Nokea
Which line of defense provides the body with innate immunity?
- A. Skin and mucous membranes
- B. Lungs
- C. Heart
- D. Tears and saliva
- E. Natural intestinal and vaginal flora
- F. Stomach acid
Correct Answer: A,D,E,F
Rationale: The innate immune system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease.
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The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is ___
Correct Answer: immunization
Rationale: The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is immunization.
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.
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.
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.