MED SURG EXAM 2
Whenlhelpinglalpatientllimitlexposureltolallergens,lWhatlshouldlthelnurselbelsurelthelp
atientlunderstands?l-lans-Thelpossiblelreservoirslandlsourcesloflallergens
Thelnurselislcaringlforlalpatientlwithlalcompromisedlimmunelsystemlandlrequireslprote
ctivelprecautions.lThellicensedlassistivelpersonnellaskslthelnurselwhylthislislnecessar
y.lWhatlislthelcorrectlresponselmadelbylthelnurse?l-
lans-"Protectivelprecautionslwillllimitlaslmuchlaslpossiblelthelnumberloflmicroorganism
sltolwhichlthelpatientlislexposed."
Alpatientlisltolhavelalmeasleslvaccine.lWhichlfactor,liflpresentlinlthelpatient'slhistory,ls
houldlbelreportedlbecauselitlmaylbelalcontraindicationltolgivinglthelimmunization?l-
lans-Thelpatientlthinkslshelmightlbelpregnant
Thelnursinglstudentlisldiscussingltheltopicloflacquiredlimmunitylwithlthelinstructor.lWhi
chlstatementlbylthelstudentlindicateslthelneedlforlfurtherlinstruction?l-
lans-"lAcquiredlimmunitylcanlbelachievedlwhenlthelpersonlislbornlwithlcertainlimmuniti
es."
Thelprimarylhealthcarelhaslproviderlhaslorderedlneutropeniclprecautionslforlalpatientl
withlneutropenia.lWhatlrestrictionslmaylbelincludedlinlprotectivelisolationlprecautions?
l-lans-Restrictionslonlfreshlfruitslandlvegetables
Thelstudentlnurselislpreparinglalpresentationlonlthelimmunelsystem.lThelstudentlislco
rrectlwhenlidentifyinglthelantibodylaslbeinglconsideredlwhat?l-lans-Alprotein
Alpediatriclpatientlhaslacquiredlmumps.lWhatlwilllthelpatientslbodylimmediatelylproduc
elinlresponseltolthelmumps?l-lans-antibodies
HospitalizedlpatientlhaslbeenltreatedlwithlIVlantibioticslForlalpostloperativelwordlinfect
ion.lWhichlofltheselislanlessentiallelementloflrebuildingltissueslaffectedlbylinfection?
l(selectlalllthatlapply)l-lans-Adequatelvitaminlintake.l
Increasedlfluidlintake
Adequatelproteinlintake.
ThelnurselexplainsltolpatientslwithlImmunelorllymphaticlsystemlproblemslthatltheylwilll
needltolbelmonitoredlforlparticularlproblems.lWhatlarelcommonlproblemslrelatedltolthe
limmunelforlthellymphaticlsystems?l(selectlalllthatlapply)l-lans-Immunosuppression.l
Fever.l
Nutritionallproblems
,Thelnurselexplainsltolthelnursinglstudentlwhichlorganslarelassociatedlwithlthellymphat
iclorlimmunelsystem?l(selectlalllthatlapply)l-lans-Tonsils.l
Thymus.l
Spleen.
Normallfloral-lans-
Microorganismslthatlnormallylexistlinlthelbodylandlprovidelalnaturallimmunitylagainstlc
ertainlinfections
Bacterial-lans-single-celledlorganismslthatllacklalnucleus;lprokaryotes
Fugusl-lans-many-celledlheterotrophiclsuchlaslyeastlorlalmushroom
Protazoal-lans-
singlelcelledlorganismslthatlcanlmovelindependentlylandlgetlfoodlbylengulfment.
Virusl-lans-
Altiny,lnonlivinglparticlelthatlinvadeslandlthenlreproduceslinsidelallivinglcell.
Riskloflexposurel-lans-
Islinfluencedlbylthellifestyle,loccupation,landlsocioeconomiclstatusloflthelhost
Youlareladmittinglalpatientlwithlanlinfectedlabdominallwound.lWoundlcultureslarelposit
ivelforlmethicillin-
resistantlStaphylococcuslaureus.lAppropriatelnursinglcarelforlthislpatientlincludes:l-
lans-Monitoringltemperaturelandlwhitelbloodlcelllcount
Temperaturelandlwhitelbloodlcelllcountlarelindicatorslforlresponseltoltherapylorlworse
ningloflinfection.
