Infection/Inflammation/Immunity (Med Surg)
What is a key nursing intervention to reduce the risk of CLABSIs? A) Changing the dressing daily. B) Using chlorhexidine for skin antisepsis. C) Flushing the line with heparin regularly. D) Applying antibiotic ointment at the insertion site.
B
Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A) Administer Norepinephrine before attempting a fluid resuscitation. B) Collect cultures and then administer IV antibiotics. C) Check blood glucose levels before starting any other treatments. D) Administer Drotrecogin Alpha within 48-72 hours.
B Cultures must be obtained prior to initiation of antibiotics. Initial administration of antibiotics should be broad spectrum.
Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment first? A) Low-dose corticosteroids B) Crystalloids IV fluid bolus C) Norepinephrine D) 2 units of Packed Red Blood Cells
B IV fluids 30mL/kg
In a patient suspected of sepsis, what is the most appropriate initial action following the VOMIT framework? A) Administering IV antibiotics. B) Checking vital signs, particularly temperature and blood pressure. C) Setting up the patient on a monitor to continuously observe heart rate. D) Providing supplemental oxygen.
B In a suspected sepsis case, it's crucial to first assess and stabilize the patient's vital signs before proceeding with other interventions. VOMIT (Vitals, Oxygen, Monitor, IV, Treatment)
A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate? A) Kaposi's sarcoma B) Candidiasis C) Hairy leukoplakia D) Coccidioidomycosis
B Other clinical manifestations include: 1. Fever 2. Cough 3. Weakness 4. N/V/D 5. SOB 6. HA 7. Night sweats 8. Lymphadenopathy
The nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory tests can indicate arthritis? A) Reticulocyte count B) Rheumatoid factor C) Direct Coomb's test D) Platelet count
B Other lab tests include ESR, CRP, and Antinuclear antibody titer (Inflammation markers) A positive antinuclear antibody titer (ANA) and symmetric joint swelling and stiffness, confirm a diagnosis of RA.
A nurse teaching a client who has human immunodeficiency virus about how the virus is transmitted. Which of the following statements should the nurse include in the teaching? A) "HIV can be transmitted as soon as a person develops manifestations." B) "HIV can be transmitted to anyone who has had contact with the infected blood." C) "HIV is transmitted through the respiratory route through droplets." D) "HIV is transmitted only during the active phase of the virus."
B Standard precautions for this patient
A patient with a penicillin allergy is prescribed amoxicillin. What is the nurse's best course of action? A) Administer the medication as prescribed. B) Administer the medication with an antihistamine. C) Hold the medication and consult with the healthcare provider. D) Substitute the medication with an over-the-counter alternative.
C
Which patient is at the highest risk for developing a Catheter-Associated Urinary Tract Infection (CAUTI)? A) A patient with intermittent catheterization. B) A patient with a urinary catheter in place for less than 24 hours. C) A patient with a long-term indwelling urinary catheter. D) A patient performing self-catheterization at home.
C
A patient with pneumonia has a respiratory rate of 30 breaths per minute and a pulse oximetry reading of 92%. What is the nurse's best immediate action? A) Reassess the patient in 30 minutes. B) Administer prescribed bronchodilators. C) Increase the flow of supplemental oxygen. D) Prepare for immediate intubation.
C A respiratory rate of 30 breaths per minute and a pulse oximetry reading of 92% in a pneumonia patient indicate respiratory compromise, necessitating immediate oxygen support. VOMIT (Vitals, Oxygen, Monitor, IV, Treatment)
A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to A) Obtain wound cultures. B) Start antibiotic therapy. C) Redress the wound with wet-to-dry dressings. D) Continue to monitor the wound for purulent drainage.
A
Which nursing intervention is crucial in preventing CAUTIs? A) Using sterile technique during catheter insertion. B.)Prescribing prophylactic antibiotics. C) Limiting fluid intake to reduce urine production. D) Encouraging bed rest to decrease catheter movement.
A
Which of the following cell types are involved in humoral immunity? A) B lymphocytes B) Helper T lymphocyte C) Suppressor T lymphocyte D) Memory T lymphocyte
A
A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate? A) Elevate the ankle above heart level. B) Remove the patient's shoe and sock. C) Apply a warm moist pack to the ankle. D) Assess the ankle's range of motion (ROM).
A Acute Care Treatment of Inflammation: R - Rest I - Ice C - Compression E - Elevation
A nurse is assessing a patient's PCA pump. Which finding would indicate the need to notify the provider? A) The patient is demanding more doses than the PCA is set to deliver. B)The patient has used the PCA less than anticipated. C) The patient reports pain relief with the current PCA settings. D) The PCA pump is delivering medication every 10 minutes.
A If the patient's demand exceeds the delivery capacity of the PCA, it may indicate inadequate pain control, necessitating a review of the pain management plan.
A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? A) "You can experience morning stiffness when you get out of bed." B) "You can experience abdominal pain." C) "You can experience weight gain." D) "You can experience low blood sugar."
