Immunity, Comfort, Nutrition

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When preparing a group about vaccines, the nurse would describe vaccines as being used to stimulate:

A. Passive immunity to a foreign protein
B. Active immunity to a foreign protein
C. Serum sickness
D. A mild disease in healthy people
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When preparing a group about vaccines, the nurse would describe vaccines as being used to stimulate:

A. Passive immunity to a foreign protein
B. Active immunity to a foreign protein
C. Serum sickness
D. A mild disease in healthy people
B
The nursing instructor is discussing immunity with her clinical group. What statement would the instructor make that would be accurate about immunity?

A. Active immunity occurs with injected antibodies that react with specific antigens
B. Serum sickness results when the body fights antibodies injected as a form of active immunity.
C. Passive immunity occurs when foreign proteins are recognized and the body produces antibodies.
D. Passive immunity is limited, lasting only as long as the antibodies circulate
D

Unlike active immunity, passive immunity is limited. It lasts only as long as the circulating antibodies last because the body does not produce its own antibodies as found in active immunity. People are born with active immunity in which the body recognizes a foreign protein and begins producing antibodies to react with specific proteins or antigens. Serum sickness is a massive immune reaction against the injected antibodies that occur with passive immunity.
The nurse is teaching a client with cellulitis about home care measures to increase comfort. Which instruction should the nurse​ provide? (Select three that​ apply.)

A. ​"Apply ice packs to the affected area."
B. ​"Apply sterile saline dressings to the affected area to promote​ drainage."
C. ​"Keep the affected area below the level of the heart."
D.​ "Wash hands thoroughly before touching the affected​ area."
E. "Apply warm moist soaks."
B, D, E

May apply COOL packs to reduce inflammation because the ice will cause too much vasoconstriction. Warm moist soaks are recommended to promote blood flow and comfort.
Sterile dressing changes using aseptic technique will allow for healing and promote drainage.
Always wash hands before touching an already infected area where they may be a break in the skin.
The nurse is providing home care instruction to the client with cellulitis. Which​ statement, if made by the​ client, should concern the​ nurse?

A. ​"I will keep all​ follow-up appointments with my healthcare​ provider."
B. ​"I will be sure to get enough rest and stay off my affected​ leg."
C. ​"I will take my antibiotics until the affected area looks less​ red."
D. ​"I will keep my affected leg elevated to keep swelling​ down.
C

"I will take my antibiotics until the affected area looks less red."
Educate patients with cellulitis that it is extremely important that they finish the entire prescription and to not stop taking them even if symptoms subside. Abrupt cessation of antibiotic therapy may result in a superinfection.
A nurse is caring for a client who has experienced a first-degree sprain of the ankle. A primary care provider writes a prescription for an analgesic medication. Which is the best intervention, besides the analgesic, should the nurse advise the client to utilize for the first 24 hours after the injury?

A. Applying ice directly to the ankle.
B. Soaking the foot in warm water for 20 minutes a day.
C. Applying ice continuously to the ankle.
D. Resting and elevating the limb as much as possible.
D

For first-degree sprains, we use RICE. Rest, Ice, Compression, and Elevation.
Yes, we want to apply ice to the affected area, but it needs to be covered with a protective layer, such as a towel, to protect the skin. Ice is also applied intermittently for 15-30 minutes at a time until swelling has improved.
A 10 year-old boy comes into the ER after playing in a game of soccer. He states that walking on the joint causes pain, but he is still able to move it. Upon assessment, the boy rates his pain a 5/10 and says that he has "rolled" that same ankle a few months prior. He is diagnosed with a first-degree trauma sprain. What other significant findings would you expect to see with this client?

A. Swelling, warmth, and tenderness above the site
B. Full range of motion in affected joint
C. "Orange-peel" skin on surrounding tissue
D. Costovertebral pain
A.