Duringlanlassessment,lyoulnotelfever,lfatigue,lgenerallweakness,lcoldlandlclammylski
n,lnausea,lvomiting,landldiarrhea.lYoulrecognizelthatlthelbodylislfightinglinfectionlbylw
hatlmeans?l-lans-Thelinflammatorylresponse
Whichlpatientlinstructionlislmostlcriticalltolalpatientlbeingldischargedlonlantibioticlthera
py?l-lans-"Takelalllthelantibioticslaslprescribed."
Whenlalpatientlislprescribedlantibiotics,litlislimportantltolstresslthatltakinglallloflthelme
dicationlhelpslpreventlantibioticlresistancelandlislneededltolcompletelylilluminatelthelin
fection.
Yoularelobservinglalnursinglstudentlwholmustlperformlaldressinglchangelforlalpatient.l
Youlwouldlinterveneliflthelstudent:l-lans-
Preparelsupplies,ldonslsterilelgloves,landlremovesltheloldldressing.
, Theloldldressinglshouldlbelremovedlwithlcleanlgloves.lIflsterilelgloveslarelusedltolrem
oveltheloldldressing,lthelgloveslwilllhaveltolbelremovedlandldiscarded,lhandslrewash,l
andlnewlsterilelgloveslreapplied.
Whenladministeringlanlorderedlantimicrobiallforlanlinfection,lyoulshouldlchecklthellabo
ratorylresultslfor:l-lans-Culturelandlsensitivity
Culturelandlsensitivitylarelspecificltolidentifyinglthelpathogen.
Thelneedlforlprotectivelisolationlandlitslparameterslarelbeinglexplainedltolthelpatient.l
Shelwails,l"howlcanlIlhuglmylchildrenlwhenlIlamllockedluplinlthislroom?
l"Anlappropriatelresponselwouldlbe:l-
lans-"Itlwon'tlbellonglbeforelyoulcanlhuglthemlagain,landlwelneedltolkeeplyoulsafelfro
mlinfection."
Althoughlalllofltheselstatementslcouldlapplyltolthislpatient,lshelislmostlconcernedlabou
tlherlfamilylatlthislpointlandlbeinglableltolseelthemlandlshowlaffection.
Youlassumelthelcareloflalpatientlwithlactivelpulmonaryltuberculosis.lYoulknowlthelapp
ropriatelmanagementloflthelpatientlincludes:l(selectlalllthatlapply)l-lans-
Placementloflthelpatientlinlalroomlwithlspeciallairlhandling.l
Useloflstandardlprecautionslwithlairbornelprecautions.l
Administrationloflorderedlantimicrobials.l
Useloflfitltestedlandl95lmasklorlrespirators.
Whichlinterventionlwouldlyoulimplementlforlalpatientlwithlactivelpulmonaryltuberculosis
lwholislsociallylisolatedlrelatedltolimposedlairbornelprecautions?l-lans-
Suggestlalternativelmeansloflcontact,lsuchlaslemaillandlphonelcalls.
Suggestinglalternativelwaysltolmaintainlsocializationladdresslisltheldiagnosis.
Yoularelcaringlforlanlolderladultlpatientlandlnotelalchangelinlmentallstatus.lThelskinlis
lflushed,lwarm,landldry.lTherelislalfull,lboundinglpulselandldecreasedlurineloutput.lInl
orderloflpriority,lwhichlactionlshouldlyoultake?l-lans-
Takelalfulllsetloflvitallsignslandlcomparelthemltolthelbaseline.(noteltrends)
Checklthelpatient'slhistoryltoldeterminelrisklforlsepsis.l
Notifylthelchargelnurseloflyourlfindings.
(Thelchargelnurselshouldlbelnotifiedlsolthatlcompletelassessmentldatalislobtainedlprio
rltolnotificationloflthelhealthcarelprovider.)
Drawlthelpatient'slbloodlaslorderedlbylthelhealthcarelproviderlforlbloodlcultures.
(drawinglbloodlandlsendinglitltolthelmicrobiologyllablforlprocessinglwilllaidlinlidentifyin
glandltreatinglthelsepsis.)
