Nur 138 Final Exam With 139 Ques ons and answers
Newest RATED A+ 2025/2026 NEW!! 100% VERIFIED
CORRECT
What is included in a physical assessment for immunity?
Assess lymph nodes, temperature, mobility, general appearance, skin, history of infec ons,
immuniza on status
Define ar ficial, acquired passive immunity?
Given an bodies to the disease rather than developing them
Ex: Immunoglobulins
Ac ve vs. Passive immunity
Ac ve is honestly earned; long term
- Vaccines: MMR
- natural infec on
- Develops memory B cells that can quickly respond to future exposure to the an gen
Passive is dona on; short term
- no memory developed
- Rabies shot
- Mom’s breastmilk
- Immunoglobulins (Rhogam, Covid)
- An venom
- Tetnus toxoid
an body vs. an gen
An gen (Ag) (aka Immunogen): A substance that causes the body to produce an immune
response.
An body (Ab): Proteins made in response to an Ag; can combine with that Ag.
,LOW WBC (Nursing Interven ons)
Neutropenic precau ons: wear a mask, be careful of infec ons, avoid crowds
Report any temp >100 to the doctor
Avoid crowds and sick people
Avoid yard work/gardening
Don't change the cat li;ler box
wash dishes in hot water or in the dishwasher. Also wash their toothbrush!
High WBC (nursing interven ons)
Infec on - iden fy, then treat the infec on
Care of client a>er exposure to allergen
Epipen, then go to the ER
Keep the epipen room temperature, keep it with you, make sure it's at room temperature, train
all the people around you
Recognize diagnos c lab changes that indicate infec on
> High WBC (>10000)
> Leukocytosis: Increased white blood cell count, indica ng the body is figh ng an infec on.
> Le> shi>: Increase in immature white blood cells, sugges ng a more severe infec on.
> Elevated C-reac ve protein (CRP): Marker of inflamma on in the body.
> Elevated erythrocyte sedimenta on rate (ESR): Non-specific marker of inflamma on.
> Posi ve cultures: Growth of bacteria or other pathogens in a sample of body fluid.
Complica ons of NSAID use in older adults
> GI : NSAIDs can irritate the stomach lining and increase the risk of ulcers and bleeding.
> Kidneys: blood urea nitrogen, crea nine. NSAIDs can decrease blood flow to the kidneys
leading to a decline in kidney func on. This risk is par cularly high in older adults who may
already have reduced kidney func on.
> Liver: AST/ALT elevated liver enzymes NSAIDs can cause a temporary increase in liver
enzymes, which can indicate liver damage.
> Heart a6ack and stroke: risk increased, especially in high doses and with long-term use.
Addi onal considera ons:
,Dehydra on: Older adults are more suscep ble to dehydra on, which can exacerbate the risks
associated with NSAIDs. Drinking plenty of fluids is crucial.
Polypharmacy: Older adults o>en take mul ple medica ons, which can increase the risk of
interac ons and side effects. Careful monitoring and coordina on of medica ons are essen al.
Underlying health condi ons: Certain underlying health condi ons, such as diabetes and heart
disease, can put older adults at higher risk of complica ons from NSAIDs.
Laboratory monitoring: Regular monitoring of laboratory tests such as AST, ALT, blood urea
nitrogen, crea nine, and electrolytes is crucial for detec ng early signs of organ damage
associated with NSAID use.
Indicators of a Systemic Reac on to Inflamma on
Fever: A body temperature greater than 100.4°F (38°C) is a common indicator of inflamma on.
Increased heart rate: The heart rate typically increases in response to inflamma on, as the
body a;empts to deliver more oxygen and nutrients to the affected area.
Edema (swelling): Inflamma on causes fluid build-up in ssues, leading to swelling in the
affected area or throughout the body.
Decreased urine output: When the body is figh ng inflamma on, it may retain fluids, leading to
a decrease in urine output. This can be a serious sign of impaired kidney func on.
Respiratory changes: Rapid breathing or shortness of breath can be indicators of inflamma on
affec ng the respiratory system.
