Nokea
Priority Decision: On assessment of a central venous access device (CVAD) site, the nurse observes that the transparent dressing is loose along two sides. What should the nurse do immediately?
- A. Wait and change the dressing when it is due
- B. Tape the two loose sides down and document
- C. Apply a gauze dressing over the transparent dressing and tape securely
- D. Remove the dressing and apply a new transparent dressing using sterile technique
Correct Answer: D
Rationale: Loose dressings increase infection risk; replacing the dressing with sterile technique ensures safety.
You may also like to solve these questions
Which of the following is NOT a function of the immune system?
- A. Promoting wound healing
- B. Fighting cancer
- C. Increasing pathogen reproduction
- D. Eliminating cell debris
Correct Answer: C
Rationale: The correct answer is C: Increasing pathogen reproduction. The immune system's main function is to protect the body from pathogens and foreign invaders, not to promote their reproduction. A: Promoting wound healing is correct as the immune system helps in tissue repair. B: Fighting cancer is correct as the immune system plays a role in recognizing and destroying cancerous cells. D: Eliminating cell debris is correct as the immune system helps in clearing out dead or damaged cells to maintain tissue health.
What is a significant consequence of the evolutionary arms race between hosts and pathogens?
- A. Pathogens evolve slower than hosts
- B. Hosts develop epigenetic changes for immune adaptation
- C. Mutations in hosts always outpace pathogen evolution
- D. Hosts and pathogens remain static in their interactions
Correct Answer: B
Rationale: The correct answer is B because hosts developing epigenetic changes for immune adaptation is a significant consequence of the evolutionary arms race between hosts and pathogens. This adaptation allows hosts to better defend against evolving pathogens over time. This process is dynamic, as both hosts and pathogens continuously evolve in response to each other.
Choice A is incorrect because pathogens can evolve rapidly to adapt to host defenses. Choice C is incorrect because while hosts may have mutations that provide advantages, pathogens can also evolve to overcome host defenses. Choice D is incorrect as the interaction between hosts and pathogens is characterized by constant adaptation and change, not remaining static.
Which complement pathway is triggered by mannose-binding lectin (MBL)?
- A. Alternative pathway
- B. Classical pathway
- C. Lectin pathway
- D. Terminal pathway
Correct Answer: C
Rationale: The correct answer is C, Lectin pathway. MBL recognizes pathogen-associated molecular patterns containing mannose, initiating the lectin pathway. MBL binds to mannose on microbial surfaces, activating MBL-associated serine proteases, leading to the formation of the C3 convertase. This triggers the rest of the complement cascade.
A: Alternative pathway is triggered by spontaneous hydrolysis of C3, not by MBL.
B: Classical pathway is activated by antigen-antibody complexes, not MBL.
D: Terminal pathway (also known as the membrane attack complex) is the final step of all complement pathways, not specifically triggered by MBL.
Which of the following is correct about lectin receptors?
- A. They recognize microbial carbohydrates
- B. They are expressed on phagocytes
- C. They can be classified as pattern recognition receptors
- D. All of the above is correct
Correct Answer: D
Rationale: The correct answer is D - All of the above. Lectin receptors recognize microbial carbohydrates, are expressed on phagocytes, and can be classified as pattern recognition receptors. Lectins are proteins that bind specifically to certain carbohydrates, allowing them to recognize and interact with pathogens. Phagocytes express lectin receptors to help identify and engulf pathogens. Additionally, lectin receptors are considered pattern recognition receptors because they recognize specific patterns or structures commonly found on pathogens. Therefore, all three statements are true, making option D the correct answer.
The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse's immediate action?
- A. The patient's fingers swollen and warm.
- B. The patient complains of generalized pain 5/10.
- C. The capillary refill time is 8 seconds.
- D. The patient's fingers are pink and cool bilaterally.
Correct Answer: C
Rationale: The correct answer is C because a capillary refill time of 8 seconds indicates poor perfusion, which could be a sign of compromised blood flow to the fingers post-surgical decompression. This finding requires immediate action to prevent complications such as ischemia or impaired wound healing.
A: Swollen and warm fingers are expected after surgery due to inflammation.
B: Generalized pain can be managed with appropriate pain relief measures and is not an immediate concern post-surgery.
D: Pink and cool fingers indicate adequate perfusion and are normal findings post-surgery.