prepu Taylor fundamental

acquired immunity

develops after births

The nurse is evaluating a 42-year-old client who says that he is feeling stressed. Which of the following does the nurse know that could be a cause of stress for this age group? A. Being caught in the sandwich generation B. Retirement C. Social isolation D. Losing driving privileges

A. Being caught in the sandwich generation

An older adult is admitted to the health care facility with a diagnosis of depression. The nurse would be especially alert for: a. sleep problems. b. suicidal thoughts. c. poor cognitive performance. d. lack of initiative.

B. suicidal thought they are all manifestations of depression but suicide is a serious consequence

Based on an understanding of the cognitive changes that normally occur with aging, what might the nurse expect a newly hospitalized older adult to do? A. talk rapidly but be confused B. take longer to respond and react C. interrupt with frequent questions D. withdraw from strangers

B. take longer to respond and react

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? A. Shaving the face of a resident who has worn a beard for several years B. Using a tool to remove a contact lens that has adhered to the resident's eye C. Providing oral care to a client who has cognitive deficits and a decreased level of consciousness D. Providing a tub bath to a resident who is unable to mobilize independently

B. using a tool to remove a contact lens that has adhered to the resident's eye

The nurse is preparing to administer the measles, mumps and rubella (MMR) vaccine to a child. Which would be a contraindication to administering the vaccine at that time? A. The child is allergic to eggs. B. The child is to receive the varicella vaccine on the same day. C. The child received the intranasal flu vaccine 2 weeks ago. D. The child's mother is currently pregnant.

C

A patient with a recent diagnosis of HIV infection has expressed to the nurse that he is motivated to learn as much about his disease as possible. The patient has heard and read about the role of the different T cells, but is unclear of their roles in the immune response. Which of the following roles of T cells should the nurse identify? Select all that apply. A. Secreting cytokines B. Directly attacking antigens C. Stimulating the immune system D. Producing antibodies E. Activating other T cells

C, A, E, B

A client comes to the clinic with symptoms of fatigue, fever, severe joint pain, and headache. Based on these symptoms, the nurse anticipates which laboratory tests may be prescribed? Select all that apply. A. Urinalysis B. Hematocrit C. White blood cell count (WBC) D. Erythrocyte sedimentation rate (ESR) E. Platelet count

C, D

A client has tested positive for colonization with a multidrug-resistant organism (MDRO) and has been placed on contact precautions. Which actions should be included in this client's care? Select all that apply. A. Appoint one specific nurse to provide all of the client's care for the duration of a shift. B. Ensure that all care providers have current immunizations against the microorganism. C. Use appropriate PPE. D. Arrange for the client to be housed in a single room. E. Change the client's linens and gown at least twice daily.

C, D

While assessing a client diagnosed with inflammatory bowel disease, the nurse should assess for which systemic manifestations? Select all that apply. A. Rheumatoid arthritis B. Thrombocytopenia C. Hypercoagulability of blood D. Mouth inflammation E. Autoimmune anemia

C, D, E

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? A. To turn the head away from the area whenever coughing B. To remain in bed for the next 4 hours C. To splint the area when engaging in activity D. To ambulate using a cane or walker

C. to point the area when engaging in activity

Cryptococcus meningitis is suspected in a client with HIV. Which manifestations would be consistent with cryptococcus meningitis? Select all that apply. A. Vacant stare B. Psychomotor slowing C. Hyperreflexia D. Seizures E. Stiff neck

D, E

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? A. Apply a skin protectant to the incision site. B. Apply a transparent dressing over the incision site. C. Apply a sterile gauze sponge over the incision site. D. Apply a skin protectant to the skin around the incision

D. apply skin protectant to the skin around the incision

An older adult client being cared for at home has developed a decubitus injury. The nurse would instruct the family caregiver to institute measures to: A. promote bowel elimination. B. improve nutrition. C. control incontinence. D. relieve sustained pressure.

D. relieve sustained pressure

The nurse is preparing to enter a client's room who is on airborne precautions. Which technique should the nurse use when wearing a nonparticulate respirator (N-95) mask? Select all that apply. A. Tie the upper strings of mask snugly against back head. B. Discard the mask in a paper lined wastebasket. C. Remove the mask by grasping the front of mask. D. Replace the mask after 20-30 minutes. E. The mask covers the nose and mouth.

