Immunity
5. A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. What precautions should the nurse take? A. Put on a gown when entering the room. B. Place the client with another client who has TB. C. Wear a particulate respirator when caring for the client. D. Don a surgical mask with a face shield when entering the room.
Answer: C A high-particulate filtration mask that meets Center for Disease Control (CDC) performance criteria for a tuberculosis respirator must be worn to protect health care providers from exposure to the Mycobacterium tuberculosis organism. Airborne transmission-based precautions do not require a gown unless contact with respiratory secretions is anticipated. The client should be placed in a private room with negative pressure and multiple full air exchanges per hour vented to the outside environment.
2. When comparing ulcerative colitis and Crohn's disease, a nurse considers that they are similar yet dissimilar in many ways. What clinical manifestation is common to clients with Crohn's disease and not to clients with ulcerative colitis? A. Diarrhea B. Weight loss C. Right lower quadrant pain D. Decreased hematocrit
Correct Answer: C Right lower quadrant pain is typical with Crohn's disease; left lower quadrant pain is typical with ulcerative colitis. Diarrhea is common to both conditions to varying degrees. Weight loss is common to both conditions to varying degrees. Decreased hematocrit is common to both conditions to varying degrees.
4. A client has a large open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing? A. Use a separate square gauze to cleanse each half of the wound. B. Apply new Montgomery straps each time the dressing is changed. C. Hold the wet gauze with the tips of the forceps higher than the wrist. D. Cleanse the wound with wet sterile gauze from the center of the wound outward.
Correct Answer: D Wounds should be cleansed from the center outward or from the top to the bottom; this ensures that cleansing is done from the least to the most contaminated area. A new sterile gauze square should be used for each swipe of the wound.
1. A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply. A. Butterfly facial rash B. Firm skin fixed to tissue C. Inflammation of the joints D. Muscle mass degeneration E. Inflammation of small arteries
Correct Answers: A and C The connective tissue degeneration of SLE leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the malar region. Polyarthritis occurs in most clients, with joint changes similar to those seen in rheumatoid arthritis.
3. The nurse is caring for a client 1 week after a client had an above-the-knee amputation. To control edema of the residual limb, the nurse should plan to: A. Administer diuretic as needed. B. Restrict the client's oral fluid intake. C. Rewrap the elastic bandage as necessary. D. Keep the residual limb elevated on a pillow.
Correct: C Elastic bandages compress the residual limb, preventing edema and promoting residual limb shrinkage and molding; the bandage must be rewrapped when it loosens.
