NURSING MED SURG MS EXAM 2 - Jersey
College 100%VERIFIED QUESTIONS AND
ANSWERS
When helping a patient limit exposure to allergens, What should the nurse be sure the patient
understands? - ANSWER-The possible reservoirs and sources of allergens
The nurse is caring for a patient with a compromised immune system and requires protective
precautions. The licensed assistive personnel asks the nurse why this is necessary. What is the correct
response made by the nurse? - ANSWER-"Protective precautions will limit as much as possible the
number of microorganisms to which the patient is exposed."
A patient is to have a measles vaccine. Which factor, if present in the patient's history, should be
reported because it may be a contraindication to giving the immunization? - ANSWER-The patient thinks
she might be pregnant
The nursing student is discussing the topic of acquired immunity with the instructor. Which statement
by the student indicates the need for further instruction? - ANSWER-" Acquired immunity can be
achieved when the person is born with certain immunities."
The primary healthcare has provider has ordered neutropenic precautions for a patient with
neutropenia. What restrictions may be included in protective isolation precautions? - ANSWER-
Restrictions on fresh fruits and vegetables
The student nurse is preparing a presentation on the immune system. The student is correct when
identifying the antibody as being considered what? - ANSWER-A protein
A pediatric patient has acquired mumps. What will the patients body immediately produce in response
to the mumps? - ANSWER-antibodies
Hospitalized patient has been treated with IV antibiotics For a post operative word infection. Which of
these is an essential element of rebuilding tissues affected by infection? (select all that apply) -
ANSWER-Adequate vitamin intake.
Increased fluid intake
Adequate protein intake.
The nurse explains to patients with Immune or lymphatic system problems that they will need to be
monitored for particular problems. What are common problems related to the immune for the
lymphatic systems? (select all that apply) - ANSWER-Immunosuppression.
Fever.
Nutritional problems
The nurse explains to the nursing student which organs are associated with the lymphatic or immune
system? (select all that apply) - ANSWER-Tonsils.
,Thymus.
Spleen.
Normal flora - ANSWER-Microorganisms that normally exist in the body and provide a natural immunity
against certain infections
Bacteria - ANSWER-single-celled organisms that lack a nucleus; prokaryotes
Fugus - ANSWER-many-celled heterotrophic such as yeast or a mushroom
Protazoa - ANSWER-single celled organisms that can move independently and get food by engulfment.
Virus - ANSWER-A tiny, nonliving particle that invades and then reproduces inside a living cell.
Risk of exposure - ANSWER-Is influenced by the lifestyle, occupation, and socioeconomic status of the
host
You are admitting a patient with an infected abdominal wound. Wound cultures are positive for
methicillin-resistant Staphylococcus aureus. Appropriate nursing care for this patient includes: -
ANSWER-Monitoring temperature and white blood cell count
Temperature and white blood cell count are indicators for response to therapy or worsening of
infection.
During an assessment, you note fever, fatigue, general weakness, cold and clammy skin, nausea,
vomiting, and diarrhea. You recognize that the body is fighting infection by what means? - ANSWER-The
inflammatory response
Which patient instruction is most critical to a patient being discharged on antibiotic therapy? - ANSWER-
"Take all the antibiotics as prescribed."
When a patient is prescribed antibiotics, it is important to stress that taking all of the medication helps
prevent antibiotic resistance and is needed to completely illuminate the infection.
You are observing a nursing student who must perform a dressing change for a patient. You would
intervene if the student: - ANSWER-Prepare supplies, dons sterile gloves, and removes the old dressing.
The old dressing should be removed with clean gloves. If sterile gloves are used to remove the old
dressing, the gloves will have to be removed and discarded, hands rewash, and new sterile gloves
reapplied.
When administering an ordered antimicrobial for an infection, you should check the laboratory results
for: - ANSWER-Culture and sensitivity
, Culture and sensitivity are specific to identifying the pathogen.
The need for protective isolation and its parameters are being explained to the patient. She wails, "how
can I hug my children when I am locked up in this room? "An appropriate response would be: - ANSWER-
"It won't be long before you can hug them again, and we need to keep you safe from infection."
Although all of these statements could apply to this patient, she is most concerned about her family at
this point and being able to see them and show affection.
You assume the care of a patient with active pulmonary tuberculosis. You know the appropriate
management of the patient includes: (select all that apply) - ANSWER-Placement of the patient in a
room with special air handling.
Use of standard precautions with airborne precautions.
Administration of ordered antimicrobials.
Use of fit tested and 95 mask or respirators.
Which intervention would you implement for a patient with active pulmonary tuberculosis who is
socially isolated related to imposed airborne precautions? - ANSWER-Suggest alternative means of
contact, such as email and phone calls.
Suggesting alternative ways to maintain socialization address is the diagnosis.
You are caring for an older adult patient and note a change in mental status. The skin is flushed, warm,
and dry. There is a full, bounding pulse and decreased urine output. In order of priority, which action
should you take? - ANSWER-Take a full set of vital signs and compare them to the baseline.(note trends)
Check the patient's history to determine risk for sepsis.
Notify the charge nurse of your findings.(The charge nurse should be notified so that complete
assessment data is obtained prior to notification of the healthcare provider.)
Draw the patient's blood as ordered by the healthcare provider for blood cultures.(drawing blood and
sending it to the microbiology lab for processing will aid in identifying and treating the sepsis.)
Cross infection among members of the household to care for a relative with a severe infection can be
prevented by which behaviors? (Select all that apply) - ANSWER-Practicing good hand hygiene.
Using a diluted bleach to clean surfaces.
Sealing used dressings in impermeable bags
Sepsis - ANSWER-The presence of specific signs and symptoms in the setting of a known or suspected
infection.
