Ch12 Test Bank Docx Nursing Care Of Patients With Infections - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 12 Nursing Care of Patients with Infections and Inflammation
1) A patient has an elevated basophil count. What should this laboratory value indicate to the nurse?
1. The patient is experiencing an acute hypersensitivity reaction.
2. The patient has a gastrointestinal infection.
3. The patient is fighting a tuberculosis infection.
4. The patient is fighting cancer.
Page Ref: 324
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.
2) The nurse is caring for a patient recovering from a splenectomy. What should the nurse realize will occur regarding this patient's immunity?
1. The liver and bone marrow will take over the spleen's functions.
2. The patient will need to avoid infections every day of his life.
3. The patient will have edematous lymph glands throughout his body.
4. The thymus gland will take over the spleen's functions.
Page Ref: 326
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.
3) A patient's white blood cell (WBC) count is 11,000/mm3. What does the nurse understand this value to represent?
1. Total number of circulating leukocytes
2. Total number of circulating neutrophils
3. Total number of circulating eosinophils
4. Total number of circulating basophils
Page Ref: 342
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
4) A patient sustains fractures to the ribs, both femurs, and one humerus. What should the nurse include when planning care for this patient's immunologic status?
1. Monitor complete blood count daily.
2. Limit food rich in iron.
3. Perform passive range of motion to unaffected extremities.
4. Keep on bed rest.
Page Ref: 326
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
5) A patient is diagnosed with a positive tuberculosis skin test. What should the nurse realize causes this type of response?
1. Performing a cell-mediated inflammatory response
2. Promoting phagocytosis of the antigen by neutrophils
3. Clumping antigens to form a noninvasive aggregate
4. Coating the antigen with antibodies
Page Ref: 335
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.
6) A patient is happy that a spouse did not catch a cold that other family members have experienced. Which immune response is the spouse most likely experiencing?
1. Helper T cells had a memory of a previous exposure to the same virus that caused the patient's illness.
2. Suppressor T cells killed the virus.
3. The virus was eliminated via phagocytosis by neutrophils.
4. Cytokines were released.
Page Ref: 333
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.
7) The nurse is caring for a patient diagnosed with a lung infection. Which immunoglobulin level should the nurse expect to be elevated in this patient?
1. Immunoglobulin A
2. Immunoglobulin M
3. Immunoglobulin E
4. Immunoglobulin D
Page Ref: 331
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
8) A patient who just delivered a newborn baby is concerned that the baby will "catch" a cold from a healthcare provider who was coughing and sneezing in the delivery room. How should the nurse respond?
1. "The baby has some protection from infections from the time of birth."
2. "The baby should be isolated."
3. "I will be sure to have everyone check the baby's temperature for signs of an infection."
4. "The healthcare provider should not have been participating in your care."
Page Ref: 331
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.
9) The nurse is concerned that a patient is exhibiting signs and symptoms of inflammation. What did the nurse assess to come to this conclusion? Select all that apply.
1. Leg edema
2. Severe pain from swelling
3. Severe erythema of leg
4. Leg cool to the touch
5. Decreased peripheral pulses
Page Ref: 340
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
10) An older patient has a small pressure ulcer on the coccyx. What should the nurse do to promote healing of the wound?
1. Encourage high-protein food choices in the diet.
2. Limit carbohydrate intake.
3. Encourage a high intake of vitamin E.
4. Restrict caloric intake.
Page Ref: 341
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
11) The nurse believes that a patient is experiencing a systemic reaction associated with an inflammatory response. Which assessment finding supports this nurse's belief?
1. Edematous groin lymph nodes
2. Erythema
3. Edema
4. Pain
Page Ref: 341
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
12) A patient recovering from knee surgery has a surgical infection. What finding indicates that the patient is experiencing a systemic reaction? Select all that apply.
1. WBC 14,200 mm3
2. Lymph node swelling
3. Erythema
4. Pain at the surgical site
5. Respiratory rate of 16
Page Ref: 341
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
13) The nurse is concerned that an older patient could be at risk for developing an infection. Which intervention led to this conclusion?
1. Urinary catheterization
2. Applying anti-embolism stockings
3. Ambulation with the assistance of a walker
4. Medicating for pain as needed prior to physical therapy
Page Ref: 350
Cognitive Level: Analyzing
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
14) The nurse is planning care for a patient at risk for developing an infection. Which intervention should the nurse include in the plan of care?
