PREPU EXAM 3
A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching? "I will limit the use of emollient skin cream to once a week." "I will expect to have a mild, occasional fever." "I will avoid people who have just received an immunization." "I might experience harmless white patches in my mouth."
"I will avoid people who have just received an immunization."
A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions?
1. Assess the client's airway 2. Call the emergency response team 3. Apply high-flow oxygen 4. Initiate IV access. 5. Administer IV epinephrine 6. Administer IV antihistamines
A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse? "It is important that you continue to take your medication to avoid an acute exacerbation." "Be sure to let the physician know after you stop your medications." "As long as you are not having symptoms, you can take a medication vacation." "If you don't take your medication, you will become very ill."
"It is important that you continue to take your medication to avoid an acute exacerbation."
A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make? "These organs support immunity." "These organs are used in digestion." "These organs regulate electrolyte balance." "These organs assist vitamin absorption."
"These organs support immunity."
The nurse is discharging a 4-year-old boy from the emergency department. The boy was seen for an insect bite that became swollen and reddened and warm and painful to touch. The client's vital signs are all within normal range for age. While giving discharge instructions to the client's father, he asks why the child is not going to get antibiotics for the infected insect bite. What would be your best response? "I'll make sure the doctor is made aware that you'd like your son to have a course of antibiotics." "Infection is not the same as inflammation. What your son has is inflammation." "In children who are previously healthy, inflammation and infections usually resolve without the need for drugs." "This is a local inflammatory response to the insect bite; it is not an infection so antibiotics will not help."
"This is a local inflammatory response to the insect bite; it is not an infection so antibiotics will not help."
A client is undergoing testing to determine the overall function of her immune system. Which test will best identify the functioning of the client's cellular immune system? -Specific antibody response -Total serum globulin assessment -Delayed hypersensitivity skin test -Immunoglobulin testing
-Delayed hypersensitivity skin test
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. -The body's lymphoid tissue decreases with age. -The body's number of B-cell lymphocytes decreases with age. -The amount of antibody produced in response to most foreign antigens decreases with age. -The body's number of T-cell lymphocytes decreases with age.
-The amount of antibody produced in response to most foreign antigens decreases with age. -The body's number of T-cell lymphocytes decreases with age.
A nurse is wearing personal protective equipment and is preparing to leave a client's room after providing care. After untying the ties at the waist of the gown, which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
1. gloves 2. eyewear 3. gown 4. mask
A charge nurse is planning to admit several clients to the medical unit. Which of the following clients should the nurse assign to a private room? A client who has a fever of unknown origin A client who had a total hip arthroplasty A client who is HIV positive A client who is neutropenic
A client who is neutropenic
The nurse is caring for a client with an abscess on his back. The nurse observes purulent drainage coming from the abscess. What type of specimen does the nurse anticipate the physician will order to determine the type of bacteria present in the exudate? White blood cell (WBC) count Test for ova and parasites A culture A sensitivity test
A culture
The nurse is educating a patient with allergic rhinitis about how the condition is induced. What should the nurse include in the education on this topic? Topical creams or ointments Airborne pollens or molds Parenteral medications Ingested foods
Airborne pollens or molds
An office worker takes a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? Delayed-type (type IV) Immune complex (type III) Anaphylactic (type 1) Cytotoxic (type II)
Anaphylactic (type 1) Explanation: The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.
Which response is a humoral immune response? Transplant rejection Anaphylaxis Delayed hypersensitivity Intracellular infections
Anaphylaxis Explanation: Anaphylaxis is an example of a humoral response. Cellular responses include transplant rejection, intracellular infections, and delayed hypersensitivity.
Diagnostic testing has revealed a deficiency in the function of a client's complement system. This client is likely to have an impaired ability to do what action? Collect immune complexes during inflammation Bridge natural and acquired immunity Protect the body against viral infection Mark the parameters of the immune response
Bridge natural and acquired immunity Explanation: Complement has three major physiologic functions: defending the body against bacterial infection, bridging natural and acquired immunity, and disposing of immune complexes and the by-products associated with inflammation.