-when a pathogen enters the bloodstream causing an systemic inflammatory response
College 100%VERIFIED QUESTIONS AND
ANSWERS
When helping a patient limit exposure to allergens, What should the nurse be sure the patient
understands? - ANSWER-The possible reservoirs and sources of allergens
The nurse is caring for a patient with a compromised immune system and requires protective
precautions. The licensed assistive personnel asks the nurse why this is necessary. What is the correct
response made by the nurse? - ANSWER-"Protective precautions will limit as much as possible the
number of microorganisms to which the patient is exposed."
A patient is to have a measles vaccine. Which factor, if present in the patient's history, should be
reported because it may be a contraindication to giving the immunization? - ANSWER-The patient thinks
she might be pregnant
The nursing student is discussing the topic of acquired immunity with the instructor. Which statement
by the student indicates the need for further instruction? - ANSWER-" Acquired immunity can be
achieved when the person is born with certain immunities."
The primary healthcare has provider has ordered neutropenic precautions for a patient with
neutropenia. What restrictions may be included in protective isolation precautions? - ANSWER-
Restrictions on fresh fruits and vegetables
The student nurse is preparing a presentation on the immune system. The student is correct when
identifying the antibody as being considered what? - ANSWER-A protein
A pediatric patient has acquired mumps. What will the patients body immediately produce in response
to the mumps? - ANSWER-antibodies
Hospitalized patient has been treated with IV antibiotics For a post operative word infection. Which of
these is an essential element of rebuilding tissues affected by infection? (select all that apply) -
ANSWER-Adequate vitamin intake.
Increased fluid intake
Adequate protein intake.
The nurse explains to patients with Immune or lymphatic system problems that they will need to be
monitored for particular problems. What are common problems related to the immune for the
lymphatic systems? (select all that apply) - ANSWER-Immunosuppression.
Fever.
Nutritional problems
The nurse explains to the nursing student which organs are associated with the lymphatic or immune
system? (select all that apply) - ANSWER-Tonsils.
,Thymus.
Spleen.
Normal flora - ANSWER-Microorganisms that normally exist in the body and provide a natural immunity
against certain infections
Bacteria - ANSWER-single-celled organisms that lack a nucleus; prokaryotes
Fugus - ANSWER-many-celled heterotrophic such as yeast or a mushroom
Protazoa - ANSWER-single celled organisms that can move independently and get food by engulfment.
Virus - ANSWER-A tiny, nonliving particle that invades and then reproduces inside a living cell.
Risk of exposure - ANSWER-Is influenced by the lifestyle, occupation, and socioeconomic status of the
host
You are admitting a patient with an infected abdominal wound. Wound cultures are positive for
methicillin-resistant Staphylococcus aureus. Appropriate nursing care for this patient includes: -
ANSWER-Monitoring temperature and white blood cell count
Temperature and white blood cell count are indicators for response to therapy or worsening of
infection.
During an assessment, you note fever, fatigue, general weakness, cold and clammy skin, nausea,
vomiting, and diarrhea. You recognize that the body is fighting infection by what means? - ANSWER-The
inflammatory response
Which patient instruction is most critical to a patient being discharged on antibiotic therapy? - ANSWER-
"Take all the antibiotics as prescribed."
When a patient is prescribed antibiotics, it is important to stress that taking all of the medication helps
prevent antibiotic resistance and is needed to completely illuminate the infection.
You are observing a nursing student who must perform a dressing change for a patient. You would
intervene if the student: - ANSWER-Prepare supplies, dons sterile gloves, and removes the old dressing.
The old dressing should be removed with clean gloves. If sterile gloves are used to remove the old
dressing, the gloves will have to be removed and discarded, hands rewash, and new sterile gloves
reapplied.
When administering an ordered antimicrobial for an infection, you should check the laboratory results
for: - ANSWER-Culture and sensitivity
, Culture and sensitivity are specific to identifying the pathogen.
The need for protective isolation and its parameters are being explained to the patient. She wails, "how
can I hug my children when I am locked up in this room? "An appropriate response would be: - ANSWER-
"It won't be long before you can hug them again, and we need to keep you safe from infection."
Although all of these statements could apply to this patient, she is most concerned about her family at
this point and being able to see them and show affection.
You assume the care of a patient with active pulmonary tuberculosis. You know the appropriate
management of the patient includes: (select all that apply) - ANSWER-Placement of the patient in a
room with special air handling.
Use of standard precautions with airborne precautions.
Administration of ordered antimicrobials.
Use of fit tested and 95 mask or respirators.
Which intervention would you implement for a patient with active pulmonary tuberculosis who is
socially isolated related to imposed airborne precautions? - ANSWER-Suggest alternative means of
contact, such as email and phone calls.
Suggesting alternative ways to maintain socialization address is the diagnosis.
You are caring for an older adult patient and note a change in mental status. The skin is flushed, warm,
and dry. There is a full, bounding pulse and decreased urine output. In order of priority, which action
should you take? - ANSWER-Take a full set of vital signs and compare them to the baseline.(note trends)
Check the patient's history to determine risk for sepsis.
Notify the charge nurse of your findings.(The charge nurse should be notified so that complete
assessment data is obtained prior to notification of the healthcare provider.)
Draw the patient's blood as ordered by the healthcare provider for blood cultures.(drawing blood and
sending it to the microbiology lab for processing will aid in identifying and treating the sepsis.)
Cross infection among members of the household to care for a relative with a severe infection can be
prevented by which behaviors? (Select all that apply) - ANSWER-Practicing good hand hygiene.
Using a diluted bleach to clean surfaces.
Sealing used dressings in impermeable bags
Sepsis - ANSWER-The presence of specific signs and symptoms in the setting of a known or suspected
infection.
-when a pathogen enters the bloodstream causing an systemic inflammatory response
