QUIZ 4
Which nursing observation would indicate that the nurse hold the medication warfarin (Coumadin)? a. An INR (international normalize ratio) of 1.8 b. An INR of 4.8 c. A partial thromboplastin time (APTT) level of 25 seconds d. An APTT level of 35 seconds
B The INR of 4.8 is too high. The dosage of warfarin is adjusted to maintain an INR between 2 and 3. A level of 4.8 indicates that the patient is at risk for excessive bleeding. An INR of 1.8 is below the therapeutic range and would indicate the need for warfarin. APPT is not used to monitor effectiveness of the dose for warfarin.
An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the childs growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for a. primary immunodeficiency. b. secondary immunodeficiency. c. cancer. d. autoimmunity.
A Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.
The nurse would expect to administer an anticoagulant to a patient following which surgery? a.Hip replacement b.Hysterectomy c.Abdominal aorta aneurism (AAA) repair d.Appendectomy
A Prophylactic anticoagulation is used for hip replacement because of the high risk of developing a deep vein thrombosis after hip replacement. Anticoagulants are not routinely administered to patients with hysterectomies, AAA repairs, and appendectomies.
Which statement by a patient indicates additional teaching is required about the medication warfarin? a. I will continue my diabetic diet and restrict sugar. b. I will increase the intake of green, leafy vegetables for a more healthful diet. c. I will restrict the intake of foods high in vitamin C. d. I will increase the amount of protein in my diet to protect my kidneys.
B Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an anticoagulant that acts by interfering with vitamin Kdependent clotting factors. If the amount of vitamin K is increased in the diet, the medication dose may need to be adjusted. A diabetic diet would be continued as indicated for a patient receiving warfarin. Vitamin C is not related to warfarin.
A patient states that his/her legs have pain with walking that decreases with rest. The nurse observes absence of hair on the patients lower leg and the patient has a thready posterior tibial pulse. How would the nurse position the patients legs? a. Elevated b. crossed at the knee c.slightly bent with a pillow under the knees d. Dependent position
D A patient with arterial insufficiency is taught to position their legs in a dependent position to use gravity to help perfuse the tissues. Crossing legs at the knee may interfere with blood flow. Slightly bent legs do not enhance blood flow.
In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. This test will identify a. whether a patient has an infection. b. where an infection is located. c. what cells are being utilized by the body to attack an infection. d. what specific type of pathogen is causing an infection.
D People can transmit pathogens even if they dont currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.
The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patients respirations are 26 breaths/min with pulse 112 beats/min and weak. The nurse suspects that the patient is experiencing a(n) a. suppressed immune response. b. hyperimmune response. c. allergic reaction. d. anaphylactic reaction.
D The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.
Which of the following patients would the nurse anticipate the collaborative treatment of regular phlebotomies? a. Hemophilia b. Thrombocytopenia c. Eosinophilia d. Polycythemia
D The removal of blood by using phlebotomy is used for thrombocytopenia to decrease the blood volume and decrease blood viscosity to prevent the formation of blood clots. Hemophilia and thrombocytopenia would not benefit from phlebotomy; eosinophilia is an overproduction of eosinophils from an abnormal allergic reaction and is treated with removal of the agent the person is allergic to and possibly administration of steroids.
The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation if a. his immune system is functioning properly. b. he is properly vaccinated. c. he has an infection. d. the suppressor T-cells in his body are activated.
A Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the bodys response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.
The nurse is making a home visit to a patient who was discharged from the hospital on Lovenox and warfarin following replacement of the patients pacemaker. Which observation indicates excessive bleeding? (Select all that apply.) a.New ecchymosis on the abdomen b. A nosebleed that does not stop with pressure c. pain of the lower extremity with flexion d. extreme fatigue e. pallor f.Sudden onset of severe headache
A, B, D, E, F Excessive bleeding includes large bruises that may be increasing in size, nosebleeds, extreme fatigue from decreased tissue oxygenation due to decreased hemoglobin, and sudden onset of a severe headache, which may indicate a cerebral hemorrhage. Pain in the lower extremity may be a result of a deep vein thrombosis. Pain of the legs with flexion may be associated with venous thrombosis.
Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition
A, C, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection.
Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours
B The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.
The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patients discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population
B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.
A patient on a medical surgical unit has a platelet count of 90,000 per mm3. The nurse knows to include which of the following precautions in discharge instructions? a.Use a standard safety razor for shaving. b. use a soft bristle tooth brush c.Have aggressive dental care immediately to prevent dental caries. d. do not eat frust fruit
B The use of a soft bristle toothbrush will help prevent bleeding of the gums in a patient with thrombocytopenia. The blade of a safety razor can nick or cut the skin and cause bleeding. Dental care can cause gum bleeding. The consumption of fresh fruit is not part of bleeding precautions.
The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a a. host. b. mode of transmission. c. portal of entry. d. reservoir.
C Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.
The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a. Administration of protease inhibitors b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission d. Preventing visitors from entering the room e. Administration of intravenous fluids f. Strict monitoring of intake and output
B, C, E, F Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protective equipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.
The parents of a newborn question the nurse about the need for vaccinations: Why does our baby need all those shots? Hes so small, and they have to cause him pain. The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC)
B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient wont get the disease, but it decreases the potential to contract the illness. No medication is risk free.
While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she states which of the following? a. My body will treat the new kidney like my original kidney. b. I will have to make sure that I avoid being around people. c. The medications that I take will help prevent my body from attacking my new kidney. d. My body will only have a problem with my new kidney if the donor is not directly related to me.
C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they dont have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.
The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse explains to the patient that the goal of medication treatments for RA is to a. eradicate the disease. b. enhance immune response. c. control inflammation. d. manage pain.
C Medications for RA are intended to control the inflammation that results from the bodys hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.
While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of a _____ infection. a. bacterial b. fungal c. parasitic d. viral
C Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.
A nurse is teaching a group of businesspeople about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following? a. When traveling outside of the country, I need to be sure that I receive appropriate vaccinations. b. Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance. c.If I dont feel sick, then I dont have to worry about transmitted diseases. d. I need to be sure to have good hygiene practices when traveling in crowded planes and trains.
C People can transmit pathogens even if they dont currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.