E, D, A

At 39 weeks' gestation, a pregnant client visits the physician for a scheduled prenatal checkup. The physician determines that the fetus has developed an infection in utero and sends the client for an emergency cesarean delivery. The client is very concerned about the health of her unborn child. Based on knowledge of the immune system, the delivery room nurse explains about which immunoglobulin that will be increased in the fetus at the time of birth and will be actively fighting the infection? IgG IgA IgM IgD

IgG

Two types of lymphocytes

T cells and B cells

what is secondary immune deficiency

deficiency result from some interference with an already developed immune system; usually acquired later in life

what is primary immune deficiencies

deficiency results from improper development of immune cells or tissues; usually congenital or inherited

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? circular turn spiral-reverse turn spica turn figure-of-eight turn

figure-of-eight turn

An elderly client is diagnosed with a respiratory infection. While reviewing age-related changes in the immune system, what would the nurse identify as having contributed to this client's infection? Decreased phagocytosis by Kupffer cells Impaired ciliary action from exposure to environmental toxins Failure of the immune system to differentiate "self" from "non-self" Decreased sensation and slowing of reflexes

impaired ciliary action from exposure to environmental toxins

natural immunity

is present at birth

cells involved in the fist line of defense

monocytes, macrophages, dendritic cells, natural killer cells, basophils, eosinophil, granulocytes

autoimmunity

normal protective immune response paradoxically turns against or attacks the body, leading to tissue damage

A nurse is teaching a community group about healthy lifestyles. A participant asks about how to maintain a healthy immune system. The nurse informs the group that which factor will positively affect the immune system? Rigorous, competitive exercise Residential exposure to radiation Poor nutritional status Strong family and community connections

strong family and community connections

Hypersensitivity

the body produces inappropriate or exaggerates responses to specific antigens

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

the client should be placed in side-lying position to prevent aspiration

A client is cutting vegetable for dinner and accidently cuts his finger. What response is desirable to destroy foreign agents such as microorganisms to prevent infection from developing in the finger? Passive immunity The release of memory cells The release of antibodies A cell-mediated response

the release of antibodies

A client has a fissure on her finger due to chafing. The client asks, "How long will it be painful?" The nurse explains that the inflammation phase will last: 2 weeks. 5 days. 3 days. 7 days.

3 days

Since older adults do not always have a fever with an infection, the extended-care facility personnel should observe client for: A. agitation. B. lethargy. C. tachycardia. D. hypertension.

A

A nurse is exposed to hepatitis C and receives a shot of gamma globulin. What type of immunity does this nurse have? A. Passive immunity B. Artificially acquired active immunity C. Natural immunity D. Naturally acquired active immunity

A

The nurse is discussing traditional cultural beliefs relating to skin care and healing with a group of nursing students. Which remark by a participant indicates the need for further instruction? A. Body image is of little importance to the traditional French cultural beliefs. B. Canadians traditionally are concerned about the cost of medical treatment. C. Native Americans often believe in the use of herbal or spiritual therapy. D. Asian culture often embraces the use of acupuncture.

A. body image is of little importance to the traditional french cultural beliefs

A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply. A. "Increased appetite will provide better nutrition to help with healing." B. "It may take longer for an older adult to heal." C. "Consider having a home health aide to assist with bathing and personal care." D. "Older adults with lots of sun exposure may experience delayed healing." E. "Depression after surgery is normal; this will not affect healing processes."

