RNSG-233 exam 2 study guide questions with answers
11. Which statement by a patient would alert the nurse to a possible immunodeficiency disorder?
a. “I take one baby aspirin every day to prevent stroke.”
b “I usually eat eggs or meat for at least 2 meals a day.”
.
c. “I had my spleen removed many years ago after a car accident.”
d “I had a chest x-ray 6 months ago when I had walking pneumonia.”
.
ANS: C Splenectomy increases the risk for septicemia from bacterial infections. The patient’s protein intake is
good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does
not have enough radiation to suppress immune function
. A patient who is receiving immunotherapy has just received an allergen injection. Which assessment
finding is
most important to communicate to the health care provider?
a. The patient’s IgG level is increased.
b. The injection site is red and swollen.
c. The patient’s allergy symptoms have not improved.
d. There is a 2-cm wheal at the site of the allergen injection.
ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An
increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because
immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient’s symptoms is
not expected after a few months
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale,
hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless
because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn.
With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit
erythema, blanching, and pain (L Ch. 25)
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the
following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L),
and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C The patient’s laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the
microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion
is inappropriate, although transfusions may be needed after the emergent phase once the patient’s fluid balance has
been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours;
likely every1 hour
,RNSG-233 exam 2 study guide questions with answers
4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial
volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875
mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b 523 mL/hour
.
c. 938 mL/hour
d 1250 mL/hour
.
ANS: C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other
half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr
6. A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain
adequate nutrition, the nurse should plan to take which action?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5000 kcal per day.
d. Administer multiple vitamins and minerals in the IV solution.
ANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48
hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet
nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals
may be administered during the emergent phase, but these will not assist in meeting the patient’s caloric needs.
Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely
used in burn patients (L Ch. 25)
7. While the patient’s full–thickness burn wounds to the face are exposed, what is the best nursing action to
prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Administer IV antibiotics to prevent bacterial colonization of wounds.
d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.
ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound
contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the
dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for
patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns
because of the lack of circulation
6. A patient tells the nurse that he’s happy that his wife did not “catch” the same cold from which he has recently
recovered. The nurse realizes that what most likely occurred in his wife?
1. Helper T cells had a memory of a previous exposure to the same virus that caused the patient’s illness.
2. Suppressor T cells killed the virus
3. The virus was eliminated via phagocytosis by neutrophils.
4. Cytokines were released.
Correct Answer: 1 Global Rationale: Helper T cells stimulate B cells to make antibodies to specific antigens. These
cells then have a “memory” of exposure, which will lead to a quick response if another exposure occurs. In this
scenario, the wife must have had a previous exposure to the same virus that caused the patient’s cold, and because of
this “memory,” the body immediately responded by eliminating the cold virus. Suppressor T cells stop the immune
, RNSG-233 exam 2 study guide questions with answers
process and would not kill virus cells. Phagocytosis of the virus by neutrophils is an antibody-mediated response.
This scenario describes a cell-mediated immune response. Cytokines are chemical messengers produced by cells to
either increase the flow of white blood cells to a body area or coat an antigen to encourage phagocytosis.
(LM Ch. 12)
7. The nurse is caring for a patient diagnosed with a lung infection. Which immunoglobulin level should the nurse
expect to be elevated in this patient?
1. Immunoglobulin A
2. Immunoglobulin M
3. Immunoglobulin E
4. Immunoglobulin D
Answer: 1 Global Rationale: Immunoglobulins are made in response to a primary or initial exposure to an antigen.
Immunoglobulin A is most commonly found in secretions, and its major function is to protect the eyes, mouth,
nose, gastrointestinal tract, and lungs from diseases caused by viruses and bacteria. For the patient with a lung
infection, this immunoglobulin level will likely be the highest. Immunoglobulin M is the first antibody produced in
the primary immune response and is first produced during embryonic development. Immunoglobulin E is the
primary antibody in the allergic response. Immunoglobulin D is the cell that is least understood and is present in
small quantities in the blood
13. The nurse is concerned that an older adult patient could be at risk for developing an infection. Which
intervention led to this concern for the patient?
1. Urinary catheterization
2. Applying anti-embolism stockings
3. Ambulation with the assistance of a walker
4. Medicating for pain as needed prior to physical therapy
Answer: 1 Global Rationale: Invasive procedures and altered immune defenses are the main factors contributing
to hospital-acquired infection. Urinary catheterization is the number one cause. The use of anti-embolism
stockings, ambulating with a walker, and medicating for pain are not associated with nosocomial infections
3. A patient tells the nurse that she used to get the “common cold” at least three times a year but now can’t
remember the last time she had one. What should the nurse realize this patient is describing?
1. Healthy B cell functioning
2. Healthy helper T cell functioning
3. T cell secretion of antibodies
4. Healthy regulator T cell functioning
Answer: 1 Global Rationale: B cells produce antibodies, also known as immunoglobulins, that inactivate an
invading antigen. Memory cells “remember” an antigen, and, when exposed to it a second time, immediately initiate
the immune response. T cells do not secrete antibodies. T cells are subdivided into effector cells and regulator cells.
