Acute & Chronic Exam 1 UPDATED ACTUAL Questions and CORRECT Answers
When an infection is severe or prolonged, the body Shift to the left
cannot manufacture neutrophils quickly enough, causing
the release of bands into the blood. How would the
nurse document this in the chart?
A nurse is planning care for several clients who have Primary Intention- Surgical removal of a mole
wounds that are healing. The nurse recognizes that most Secondary Intention- Traumatic knife wound.
wounds heal by connective tissue repair. Match the Tertiary Intention- An infected wound left open.
following descriptions of the clients' wounds with the
types of repair healing in the column on the right. The
types of repair healing may be used more than once.
Primary Intention
Secondary Intention
Tertiary Intention
Traumatic knife wound
Surgical removal of a mole
An infected wound left open
Neutrophils _________ bacteria, other foreign material and Phagocytize (engulf)
damaged cells.
A nurse assesses a surgical client the morning of his first Document the assessment.
postoperative day and notes redness and warmth around
the incision. Which action by the nurse is most
appropriate at this time?
- Notify the health care provider.
- Document the assessment.
- Re-assess the wound every hour.
- Obtain wound cultures.
The chemical mediator that is the primary agent involved Histamine
in the vascular phase of the inflammatory response is
Natural Killer Cells Involved in recognition and killing of virus infected cells that play a viral role in
immune surveillance for malignant cell changes.
Monocytes Responsible for capturing, processing, and presenting the antigen to the
lymphocyte.
Macrophages Present to circulating T or B Lymphocytes triggering immune response.
Breastfeeding Example of passive acquired natural immunity.
Quadrivalent Flu Vaccine Example of active acquired artificial immunity
,Recovered from Measles Injection Example of active acquired natural immunity.
Hepatitis Immune Globulin (HBIG) Example of passive acquired artificial immunity
Immunoglobulin G (IgG) It is an antibody that is produced from the secondary immune response fighting
against harmful invaders such as bacteria and viruses.
A 75-year-old male patient has been on the ventilator Stage 1 pressure injury
and on bed rest for 1 week. While performing her
assessment, the nurse noticed a non-blanchable redness
in the sacrum area. The skin was intact. The nurse
documents in the chart as
- Stage 1 pressure injury
- Stage 2 pressure injury
- Deep tissue pressure injury
- Unstable pressure injury
When an antigen enters the body for the first time, the Immunoglobulin M (IgM)
humoral immunity primary immune response produces
what antibody?
- T killer cells
- Immunoglobulin M (IgM)
- B and T lymphocytes
- Immunoglobulin G (IgG)
What are physical manifestations of local inflammation? - Redness
Select all that apply. One, some, or all responses may - Pain
be correct. - Swelling
- Loss of Function
- Redness
- Pain
- Swelling
- Fever
- Elevated WBC count
- 10% bands
- Loss of function
What type of exudate formation is most likely - Purulent
developed?
- Catarrhal
- Fibrinous
- Hemorrhagic
- Purulent
- Serosanguinous
- Serous
, What are the systemic manifestations of inflammation? - Fever
Select all that apply. One, some, or all responses may - Elevated WBC count
be correct. - Shift to the left
Correct! - Pulse rate of 110
- Fever
- Elevated WBC count
- Shift to the left
- Nausea
- Pulse rate of 110
- Hyperemia from vasodilation
What is the significance of WBC count? - increased WBC with leukocytosis is a systemic manifestation of inflammation and
infection.
- Increased WBC with leukocytosis is a systemic
manifestation of inflammation and infection.
- It indicates a local inflammatory response.
- The white count is in the normal range.
- Decreased WBC with leukopenia indicating most likely
aplastic anemia.
What type of healing is most likely occurring at the - Secondary Intention
wound?
- Primary Intention
- Secondary Intention
- Tertiary Intention
The patient has a fever of 103.4 temperature. Which - Giving antipyretics on regular base schedule.
intervention would be the most effective in restoring
normal body temperature?
- Giving antipyretics on a regular base schedule.
- Rest, Ice, Compression, Elevation.
- Using a cooling blanket and sponge baths while the
patient is febrile.
- Giving prescribed antibiotics and placing warm blankets
for comfort.
What tasks can be delegated to an advanced unlicensed - Dressing changes.
assistant (AUA) personnel for a patient? - Report changes in the wound appearance.
- Report drainage.
- Perform a cardiovascular physical assessment
- Dressing changes.
- Report changes in the wound appearance.