B, C, D

The nurse has delegated oral care for an unconscious client to an unlicensed assistive personnel (UAP). Which UAP action requires immediate nursing intervention? A. applying petroleum jelly to lips B. placing the client supine to perform mouth care C. moistening oral swabs before inserting them into the mouth D. mixing equal parts baking soda and table salt in warm water to be used to remove accumulated secretions

B. placing the client in supine position to preform mouth care

When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this? Artificially acquired active immunity Natural immunity Naturally acquired active immunity Passive immunity

artificially acquired immunity

Where are WBCs produced?

bone marrow

two general types of immunity

natural (innate) and acquired (adaptive)

A patient with HIV has been on antiretroviral therapy (ART) for 6 months. The patient comes to the clinic with home medications and the nurse observes that there are too many pills in the container. What does the nurse know about the factors associated with nonadherence to ART? (Select all that apply.) A. Active substance abuse B. Lives alone C. Taking other medication D. Lack of social support E. Depression

A, D, E

A nurse should include which information when educating the client's parents on the varicella vaccine? (Select all that apply.) A. Discuss common adverse reactions. B. The benefits of immunization. C. Instruct the parents to bring immunization records to all visits. D. Provide the date for return for the next vaccination. E. The risk of contracting vaccine-preventable diseases.

A,B,C,D,E

A client's risk for the development of a pressure injury is most likely due to which lab result? sodium 135 mEq/L albumin 2.5 mg/dL glucose 110 mg/dL hemoglobin A1C 7%

Albumin 2.5 mg/dL

A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of his last tetanus shot, which he tells the nurse was more than 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what? A bacteria An antigen An antibody A virus

Antibody

A nursing student assists a registered nurse to admit a client with a primary immunodeficiency. The nurse explains to the student that primary immunodeficiencies predispose people to three conditions. Which of the following three are those conditions? A. Malnutrition B. Autoimmunity C. Cancer D. Severe infections E. Phagocytic dysfunction

B, C, D

The nurse is preparing an educational program for her peers regarding vaccinations. What information should the nurse include? Select all that apply. A. All vaccines are stored in the refrigerator. B. Parents must be given the proper Vaccine Information Statements prior to administration of the vaccine. C. The Vaccine Information Statements include information on the route each vaccine is given. D. The CDC provides the recommended schedule for vaccines. E. The manufacturer's package insert can be given to the parents to read if the Vaccine Information Statement is not available.

B, D

The nurse is monitoring a student who is performing surgical hand asepsis. Which student actions indicate the need for further education from the nurse? Select all that apply. A. washing the nails and all surfaces of each finger B. cleaning beneath each fingernail with a file C. using at least five strokes for cleansing in each area D. dropping the soapy sponge in the sink to discard E. dropping hands to side when the wash is complete F. wearing a gold wedding band

C, E, F

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: A. evisceration B. herniation C. dehiscence

C. dehiscence

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)? A. tub bath B. bag bath C. traditional bed bath with linen change D. shower with assist

C. traditional bed bath with linen

A client with human immunodeficiency virus undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. What accurate conclusion can the nurse make? A. The client has no previous exposure to the antigens injected. B. The client has antibodies to the antigens. C. The client isn't allergic to the antigens and therefore doesn't react. D. The client is immunodeficient and won't have a skin response.

D

The nurse is caring for a child with swollen, painful joints. Which nonpharmacologic measure is most important to implement for pain relief? A. Perform gentle passive range-of-motion exercises. B. Massage the painful joints. C. Encourage the child to change position in bed every 2 hours. D. Provide a bedside commode.

D

A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as: A. emotional abuse. B. neglect. C. exploitation. D. abandonment.

D abandonment

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply. A. a wound that takes approximately 2 weeks for the edges to appear approximated and heal together B. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. C. a wound with increased swelling and drainage that may occur during the first 5 days of wound healing D. a wound that forms exudate due to the inflammatory response E. a wound that does not feel hot and tender upon palpation F. incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes

E, D, B

The nurse triaged a number of clients in the emergency department. Which clients would the nurse identify as Risk for Infection? Select all that apply. A. the older adult client who is cachectic in appearance B. the client who is taking antihypertensive medications and experienced orthostatic hypotension C. the client whose electrocardiogram (EKG) and cardiac enzymes are normal D. the client who reports abdominal pain for 1 day and exhibits an elevated white blood cell count E. the client who has AIDS and is taking antiretroviral medications F. the client who has breast cancer, is receiving chemotherapy, and has a low white blood cell (WBC) count

E, D, F, A

Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process? Select all that apply. A. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. B. Nurses limit the spread of microorganisms by directing the chain of infection. C. Nurses use personal protective equipment (PPE), which is the most effective way to help prevent the spread of organisms. D. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. E. Nurses practice asepsis, which encompasses all activities to prevent infection. F. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection.