Signs and symptoms of a trauma sprain will be related to the inflammatory process. This includes swelling, redness, warmth, tenderness and decreased ROM.
3. A 23 year old patient is admitted with suspected appendicitis. The patient states he is having pain around the umbilicus that extends into the lower part of his abdomen. In addition, he says that the pain is worse on the right lower quadrant. The patient points to his abdomen at a location which is about a one-third distance between the anterior superior iliac spine and umbilicus. This area is known as what?

A. Rovsing's Point
B. Hamman's Point
C. McBurney's Point
D. Murphy's Point
C

In a patient who has appendicitis, pain will begin in the periumbilical area and after 4-6 hours will localize over McBurney's point. Other classic signs include rebound tenderness, nausea, and a low-grade fever.
9. A patient is scheduled for appendectomy at noon. While performing your morning assessment, you note that the patient has a fever of 103.8 'F and rates abdominal pain 9 on 1-10. In addition, the abdomen is distended and the patient states, "I was feeling better last night but it seems the pain has become worst." The patient is having tachycardia and tachypnea. Based on the scenario, what do you suspect the patient is experiencing?

A. Pulmonary embolism
B. Colon Fistulae
C. Peritonitis
D. Hemorrhage
C

Based on the patient's presenting symptoms, the patient is most likely experiencing peritonitis because the appendix has ruptured. The key clues in this scenario are the classic signs and symptoms of peritonitis (tachycardia, tachypnea, high temperature, and abdominal pain/distension) along with the patient's statement that they were feeling better last night.
A nurse is assessing a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask?

A. "Does your child wear a hat outdoors in the cold weather?"
B. "Does anyone smoke around or in the same house as your child?"
C. "Have you given your child aspirin recently?"
D. "Is your child's diet high in gluten?"
B

OM is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear space and prolongs inflammation and impedes drainage from the ear.
A nurse is teaching the parents of an infant who has otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include?

A. Chill the medication prior to administration.
B. Massage the anterior of the infants ear following administration.
C. Hyperextend the infants neck during administration.
D. Pull the auricle up and back during administration.
B