A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention? Insert an IV line. Count the respiratory rate. Administer oxygen. Prepare equipment for intubation.
Count the respiratory rate.
Which cells present the antigen to T cells and initiate the immune response?
Macrophages Explanation: Macrophages initiate the immune response. B cells are programmed to produce one specific antibody. Antigens are substances that induce the production of antibodies. Haptens are incomplete antigens.
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care? Insert an indwelling catheter to monitor sediment in the urine. Take the client's temperature once per shift. Provide the client with fresh fruit to avoid constipation. Limit the number of health care workers entering the room.
Limit the number of health care workers entering the room.
Which of the following is the single largest preventable cause of cancer? Asbestos Arsenic Pesticides Tobacco
Tobacco
A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results?
WBC count 20,000/mm3 Explanation: This result exceeds the expected reference range for WBC of 5,000 to 10,000/mm3. The client's elevated WBC count indicates infection. The nurse should notify the surgeon.
A nursing assistant is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the nursing assistant to wash her hands and to ensure that the client is placed: on contact isolation. on neutropenic precautions. on protective isolation. in a negative-pressure room.
a) on contact isolation Negative-pressure isolation is for air-borne contact. Protective isolation is for immunocompromised patients. Neutropenic Precautions are for patients with a neutrophil count of 1,000 or less.
The nurse is teaching a client about carcinogens. What carcinogens does the nurse include in the teaching? Select all that apply. chemical agents hormone replacement therapy dietary substances defective genes environmental factors viruses
chemical agents hormone replacement therapy dietary substances defective genes environmental factors viruses
A client visits the employee health department because of mild itching and a rash on both hands. What will the employee health nurse focus on during the assessment interview? laundry detergent or bath soap changes medication allergies chemical and latex glove use life stressors the nurse may be experiencing
chemical and latex glove use Explanation: Because the itching and rash are localized, the employee health nurse will suspect an environmental cause in the workplace. With the advent of standard precautions, many nurses have experienced allergies to latex gloves. Allergies to medications, laundry detergents, or bath soaps and dermatologic reactions to stress usually elicit a more generalized or widespread rash.
A nurse is providing care to a client with a history of atopic dermatitis who has numerous lesions on the arms, neck, and legs. The client states, "My skin is so ugly. I can't imagine what people must think when they look at me. I can't look at myself sometimes." What will the nurse include on the client's plan of care? deficient knowledge disturbed body image feelings of depression pain
disturbed body image
A client has a known allergy to peanuts, meaning that the client's immune system has identified peanuts as a foreign invader and has produced specific cells to attack if the client should come in contact with peanuts again. The formation of these specific cells is known as: inflammatory response memory response cell-mediated response humoral response
humoral response Explanation:The B-cell lymphocytes mature in the bone marrow and migrate to the spleen and other lymphoid tissues such as the lymph nodes. When stimulated by T cells, the B cells become either plasma or memory cells. Plasma cells produce antibodies. Formation of antibodies is called a humoral response.
A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action? providing pain relief measures encouraging activity maintaining an open airway decreasing anxiety
maintaining an open airway
Ibuprofen affects the immune system by causing thrombocytopenia. pancytopenia. hemolytic anemia. neutropenia.
neutropenia Explanation: Ibuprofen causes leukopenia and neutropenia. Phenylbutazone causes pancytopenia. Cefuroxime sodium causes thrombocytopenia and hemolytic anemia.
During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply. fomites infectious agent virulence portal of entry susceptible host
susceptible host portal of entry infectious agent Explanation: The six components involved in the transmission of microorganisms are described as the chain of infection. All components in the chain of infection must be present to transmit an infectious disease from one human or animal to a susceptible host: an infectious agent, an appropriate reservoir, exit route, means of transmission, portal of entry, and susceptible host.
A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity (AMI). Which of the following information should the nurse confirm about AMI? AMI is mediated by antibodies produced by B-lymphocytes. Humoral immune response is mediated by T-lymphocytes. AMI involves phagocytic natural killer cells. AMI defends only against viral infections.
AMI is mediated by antibodies produced by B-lymphocytes.