F, D, A, E

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order. A. proliferation B. inflammation C. hemostasis D. Maturation

Hemostasis, inflammatory, proliferation, maturation

Gammopathies

Overproduction of immunoglobulins

A client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. What is the most important factor related to the client's assessment? The client's diet The client's home environment The client's use of other drugs The client's age

The client's use of other drugs

Which condition is associated with impaired immunity relating to the aging client? Increase in peripheral circulation Increase in humoral immunity Breakdown and thinning of the skin Decrease in inflammatory cytokines

breakdown and thinning of the skin

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell? Basophil Neutrophil Lymphocyte Monocyte

lymphocyte

A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection? Artificially acquired active immunity Artificially acquired passive immunity Naturally acquired passive immunity Naturally acquired active immunity

naturally acquired active immunity

Which assessment finding best confirms the diagnosis of systemic lupus erythematosus (SLE)? A. Negative anti-DNA antibody test B. Joint pain C. Facial rash D. Elevated antinuclear antibodies (ANA) levels

A

The nurse is considering the use of a power stand-assist machine with a client who has difficulty getting out of bed. The nurse will choose a different assistive device if which assessments are present? Select all that apply. A. The client is oriented to self, but not time or place. B. The client makes no attempt to help with transfers. C. The client has an above-the-knee amputation of the right leg. D. The client weighs 200 lb (91 kg). E. The client has an abdominal hernia.

A, B

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply. A. a wound that forms exudate due to the inflammatory response B. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. C. a wound that does not feel hot and tender upon palpation D. a wound with increased swelling and drainage that may occur during the first 5 days of wound healing E. a wound that takes approximately 2 weeks for the edges to appear approximated and heal together F. incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes

A, B, C

A nurse at health care facility uses a mask to prevent spread of microorganisms by droplet or airborne transmission. What action(s) is appropriate by the nurse when using masks? Select all that apply. A. Touch only the strings of the mask during removal. B. Change the mask every 20 to 30 minutes. C. Position the mask so that it covers the nose and mouth. D. Avoid touching the mask once it is in place. E. Discard used masks into a regular wastebasket.

A, B, C, D

A mother brings her 4-month-old infant to the clinic for a wellness checkup. Which immunizations should the infant receive? Select all that apply. A. diphtheria, tetanus, and pertussis (DTaP) B. rotavirus (RV) C. Haemophilus influenzae type B (Hib) D. pneumococcal (PCV) E. inactivated polio virus (IPV) F. hepatitis B (HepB)

A, B, C, D, E

While administering influenza vaccines for the general public, the nurse will advise which clients to avoid taking the influenza shot? Select all that apply. A. Client with Guillain-Barré syndrome B. Client with anaphylactic hypersensitivity to eggs C. Client who has pain at the injection site D. Client who has a fever with possible strep throat E. Client who is HIV positive

A, B, D

A nurse is preparing a presentation about human immunodeficiency virus (HIV) for a local community group. What would the nurse include in the presentation about HIV transmission? Select all that apply. A. The risk of acquiring HIV through the transfusion of blood products is almost nonexistent. B. The amount of HIV contained in body fluids on exposure is associated with the risk for infection. C. HIV transmission from mother-to child occurs primarily during pregnancy while the fetus is in utero. D. Sharing of infected equipment used to inject drugs increases the risk for infection. E. HIV can be found in seminal fluid, vaginal secretions, and breast milk.

