Nokea
The nurse understands that an anaphylactic reaction is considered which of the following types of hypersensitivity reactions?
- A. Type I
- B. Type III
- C. Type II
- D. Type IV
Correct Answer: A
Rationale: The correct answer is A: Type I hypersensitivity reaction. In Type I hypersensitivity, anaphylactic reactions involve immediate IgE-mediated responses to allergens, leading to histamine release and potentially life-threatening symptoms. This type of reaction is characterized by rapid onset and systemic involvement. Choices B, C, and D are incorrect because Type III reactions involve immune complex deposition leading to inflammation (B), Type II reactions involve cytotoxic antibodies targeting cells (C), and Type IV reactions involve delayed cell-mediated responses (D).
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A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)
- A. Rank all the patient’s nursing diagnoses in order of priority.
- B. Do not change priorities once they’ve been established.
- C. Set priorities based solely on physiological factors.
- D. Consider time as an influencing factor.
Correct Answer: A
Rationale: The correct answer is A because ranking all the patient's nursing diagnoses in order of priority allows the nurse to address the most critical needs first. By prioritizing based on the urgency and potential impact on the patient's health, the nurse can ensure that interventions are carried out effectively.
B is incorrect because priorities may need to be adjusted based on the patient's changing condition. C is incorrect as priorities should consider not only physiological but also psychological and sociological factors. D is incorrect because time is an influencing factor, but it should not be the sole consideration when prioritizing interventions.
A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (azidothymidine, AZT [Retrovir]). To check for adverse drug effects, the nurse should monitor the results of laboratory test?
- A. RBC count
- B. Serum calcium
- C. Fasting blood glucose
- D. Platelet count
Correct Answer: D
Rationale: The correct answer is D: Platelet count. Zidovudine (AZT) is known to cause bone marrow suppression, leading to decreased platelet production. Monitoring platelet count is crucial to detect early signs of thrombocytopenia, a common adverse effect of AZT.
Rationale:
A) RBC count: AZT can cause anemia, not specifically affecting the RBC count.
B) Serum calcium: AZT does not typically affect calcium levels.
C) Fasting blood glucose: AZT can cause hyperglycemia, but fasting blood glucose monitoring is not as critical as monitoring platelet count for AZT therapy.
What is the primary purpose of using measurable client outcomes during the nursing process?
- A. To diagnose client conditions accurately.
- B. To evaluate the effectiveness of nursing interventions.
- C. To prioritize nursing diagnoses effectively.
- D. To guide documentation in the client’s health record.
Correct Answer: B
Rationale: The primary purpose of using measurable client outcomes during the nursing process is to evaluate the effectiveness of nursing interventions. This is crucial in determining whether the care provided has led to the desired outcomes for the client's health. By measuring outcomes, nurses can assess if the interventions are successful, make any necessary adjustments to the care plan, and ensure optimal patient outcomes.
Choice A is incorrect because diagnosing client conditions accurately is not the primary purpose of using measurable client outcomes; it is more related to the initial assessment phase.
Choice C is incorrect because prioritizing nursing diagnoses effectively is an important aspect of the nursing process, but it is not the primary purpose of using measurable client outcomes.
Choice D is incorrect because while documentation in the client's health record is important, it is not the primary purpose of using measurable client outcomes.
A 40 year old woman with aplastic anemia is prescribed estrogen with progesterone. The nurse can expect that these medications are given for which of the following reasons?
- A. To stimulate bone growth
- B. To enhance sodium and potassium
- C. To regulate fluid balance absorption
- D. To promote utilization and storage of fluids
Correct Answer: A
Rationale: The correct answer is A: To stimulate bone growth. Estrogen and progesterone are hormones that play a crucial role in maintaining bone density and promoting bone growth. In postmenopausal women or individuals with conditions like aplastic anemia, bone health can be compromised. Estrogen helps in preventing bone loss and maintaining bone strength, while progesterone also contributes to bone formation. Therefore, in this scenario, these medications are likely prescribed to help improve bone health in the woman with aplastic anemia.
Incorrect choices:
B: Estrogen and progesterone do not directly enhance sodium and potassium levels.
C: Estrogen and progesterone do not regulate fluid balance absorption directly.
D: Estrogen and progesterone do not specifically promote utilization and storage of fluids.
Which of the following is the function of macrophages and neutrophils?
- A. Phagocytosis
- B. Complement fixation
- C. Antibody production
- D. Suppression of autoimmunity
Correct Answer: A
Rationale: The correct answer is A: Phagocytosis. Macrophages and neutrophils are both types of phagocytes responsible for engulfing and digesting pathogens such as bacteria. This process helps in clearing infections and maintaining immune homeostasis.
Summary:
- Choice B (Complement fixation) is incorrect as it refers to a process where complement proteins bind to pathogens to enhance their removal by phagocytes.
- Choice C (Antibody production) is incorrect as macrophages and neutrophils do not produce antibodies. They mainly rely on phagocytosis for pathogen clearance.
- Choice D (Suppression of autoimmunity) is incorrect as these cells are involved in innate immunity and do not play a direct role in regulating autoimmunity.