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.) Bradycardia An increase in neutrophils An increase in RBCs An increase in platelets Localized edema
An increase in neutrophils Localized edema
An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization? American Nurses Association (ANA) Centers for Disease Control and Prevention (CDC) Environmental Protection Agency (EPA) American Medical Association (AMA)
Centers for Disease Control and Prevention (CDC)
A client presents to the clinic with complaints that he began to itch and break out in hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors? Flunisolide Beclomethasone dipropionate Pseudoephedrine hydrochloride Diphenhydramine
Diphenhydramine
Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)? Tumor necrosis factor (TNF) blockers Disease-modifying antirheumatic drugs (DMARDs) Nonsteroidal anti-inflammatory drugs (NSAIDs) Glucocorticoids
Disease-modifying antirheumatic drugs (DMARDs)
A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.) Don a mask, gloves, and gown. Restrict visitors who have active infections. Limit the client from bathing daily. Instruct the client to eat cooked foods only. Dispose of all linen in the trash after use.
Don a mask, gloves, and gown. Restrict visitors who have active infections. Instruct the client to eat cooked foods only.
A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? Serosanguineous drainage Mild erythema Warmth Fever
Fever
While completing an admission assessment, the client reports a family history of ovarian cancer among a maternal grandmother, aunt, and sister. The nurse knows that these cancers are most likely associated with what etiology? Smoking and tobacco use Increased tumor suppressor genes Exposure to chemicals and spermicides Inherited gene mutation
Inherited gene mutation
The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action? Notify the provider of the client's allergy. Attach a wrist band indicating the client's allergy. Ask the client if any other foods cause such a reaction. Notify the dietary department of the client's allergy.
Notify the provider of the client's allergy.
A nurse is exposed to hepatitis C and receives a shot of gamma globulin. What type of immunity does this nurse have? Artificially acquired immunity Passive Immunity Naturally Acquired immunity Natural Immunity
Passive Immunity Explanation: Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. No memory cells are produced, and the level of the injected antibodies diminishes over a period of several weeks to a few months.
A nurse would implement droplet precautions for a client with which condition? Select all that apply. Scabies Mumps Ebola virus Parvovirus B 19 Pertussis
Pertussis Mumps Parvovirus B 19
A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction? Pruritus Diarrhea Dark urine Fever
Pruritus
The nurse is providing an education program to reduce the incidence of infection currently on the rise in the community. What areas should the nurse focus on when presenting this program? (Select all that apply.) Sanitation techniques The use of antibiotics to prevent infections Swimming in the community pool Immunization programs Regulated health practices
Regulated health practices Sanitation techniques Immunization programs
A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teaching? Remove the stinger by scraping it off with a knife blade. Apply a tourniquet. Apply a warm pack. Suck the wound.
Remove the stinger by scraping it off with a knife blade.
When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the usual portal of entry for tuberculosis? Gastrointestinal system Urinary system Integumentary system Respiratory system
Respiratory system
A client is admitted to the acute care facility for vomiting and diarrhea. An intravenous (IV) catheter is inserted for the delivery of IV fluids. A family member is with the client and observes the nurse enter the room and begin touching the IV site without washing his hands or wearing gloves. Why should the client and family member be concerned with the nurse's actions? The client will have an allergic reaction to the IV. Dislodging of the IV catheter. The nurse could develop the same symptoms. The client will develop a healthcare-associated infection.
The client will develop a healthcare-associated infection.
A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations? Bronchospasm Serum sickness Tissue damage at the site Excessive mucus secretion
Tissue damage at the site
A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells? Bacterial phagocytosis Hay fever allergy Transplant rejection Anaphylaxis
Transplant rejection
What types of cells are the primary participants in immune response? Select all that apply. monocytes B-cell lymphocytes leukocytes T-cell lymphocytes
• T-cell lymphocytes •B-cell lymphocytes
The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity? "You have inherited your parent's immunity to the disease." "You have antigens to the disease, but they do not prevent the disease." "Your symptoms are a result of your body attacking itself." "You are not immune to the disease causing the symptoms."