1. Washing the hands prior to providing care to the patient
2. Providing prophylactic antibiotic therapy as prescribed
3. Wearing a mask when caring for the patient
4. Wearing a gown and gloves when changing the patient's linen
Page Ref: 339
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
15) A patient has been intubated to receive care in the intensive care unit. Which type of infection is this patient at risk for developing?
1. Ventilation-assisted pneumonia
2. Urinary tract infection
3. Surgical wound infection
4. Intravenous site infection
Page Ref: 348-349
Cognitive Level: Analyzing
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
16) A patient is diagnosed with an antibiotic-resistant infection. Which action should the nurse take to reduce the spread of this infection?
1. Isolate the supplies used to care for this patient.
2. Transfer the patient to a semiprivate room.
3. Limit exposure to this patient.
4. Restrict visitors and plan activities to coincide with meal delivery times.
Page Ref: 349
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
17) The nurse is instructing a patient on ways to prevent the onset of infection. What should the nurse include in these instructions?
1. Wash the hands after using disposable tissues for nasal secretions.
2. Reuse disposable razors.
3. Take prescribed antibiotics until symptoms subside.
4. Do not limit interactions with people or crowds.
Page Ref: 359
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their cares | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
18) A patient is receiving intravenous vancomycin for the treatment of Clostridium difficile. Why should the nurse assess the patient for flushing, tachycardia, and hypotension during the infusion of this medication?
1. Identify red man syndrome
2. Recognize the ototoxicity effect
3. Prevent a superinfection
4. Begin treatment for hives
Page Ref: 354
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
19) A patient is prescribed a trough blood level to evaluate the therapeutic effect of an antibiotic. When should the nurse schedule this blood test to be drawn?
1. A few minutes before the next scheduled dose of medication
2. 1-2 hours after the oral administration of the medication
3. 30 minutes after the intravenous administration of the medication
4. During the infusion of the antibiotic
Page Ref: 351
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
20) A patient is diagnosed with active tuberculosis. For which type of isolation should the nurse prepare this patient?
1. Airborne
2. Standard
3. Droplet
4. Contact
Page Ref: 340
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
21) The nurse needs to obtain a sputum specimen for culture and sensitivity from a patient. When should the nurse obtain this specimen?
1. Before the first dose of antibiotics is administered
2. Immediately after the first dose of antibiotic is administered
3. 30 minutes after the first dose of antibiotics is administered
4. During administration of the first dose of antibiotics
Page Ref: 350
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.
22) A patient develops hyperthermia related to a diagnosis of pneumonia. Which interventions should the nurse perform to help with this problem? Select all that apply.
1. Reduce the temperature of the room.
2. Administer antipyretic medications as prescribed.
3. Promote frequent rest periods.
4. Administer ice packs.
5. Restrict fluids.
Page Ref: 358-359
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
23) The nurse needs to change a patient's abdominal wound dressing. Which precaution should the nurse follow during this dressing change?
1. Standard
2. Contact
3. Droplet
4. Airborne
Page Ref: 339
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
24) The nurse has completed caring for a patient's indwelling urinary catheter. What should the nurse do after clearing used supplies and removing the gloves?
1. Wash the hands with soap.
2. Document the care provided.
3. Prepare medications for the patient.
4. Discuss with the nursing assistant additional care needs for the patient.
Page Ref: 359
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
25) A patient is receiving an aminoglycoside. Which finding should the nurse immediately report? Select all that apply.
1. History of allergy to penicillin
2. Weight gain of 5 kg in 2 days
3. Symptoms of vertigo
4. Fluid intake below 2000 mL/day
5. New prescription for IV furosemide (Lasix)
Page Ref: 354
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.
26) A patient is prescribed to receive linezolid (Zyvox) 600 mg intravenously twice a day. The medication is prepared as 600 mg/300 mL with directions to give over 120 minutes. An infusion set that administers 15 gtts/mL is available. How many drops of medication per minute should the nurse set this infusion pump to deliver? Record your answer rounding to the nearest whole number.
Page Ref: 354
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.
27) The nurse is reviewing the antibody-mediated immune response with a patient experiencing a first exposure to an antigen. What event should the nurse explain that occur in this immune response? Select all that apply.