Crosslinfectionlamonglmembersloflthelhouseholdltolcarelforlalrelativelwithlalseverelinf
ectionlcanlbelpreventedlbylwhichlbehaviors?l(Selectlalllthatlapply)l-lans-
Practicinglgoodlhandlhygiene.l
Whenlhelpinglalpatientllimitlexposureltolallergens,lWhatlshouldlthelnurselbelsurelthelp
atientlunderstands?l-lans-Thelpossiblelreservoirslandlsourcesloflallergens
Thelnurselislcaringlforlalpatientlwithlalcompromisedlimmunelsystemlandlrequireslprote
ctivelprecautions.lThellicensedlassistivelpersonnellaskslthelnurselwhylthislislnecessar
y.lWhatlislthelcorrectlresponselmadelbylthelnurse?l-
lans-"Protectivelprecautionslwillllimitlaslmuchlaslpossiblelthelnumberloflmicroorganism
sltolwhichlthelpatientlislexposed."
Alpatientlisltolhavelalmeasleslvaccine.lWhichlfactor,liflpresentlinlthelpatient'slhistory,ls
houldlbelreportedlbecauselitlmaylbelalcontraindicationltolgivinglthelimmunization?l-
lans-Thelpatientlthinkslshelmightlbelpregnant
Thelnursinglstudentlisldiscussingltheltopicloflacquiredlimmunitylwithlthelinstructor.lWhi
chlstatementlbylthelstudentlindicateslthelneedlforlfurtherlinstruction?l-
lans-"lAcquiredlimmunitylcanlbelachievedlwhenlthelpersonlislbornlwithlcertainlimmuniti
es."
Thelprimarylhealthcarelhaslproviderlhaslorderedlneutropeniclprecautionslforlalpatientl
withlneutropenia.lWhatlrestrictionslmaylbelincludedlinlprotectivelisolationlprecautions?
l-lans-Restrictionslonlfreshlfruitslandlvegetables
Thelstudentlnurselislpreparinglalpresentationlonlthelimmunelsystem.lThelstudentlislco
rrectlwhenlidentifyinglthelantibodylaslbeinglconsideredlwhat?l-lans-Alprotein
Alpediatriclpatientlhaslacquiredlmumps.lWhatlwilllthelpatientslbodylimmediatelylproduc
elinlresponseltolthelmumps?l-lans-antibodies
HospitalizedlpatientlhaslbeenltreatedlwithlIVlantibioticslForlalpostloperativelwordlinfect
ion.lWhichlofltheselislanlessentiallelementloflrebuildingltissueslaffectedlbylinfection?
l(selectlalllthatlapply)l-lans-Adequatelvitaminlintake.l
Increasedlfluidlintake
Adequatelproteinlintake.
ThelnurselexplainsltolpatientslwithlImmunelorllymphaticlsystemlproblemslthatltheylwilll
needltolbelmonitoredlforlparticularlproblems.lWhatlarelcommonlproblemslrelatedltolthe
limmunelforlthellymphaticlsystems?l(selectlalllthatlapply)l-lans-Immunosuppression.l
Fever.l
Nutritionallproblems
,Thelnurselexplainsltolthelnursinglstudentlwhichlorganslarelassociatedlwithlthellymphat
iclorlimmunelsystem?l(selectlalllthatlapply)l-lans-Tonsils.l
Thymus.l
Spleen.
Normallfloral-lans-
Microorganismslthatlnormallylexistlinlthelbodylandlprovidelalnaturallimmunitylagainstlc
ertainlinfections
Bacterial-lans-single-celledlorganismslthatllacklalnucleus;lprokaryotes
Fugusl-lans-many-celledlheterotrophiclsuchlaslyeastlorlalmushroom
Protazoal-lans-
singlelcelledlorganismslthatlcanlmovelindependentlylandlgetlfoodlbylengulfment.
Virusl-lans-
Altiny,lnonlivinglparticlelthatlinvadeslandlthenlreproduceslinsidelallivinglcell.
Riskloflexposurel-lans-
Islinfluencedlbylthellifestyle,loccupation,landlsocioeconomiclstatusloflthelhost
Youlareladmittinglalpatientlwithlanlinfectedlabdominallwound.lWoundlcultureslarelposit
ivelforlmethicillin-
resistantlStaphylococcuslaureus.lAppropriatelnursinglcarelforlthislpatientlincludes:l-
lans-Monitoringltemperaturelandlwhitelbloodlcelllcount
Temperaturelandlwhitelbloodlcelllcountlarelindicatorslforlresponseltoltherapylorlworse
ningloflinfection.