"Your symptoms are a result of your body attacking itself." Explanation: In autoimmunity, the body mistakes its own tissue for foreign tissue and begins to attack it. Symptoms develop as the body destroys tissue. The body is in effect attacking itself.
During an annual examination, an older client tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel just fine!" Based on knowledge of neoplastic disease and the aging immune system, what teaching should the nurse include in the client's plan of care? Select all that apply. -The increase in occurrence of autoimmune diseases with aging strongly suggests a predisposition toward various types of cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of finding and treating cancer early. -Education about the importance of adhering to a recommended vaccine schedule should be initiated to boost the immune system function. -Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes; therefore the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early. -Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development. -The immune system is integrated with other psychophysiological processes and is regulated by the brain. Aging of the brain can have immunologic consequences and can affect neural and endocrine function increasing the risk of cancer development.
-Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes; therefore, the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early. -The increase in occurrence of autoimmune diseases due to aging strongly suggests a predisposition to various types of cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of finding and treating cancer early. -Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development.
A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times? An EpiPen An H1 blocker An oral airway A medical alert bracelet
An EpiPen
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? Planning Evaluation Assessment Implementation
Assessment
A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? Assess the client's level of consciousness. Administer epinephrine. Auscultate for wheezing. Monitor for hypotension.
Auscultate for wheezing. Remember ABC: airway, breathing, circulation
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that apply.) Emptying urine from an indwelling urine collection bag Providing oral care Changing an ostomy pouch Delivering a food tray to a client who has AIDS Placing oral medication tablets into a client's hand
Emptying urine from an indwelling urine collection bag Providing oral care Changing an ostomy pouch
A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice? Bar soap is preferable to liquid soap. Wearing gloves is known to be an adequate substitute for handwashing. Frequent handwashing reduces transmission of pathogens from one client to another. Waterless products should be avoided in situations where running water is unavailable.
Frequent handwashing reduces transmission of pathogens from one client to another.
Which is a primary chemical mediator of hypersensitivity? Serotonin Heparin Bradykinin Histamine
Histamine Explanation: Histamine is a primary chemical mediator of hypersensitivity. Secondary mediators include serotonin, heparin, and bradykinin.
What can the nurse do to meet the challenges in caring for a patient with cancer? Set the same goals for all patients with cancer. Ensure that the patient has the financial means to afford their care. Tell the patient about the things the patient has done to cause cancer. Identify own perception of cancer and set realistic goals.
Identify own perception of cancer and set realistic goals.
A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result? Immunoglobulin G (IgG) Immunoglobulin A (IgA) Immunoglobulin E (IgE) Immunoglobulin M (IgM)
Immunoglobulin E (IgE)
A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan? Take the client's rectal temperature each day. Increase raw produce in the client's diet. Limit visitors to healthy adults. Instruct the client to floss his teeth daily.
Limit visitors to healthy adults
The nurse is performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph nodes on the left. What should the nurse document? (Select all that apply.) Reports of tenderness Temperature Location Size Consistency
Location Size Consistency Reports of tenderness
Which type of cells destroys antigens already coated with antibody? Suppressor T-cell Null Memory T-cell Natural killer (NK)
Null Cells Explanation: Null cells destroy antigens already coated with antibody. NK cells defend against microorganisms and some types of malignant cells. Memory T cells remember contact with an antigen and, on subsequent exposures, mount an immune response. Suppressor T-cells suppress the immune response.
Which of the following occurs when the antigen-antibody molecule is coated with a sticky substance what also facilitates phagocytosis? Opsonization Agglutination Complement Antigenic determinant
Opsonization
The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply. Progressive weakening of human immune systems Population movements Increased global travel Use of extended-spectrum antibiotics Globalization of food supplies
Population movements Increased global travel Use of extended-spectrum antibiotics Globalization of food supplies
Palliation refers to
Relief of symptoms of disease and promotion of comfort and quality of life. pg. 310
A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take? Humidify the client's room. Serve cooked fruit with meals. Clean dentures in a denture cup. Replace the water in flower vases with fresh water daily.
Serve cooked fruit with meals.