Altered mental status: In severe cases, inflamma on can affect the brain, leading to confusion,
disorienta on, and other changes in mental status.
Blood tests: Elevated levels of certain markers in the blood, such as C-reac ve protein (CRP) and
white blood cell count, can indicate the presence of inflamma on in the body.
Precau ons for infec on control
Contact isola on: Used for infec ons that are spread through direct contact with an infected
person or their body fluids.
Standard isola on: Used for infec ons that are spread through contact with an infected
person's respiratory secre ons.
Airborne isola on: Used for infec ons that are spread through the air when an infected person
coughs or sneezes.
, Protec ve isola on: Used to protect a person with a weakened immune system from infec on.
Contact precau ons and diseases
Private room - door can be open
Gloves
Gown- if giving direct care
Handwashing
Disposable supplies
Dedicated equipment
MRSA, C Diff, Scabies, Mul drug-resistant organisms (MRDOs).
Droplet precau ons and common diseases
Used for diseases transmi;ed via respiratory droplets when the pa ent coughs, sneezes, talks,
or breathes.
Flu, Pertussis, mumps, COVID-19
Wear a mask, maintain 3 > of separa on, proper hand hygiene, pa ent has to wear a mask if
leaving the room.
airborne precau ons and common diseases
Used for diseases that can be transmi;ed through ny airborne par cles that remain
suspended in the air for an extended period.
TB, measles, chicken pox, disseminated herpes zoster
what is a protec ve environment and the diseases that might need it?
Used for pa ents with compromised immune systems, such as those who have undergone bone
marrow transplants or organ transplants. Or who have cancer. The goal is to protect the pa ent
from environmental pathogens.
Maintain strict hand hygiene, use sterile techniques when handling invasive devices, limit
visitors and ensure that visitors follow infec on control measures.
Nursing Assessment for Infec on
Take the client's history
Assess the degree of risk for infec on through observa on and interview.
Physical assessment - local infec on = warm, redness, swelling, pain, loss of func on.
Systemic infec on = fever, increased pulse, fa gue, loss of appe te, enlarged/tender lymph
nodes.
Newest RATED A+ 2025/2026 NEW!! 100% VERIFIED
CORRECT
What is included in a physical assessment for immunity?
Assess lymph nodes, temperature, mobility, general appearance, skin, history of infec ons,
immuniza on status
Define ar ficial, acquired passive immunity?
Given an bodies to the disease rather than developing them
Ex: Immunoglobulins
Ac ve vs. Passive immunity
Ac ve is honestly earned; long term
- Vaccines: MMR
- natural infec on
- Develops memory B cells that can quickly respond to future exposure to the an gen
Passive is dona on; short term
- no memory developed
- Rabies shot
- Mom’s breastmilk
- Immunoglobulins (Rhogam, Covid)
- An venom
- Tetnus toxoid
an body vs. an gen
An gen (Ag) (aka Immunogen): A substance that causes the body to produce an immune
response.
An body (Ab): Proteins made in response to an Ag; can combine with that Ag.
,LOW WBC (Nursing Interven ons)
Neutropenic precau ons: wear a mask, be careful of infec ons, avoid crowds
Report any temp >100 to the doctor
Avoid crowds and sick people
Avoid yard work/gardening
Don't change the cat li;ler box
wash dishes in hot water or in the dishwasher. Also wash their toothbrush!
High WBC (nursing interven ons)
Infec on - iden fy, then treat the infec on
Care of client a>er exposure to allergen
Epipen, then go to the ER
Keep the epipen room temperature, keep it with you, make sure it's at room temperature, train
all the people around you
Recognize diagnos c lab changes that indicate infec on
> High WBC (>10000)
> Leukocytosis: Increased white blood cell count, indica ng the body is figh ng an infec on.
> Le> shi>: Increase in immature white blood cells, sugges ng a more severe infec on.
> Elevated C-reac ve protein (CRP): Marker of inflamma on in the body.
> Elevated erythrocyte sedimenta on rate (ESR): Non-specific marker of inflamma on.
> Posi ve cultures: Growth of bacteria or other pathogens in a sample of body fluid.