A, B, D, E

The nurse has collected data related to the recent occurrence of several health care-associated infections (HAIs) in the acute care facility. What nursing interventions should be implemented to decrease HAIs? Select all that apply. A. cluster clients with similar conditions B. encourage clients to receive vaccinations C. recommend that the provider consider preventative antibiotic use D. wash hands before and after client care E. select appropriate personal protective equipment (PPE) for all isolation clients

A, B, D, E

The nurse is working with a group of clients. Which clients are at risk for a skin alteration? Select all that apply. A. the client who is a roofer and spends a lot of time outdoors participating in sports B. the client who has experienced vomiting and diarrhea for several days with a loss of 12 lb (5.4 kg) in weight C. the client who experienced numbness in the right arm that has resolved after several hours D. the client who has paralysis and is unable to move in bed, turned by the nurse every 2 hours E. the client with newly diagnosed diabetes who requires management education for the disease

A, B, E, D

An older client doesn't understand why advancing age increases susceptibility to illness. What will be included in the nurse's explanation? Select all that apply. A. The body's number of T-cell lymphocytes decreases with age. B. The body's lymphoid tissue decreases with age. C. The amount of antibody produced in response to most foreign antigens decreases with age. D. The body's number of B-cell lymphocytes decreases with age.

A, C

The nurse is caring for a client with acute gout. The nurse reviews the client's medical history for what possible contributors to secondary gout? Select all that apply. A. A decreased glomerular filtration rate B. Has been taking a cytotoxic medication C. Diagnosed with a hemolytic anemia D. History of consuming high purine foods E. A family history of primary gout

A, C, B

The nurse is educating a parent about symptoms that may indicate an infection is present in the newborn. What should the nurse include when educating this parent? Select all that apply. A. Fever B. Lethargy C. Restlessness D. Bloating E. Poor feeding

A, C, B, E

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. A. Place the swab in the culture tube when done. B. Tap the outside of the culture tube with the swab before placing it in the tube. C. Press and rotate the swab several times over the wound surfaces. D. Insert a swab into the wound. Use the same swab for both wound sites. E. Touch the swab to the intact skin at the wound edges.

A, C, D

An adult child accompanies an older adult client to the clinic and states, "I am not sure what is going on with my parent but I think it is depression." What questions should the nurse ask the client to determine if he or she is depressed? Select all that apply. A. "Have you lost interest in things you previously found pleasurable?" B. "What foods do you like to eat?" C. "Can you tell me what your sleep patterns are?" D. "Have you had any changes in weight recently such as a gain or loss?" E. "Have you been seeing things that no one else seems to see?"

A, C, D

The nurse has provided instruction to the client concerning the use of the sitz bath. After the instruction the nurse is evaluating the client's understanding of the education. Which findings indicate the need for further instruction? Select all that apply. a. The client uses cool water for the treatment. b. The client reports the treatment will promote circulation to the problem area. c. The client heats the water to a temperature between 115°F (46°C) and 120°F (49°C). d. The client explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction. e. The client reports that the treatment will take approximately 20 minutes.

A, C, D

A 22-year-old male client presents with an enlarged firm testis and scrotal edema and is suspected to have orchitis. The nurse includes what actions in the plan of care? Select all that apply. A. Application of cold packs B. STAT antibiotic therapy C. Elevation of the scrotum D. Restriction of client's activity E. Collection of urethral cultures

A, C, D, E

A client asks a nurse, "What can I use to decrease my risk of exposure to HIV?" What will the nurse include as effective in reducing the risk of HIV exposure? Select all that apply. A. Polyurethane female condoms B. Lambskin condoms C.Latex male condoms D. Dental dams E. Sexual abstinence

A, C, D, E

The nurse is assessing a client admitted from a long-term facility. Which assessment finding could indicate an increased risk for infection? Select all that apply. A. ineffective cough B. elevated blood pressure C. presence of an indwelling urethral catheter D. hyperactive bowel sounds E. 2 cm by 2 cm break in skin on sacrum

A, C, E

A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply. A. Norovirus B. E. coli C. Candida albicans D. Clostridium difficile E. Staphylococcus aureas

A, D

The nurse is caring for a client with a T-cell disorder. What clinical manifestation does the nurse determine will be present? A. Lymphopenia is usually present. B. There is complete lack of antibody production. C. It is autosomal dominant. D. Chronic mucocutaneous candidiasis is an associated disorder. E. Adrenal glands fail to develop.

