoholic beverages per day

b

the cardiac classification of metoprolol is

beta blocker

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. Administer subcutaneous epinephrine. b. Remind the patient to remain calm. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site.

c

An 82-year-old man is being cared for at home by his family. A pressure injury on his right buttock measures 1 x 2 x 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. the nurse would document this as a stage 1. t or f

false stage 3

which is an ace inhibitor?

lisinopril

The daughter of a man with Huntington's disease is having presymptomatic genetic testing done. A positive result means she will get the disease. t or f

true

a pt was given an im injection of penicillin in the gm and developed dyspnea, feeling her throat is closing, and weakness within minutes. the nurse's first action should be to be giving an epi-pen. t or f

true