Massaging the ear following administration facilitates installation of the medication.
A nurse is teaching a class of new parents about the manifestations of otitis media. Which of the following manifestations should the nurse include? (Select four that apply). A. Crying and fussiness B. Pulling of the ear C. Itching of the external canal D. Loss of appetite E. Sleep disturbanceA, B, D, E These are all signs and symptoms in a child that may indicate otitis media. A few other symptoms include vomiting and fever.The nurse is discharging a client with a health-care facility acquired UTI. Which information should the nurse include in the discharge teaching? A. Limit fluid intake so the urinary tract can heal B. Collect a routine urine specimen for culture C. Take all the antibiotics as prescribed D. Tell the client to void every 5-6 hoursC Taking all antibiotics as prescribed is vital in treating bacterial infections. Do not save them or stop when they feel better. Cessation in antibiotic therapy can lead to antibiotic resistant bacteria. Flush the bladder by increasing fluid intake. If doing a culture, it needs to be a clean catch and not a routine void. The patient needs to be voiding every 2-3 hours to prevent bacterial growth from urinary stasis.A patient, who is having spasms and burning while urinating due to a UTI, is prescribed "Pyridium" (Phenazopyridine). Which option below is a normal side effect of this drug? A. Hematuria B. Crystalluria C. Urethra mucous D. Orange colored urineD A side effect of Pyridium, an antispasmodic, is orange colored urine and can be expected.You're caring for a patient with an indwelling catheter. The patient complains of spasm like pain at the catheter insertion site. Which of the following options below are other signs and symptoms the patient could experience or the nurse could observe if a urinary tract infection was present? (Select all that apply) A. Increased WBC B. Crystalluria C. Positive McBurney's Sign D. Feeling the need to void even though a catheter is present E. Dark and cloudy urine F. CrampingA, D, E, F These are common signs of a UTI. B and C are not.You're providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement is INCORRECT? A. "Void immediately after sexual intercourse." B. "Avoid wearing tight fitting underwear." C. "Try to void every 2-3 hours." D. "Use scented sanitary napkins or tampons during menstruation."D The patient should avoid scented sanitary napkins or tampons during menstruation. Options A, B and C are all correct statements on how to avoid a UTI.You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. Which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately? A. "I'm seeing yellow halos around the light." B. "My mouth tastes like metal." C. "My head hurts." D. "I have this constant ringing in my ears."D Vancomycin can cause ototoxicity. Roaring or ringing in the ears are a possible sign/symptom of this adverse effect. Option A happens with Digoxin toxicity. Options B and C are vague and are not a common adverse reaction to Vancomycin.A nurse is caring for an older adult who has aspiration pneumonia. Which age-related changes contributes to the development of aspiration pneumonia? A. Decreased gastric secretions B. Diminished cough reflex C. Decreased sense of smell D. Degenerative joint diseaseB Physiological changes, including diminished cough reflex, can lead to aspiration and causing pneumonia.The nurse is caring for a client diagnosed with pneumonia resulting from Staphylococcus aureus. Which classification of medication should the nurse anticipate the healthcare provider will order to eradicate the​ infection? A. Corticosteroid B. Cephalosporin C. Antitussive D. BronchodilatorB In patients with viral pneumonia, the medical management is primarily supportive with medications such as steroids, antitussives, and bronchodilators to aid in ventilation. When a patient has bacterial pneumonia such as pneumonia resulting from Staph A., it must be treated with antibiotics such as Cephalosporin. Always remember to acquire a culture before administration, assess significant labs, educate on how to take antibiotics and teaching the client what to monitor for.A nurse is discussing a plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include? A. "You will need to apply a cold pack to the site 3 times a day." B. "Your provider might ask you to walk frequently to increase circulation to the area." C. "You will need to limit your consumption of high protein foods." D. "Your provider might prescribe you a central catheter line for long-term antibiotic therapy."D Osteomyelitis is an acute bone infection that can be chronic or acute. The client will require weeks to months of IV antibiotic therapy for treatment. Therefore, the nurse should discuss the need for long-term therapy.A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will be included in the initial plan of care? A. Immobilization of the left leg B. Positioning the left leg in flexion C. Assisted weight-bearing ambulation D. Quadriceps-setting exercise repetitionsA Immobilization of the affected leg helps decrease pain and reduce the risk for