Bowel/Digestion
When fluid intake is inadequate or output is excessive the passage of chyme slows and the absorption of fluid increases. What is the end result in feces?
Feces that is harder and drier than normal.
The warmth and redness that accompany inflammation result from which of the following steps in the inflammatory process?
Hyperemia
stages of infection
Incubation period - pathogen replicates but not yet causing symptoms
Prodromal stage - symptoms begin to appear
Full stage of illness - maximal impact of the infectious process
Convalescent period - infection is contained and the pathogen eliminated; affected tissues are repaired
What is active immunity?
what is an example of active immunity?
what is passive immunity?
what is an example of passive immunity?
which type of immunity is more immediate?
Does passive immunity last for a longer or shorter term?
the immunity that results from the production of antibodies by the immune system in response to the presence of an antigen.
Vaccination, in which the body produces antibodies in response to the presence of antigen
when individuals receive antibodies from another person rather than producing them through their own immune system
breast feeding
giving blood products with antibodies
passive
Shorter- can last a few weeks to months
A nurse is preparing to administer triazolam 0.25 mg PO. Available is triazolam 0.125 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number).
0.25 mg / 0.125 mg = 2 tablets
ANS: 2 tablets
Sufficient bulk provides fecal volume. What are some examples.
raw fruits/veggies, bran products, whole grain cereal and bread.
In the presence of inflammation, a client's erythrocyte sedimentation rate (ESR)
increases due to the increased proportion of fibrinogen in the blood.
Healthcare-associated infection (HAI)
Timing?
Top 3?
during stay
- >48 hours after admittance
-Top 3 = UTI (most common), surgical site infection, pneumonia
The nurse is conducting a physical assessment for a client with a compromised immune system. Which actions by the nurse are appropriate? Select all that apply.
A) Assessing general appearance
B) Recommending increased fluid intake
C) Inspecting the mucous membranes of the nose and mouth
D) Palpating the cervical lymph nodes
E) Checking joint range of motion (ROM), including that of the spine
Answer: A, C, D, E
Explanation: A) The techniques of inspection and palpation are especially important in assessing a client's immune system. The nurse will assess the client's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the client's ROM, including that of the spine. Although recommending that the client increase fluid intake may be an appropriate nursing intervention, it is not an action that is conducted during the physical assessment for this client.
A nurse is preparing to administer albuterol 4 mg PO every 6 hr. Available is albuterol syrup 2 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number).
10 mL
Your patient has diarrhea what bowel sounds do you expect?, what happens to the electrolytes and skin? What are some clinical manifestations you expect?
hyperactive bowel sounds, skin breakdown, decreased time for electrolyte absorption, some symptoms are fatigue, weakness, mailise, emaciation
What is regeneration vs repair?
regeneration is the replacement of destroyed cells with the same type.
Repair is destroyed cell replaced with scar tissue.
the nurse is caring for a client who is exhibiting signs of a systemic infection following surgery. Which diagnostic tests would the nurse anticipate being ordered? Select all that apply.
A) Serum electrolyte levels
B) Urinalysis
C) White blood cell differential
D) White blood cell count
E) Wound culture
B, C, D, E
Explanation: A) Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess the presence of bacteria or blood in the urine. An elevated WBC and 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.
Nonspecific vs. Specific
Nonspecific protective mechanisms repel off all microorganisms equally, while the specific immune responses are tailored to particular types of invaders. Both work together to fight off organisms from entering and proliferating within the body.
A nurse is preparing to administer fluoxetine 35 mg PO daily. Available is fluoxetine solution 20 mg/5 mL. How many mL should the nurse administer daily? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
35 mg / 4 mg = 8.75 mL
ANS: 8.8 mL
What is the manifestations of fecal impaction? What will the stool smell/look like?
passage of liquid, foul smelling fecal material in the absence of a formed stool
What is the purpose of inflammatory process and what is chemotaxis?
Defense against tissue injury, infection, allergy, heat, chemical and autoimmune reaction
Chemotaxis is movement of leukocytes to the area of damage
opportunistic pathogens- who do they affect
causes disease only in susceptible individuals
Which of the following cells would be classified as granulocytes?
A) Helper T cells
B) Macrophages
C) Natural killer (NK) cells
D) Eosinophils
Answer: D
Explanation: A) There are three types of granulocytes: neutrophils, eosinophils, and basophils. Macrophages are mature monocytes and thus would not be classified as granulocytes. Helper T and NK cells are both lymphocytes, not granulocytes
A nurse is preparing to administer potassium chloride 15 mEq PO every 12 hr. Available is potassium chloride liquid 20 mEq/15 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number).
(20 mEq/15 mL) (x mL/ 15 mEq) = 11.25
ANS: 11 mL
The nurse is caring for a client who is experiencing intermittent constipation. The client has been advised to increase the amount of dietary fiber. Which food selections by the client indicate that teaching has been effective? Select all that apply.
A) Rice
B) Carrot slices
C) Spinach salad
D) Bananas
E) Peas
Answer: B, C, E
Explanation: A) Dietary fiber increases stool bulk. Vegetable fiber—such as that in carrot slices, spinach, and peas—is an excellent source of dietary fiber. The remaining selections are examples of constipating foods.
Which dietary information should the nurse teach to enhance the healing process?
A high-carbohydrate, high-protein diet is best for healing
colonization- what is an example of one
process by which strains of microorganisms become resident flora- MRSA for healthcare workers
There are three types of transplant rejection: hyperacute, acute, and chronic. explain each. What ethnic group has the highest rate of transplant rejections?
Hyperacute rejection occurs within minutes or hours of transplantation and is characterized by organ swelling, clot formation, and hemorrhage.
Acute rejection occurs in the weeks following transplantation and is marked by pain, swelling, and enlargement of the transplanted organ.
Chronic rejection occurs months after transplantation and involves slow, insidious organ failure
African Americans have the highest rate of transplant rejections.
A nurse is preparing to administer 5% dextrose in 0.45% sodium chloride 1,000mL IV to infuse over 12hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
83mL/hr