The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient received which type of immunity?
- A. active natural
- B. passive natural
- C. active artificial
- D. passive artificial
Correct Answer: D
Rationale: When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is considered a passive artificial immunity.
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In which time frame must blood be transfused within once it has been removed from refrigeration?
- A. 2 hours
- B. 4 hours
- C. 6 hours
- D. 3 hours
Correct Answer: B
Rationale: Blood must be administered within 4 hours after removal from refrigeration, and blood components within 6 hours of removal.
The nurse outlines the functions of the immune system as those actions which have which function?
- A. prevent hemorrhage.
- B. protect the body's internal environment.
- C. maintain the hemoglobin level.
- D. maintain the homeostasis by removing damaged cells.
- E. prevent dangerous blood clots from forming.
Correct Answer: B,D
Rationale: The three main functions of the immune system are to protect the body's internal environment by destroying antigens and pathogens, and maintenance of homeostasis by removing damaged cell.
The nurse has arrived at the patient's bedside with a unit of packed cells to be connected to an IV that is infusing. When the registered nurse arrives, which action do the nurses take first?
- A. Check to ensure that the donor and recipient numbers match according to policy.
- B. Request the patient to sign the card on the packed cells.
- C. Immediately administer the packed cells.
- D. Check the patient's ID bracelet and then administer the packed cells.
Correct Answer: A
Rationale: Donor and recipient numbers are specific and must be thoroughly checked and the patient identified with an armband.
A patient who works in a plant nursery and has experienced an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment?
- A. I need to think about a change in my occupation.'
- B. I will learn to administer epinephrine so that I will be prepared if I am stung again.'
- C. I should wear a Medic-Alert bracelet indicating my allergy to insect stings.'
- D. I will need to take maintenance doses of corticosteroids to prevent reactions to further stings.'
Correct Answer: D
Rationale: The nurse?s responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance doses of corticosteroids because this was a short, rapid reaction.
Which symptom would be classified as a mild transfusion reaction?
- A. Orthopnea
- B. Tachycardia
- C. Hypotension
- D. Wheezing
Correct Answer: A
Rationale: Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea.
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