pathologic fractures. Weight-bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures.A patient with osteomyelitis has a nursing diagnosis of risk for injury. What is an appropriate nursing intervention for this patient? A. Use careful and appropriate disposal of soiled dressings. B. Gently handle the involved extremity during movement. C. Measure the circumference of the affected extremity daily. D. Provide range-of-motion (ROM) exercise q4hr to the involved extremity.B The patient with osteomyelitis is at risk for pathologic fractures at the site of the infection because of weakened, devitalized bone and careful handling of the extremity is necessary. Careful handling of dressings is necessary to prevent the spread of infection to others, but is not related to preventing injury to this patient. Splints may be used to immobilize the limb, ROM exercises will be limited because of the possibility of spreading infection, and edema is not a common finding in osteomyelitis. PREVENTION IS KEYA client has a PCA pump infusion to manage post-op pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 out of 10. What should the nurse check first? A. Check the PCA pump function B. Inspect the infusion site C. Assess vital signs D. Notify HCPB Always check your patient FIRST! In the question, they mention that the medication is being infused yet the patients pain has not subsided. Assess the infusion site to rule out infiltration. Furthermore, it is important to assess PQRST as well.On the first day after abdominal surgery, a client receiving hydromorphone via PCA pump reports that the pain 10/10 after consistently using his PCA. What is the first action you should take? A. Deliver a bolus dose per the standing order B. Notify the physician C. Try nonpharmacologic comfort measures. D. Asses the patient's pain quality, intensity and location.D ADPIE! Yes, you have a pain assessment for your patient, but if the pain medication has not treated the patients pain, it calls for further assessment. Remember PQRST.Which nursing action will be most effective in reducing pain in a client following an abdominal surgery? A. Include the teaching of pain management in preoperative teaching. B. Teach the client's family about patient controlled analgesia postoperatively. C. Ensure client discontinues anticoagulant therapy 10 days prior to surgery. D. Turn and reposition the client every four hours and encourage incentive spirometry hourly.A It is essential to always include pain management teaching to a client when they are not under the influence of pain medications.A nurse is monitoring a client who is receiving opioid analgesia for side effects of the medication. Which effects should the nurse anticipate? Select all that apply. A. Urinary incontinence B. Urinary retention C. Sedation D. Diarrhea E. Respiratory depressionB, C, E Remember when thinking about opioid side effects that, OOOpioids slOOOw everything down. This includes respirations, elimination function, and thought processes.The nurse is evaluating teaching provided to a client with peripheral arterial disease. Which client observation indicates teaching has been effective? A. Sitting in a chair with a pillow behind his knees B. Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer C. Sitting in a chair with their legs crossed D. Using a vape or e-cigarette instead of their cigarettesB In patients that have PAD, they typically have dry and hairless legs due to poor oxygenation and nutrition being carried to the tissues by the blood. Patients with PAD are also at risk for sores and injury on their feet/toes because of the peripheral neuropathy and poor wound healing. It is important to educate client on skin care.The nurse is planning care for an older client with chronic venous insufficiency. What should the nurse plan to teach this client? A. Keep the legs dependent as much as possible and elevate only when asleep. B. Wear elastic hose as prescribed. C. Standing will prevent the progression of the disease. D. Cross legs only at the knees.B Peripheral vascular disease is defined as inadequate blood flow from lower extremities back to the heart. The squeezing action of the compression sock or elastic hose helps to force the blood in the leg veins to return to the heart, taking fluid that has been trapped in the tissue with it.The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? A. Monitor the client's urinary output. B. Assess the client's pain and rule out complications. C. Increase the client's oral fluid intake. D. Use a safety gait belt when ambulating the client.B ADPIE! You always want to assess you patient first before implementing any kind of intervention, especially when they are a newly admit to your floor.The nurse on a urology unit is working with a patient who has been diagnosed with renal calculi. When planning this patient's health education, what nutritional guidelines should the nurse provide? (Select all that apply) A. Restrict protein intake B. Follow a high calcium diet C. Avoid strawberries, chocolate, and peanuts D. Eat less organ meat E. Increase intake of potassium rich foods F. Increase fluid intakeA, C, D, F When