A, D

A client is being discharged after successful treatment of an acute episode of gout. What information will the nurse include in discharge teaching? Select all that apply. A. Avoid eating organ meats such as liver and sweetbreads. B. Avoid eating salty foods such as pretzels and sardines. C. Take the prescribed allopurinol at the first sign of a flare. D. If consuming alcohol, be sure to do so in moderation. E. For the joint pain, over-the-counter NSAIDs may help.

A, D, E

A nurse works in an employee health department of a hospital. She was asked to treat a staff nurse who was exposed to blood from a patient with an HIV infection. The nurse practitioner instituted a PEP protocol that includes which of the following actions? Select all that apply. A. Continue HIV medications for 4 weeks postexposure. B. Practice safe sex for 2 weeks (time for HIV medications to reach a satisfactory blood level). C. Start prophylaxis medications between 3 to 6 hours after exposure. D. Initiate postexposure testing after 4 weeks. E. Finish postexposure testing at 6 months.

A, D, E

An older adult client is scheduled to receive passive range-of-motion (ROM) exercises. The family is present to learn how to do the exercises for the client at home. What interventions would the nurse include? Select all that apply. A. perform the exercise to the point of resistance B. ask the unlicensed assistive personnel (UAP) to perform the exercises and teach the family C. massage the client's leg if the client reports sudden sharp pain in the leg during exercise D. perform the range-of-motion exercises once a day E. provide slow and gentle movements while supporting the extremity

A, E

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. A. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. B. For impaired physical mobility, perform ROM exercises every 2 hours. C. For increased cardiac workload, instruct the client to lie in the prone position. D. For ineffective breathing patterns, encourage shallow breathing and coughing. E. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours. F. For constipation, increase fluid intake and roughage.

A, E, F

The wound care nurse is performing assessment of clients. Which wound complications does the nurse report to the health care provider? Select all that apply. A. fistula formation B. a wound with a pink wound bed and no drainage present C. a wound with approximated edges 3 days after a surgical procedure D. partial disruption of wound layers E. viscera protruding through the incisional area F. a wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5

A,D,E,F

Mrs. Jimenez, age 79, became a widow earlier this year and now resides alone in the house that she and her husband shared for 30 years. Her children have encouraged her to move, but she expresses a desire to remain in her home, despite some slight mobility challenges. The nurse who provides occasional home healthcare for Mrs. Jimenez should first propose which of the following? a. Home modification b. Assisted living c. A nursing home d. Homesharing

A. Home modifications

An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence? A. Stress B. Urge C. Overflow D. Functional

A. Stress

T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do? A. T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person. B. T-cell and B-cell lymphocytes respond to the body's invasion by macrophages. C. T-cell and B-cell lymphocytes react to the body's lack of B12 . D. T-cell and B-cell lymphocytes distinguish harmful treatments from curative treatments.

A. T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? a. Cut the nail straight across. b. Remove ingrown toenails. c. Soak the foot in witch hazel. d. Protect the foot from blisters

A. cut the nail straight across

An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition? A. Delirium B. Dementia C. Disorientation D. Depression

A. delirium

When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that: a. hair should be washed as often as necessary. b. lubricants or oils should not be used. c. braids should be undone every day. d. combs should be washed as often as necessary.

A. hair should be washed as often as possible

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals? A. She has motivation to participate in self-care. B. She has good mobility around her home. C. She has hot water to bathe in. D. She has family and friends who help her with self-care.

A. she has motivation to participate in self-care

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? A. The nurse works outward from the wound in lines parallel to it. B. The nurse swabs the wound with povidone-iodine to fight infection in the wound. C. The nurse swabs the wound from the bottom to the top. D. The nurse uses friction when cleaning the wound to loosen dead cells.

A. the nurse works outward from the wound in lines parallel to it

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. A. Use a dry sterile applicator at a 90-degree angle to measure depth. B. Draw the shape of the wound with a description. C. Assess color, drainage, presence of pain, or complications. C. Chart tunneling by using a quadrant approach to describe the location. D. Measure the wound's length and width.

