Nokea
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.
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Which is humoral immunity based on?
- A. Production of antibodies by B cells
- B. T cells are activated by an antigen
- C. The body's response to an antigen
- D. Sensitized T cells destroy the antigen
- E. Helper T cells activate phagocytosis
Correct Answer: A,C,E
Rationale: Both types of immunity are in response to an antigen, In the humoral response, helper T cells activate phagocytosis and the production of antibodies by the B cells. B cells are the main player in humoral response.
The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutaneous injection of epinephrine. For which effect will the nurse assure the anxious patient this will have?
- A. Cause vasodilation.
- B. Produce bronchodilation.
- C. Cause productive coughing.
- D. Reduction of pulse rate.
Correct Answer: B
Rationale: The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces bronchodilation and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 20 minutes. The patient may experience an increase in heart rate.
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 advice will the nurse provide for a 94-year-old patient with deteriorated cell-mediated immunity?
- A. Avoiding the influenza vaccine
- B. Getting pneumonia vaccine
- C. Having skin tests for all antigens
- D. Taking large doses of β-carotene
Correct Answer: B
Rationale: As the older adult loses some of the cell-mediated immunity, especially against pneumonia and influenza, it is recommended that they acquire the immunization.
For which purpose is plasmapheresis used in the treatment of rheumatoid arthritis?
- A. To add corticosteroids to relieve pain.
- B. To remove pathologic substances present in the plasma.
- C. To remove waste products such as urea and albumin.
- D. To add antinuclear antibodies
Correct Answer: B
Rationale: Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease.