COMPLETE ANSWERS VERIFIED
◉ a. Assess the client for more specific signs. Answer: 2. A nurse is
assessing an older client for the presence of infection. The client's
temperature is 97.6° F (36.4° C). What response by the nurse is best?
a. Assess the client for more specific signs.
b. Conclude that an infection is not present.
c. Document findings and continue to monitor.
d. Request that the provider order blood cultures.
◉ a. "Avoid large crowds and people who are ill.". Answer: 3. A client
is taking prednisone to prevent transplant rejection. What
instruction by the nurse is most important?
a. "Avoid large crowds and people who are ill."
b. "Check over-the-counter meds for acetaminophen."
c. "Take this medicine exactly as prescribed."
d. "You have a higher risk of developing cancer."
◉ a. Assessing vaccination records for booster shot needs. Answer:
4. A clinic nurse is working with an older client. What assessment is
most important for preventing infections in this client?
a. Assessing vaccination records for booster shot needs
,b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes
◉ b. Purulent drainage. Answer: 5. A client has a leg wound that is in
the second stage of the inflammatory response. For what
manifestation does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
◉ a. Bone marrow. Answer: 6. A nursing student learning about
antibody-mediated immunity learns that the cell with the most
direct role in this process begins development in which tissue or
organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils
◉ c. Natural active. Answer: 7. The nurse understands that which
type of immunity is the longest acting?
,a. Artificial active
b. Inflammatory
c. Natural active
d. Natural passive
◉ d. Suppressor T cells. Answer: 8. The nurse working with clients
who have autoimmune diseases understands that what component
of cell-mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T cells
c. Natural killer cells
d. Suppressor T cells
◉ a. Dialysis. Answer: 9. A client has been on dialysis for many years
and now is receiving a kidney transplant. The client experiences
hyperacute rejection. What treatment does the nurse prepare to
facilitate?
a. Dialysis
b. High-dose steroid administration
c. Monoclonal antibody therapy
d. Plasmapheresis
, ◉ c. Creatinine of 3.9 mg/dL. Answer: 10. A nurse is assessing a
client for acute rejection of a kidney transplant. What assessment
finding requires the most rapid communication with the provider?
a. Blood urea nitrogen (BUN) of 18 mg/dL
b. Cloudy, foul-smelling urine
c. Creatinine of 3.9 mg/dL
d. Urine output of 340 mL/8 hr
◉ b. Identical twin. Answer: 11. The nurse working in an organ
transplantation program knows that which individual is typically the
best donor of an organ?
a. Child
b. Identical twin
c. Parent
d. Same-sex sibling
◉ d. Treat the client as if he or she has tuberculosis (TB).. Answer:
12. An older adult has a mild temperature, night sweats, and
productive cough. The client's tuberculin test comes back negative.
What action by the nurse is best?
a. Recommend a pneumonia vaccination.
b. Teach the client about viral infections.
c. Tell the client to rest and drink plenty of fluids.
d. Treat the client as if he or she has tuberculosis (TB).