Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of
Candida albicans in that area. It is important to ask the patient about current medications to obtain
information that mayassist with diagnosis. The body contains normal flora (microorganisms) that live on
the surface of skin, saliva, oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of
the vagina causes vaginal secretions to achieve a low pH, inhibiting the growth of many microorganisms.
Visiting the primary health care provider is important for the patient’s health maintenance but is not the
priority. Learning about the patient’s eating and sleeping habits will assist in the plan of care but is not the
priority.
4. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident.
Whichsigns and symptoms will the nurse assess for to determine if the child is experiencing a
localized
inflammatory response?
Malaise, anorexia, enlarged lymph nodes, and increased white blood
a. cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
43
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,d. Edema, redness, tenderness, and loss of function
ANS: D
The body’s cellular response to an injury is seen as inflammation. Signs of localized inflammation
include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part.
Systemic signs of inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes
and increased white blood cells. Chest pain, shortness of breath, and nausea and vomiting are signs
and symptoms of a cardiac alteration.Dizziness and disorientation to time, date, and place may
indicate a neurologic alteration.
5. Which interventions utilized by the nurse will indicate the ability to recognize a localized
inflammatory response?
a. Vigorous range-of-motion exercises
b. Turn, cough, and deep breathe
c. Orient to date, time, and place
d. Rest, ice, and elevation
ANS: D
Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of
function in the affected body part. One sign of the inflammatory response, particularly after an injury, is
swelling or edema. Resting the affected injured area, using ice as ordered, wrapping the area to provide
support—particularly if it is an extremity—and elevating the injured area will help to decrease swelling
or edema. Turning, coughing, and deep breathing are utilized for postoperative patients and for
immobilized patients to help prevent an infectious process such as pneumonia. Orientation to date,
time, and place is an intervention utilized with many different types of patients who may be confused.
Vigorous range of motion would irritate the inflammatory process. Range of motion is utilized for
individuals who need to improve movement of their extremities, including immobilized patients.
6. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for
developing aninfection?
a. A patient who is in observation for chest pain
b. A patient who has been admitted with dehydration
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,d. Edema, redness, tenderness, and loss of function
c. A patient who is recovering from a right total hip surgery
d. A patient who has been admitted for stabilization of heart problems
ANS: C
The patient who is recovering from a right total hip surgery has a large incision from the surgery. This
break in the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous
membranes allows pathogens to enter and exit the body. The patient has had anesthesia, which
depresses the respiratory system and has the potential to decrease the expansion of alveoli and to
increase the chance of infection in the respiratory system. A patient who is having chest pain,
experiencing dehydration, or being admitted with heart problems does not have open incisions that
break the skin; therefore, his or her infection risk is lower.
7. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular
access
(IV) device. Which nursing intervention is a priority in this procedure?
a. Review the procedure with the patient.
b. Position the patient comfortably.
c. Maintain surgical aseptic technique.
dr.j
, d. Gather available supplies.
ANS: C
dr.j
Candida albicans in that area. It is important to ask the patient about current medications to obtain
information that mayassist with diagnosis. The body contains normal flora (microorganisms) that live on
the surface of skin, saliva, oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of
the vagina causes vaginal secretions to achieve a low pH, inhibiting the growth of many microorganisms.
Visiting the primary health care provider is important for the patient’s health maintenance but is not the
priority. Learning about the patient’s eating and sleeping habits will assist in the plan of care but is not the
priority.
4. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident.
Whichsigns and symptoms will the nurse assess for to determine if the child is experiencing a
localized
inflammatory response?
Malaise, anorexia, enlarged lymph nodes, and increased white blood
a. cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
43
dr.j
,d. Edema, redness, tenderness, and loss of function
ANS: D
The body’s cellular response to an injury is seen as inflammation. Signs of localized inflammation
include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part.
Systemic signs of inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes
and increased white blood cells. Chest pain, shortness of breath, and nausea and vomiting are signs
and symptoms of a cardiac alteration.Dizziness and disorientation to time, date, and place may
indicate a neurologic alteration.
5. Which interventions utilized by the nurse will indicate the ability to recognize a localized
inflammatory response?
a. Vigorous range-of-motion exercises
b. Turn, cough, and deep breathe
c. Orient to date, time, and place
d. Rest, ice, and elevation
ANS: D
Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of
function in the affected body part. One sign of the inflammatory response, particularly after an injury, is
swelling or edema. Resting the affected injured area, using ice as ordered, wrapping the area to provide
support—particularly if it is an extremity—and elevating the injured area will help to decrease swelling
or edema. Turning, coughing, and deep breathing are utilized for postoperative patients and for
immobilized patients to help prevent an infectious process such as pneumonia. Orientation to date,
time, and place is an intervention utilized with many different types of patients who may be confused.
Vigorous range of motion would irritate the inflammatory process. Range of motion is utilized for
individuals who need to improve movement of their extremities, including immobilized patients.
6. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for
developing aninfection?
a. A patient who is in observation for chest pain
b. A patient who has been admitted with dehydration
dr.j
,d. Edema, redness, tenderness, and loss of function
c. A patient who is recovering from a right total hip surgery
d. A patient who has been admitted for stabilization of heart problems
ANS: C
The patient who is recovering from a right total hip surgery has a large incision from the surgery. This
break in the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous
membranes allows pathogens to enter and exit the body. The patient has had anesthesia, which
depresses the respiratory system and has the potential to decrease the expansion of alveoli and to
increase the chance of infection in the respiratory system. A patient who is having chest pain,
experiencing dehydration, or being admitted with heart problems does not have open incisions that
break the skin; therefore, his or her infection risk is lower.
7. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular
access
(IV) device. Which nursing intervention is a priority in this procedure?
a. Review the procedure with the patient.
b. Position the patient comfortably.
c. Maintain surgical aseptic technique.
dr.j
, d. Gather available supplies.
ANS: C
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