STUDY
Which function may be facilitated by a tracheostomy?
Breathing
Which test is used to monitor immune status in HIV-positive patients?
a. ELISA
b. Western blot
c. CD4 count
d. Rapid antibody test
c. CD4 count
Which medication is the most common and effective antiplatelet aggregation agent?
a. Warfarin
b. Aspirin
c. Alteplase (Activase)
d. Tenecteplase (TNKase)
b. Aspirin
Which type of immunity is acquired through vaccination?
a. Natural active
b. Artificial active
c. Natural passive
d. Artificial passive
b. Artificial active
Which assessment finding may be indicative of laryngeal cancer?
a. Persistent Hoarseness
b. Difficulty swallowing
c. Sleep apnea and snoring
d. Anemia
a. Persistent Hoarseness
The nurse is caring for a patient with suspected right-sided heart failure. Which manifestation best supports this potential diagnosis?
a. Wheezing
b. Edema
c. Orthopnea
d. Pallor
b. Edema
An infarction is an area of necrosis in tissue caused by an obstruction to the flow of blood for a prolonged period.
True or False?
True
The nurse is caring for a patient with atrial fibrillation who asks why she needs to take warfarin. Which statement best answers the patient’s question?
a. Warfarin prevents clots from forming in the atria
b. Warfarin increases the ejection fraction
c. Warfarin keeps the atrial fibrillation from involving the ventricles
d. Warfarin increases cardiac output
a. Warfarin prevents clots from forming in the atria
Which assessments indicate immune system function?
a. CBC with differential
b. ESR
c. CD4 count
d. Liver enzymes
e. Immunoglobulin levels
a. CBC with differential
c. CD4 count
e. Immunoglobulin levels
The nurse is caring for a patient with a deep venous thrombosis (DVT). Which medication would likely be used for initial inpatient treatment?
a. Dabigatran (Pradaxa)
b. Heparin
c. Warfarin (Coumadin)
d. Edoxaban (Lixiana)
b. Heparin
During clinical rounds, which patient is at highest risk for infection?
a. A 22-year-old with a sprained ankle
b. A 65-year-old with diabetes and a Foley catheter
c. A 40-year-old post-op appendectomy
d. A 30-year-old with seasonal allergies
b. A 65-year-old with diabetes and a Foley catheter
The nurse is caring for a patient with peripheral arterial disease who complains of 3/10 pain in the lower extremities. The nurse observes a 0.5 cm ´ 1 cm ulcer on the left lower leg, and the lower legs are shiny and hairless bilaterally. The nurse identifies which priority problem statement/nursing diagnosis?
a. Altered skin integrity related to ulcers on lower extremities
b. Acute pain related to ischemia to lower extremities
c. Injury related to loss of peripheral circulation
a. Altered skin integrity related to ulcers on lower extremities
Why is fibromyalgia difficult to diagnose?
a. It has a known biomarker
b. Symptoms mimic other conditions
c. It causes visible joint deformities
d. It is confirmed by X-ray
b. Symptoms mimic other conditions
Select all characteristics of acquired immunity:
a. Involves memory cells
b. Immediate response
c. Specific to pathogens
d. Includes skin and mucous membranes
e. Develops over time
a. Involves memory cells
c. Specific to pathogens
e. Develops over time
Which factor is the most common cause of airway obstruction in the unconscious adult or child who is older than 1 year of age?
a. Food
b. Tongue
c. Unknown objects
d. The heart Stopping
b. Tongue
A patient asks about PrEP and HIV treatment.
Which nurse response is most accurate?
a. “PrEP cures HIV.”
b. “PrEP reduces your risk if taken consistently.”
c. “HIV treatment eliminates the virus.”
d. “PrEP is only for people who are HIV positive.”
b. “PrEP reduces your risk if taken consistently.”
Which organism would the nurse associate with development of bacterial pneumonia?
a. Pneumocystis jirovecii
b. Neisseria meningitidis
c. Streptococcus pneumoniae
d. Mycobacterium tuberculosis
c. Streptococcus pneumoniae
Which factor contributes to contact dermatitis?
a. Viral infection
b. Genetic mutation
c. Allergen exposure
d. Bacterial colonization
c. Allergen exposure
The nurse is caring for a patient experiencing epistaxis. What action should the nurse take first?
a. Obtain the patient's vital signs
b. Firmly pack the nostrils with gauze
c. Apply a cold compress
d. Instruct the patient to sit forward and pinch the nose
d. Instruct the patient to sit forward and pinch the nose
Which statement best differentiates primary from acquired immune deficiency?
a. Primary is caused by medications
b. Acquired is genetic
c. Primary is congenital
d. Acquired is present at birth
c. Primary is congenital
The nurse is caring for a patient with a closed-chest drainage system with chest tubes. Which observation confirms that the system is intact and working?
a. The water level in the water-seal chamber fluctuates.
b. The level of fluid in the collection chamber rises.
c. There are constant bubbles in the water-seal chamber.
d. The suction has been attached.
a. The water level in the water-seal chamber fluctuates.
A patient is diagnosed with Hodgkin lymphoma.
Which diagnostic finding supports this diagnosis?
a. Elevated eosinophils
b. Presence of Reed-Sternberg cells
c. Low platelet count
d. Positive ANA test
b. Presence of Reed-Sternberg cells
A patient sustains partial-thickness burns.