following through with these nutritional guidelines, the patient that was diagnosed is decreasing their risk for acquiring more in the future. Strawberries, chocolate, peanuts, beets, and teas are high in oxalates which is the most common type of renal calculi. Organ meats are high in uric acid and increasing fluid intake will help with passage of stones as well as maintaining hydration.A patient who has sickle cell disease is admitted with sickle cell crisis and reports severe bilateral joint pain. Which of these analgesic medications on the pain treatment protocol will be best for the nurse to administer initially? A. Ibuprofen 800 mg PO B. Morphine sulfate 4mg IV C. Hydromorphone liquid 5 mg PO D. Fentanyl 25 mcg/hr transdermal patchB Sickle cell patients are typically in severe pain due to the sickle shaped red blood cells flowing through their body. It is most prevalent in the joints and Morphine is the general pain medication used with these patients.A patient with sickle cell disease is admitted with splenic pooling. Their BP is 86/47 mmHg, and heart rate is 124 bpm. Which of these actions will the nurse take first? A. Complete a head-to-assessment B. Draw blood for type and cross-match C. Infuse NS at 250 mL/hr D. Ask the patient about vaccination historyC The first intervention in a patient who is experiencing sickle cell crisis is to push fluids.Which of the following is a potential complication that occurs specifically to a male client diagnosed with sickle cell crisis? A. Chest syndrome B. Compartment syndrome C. Priapism D. Hypertensive crisisC Priapism is when a patient has a penile erection lasting longer than 3 hours and is specific to acute sickle cell crisis.A 30 year old man comes to the ER with the chief complaint of erection lasting more than 4 hours. He has a history of sickle cell anemia. What is the initial intervention required by the nurse? A. Administer lactated ringer's at 125ml/hr B. Administer two units of packed red blood cells C. Administer 2 units of plasma D. Administer IV furosemide STATA The administration of fluids with the condition of priapism will allow for the blood that has pooled in the penis to flow elsewhere.A nurse in a providers office is assessing a client who has GERD. The nurse should expect the client to report which of the following manifestations? (Select all that apply) A. Regurgitation B. Retrosternal burning C. Belching D. Heartburn E. Weight lossA, B, C, D Regurgitation and heartburn are primary significant signs of GERD. Retrosternal burning and belching are also common manifestations.A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the clients diet? A. Oranges and tomatoes B. Carrots and bananas C. Potatoes and squash D. Whole wheat and beansA Symptoms of GERD worsen following the oral intake of substances that decrease lower esophageal stricture pressure. These also include alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint.A nurse is teaching a client about dietary recommendations to lower high blood pressure. Which of the following statements by the client indicates understanding? A. "My daily sodium consumption should be 3,000 mg." B. "I should consume foods high in potassium and calcium." C. "My limit is three cigarettes a day." D. "I should increase my fat intake."B To treat hypertension, the DASH diet is encouraged. This includes modifying the diet to consuming foods high in potassium, calcium (low-fat dairy products), and low salt. Encourage these clients to avoid canned foods, sauces, chips, pretzels and smoked meat. Apricots, bananas, tomatoes and potatoes are high in potassium. Think: Shop on the OUTSIDE perimeters of the store where all of the fresh produce is! Avoid going to the isles.As a nurse, it is our job to educate patients on heart healthy dietary habits. Which of the following should be including in the teaching of lowering cholesterol and blood pressure? (Select all that apply) A. Encourage the patient to read labels and educate the patient about appropriate food choices B. Limit alcohol intake C. Focus on red meats in the diet E. Exercise F. Weight loss G. Smoking CessationA, B, E, F, G These answer choices are recommendations of the Dash Diet and aid in lowering blood pressure and cholesterol.A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central line. Which of the following actions should the nurse perform? A. Change the tube ever 12 hrs B. Check the clients blood glucose every 8 hrs C. Apply a new dressing to the IV site every 76 hrs D. Weigh the client dailyD The nurse should weigh the client daily due to the risk of fluid and electrolyte imbalances. Other interventions include monitoring I/O's, pertinent labs, vital signs to evaluate the client's underlying condition. *Keep in mind that total parenteral nutrition is typically long-term, the solution is nutritionally complete, and the solution will contain higher than 10% Dextrose.A nurse is administering bolus enteral feedings to a client who is undergoing chemotherapy. Which of the following are appropriate nursing interventions? (Select all that apply) A. Verify the presence of bowel sounds B. Flush the feeding tube with warm