Chapter 5 Immunity
A physician has told a patient that he has an autoimmune condition. What is the correct term for this type of condition?
the patients immune system is attacking his own tissues.
dehydration s/s in older adults and what is the early indicators
Earliest indicators: confusion and weakness **
-Decreased urine output
-Increased HR
-Decreased BP
-Constipation
-Elevated temp
-Decreased level of consciousness
Which of the following are major electrolytes in intracellular fluid?
1) Sodium & chloride
2) potassium & phosphate
3) calcium & bicarb
4) magnesium & phosphate
Sodium and Chloride
Explain the difference between infiltration and phlebitis
phlebitis (inflammation of the vein) s/s: redness, swelling, warmth, tenderness, possibility of thrombophlebitis
to fix phlebitis: stop transfusion and restart at a different site maybe apply a warm compress notify the MD, do not remove the IV in case you have to admin a antidote
infiltration (leakage of fluid from a blood vessel) s/s: pain, burning, pale & puffy at sight, may feel hard and cool
to fix infiltration: stop transfusion and start at another site, elevate extremity, notify MD if infusion contained vesicant infiltrates
An IV solution of 0.45% sodium chloride is given if the patient has experienced what?
1) excessive fluid loss
2) cerebral edema
3) excessive sodium loss
4) burns
Excessive fluid loss
The first phase of the inflammatory process, capillary permeability increases. What purpose does this serve?
Allows monocytes and neutrophils to pass ino the inflamed tissue.
What are the three lines of defense?
1st line of defense: intact skin and mucous membrane
2nd line of defense: Phagocytosis and inflammation
3rd line of defense: Immunity
Which respiratory changes occur w/ metabolic alkalosis? SATA
1) deep, paid respirations
2) slow, shallow respirations
3) dyspnea
4) intermittent apnea
5) tachypnea
Slow shallow respirations
dyspnea
intermittent apnea
Explain nursing treatment focus for hypovolemia
stop external bleeding with direct pressure, pressure dressing and tourniquet (last resort)
reduce intra abdominal or retroperitoneal bleeding or prepare for emergency surgery
admin lactated ringer solution or normal saline
transfuse with fresh whole blood, packed cells, fresh-frozen plasma, platelets, or other clotting factors if improvement does not occur with crystalloid administration
conduct auto transfusion
use of non blood plasma expanders or colloids remains controversial
Irrigation of an occluded IV cannula is not recommended b/c why?
Clots may be forced into the blood stream
Which classification of medications often places patients at risk for infection? SATA
1) Immunosuppresants
2) antihypertensives
3) steroids
4) antieplieptics
5) diuretics
Immunosupresants
Steroids
Antieplieptics
Explain the difference between intra and extracellular fluid.
Intracellular fluid: within the cell. most of the fluid is found here.
extracellular fluid: outside of the cell. found in the blood vessels in the form of plasma or serum (intravascular) and fluid surrounding the cell includes lymph fluid and elsewhere such as the digestive secretions, sweat, and cerebrospinal fluid. (interstitial fluid)
Which of the following are electrolytes? SATA
1) bilirubin
2) urea
3) magnesium
4) phosphate
5) creatine
6) sodium
7) potassium
8) chloride
9) calcium
Bilirubin
Magnesium
Creatine
Sodium
Chloride
Calcium
Patient is having kussmals respirations and confused. His ABG showed pH is 6, HCO3 is 19 and PaCO2 is 42. What is happening?
Metabolic acidosis.
Which of the following interventions is/are recommended when an older adult requires peripheral intravenous therapy? SATA
1) pad the armboard, if used
2) protect the skin from adhesive tape
3) place immobilizer over the infusion site
4) use bp cuff rather than tourniquet
pad the armboard
protect the kin from adhesive tape
use bp cuff instead of tourniquet
Which body symptoms are involved in immunity? SATA
1) bone marrow
2)heart
3) lymph nodes
4) spleen
5) thyroid
Bone marrow
Lymph nodes
spleen
What actions will the nurse take once she notices the first sign of anaphylaxis?
Seek immediate medical help. call 911 and get to the nearest emergency facility for the first sign of anaphylactic reaction. FIRST
Identify the allergen.
follow-up with the specialist
Carry epinephrine for emergencies
Remember ABC’s (PROTECT THE AIRWAY FIRST)
when reviewing a patients lab results the nurse notes that the patients has potassium imbalance. Which of the following nursing assessments is most important?
1) auscultate BS
2) evaluate muscle strength
3) Monitor heart and rhythm
4) assess reflexes
Monitor heart and rhythm
Patient is tachypnic and confused. His ABG showed pH of 8, PaCO2 of 30 and HCO3 of 23. What is happening?
Respiratory alkalosis
a patient is receiving fluids to treat dehydration. When she complains of SOB, your assessment reveals a 20-point increase in her systolic bp and HR of 100 bpm. The most likely cause of these findings is:
fluid volume excess related to fluid overload
Which is a sign of LOCALIZED infection?
1) fever
2) chills
3) warm skin
4) pale skin
Warm skin
What is the difference between community acquired infections and HAI?
community acquired: are acquired in day-to-day contact with the public. poverty, low immunization rates, overcrowding, unsanitary living conditions, and resistant strains of pathogens are responsible for the resurface of diseases that were once controlled. (p64)
healthcare associated infections: more serious than those acquired in the community, because strains of bacteria in the hospital are usually more virulent and often resistant to antibiotics. Can affect patients and healthcare workers.
Arrange the mechanisms that maintain acid- base balance in the correct order of occurrence?
1) renal regulation
2) buffers
3) respiratory regulation
Buffers
Respiratory regulation
Renal regulation
Explain the difference between colloids and crystalloids
Colloids: fluids in which substances are suspended Example: blood plasma
Crystalloids: fluids that contain h2o & electrolytes that can diffuse through a semipermeable membrane
What influences the rate when and infusion flows by gravity? SATA
1) height of the container
2) fluid volume in the container
3) fluid viscosity
4) canula diameter
5) venting of the fluid container
6) type of port
7) position of extremity
Height
Fluid volume of container
fluid viscosity
canula diameter
venting of the fluid container
postion or extremity