A Pain relief with activity, more pain at rest
The nursing instructor is going over laboratory results for patients with HIV/AIDS. The instructor tells the students that, upon interpretation of a patient's laboratory results, the nurse should recognize that a patient with HIV is considered to have AIDS when the CD4 T-lymphocyte cell count drops below what level? A) 200 cells/mm3 of blood B) 300 cells/mm3 of blood C) 400 cells/mm3 of blood D) 500 cells/mm3 of blood
A Patients with less than 500 CD4 cells or a viral load over 10,000 should be offered treatment. All patients with 200 or less CD4 cells should be treated. CD4 and viral load testing every 3-6 months As viral load increases, CD4 count decreases
Select the criteria below that is used to help diagnosed a patient with Acquired Immunodeficiency Syndrome (AIDS): A) CD4 count <200 cells/mm3 B) Presence of opportunistic infection C) CD4 count >1500 cells/mm3 D) WBC 9500 E) Absence of opportunistic infection
A, B
Which of the following organisms may result in the development of a nosocomial infection? (Select all that apply.) A) Staphylococcus aureus B) Mycobacterium leprae C) Pseudomonas aeruginosa D) Neisseria gonorrhea E) Escherichia coli
A, C, E
A nurse is explaining the mechanism of action of amoxicillin to a patient. Which description is most accurate? A) It strengthens the human immune response to the bacteria. B) It weakens the bacterial cell wall, leading to cell death. C) It directly kills the bacteria by disrupting their genetic material. D) It prevents the bacteria from replicating by blocking protein synthesis.
B
The nurse assess a patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? A) Obtain wound culture B) Document assessment C) Notify health care provided. D) Assess the wound every 2 hours
B
A nurse is caring for four patients. Which patient should the nurse attend to first? A) A patient with a slight fever and complaining of fatigue. B) A patient with a pulse oximetry reading of 89% and increased respiratory rate. C) A patient who needs assistance with mealtime. D) A patient awaiting discharge instructions.
B This patient is showing signs of respiratory distress, which is a critical condition requiring immediate attention. VOMIT (Vitals, Oxygen, Monitor, IV, Treatment)
A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply A) Urinary output of 60 mL over 4 hours B) Warm and flushed skin C) Tachycardia D) Bradypnea
B, C Key Sepsis/Septic Shock Findings: 1. Increased WBC 2. Increased ESR 3. Elevated lactic acid (>2) 4. Increased HR/RR 5. Fever 6. Hypotension
A 30-year-old patient is in the Acute Stage of HIV. What findings below correlate with this stage of HIV? Select all that apply: A) CD4 level <500 cells/mm3 B) No present of Opportunistic Infections C) High viral load D) Patient reports flu-like symptoms E) Patient is asymptomatic
B, C, D The Acute Stage of HIV is stage 1. In the Clinical Latency phase, or stage 2, the nurse may expect the following: 1. May be asymptomatic 2. HIV replicating at low levels 3. Length dependent on medication use 4. At the end of this stage, viral load goes up and CD4+ count goes down Stage 3 is AIDS, which is a set of symptoms resulting from HIV infection
A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate? A) "Your child does not have AIDS but this condition puts your child at risk for it later in life." B) "Your child's condition is extremely serious. Like AIDS, it will most likely be fatal." C) "Although AIDS is an immune deficiency, your child's condition is different from AIDS." D) "We need to do some more testing before we will know if your child's condition is AIDS."
C
A patient with AIDS has dark purplish brown lesions on the mucus membranes of the mouth. As the nurse you know these lesions correlate with what type of opportunistic disease? A) Epstein-Barr Virus B) Herpes Simplex Virus C) Cytomegalovirus D) Kaposi's Sarcoma
D
A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7°). Which action by the nurse is most appropriate? A) Apply a cooling blanket. B) Notify the health care provider. C) Give the prescribed PRN aspirin (Ascriptin) 650 mg. D) Check the patient's oral temperature again in 4 hours.
D 5 Cardinal Signs of Inflammation: 1. Redness 2. Swelling 3. Heat 4. Pain 5. Loss of function
A client with suspected human immunodeficiency virus (HIV) has had two positive enzyme-linked immunosorbent assay (ELISA) tests. What diagnostic test would be run next? A) Nucleic acid sequence-based amplification B) Polymerase chain reaction C) T4/T8 ratio D) Western blot assay
D ELISA test identifies antibodies, Western Blot confirms positive ELISA
A child is brought to the clinic with a rash and is subsequently diagnosed with measles. The parent reports also having had measles as a young child. What type of immunity to measles develops after the initial infection? A) Natural active immunity B) Artificial active immunity C) Natural passive immunity D) Artificial passive immunity
A Artificial active immunity; Vaccinations Natural passive immunity; Breast milk Artificial passive immunity; Medicine Natural immunity responds immediately, is non-specific, and has no memory Acquired immunity responds slowly, is very specific, and has a memory
A patient with rheumatoid arthritis presents with an elevated ESR (erythrocyte sedimentation rate), increased joint swelling, and a fever of 101°F. What should be the nurse's priority? A) Administering an antipyretic for fever. B) Applying a cold compress to swollen joints. C) Assessing the patient's pain level. D) Immediately reporting these findings to the healthcare provider.
D The combination of elevated ESR, increased joint swelling, and fever indicates a potential exacerbation of rheumatoid arthritis or an infection, necessitating prompt assessment and intervention by a healthcare provider. VOMIT (Vitals, Oxygen, Monitor, IV, Treatment)