Nokea
A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?
- A. Innate immunity
- B. Passive immunity
- C. Acquired immunity
- D. Natural immunity
Correct Answer: C
Rationale: Immunizations provide acquired immunity, as they introduce antigens into the body, prompting the production of antibodies.
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A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct Answer: B
Rationale: Nausea is a sign of intolerance to enteral feedings, which may also include vomiting and dumping syndrome.
A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
- A. I should apply clean dressings over the top of blood-saturated dressings and hold pressure.
- B. I will rinse the wound with hot water to cleanse it.
- C. I can remove the dressing once the bleeding stops.
- D. I should apply antibiotic ointment directly to the wound.
Correct Answer: A
Rationale: Applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue.
A nurse is reviewing the health history of an older adult who has a hip fracture. The nurse should identify what is a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct Answer: B
Rationale: Urinary incontinence is a risk factor for skin breakdown and pressure injuries.
A nurse is planning a community education program about colorectal cancer. Which of the following risk factors should the nurse identify as modifiable?
- A. Family history
- B. Smoking
- C. Age
- D. Gender
Correct Answer: B
Rationale: Smoking is a modifiable risk factor for colorectal cancer.
A nurse is caring for a client who expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Reassure the client that everything will be fine
- B. Ask the client to describe feelings
- C. Tell the client to stay positive
- D. Provide information about the surgery
Correct Answer: B
Rationale: Asking the client to describe their feelings allows the nurse to understand the specific concerns and anxieties the client is experiencing.