Nokea
A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
- A. Assessing vaccination records for booster shot needs
- B. Encouraging the client to eat a nutritious diet
- C. Instructing the client to wash minor wounds carefully
- D. Teaching hand hygiene to prevent the spread of microbes
Correct Answer: A
Rationale: Older adults may have insufficient antibodies against microbes to which they have been exposed. Assessing vaccination records ensures they receive necessary booster shots to maintain immunity.
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The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include?
- A. Edema
- B. Pulacheness
- C. Pallor
- D. Redness
- E. Warmth
Correct Answer: A,D,E
Rationale: The five cardinal signs of inflammation are redness (rubor), warmth (calor), pain (dolor), swelling (edema), and decreased function (functio laesa).
The student nurse learns that the most important function of inflammation and immunity is which purpose?
- A. The majority has bacteria of damage vaccines.
- B. Preventing any entry of foreign material
- C. Providing protection against invading organisms
- D. Regulating the process of self-tolerance
Correct Answer: C
Rationale: The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents.
A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
- A. Kidney transplant
- B. High-dose steroid administration
- C. Monoclonal antibody therapy
- D. Plasmapheresis
Correct Answer: A
Rationale: Hyperacute rejection occurs within minutes of transplantation and is irreversible. The organ must be removed, and the client returns to dialysis.
Which processes need to be functional and interact with each other for a person to be immunocompetent?
- A. Antibody-mediated immunity
- B. Cell-mediated immunity
- C. Inflammation
- D. Red blood cells
- E. White blood cells
Correct Answer: A,B,C
Rationale: Immunocompetence requires the interaction of antibody-mediated immunity, cell-mediated immunity, and inflammation to effectively protect the body against pathogens.
A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important?
- A. Avoid large crowds and people who are ill.
- B. Client who is reduce client control of acetaminophen.
- C. Take this medicine exactly as is prescribed.
- D. You have a higher risk of developing cancer.
Correct Answer: A
Rationale: Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill to reduce the risk of infection.