1. Antigen-binding fragment (Fab) decreases.
2. An antigen begins the process of reaction.
3. Memory B cells and plasma cells are cloned.
4. T helper cells are stimulated.
5. Cell division and differentiation occur.
Page Ref: 332
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.
28) The nurse suspects that a patient is experiencing a local inflammatory response. What finding would support this conclusion? Select all that apply.
1. Temperature under 96.8°F (36°C)
2. Heat at the site of injury
3. Increased platelets
4. Edema
5. Functional impairment
Page Ref: 340
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
29) A patient has been prescribed cefuroxime (Ceftin). What should the nurse teach the patient about this medication? Select all that apply.
1. Take on an empty stomach.
2. Avoid alcohol.
3. Report any hearing loss.
4. Eat yogurt daily.
5. Complete the prescription.
Page Ref: 353
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
30) A patient who has never experienced a reaction to a bee sting develops intense edema and redness at the site of a sting. For which type of immune response should the nurse provide care for this patient?
1. Mobilization of lymphocytic memory T cells
2. Activation of granulocytes
3. Creation of neutrophils
4. Circulation of eosinophils
Page Ref: 335
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
31) A patient recovering from a splenectomy asks what impact the loss of the organ will have on the quality of life. Which response should the nurse make?
1. "You will have to avoid getting colds and flu."
2. "Your stomach will assume its functions."
3. "Your liver and bone marrow will assume its functions."
4. "A spleen is not really necessary."
Page Ref: 326
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
32) The nurse is caring for a patient with a localized inflammatory response. Which stage should the nurse expect the patient to experience with this response? Select all that apply.
1. Basilar
2. Cellular
3. Vascular
4. Tissue repair
5. Keratosis
Page Ref: 327
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.
33) A patient with an inflammatory response is prescribed a nonsteroidal anti-inflammatory drug (NSAID). For which reason should the nurse suspect the patient was prescribed this medication?
1. Increase the production of histamine
2. Increase the flow of serosanguineous drainage
3. Reduce the production of serotonin
4. Reduce prostaglandin synthesis
Page Ref: 327
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.
34) A patient with a compromised immune system is admitted to the hospital with an infection. What care should the nurse expect this patient to require?
1. Early discharge to recover from the infection at home
2. Placement in a semiprivate room
3. Isolation techniques to protect the patient from further infection
4. Placement in respiratory isolation
Page Ref: 358
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
35) One school district is not requiring vaccinations for children who are starting school. What could be the result of this decision?
1. Healthier children
2. A reduction in the number of colds and flu in the school
3. Lower school costs
4. An epidemic of an illness that could have been avoided with immunization
Page Ref: 335
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.
36) A patient is having skin testing done to assess for allergies. What should the nurse identify as evidence of exposure to an antigen?
1. Itching at the site
2. Area approximately 1 mm in diameter of induration and erythema
3. Induration and erythema not evident until after 5 days
4. Area larger than 10 mm of induration and erythema
Page Ref: 335
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
37) An older patient with a history of lung disease had a pneumococcal vaccination 10 years ago. What should be done for this patient?
1. Draw a blood culture.
2. Remind the patient that he needs a booster in 5 years.
3. Remind the patient that he does not need a flu vaccination.
4. Suggest that the patient have a pneumococcal booster during this visit.
Page Ref: 337
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
38) A patient who received a vaccination 2 weeks ago returns to the clinic with a wound at the inoculation site. What does the nurse realize about this patient?
1. The patient is experiencing a severe local reaction to the inoculation.
2. The patient is allergic to the inoculation.
3. The patient is scratching the inoculation site.
4. The patient is demonstrating signs of the disease that the inoculation was intended to prevent.
Page Ref: 337
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
39) A patient asks the nurse how long it will be before a leg wound heals. What phase of wound healing should the nurse explain to this patient? Select all that apply.
1. Inflammation
2. Deconstruction
3. Reconstruction
4. Resolution
5. Dissolution
Page Ref: 330
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.
40) The nurse is assessing a patient's arm for inflammation. Which is a sign that a localized inflammatory process is occurring? Select all that apply.