Complica ons of NSAID use in older adults
> GI : NSAIDs can irritate the stomach lining and increase the risk of ulcers and bleeding.
> Kidneys: blood urea nitrogen, crea nine. NSAIDs can decrease blood flow to the kidneys
leading to a decline in kidney func on. This risk is par cularly high in older adults who may
already have reduced kidney func on.
> Liver: AST/ALT elevated liver enzymes NSAIDs can cause a temporary increase in liver
enzymes, which can indicate liver damage.
> Heart a6ack and stroke: risk increased, especially in high doses and with long-term use.
Addi onal considera ons:
,Dehydra on: Older adults are more suscep ble to dehydra on, which can exacerbate the risks
associated with NSAIDs. Drinking plenty of fluids is crucial.
Polypharmacy: Older adults o>en take mul ple medica ons, which can increase the risk of
interac ons and side effects. Careful monitoring and coordina on of medica ons are essen al.
Underlying health condi ons: Certain underlying health condi ons, such as diabetes and heart
disease, can put older adults at higher risk of complica ons from NSAIDs.
Laboratory monitoring: Regular monitoring of laboratory tests such as AST, ALT, blood urea
nitrogen, crea nine, and electrolytes is crucial for detec ng early signs of organ damage
associated with NSAID use.
Indicators of a Systemic Reac on to Inflamma on
Fever: A body temperature greater than 100.4°F (38°C) is a common indicator of inflamma on.
Increased heart rate: The heart rate typically increases in response to inflamma on, as the
body a;empts to deliver more oxygen and nutrients to the affected area.
Edema (swelling): Inflamma on causes fluid build-up in ssues, leading to swelling in the
affected area or throughout the body.
Decreased urine output: When the body is figh ng inflamma on, it may retain fluids, leading to
a decrease in urine output. This can be a serious sign of impaired kidney func on.
Respiratory changes: Rapid breathing or shortness of breath can be indicators of inflamma on
affec ng the respiratory system.
Altered mental status: In severe cases, inflamma on can affect the brain, leading to confusion,
disorienta on, and other changes in mental status.
Blood tests: Elevated levels of certain markers in the blood, such as C-reac ve protein (CRP) and
white blood cell count, can indicate the presence of inflamma on in the body.
Precau ons for infec on control
Contact isola on: Used for infec ons that are spread through direct contact with an infected
person or their body fluids.
Standard isola on: Used for infec ons that are spread through contact with an infected
person's respiratory secre ons.
Airborne isola on: Used for infec ons that are spread through the air when an infected person
coughs or sneezes.
, Protec ve isola on: Used to protect a person with a weakened immune system from infec on.
Contact precau ons and diseases
Private room - door can be open
Gloves
Gown- if giving direct care
Handwashing
Disposable supplies
Dedicated equipment
MRSA, C Diff, Scabies, Mul drug-resistant organisms (MRDOs).
Droplet precau ons and common diseases
Used for diseases transmi;ed via respiratory droplets when the pa ent coughs, sneezes, talks,
or breathes.
Flu, Pertussis, mumps, COVID-19
Wear a mask, maintain 3 > of separa on, proper hand hygiene, pa ent has to wear a mask if
leaving the room.
airborne precau ons and common diseases
Used for diseases that can be transmi;ed through ny airborne par cles that remain
suspended in the air for an extended period.
TB, measles, chicken pox, disseminated herpes zoster
what is a protec ve environment and the diseases that might need it?
Used for pa ents with compromised immune systems, such as those who have undergone bone
marrow transplants or organ transplants. Or who have cancer. The goal is to protect the pa ent
from environmental pathogens.
Maintain strict hand hygiene, use sterile techniques when handling invasive devices, limit
visitors and ensure that visitors follow infec on control measures.
Nursing Assessment for Infec on
Take the client's history
Assess the degree of risk for infec on through observa on and interview.
Physical assessment - local infec on = warm, redness, swelling, pain, loss of func on.
Systemic infec on = fever, increased pulse, fa gue, loss of appe te, enlarged/tender lymph
nodes.