- Report drainage.
- Administer medications
When an infection is severe or prolonged, the body Shift to the left
cannot manufacture neutrophils quickly enough, causing
the release of bands into the blood. How would the
nurse document this in the chart?
A nurse is planning care for several clients who have Primary Intention- Surgical removal of a mole
wounds that are healing. The nurse recognizes that most Secondary Intention- Traumatic knife wound.
wounds heal by connective tissue repair. Match the Tertiary Intention- An infected wound left open.
following descriptions of the clients' wounds with the
types of repair healing in the column on the right. The
types of repair healing may be used more than once.
Primary Intention
Secondary Intention
Tertiary Intention
Traumatic knife wound
Surgical removal of a mole
An infected wound left open
Neutrophils _________ bacteria, other foreign material and Phagocytize (engulf)
damaged cells.
A nurse assesses a surgical client the morning of his first Document the assessment.
postoperative day and notes redness and warmth around
the incision. Which action by the nurse is most
appropriate at this time?
- Notify the health care provider.
- Document the assessment.
- Re-assess the wound every hour.
- Obtain wound cultures.
The chemical mediator that is the primary agent involved Histamine
in the vascular phase of the inflammatory response is
Natural Killer Cells Involved in recognition and killing of virus infected cells that play a viral role in
immune surveillance for malignant cell changes.
Monocytes Responsible for capturing, processing, and presenting the antigen to the
lymphocyte.
Macrophages Present to circulating T or B Lymphocytes triggering immune response.
Breastfeeding Example of passive acquired natural immunity.
Quadrivalent Flu Vaccine Example of active acquired artificial immunity
,Recovered from Measles Injection Example of active acquired natural immunity.
Hepatitis Immune Globulin (HBIG) Example of passive acquired artificial immunity
Immunoglobulin G (IgG) It is an antibody that is produced from the secondary immune response fighting
against harmful invaders such as bacteria and viruses.
A 75-year-old male patient has been on the ventilator Stage 1 pressure injury
and on bed rest for 1 week. While performing her
assessment, the nurse noticed a non-blanchable redness
in the sacrum area. The skin was intact. The nurse
documents in the chart as
- Stage 1 pressure injury
- Stage 2 pressure injury
- Deep tissue pressure injury
- Unstable pressure injury
When an antigen enters the body for the first time, the Immunoglobulin M (IgM)
humoral immunity primary immune response produces
what antibody?
- T killer cells
- Immunoglobulin M (IgM)
- B and T lymphocytes
- Immunoglobulin G (IgG)
What are physical manifestations of local inflammation? - Redness
Select all that apply. One, some, or all responses may - Pain
be correct. - Swelling
- Loss of Function
- Redness
- Pain
- Swelling
- Fever
- Elevated WBC count
- 10% bands
- Loss of function
What type of exudate formation is most likely - Purulent
developed?
- Catarrhal
- Fibrinous
- Hemorrhagic
- Purulent
- Serosanguinous
- Serous
, What are the systemic manifestations of inflammation? - Fever
Select all that apply. One, some, or all responses may - Elevated WBC count
be correct. - Shift to the left
Correct! - Pulse rate of 110
- Fever
- Elevated WBC count
- Shift to the left
- Nausea
- Pulse rate of 110
- Hyperemia from vasodilation
What is the significance of WBC count? - increased WBC with leukocytosis is a systemic manifestation of inflammation and
infection.
- Increased WBC with leukocytosis is a systemic
manifestation of inflammation and infection.
- It indicates a local inflammatory response.
- The white count is in the normal range.
- Decreased WBC with leukopenia indicating most likely
aplastic anemia.
What type of healing is most likely occurring at the - Secondary Intention
wound?
- Primary Intention
- Secondary Intention
- Tertiary Intention
The patient has a fever of 103.4 temperature. Which - Giving antipyretics on regular base schedule.
intervention would be the most effective in restoring
normal body temperature?
- Giving antipyretics on a regular base schedule.
- Rest, Ice, Compression, Elevation.
- Using a cooling blanket and sponge baths while the
patient is febrile.
- Giving prescribed antibiotics and placing warm blankets
for comfort.
What tasks can be delegated to an advanced unlicensed - Dressing changes.
assistant (AUA) personnel for a patient? - Report changes in the wound appearance.
- Report drainage.
- Perform a cardiovascular physical assessment
- Dressing changes.
- Report changes in the wound appearance.
- Report drainage.
- Administer medications