B, D, C

A client with polymyalgia rheumatica (PR) is being discharged on prednisone. What teaching should the nurse include? Select all that apply. A. "You will be taught how to titrate the dosing of the drug based on your symptoms." B. "Stopping the medication abruptly can have very serious health consequences." C. "It is normal to have fluctuations in your PR symptoms while on this medication." D. "You should notice rapid improvement in your symptoms with this medication." E. "There are many adverse effects with this medication that make it difficult to take."

B, D, E

When caring for a client with a deeply infected wound that has been slow to heal, the nurse recognizes which of these are considered inflammatory mediators present during wound healing? Select all that apply. A. Globulins B. Complement C. Thrombocytes D. Tumor necrosis alpha E. Vascular endothelial growth factor

B, D, E

What would necessitate cautious use of a vaccine in a child? (Select all that apply.) A. History of febrile convulsions B. Acute infection C. Immune deficiency D. Allergy to a vaccine component E. History of brain injury F. Blood transfusion within the past 3 months

B, E, A

A client has been prescribed graduated compression stockings to wear for the next three weeks. The nurse will implement which interventions? Select all that apply. A. Plan to put the stockings on the client right before bedtime. B. Order at least two pairs of stockings. C. Launder the stockings at least every three days. D. Measure each leg and take an average to determine size to order. E. Remove the stockings and massage the legs once each day.

B,C

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? A. Notify the surgeon STAT B. Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement B. Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon C. Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

B.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. B. A Penrose drain promotes passive drainage into a dressing. C. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. D. A Penrose drain is a closed drainage system that is connected to an electronic suction device.

B. Penrose drain promotes drainage into dressing

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound A. antihypertensive B. corticosteroids C. potassium supplement d. laxative

B. corticosteroids

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? A. a client with cardiovascular disease B. a critical care client C. a newborn D. an older client with arthritis

B. critical care client

A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse? A. Discard the swab and inform the health care provider that the wound is too infected to culture B. Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab C. Obtain the swab as prescribed and send it to the lab for culture D. Obtain the swab and then clean the wound

B. discard the swab, clean the wound with a nonatimicrobrial cleanser, and contain another swab

An 84-year-old client has returned from the postanesthesia care unit. The client is oriented to name only. The client's family is very upset because before having surgery the client knew the family. The client is diagnosed with delirium. Which action should the nurse take to help the family with their emotions? A. Coordinate a family meeting to make sure everyone has the same information. B. Explain that delirium is a state of confused thinking and usually lasts only a short time. C. Refer the family to the health care provider for support. D. Introduce the family to the hospital chaplain for religious counseling

B. explain that delirium is a state of confused thinking and usually lasts only a short time

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse? A. washing the skin with soap and water prior to shaving B. pulling the razor against the direction of hair growth C. rinsing the razor after each stroke of the razor D. applying direct pressure to an area that is bleeding

B. pulling the razor against the direction of the hair growth. (it should go with the growth of hair)

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: A. to divert drainage to the peritoneal cavity. B. to provide drainage for bile. C. to decrease dead space by decreasing drainage. D. to provide a sinus tract for drainage.

B. to provide drainage for the bile

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should: A. encourage the client to bathe daily as part of protection from infection. B. understand that his culture may influence his hygiene and ask him his preference. C. give the client a bath pan and tell him she will return when he has finished. D. ask another nurse to assist in giving the client a complete bath every other day.

B. understand that his culture may influence his hygiene and ask him his preferences

At a well-child visit, the nurse is observing siblings at play. Which observed behaviors would be of concern to the nurse and would require additional assessment? Select all that apply. A. The 3-year-old runs circles while the 18-month-old chases. B. The 18-month-old does not follow the others up a set of three stairs. C. The 3-year-old sits by as the 5-year-old stacks a tower of blocks. D. The 3-year-old does not join the 5-year-old in the jumping game. E. The 5-year-old is jumping off a step pretending to fly.

C,D

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: A. a rash related to immobility. B. an allergic reaction to medications. C. a rash related to a yeast infection. D. an allergic reaction to detergent.