The nurse is admitting a client to the medical-surgical unit after a diagnosis of cellulitis of the calf. What factors does the nurse know impact the processes of inflammation, repair, and replacement? Select all that apply. Severity of the injury Social relationships Familial support Condition of the host Nature of the injury
Severity of Infection condition of the host nature of the injury
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? Urticaria Stridor Vomiting Hypotension
Stridor
What nursing action best demonstrates primary cancer prevention? Teaching testicular self-examination Encouraging yearly Pap tests Teaching clients to wear sunscreen Facilitating screening mammograms
Teaching clients to wear sunscreen
A newly diagnosed cancer client is crying and states the following to the nurse: "I promised God that I will be a better person if I can just get better." What is the appropriate assessment of this comment by the nurse? Loss is inevitable so client is making final plans. The cancer is viewed as a punishment from past actions. Anger directed toward nursing staff is not unusual in dealing with cancer clients. The client is just trying to protect self from potential loss.
The cancer is viewed as a punishment from past actions.
A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client? WBC 1,400/mm3 RBC 4.3 x 10¹² /L Hgb 12.1 g/dL Hct 36.5% Platelets 170,000/mm3 Albumin 4.5 g/dL The client has an increased risk for bleeding. The client should receive a diet with increased protein. The client has an increased risk of infection. The client should receive an erythropoiesis stimulating agent.
The client has an increased risk of infection.
A family member of a client in a long-term care facility asks the nurse why he cannot insert a catheter so the client will not develop skin breakdown from being wet. What should the explanation include when the nurse responds to the family member? Catheters are no longer used for treatment of incontinence. The invasive nature of the catheter provides a portal for infection. Older adult residents are able to have catheters inserted if the family requests them. If a catheter is inserted, it must be flushed with normal saline daily.
The invasive nature of the catheter provides a portal for infection.
A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
The nurse should remove the most contaminated item of PPE first and the least contaminated item last. The gloves are the most contaminated, so the nurse should remove them first, and then the eyewear, the gown, and finally, the mask. Finally, the nurse should perform hand hygiene and then leave the room.
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse informs the client that she should self-administer epinephrine in what site? Forearm Thigh Deltoid muscle Abdomen
Thigh
A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication? Tinnitus Clay colored stools Nystagmus Respiratory depression
Tinnitus Explanation: The nurse should identify tinnitus, or ringing in the ears, as an adverse effect of aspirin that indicates salicylism.
Nursing students are reviewing the various infectious diseases that require transmission-based precautions. The students demonstrate understanding of the information when they identify which infectious disease as requiring airborne precautions? Scabies Tuberculosis Rubella Impetigo
Tuberculosis Explanation:Airborne precautions are used for clients with tuberculosis. Contact precautions would be appropriate for clients wtih scabies or impetigo. Droplet precautions are appropriate for clients with rubella
A client has recently been diagnosed with rheumatoid arthritis, and is also receiving further testing for disorders of the immune system. The client works as an aide at a facility caring for children infected with AIDS. Which factors will hold significant implications during the client's assessment? Select all that apply. diet work environment age history of immunizations and allergies use of other drugs Her home environment
work environment history of immunizations and allergies use of other drugs
The nurse is administering a sympathomimetic drug to a patient. What areas of concern does the nurse have when administering this drug? (Select all that apply.) Causes bronchodilation Causes laryngospasm Causes bronchoconstriction Constricts integumentary smooth muscle Dilates the muscular vasculature
• Causes bronchodilation • Constricts integumentary smooth muscle • Dilates the muscular vasculature
Which of the following are actions of chemical mediators? Select all that apply. a) Walling off the pathogen b) Minimize blood loss c) Regeneration of scar tissue. d) Activating phagocytes e) Promoting formation of fibrous scar tissue
• Minimize blood loss • Walling off the pathogen • Activating phagocytes • Promoting formation of fibrous scar tissue • Regeneration of scar tissue. Explanation:Chemical mediators assist this response by minimizing blood loss, walling off the pathogen, activating phagocytes, and promoting formation of fibrous scar tissue and regeneration of injured tissue