Nokea
A nurse is assessing any older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best?
- A. Assess the client for more specific signs
- B. Conclude that an infection is not present
- C. Conclude that an infection is not present.
- D. Request that the provider order blood cultures.
Correct Answer: A
Rationale: Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection.
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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.
A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn?
- A. Basophils are only involved in the general inflammatory process
- B. Basophils are only involved in the general inflammatory process
- C. Macrophages participate in many episodes of phagocytosis
- D. Monocytes turn into macrophages after they enter body tissues
- E. Neutrophils can only take part in one episode of phagocytosis
Correct Answer: B,C,D,E
Rationale: Basophils are involved in both general inflammation and allergic/hypersensitivity responses. Macrophages can perform multiple phagocytosis episodes, monocytes differentiate into macrophages in tissues, and neutrophils are limited to one phagocytosis event.
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.
The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ?
- A. Child
- B. Identical twin
- C. Parent
- D. Same-sex sibling
Correct Answer: B
Rationale: An identical twin is the best donor because their genetic makeup is identical to the recipient, minimizing the risk of rejection.
An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best?
- A. Administer pneumonia vaccination
- B. Recognize the client may have a false negative TB test
- C. Teach the client about viral infections
- D. Treat the client as if he or she has tuberculosis (TB)
- E. Tell the client to rest and drink plenty of fluids
Correct Answer: D
Rationale: Due to age-related decreases in T lymphocytes, older adults may have a falsely negative TB test. Given symptoms suggestive of TB, the nurse should treat the client as if they have TB.