Duringlanlassessment,lyoulnotelfever,lfatigue,lgenerallweakness,lcoldlandlclammylski
n,lnausea,lvomiting,landldiarrhea.lYoulrecognizelthatlthelbodylislfightinglinfectionlbylw
hatlmeans?l-lans-Thelinflammatorylresponse
Whichlpatientlinstructionlislmostlcriticalltolalpatientlbeingldischargedlonlantibioticlthera
py?l-lans-"Takelalllthelantibioticslaslprescribed."
Whenlalpatientlislprescribedlantibiotics,litlislimportantltolstresslthatltakinglallloflthelme
dicationlhelpslpreventlantibioticlresistancelandlislneededltolcompletelylilluminatelthelin
fection.
Yoularelobservinglalnursinglstudentlwholmustlperformlaldressinglchangelforlalpatient.l
Youlwouldlinterveneliflthelstudent:l-lans-
Preparelsupplies,ldonslsterilelgloves,landlremovesltheloldldressing.
, Theloldldressinglshouldlbelremovedlwithlcleanlgloves.lIflsterilelgloveslarelusedltolrem
oveltheloldldressing,lthelgloveslwilllhaveltolbelremovedlandldiscarded,lhandslrewash,l
andlnewlsterilelgloveslreapplied.
Whenladministeringlanlorderedlantimicrobiallforlanlinfection,lyoulshouldlchecklthellabo
ratorylresultslfor:l-lans-Culturelandlsensitivity
Culturelandlsensitivitylarelspecificltolidentifyinglthelpathogen.
Thelneedlforlprotectivelisolationlandlitslparameterslarelbeinglexplainedltolthelpatient.l
Shelwails,l"howlcanlIlhuglmylchildrenlwhenlIlamllockedluplinlthislroom?
l"Anlappropriatelresponselwouldlbe:l-
lans-"Itlwon'tlbellonglbeforelyoulcanlhuglthemlagain,landlwelneedltolkeeplyoulsafelfro
mlinfection."
Althoughlalllofltheselstatementslcouldlapplyltolthislpatient,lshelislmostlconcernedlabou
tlherlfamilylatlthislpointlandlbeinglableltolseelthemlandlshowlaffection.
Youlassumelthelcareloflalpatientlwithlactivelpulmonaryltuberculosis.lYoulknowlthelapp
ropriatelmanagementloflthelpatientlincludes:l(selectlalllthatlapply)l-lans-
Placementloflthelpatientlinlalroomlwithlspeciallairlhandling.l
Useloflstandardlprecautionslwithlairbornelprecautions.l
Administrationloflorderedlantimicrobials.l
Useloflfitltestedlandl95lmasklorlrespirators.
Whichlinterventionlwouldlyoulimplementlforlalpatientlwithlactivelpulmonaryltuberculosis
lwholislsociallylisolatedlrelatedltolimposedlairbornelprecautions?l-lans-
Suggestlalternativelmeansloflcontact,lsuchlaslemaillandlphonelcalls.
Suggestinglalternativelwaysltolmaintainlsocializationladdresslisltheldiagnosis.
Yoularelcaringlforlanlolderladultlpatientlandlnotelalchangelinlmentallstatus.lThelskinlis
lflushed,lwarm,landldry.lTherelislalfull,lboundinglpulselandldecreasedlurineloutput.lInl
orderloflpriority,lwhichlactionlshouldlyoultake?l-lans-
Takelalfulllsetloflvitallsignslandlcomparelthemltolthelbaseline.(noteltrends)
Checklthelpatient'slhistoryltoldeterminelrisklforlsepsis.l
Notifylthelchargelnurseloflyourlfindings.
(Thelchargelnurselshouldlbelnotifiedlsolthatlcompletelassessmentldatalislobtainedlprio
rltolnotificationloflthelhealthcarelprovider.)
Drawlthelpatient'slbloodlaslorderedlbylthelhealthcarelproviderlforlbloodlcultures.
(drawinglbloodlandlsendinglitltolthelmicrobiologyllablforlprocessinglwilllaidlinlidentifyin
glandltreatinglthelsepsis.)
Crosslinfectionlamonglmembersloflthelhouseholdltolcarelforlalrelativelwithlalseverelinf
ectionlcanlbelpreventedlbylwhichlbehaviors?l(Selectlalllthatlapply)l-lans-
Practicinglgoodlhandlhygiene.l