Which assessment is most critical?
a. Capillary refill
b. Pain level
c. Airway status
d. Skin turgor
c. Airway status
The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and agitated. The patient’s temperature is 100°F, and his pulse, blood pressure, and respirations are elevated since the last assessment 6 h ago. What action should the nurse take first?
a. Auscultate the patient's lungs
b. Administer the sedative as ordered
c. Assess the patient's oxygen saturation
d. Administer the ordered analgesic for discomfort
c. Assess the patient's oxygen saturation
For a stage 3 pressure ulcer, appropriate interventions include:
a. Debridement
b. Moist wound dressing
c. Antibiotic therapy
d. Frequent repositioning
a. Debridement
b. Moist wound dressing
d. Frequent repositioning
Which of the following best describes the innate immune response?
a. It develops after exposure to specific antigens
b. It includes B-cell and T-cell activation
c. It provides immediate, nonspecific defense
d. It requires memory cell formation
c. It provides immediate, nonspecific defense
A patient with seasonal allergies seeks help.
Which nursing interventions are appropriate?
a. Educate on allergen avoidance
b. Recommend antihistamines
c. Encourage exposure to allergens
d. Monitor for anaphylaxis
a. Educate on allergen avoidance
b. Recommend antihistamines
d. Monitor for anaphylaxis
Which condition would the nurse associate with infected pleural cavity fluid and thick, purulent exudate?
a. Empyema
b. Pneumonia
c. Emphysema
d. Tuberculosis
a. Empyema
Which of the following is NOT caused by autoimmune dysfunction?
a. Rheumatoid arthritis
b. Type 1 diabetes
c. Asthma
d. Lupus
c. Asthma
The nurse is caring for a patient who has a new prescription for a loop diuretic. Which nutritional intervention is most important for the nurse to add to the care plan?
a. Increase intake of leafy green vegetables.
b. Increase intake of bananas and potatoes.
c. Avoid foods like canned soups and hot dogs.
b. Increase intake of bananas and potatoes.
When providing care for a patient at risk for thrombus development, secondary to a total hip replacement, which symptom would the nurse associate with the occurrence of a pulmonary embolus (PE)?
a. The patient becomes bradycardic
b. The patient develops hypotension
c. The patient complains of dyspnea
d. the patient complains of sharp pain in left calf
c. The patient complains of dyspnea
Which steps occur during an allergic reaction?
a. Mast cell degranulation
b. Histamine release
c. Vasoconstriction
d. Bronchodilation
e. Increased capillary permeability
a. Mast cell degranulation
b. Histamine release
e. Increased capillary permeability
Which disorder(s) is/are examples of congenital heart defects? (Select all that apply.)
a. Arteriosclerosis
b. Coarctation of the aorta
c. Septal defects
d. Valvular defects
e. Atherosclerosis
b. Coarctation of the aorta
c. Septal defects
d. Valvular defects
Ideal actions of immunosuppressive drugs include:
a. Enhancing antibody production
b. Reducing inflammation
c. Preventing organ rejection
d. Stimulating T-cell activity
e. Suppressing autoimmune responses
b. Reducing inflammation
c. Preventing organ rejection
e. Suppressing autoimmune responses
Which factors may affect the volume of cardiac output? (Select all that apply.)
a. Heart rate
b. Peripheral pulses
c. Preload
d. Contraction strength
e. Afterload
a. Heart rate
c. Preload
d. Contraction strength
e. Afterload
The nurse is caring for a patient diagnosed with an abdominal aortic aneurysm who complains of sudden, intense abdominal pain, and light-headedness. What action should the nurse take next?
a. Monitor the patient’s blood pressure every 15 minutes.
b. Contact the physician immediately.
c. Notify the patient’s family of the change in condition.
d. Continue to assess the patient’s pain.
b. Contact the physician immediately.
Case Study: Lymphatic System Role
A patient presents with swollen lymph nodes and fever. The nurse explains the lymphatic system’s role in immunity.
Which statement by the nurse is most accurate?
a. “Your lymph nodes are producing antibodies.”
b. “They’re filtering pathogens and activating immune cells.”
c. “They’re storing red blood cells for circulation.”
d. “They’re releasing histamine to fight infection.”
b. “They’re filtering pathogens and activating immune cells.”
A patient undergoing chemotherapy is neutropenic.
Which nursing precautions are appropriate?
a. Place in reverse isolation
b. Encourage fresh fruits and flowers
c. Monitor temperature frequently
d. Administer live vaccines
a. Place in reverse isolation
c. Monitor temperature frequently
Select opportunistic infections common in HIV:
a. Pneumocystis Jirovecii pneumonia
b. Kaposi sarcoma
c. Candidiasis
d. Influenza
e. Toxoplasmosis
a. Pneumocystis Jirovecii pneumonia
b. Kaposi sarcoma
c. Candidiasis
e. Toxoplasmosis
The nurse is caring for a patient admitted with chest pain to rule out a myocardial infarction (MI). The nurse observes that the patient is experiencing electrocardiogram (ECG) changes and reviews new laboratory results. Which laboratory value should the nurse report immediately?
a. Troponin of 2.4mcg/L
b. Potassium of 3.4 mEq/L
c. Creatine phosphokinase of 134 IU/L
d. Sodium of 133 mEq/L
a. Troponin of 2.4mcg/L