C. a rash related to yeast infection

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? A. autolytic debridement B. enzymatic debridement C. biosurgical debridement D. mechanical debridement

C. bio surgical

The nurse is caring for an older adult postsurgical client who will be immobile for several weeks. Which evidence prompts the nurse to monitor for a risk for infection? A. Decreased red blood cell count on laboratory results B. SpO2 reading of 89 C. Increased white blood cell count on laboratory results D. Incentive spirometry reading of less than70%

C. increasing white blood cell count on lab results

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? A. "You are seeing undermining, a type of tissue erosion." B. "This is normal tissue." C. "Necrotic tissue is devitalized tissue that must be removed to promote healing." D. "That is called slough, and it will usually fall off."

C. necrotic tissue is devitalized tissue that must be removed to promote healing

The nurse is caring for a client with an active upper respiratory infection. How will the nurse dispose of the client's unconsumed beverages and used paper tissues? A. place them into the hazardous waste container B. put them in the waste can C. double-bag items for disposal D. flush them down the toilet in the client's room

D

The nurse reviews the vaccine records of a 19-year-old and recommends a pneumococcal vaccine based on which finding? A. The client has not had a pneumococcal vaccine since early childhood . B. The client has frequent sinus infections. C. The client will be living in a college dormitory. D. The client is a smoker.

D

The nurse is admitting a client who underwent a hip replacement several weeks ago. The client now has a methicillin-resistant Staphylococcus aureus (MRSA) infection in the nonhealing hip wound. What actions would the nurse implement? Select all that apply. A. Administer intravenous vancomycin. B. Assign the client to a private room. C. Use personal protective equipment (PPE) only when performing dressing changes. D. Assess and document the client's wound. E. Post a Droplet Precautions sign on the client's door.

D, A, B

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply. A. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. B. Change the dressing midway between meals. C. Apply a nonabsorbent material over the first layer of absorbent material. D. Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. E. Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. F. Apply an absorbent dressing material as the first layer of the dressing.

D, B, A

A nurse is educating a client on how to walk with crutches. Which teaching points are recommended guidelines for this activity? Select all that apply. A. Place pressure on the axillae when walking. B. Support body weight with hands and arms. C. When climbing stairs, advance the unaffected leg past the crutches, place weight on the crutches, and then advance the affected leg followed by the crutches. D. Keep elbows close to sides. Prevent crutches from getting closer than 3 inches to the feet. E. When descending stairs, move crutches and the unaffected leg first, followed by the affected leg.

D, B, C

Gould viewed the middle years as a time when adults increase their feelings of self-satisfaction, value their spouse as a companion, and become more concerned with health. Which nursing action best facilitates this process? A. Providing entertainment for a client on bedrest B. Arranging for social services to assist with meals for a homebound client C. Counseling a client who complains of being depressed D. Encouraging a client to have regular checkups

D. encouraging a client to have regular checkups

An 85-year-old client's daughter calls the nurse and states her father is recently having periods of confusion, is unable to dress himself, and is having periods of incontinence. Which of the following should the nurse do first? A. Perform a SPICES assessment B. Teach the daughter how to use reminiscence as a therapy C. Make arrangements for the client to move to an extended-care facility D. Schedule an appointment for a physical examination

D. schedule an appointment for a physical examination

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? A. Buy a hard-bristled toothbrush to ensure proper oral hygiene. B. Reassure the client that prolonged bleeding of wounds and gums is normal. C. Take aspirin for headaches that develop. D. Use an electric razor for shaving purposes

D. use an electric razor for shaving purposes

The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents? Neutrophils Macrophages Basophils Eosinophils

Macrophages

A parent has brought a child to the clinic for a wellness check. While talking with the nurse, the parent asks the nurse to suggest a diet that will maximize the immune function of growing children. What dietary pattern should the nurse suggest? Moderate diet that is balanced and varied Diet rich in iron, zinc, and vitamin E Diet rich in amino acids and essential fatty acids Diet rich in potassium, magnesium, and sodium

Moderate diet that is balanced and varied

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect? Artificially acquired active immunity Naturally acquired active immunity Natural passive immunity Passive immunity

Naturally acquired active immunity

Which medication classification is known to inhibit prostaglandin synthesis or release? antineoplastic agents adrenal corticosteroids nonsteroidal anti-inflammatory antibiotics

Nonsteroidal anti-inflammatory