1. Purulent drainage
2. Pain
3. Hyperemia
4. Erythema
5. Induration
Page Ref: 340
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
41) A patient who is recovering from an infectious process has a poor appetite. Which nutrient is of utmost importance to support the healing process?
1. Water
2. Protein
3. Carbohydrates
4. Fats
Page Ref: 341
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
42) A patient wants to know why an infection developed after being cut on the leg with a piece of wood, but a friend who was also cut did not. How should the nurse explain this phenomenon?
1. "Maybe the wood that cut your friend wasn't dirty and infected."
2. "You must have an autoimmune disorder."
3. "The organism found you more susceptible to infection."
4. "Your friend will get an infection too. It will just develop later."
Page Ref: 346
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
43) A patient with methicillin-resistant Staphylococcus aureus (MRSA) is no longer responding to the medication vancomycin (Vancocin). What medication might be indicated for this patient?
1. Penicillin
2. Gentamycin
3. Tetracycline
4. Linezolid
Page Ref: 354
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.
44) A patient with an infection is prescribed a macrolide antibiotic. What should the nurse instruct the patient about taking this medication?
1. Take the medication on a full stomach.
2. Take the medication with a glass of milk.
3. Take the medication on an empty stomach.
4. Take the medication with a full glass of juice.
Page Ref: 354
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
45) The nurse is caring for a patient under droplet precautions. What should the nurse wear when providing care to this patient?
1. Head covering and gown
2. Shoe covering and gown
3. Gloves only
4. Mask and eye protection or face shield
Page Ref: 340
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
46) During a home visit, the nurse determines that family members would benefit from receiving the hepatitis B vaccination. Which family members did the nurse identify as being at risk for this illness? Select all that apply.
1. 29-year-old female with ovarian cysts
2. 21-year-old male with Down syndrome
3. 63-year-old male with end-stage renal disease
4. 57-year-old female newly diagnosed with diabetes mellitus
5. 32-year-old male with liver disease from acetaminophen abuse
Page Ref: 337
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
47) A patient being treated for a stage 3 pressure injury is demonstrating delayed healing. What information in the patient's medical record and history would explain this delay? Select all that apply.
1. The patient had total knee replacement 7 years ago.
2. The patient takes insulin for control of type 2 diabetes mellitus.
3. The patient takes acetaminophen 650 mg twice a day for arthritis pain.
4. The patient was diagnosed with peripheral vascular disease 5 years ago.
5. The patient was prescribed steroids for treatment of chronic lung condition.
Page Ref: 341
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.
48) The nurse is preparing instructions for a patient with an inflammation of the right lower leg. What should the nurse emphasize when teaching this patient? Select all that apply.
1. Elevate the extremity.
2. Reduce the intake of fluids.
3. Take analgesics as prescribed.
4. Increase activity to the extremity.
5. Cleanse the area with soap and water.
Page Ref: 344
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
49) A family member asks why an older patient is experiencing frequent episodes of pneumonia. What factors should the nurse discuss when responding? Select all that apply.
1. Diminished thirst reflex
2. Diminished cough reflex
3. Less production of sputum
4. Reduced bladder contractility
5. Reduced mucociliary clearance in the lungs
Page Ref: 348
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
50) A patient is prescribed metronidazole (Flagyl) for treatment of C. difficile. What should the nurse include when teaching the patient about this medication? Select all that apply.
1. Do not drink any alcohol while taking this medication.
2. Drink a minimum of 2-1/2 to 3 quarts of fluid every day.
3. Notify the healthcare provider if urine color changes to reddish brown.
4. Changes in mentation and coordination are expected when taking this medication.
5. Contact the healthcare provider if urination becomes painful when taking this medication.
Page Ref: 355
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.
Document Information
Connected Book
Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff
By LeMone, Burke, Gerene Bauldoff
Explore recommendations drawn directly from what you're reading
Chapter 10 Nursing Altered Fluid Electrolyte
DOCX Ch. 10
Chapter 11 Nursing Care Of Patients Experiencing Trauma And Shock
DOCX Ch. 11
Chapter 12 Nursing Care Of Patients With Infections And Inflammation
DOCX Ch. 12 Current
Chapter 13 Nursing Care Of Patients With Altered Immunity
DOCX Ch. 13
Chapter 14 Nursing Care Of Patients With Cancer
DOCX Ch. 14