water C. Elevate the head of the bed at 20 degrees D. Administer the feeding at room temperature E. Instill the formula over 60 minutesA, B, D Before administration, we want to ensure that the bowel is functioning properly. Flush the feeding to ensure patency, and administer at room temperature to prevent cramping. The bed should be placed at 30 degrees and instillation is usually around 5-30 minutes.A nurse is assessing a client who has hypoglycemia. Which of the following findings should the nurse expect? A. Fruity breath odor B. Diaphoresis C. Ketones in urine D. PolyuriaB A client who is hypoglycemic can have diaphoretic, cool, and clammy skin.A nurse is caring for a client who has diabetes mellitus and reports feeling shaky and weak. The clients blood glucose is 53 mg/dL. Which of the following actions should the nurse take? (Select all that apply) A. Give the client IV potassium B. Give the client 120 mL of fruit juice C. Retest the blood glucose after 15 mins D. If stable, provide a carbohydrate and protein E. Administer IV sodium bicarbonateB, C, D If a client because hypoglycemic, these are the steps that should be implemented. A carbohydrate and protein is given to stabilize the glucose levels. Depending on the severity of the episode, a small meal may be given.A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse expect? (Select all that apply) A. Steatorrhea B. Dizziness C. Tarry stools D. Epigastric pain E. Sour taste in mouthC, D, E Tarry stools would be present due to intestinal bleeding. Epigastric pain described as gnawing or a burning sensation. Sour taste in mouth is also a common sign.A nurse is providing teaching to a client who was diagnosed with peptic ulcer disease. Which of the following should the nurse include? (Select all that apply) A. Avoid black pepper and spicy foods B. Consume more shellfish C. Avoid caffeine and chocolate D. Avoid NSAIDSA, C, D, PUD can be cause by the chronic use of NSAIDS such as aspirin and ibuprofen. A and C are foods that a client with peptic ulcer disease should avoid since they promote increased gastric secretions.A nurse is teaching a client who has peptic ulcer disease about the adverse effects of omeprazole. Which of the following client statements indicates an understanding of the teaching? A. "If I experience severe diarrhea, I will call my doctor." B. "Pneumonia is associated with long-term use of this medication." C. "I will need to take this medication with food." D. "I should take a vitamin B12 while using this medication."A Clients who experience diarrhea while taking omeprazole of other proton pump inhibitors should report this finding to the provider immediately.A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which findings should the nurse expect to see? A. Decreased albumin B. Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisolA A decrease in the albumin level can be an indication of long-term protein depletion.A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse indicates ethnocentrism? A. Asking the client about some favorite food choices B. Notifying the dietician to complete the menu C. Recommending one's own favorite foods D. Asking the client's family to fill out the menuC Recommending one's own favorite foods is an example of ethnocentrism, which is the belief that one's own cultural practices are the only correct beliefs. Nurses should take this into consideration when planning and communicating nutritional goals. To prevent ethnocentrism a nurse should understand that food choices vary among culturesA nurse is performing a nutrition assessment on a client. Which of the following clinical findings are suggestive of malnutrition. (Select all that apply) A. Poor wound healing B. Dry, brittle hair C. Blood pressure 130/80 mmHg D. Weak hand grips E. Impaired coordinationA, B, D, E All of these assessment findings are indicative of malnutrition. Remember that not everyone who is malnourished looks like "skin and bones". A client's appearance can be deceiving. A client who has a healthy weight and appearance can be malnourished. Cultural, physical, and social norms must be apart of the client's assessment.A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is most accurate about the benefits of breastfeeding? A. The infant should not drink more than 32 oz in a 24 hour period. B. Helps the infant sleep through the night. C. Breastfeeding allows the infant to receive minerals and macronutrients in a form that is easily absorbed. D. Requires that multivitamin supplements be given to the infant.C Breast milk nutrients are highly absorbable since it is already predigested by the mother. Other benefits include reducing chances for disorders such as otitis media, DM, obesity, respiratory disorders, SIDS, and allergies. Babies who are formula-fed have a higher risk of gastrointestinal disturbances (colic, lactose intolerance, diarrhea and constipation).Order: Administer 2 mg morphine sulfate over 2 minutes Pharmacy sends 2 mg/4mL How many mLs per hour will you set the pump?120 mL/hrOrder: Administer 1000cc of D5NS over 10 hrs. The drop factor on your tubing is 15 gtt/cc. How may gtts/ min?25 gtts/min