Regulator T cells are divided into two subsets known as helper T cells and suppressor T cells. In addition to
destroying viruses within cells marked as “non self,” cytotoxic T cells also attack malignant cells and are
responsible for the rejection of transplanted organs and grafted tissues (LM Ch. 13)
25. A patient diagnosed with HIV has an HIV viral load test of 9,000 copies/mL. What should this test result
suggest to the nurse?
1. The current prescribed medication therapy is not effective
2. The current prescribed medication therapy is effective
3. The dose of prescribed medication can be reduced
4. A less toxic medication needs to be prescribed
Answer: 1 Rationale 1: HIV viral load tests measure the amount of actively replicating HIV. Levels correlate with
disease progression and response to antiretroviral medications. Levels greater than 5,000 to 10,000 copies/mL
indicate the need for treatment. 2: The patient’s current prescribed medication is not effective. 3: The patient’s
medication dose should not be reduced. 4: This laboratory value does not indicate toxicity (LM Ch. 13)
11. Which statement by a patient would alert the nurse to a possible immunodeficiency disorder?
a. “I take one baby aspirin every day to prevent stroke.”
b “I usually eat eggs or meat for at least 2 meals a day.”
.
c. “I had my spleen removed many years ago after a car accident.”
d “I had a chest x-ray 6 months ago when I had walking pneumonia.”
.
ANS: C Splenectomy increases the risk for septicemia from bacterial infections. The patient’s protein intake is
good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does
not have enough radiation to suppress immune function
. A patient who is receiving immunotherapy has just received an allergen injection. Which assessment
finding is
most important to communicate to the health care provider?
a. The patient’s IgG level is increased.
b. The injection site is red and swollen.
c. The patient’s allergy symptoms have not improved.
d. There is a 2-cm wheal at the site of the allergen injection.
ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An
increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because
immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient’s symptoms is
not expected after a few months
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale,
hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless
because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn.
With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit
erythema, blanching, and pain (L Ch. 25)
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the
following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L),
and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C The patient’s laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the
microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion
is inappropriate, although transfusions may be needed after the emergent phase once the patient’s fluid balance has
been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours;
likely every1 hour
,RNSG-233 exam 2 study guide questions with answers
4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial
volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875
mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b 523 mL/hour
.
c. 938 mL/hour
d 1250 mL/hour
.
ANS: C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other
half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr
6. A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain
adequate nutrition, the nurse should plan to take which action?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5000 kcal per day.
d. Administer multiple vitamins and minerals in the IV solution.
ANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48
hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet
nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals
may be administered during the emergent phase, but these will not assist in meeting the patient’s caloric needs.
Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely
used in burn patients (L Ch. 25)
7. While the patient’s full–thickness burn wounds to the face are exposed, what is the best nursing action to
prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Administer IV antibiotics to prevent bacterial colonization of wounds.
d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.
ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound
contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the
dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for
patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns
because of the lack of circulation
6. A patient tells the nurse that he’s happy that his wife did not “catch” the same cold from which he has recently
recovered. The nurse realizes that what most likely occurred in his wife?
1. Helper T cells had a memory of a previous exposure to the same virus that caused the patient’s illness.
2. Suppressor T cells killed the virus
3. The virus was eliminated via phagocytosis by neutrophils.
4. Cytokines were released.
Correct Answer: 1 Global Rationale: Helper T cells stimulate B cells to make antibodies to specific antigens. These
cells then have a “memory” of exposure, which will lead to a quick response if another exposure occurs. In this
scenario, the wife must have had a previous exposure to the same virus that caused the patient’s cold, and because of
this “memory,” the body immediately responded by eliminating the cold virus. Suppressor T cells stop the immune
, RNSG-233 exam 2 study guide questions with answers
process and would not kill virus cells. Phagocytosis of the virus by neutrophils is an antibody-mediated response.
This scenario describes a cell-mediated immune response. Cytokines are chemical messengers produced by cells to
either increase the flow of white blood cells to a body area or coat an antigen to encourage phagocytosis.
(LM Ch. 12)
7. The nurse is caring for a patient diagnosed with a lung infection. Which immunoglobulin level should the nurse
expect to be elevated in this patient?
1. Immunoglobulin A
2. Immunoglobulin M
3. Immunoglobulin E
4. Immunoglobulin D
Answer: 1 Global Rationale: Immunoglobulins are made in response to a primary or initial exposure to an antigen.
Immunoglobulin A is most commonly found in secretions, and its major function is to protect the eyes, mouth,
nose, gastrointestinal tract, and lungs from diseases caused by viruses and bacteria. For the patient with a lung
infection, this immunoglobulin level will likely be the highest. Immunoglobulin M is the first antibody produced in
the primary immune response and is first produced during embryonic development. Immunoglobulin E is the
primary antibody in the allergic response. Immunoglobulin D is the cell that is least understood and is present in
small quantities in the blood
13. The nurse is concerned that an older adult patient could be at risk for developing an infection. Which
intervention led to this concern for the patient?
1. Urinary catheterization
2. Applying anti-embolism stockings
3. Ambulation with the assistance of a walker
4. Medicating for pain as needed prior to physical therapy
Answer: 1 Global Rationale: Invasive procedures and altered immune defenses are the main factors contributing
to hospital-acquired infection. Urinary catheterization is the number one cause. The use of anti-embolism
stockings, ambulating with a walker, and medicating for pain are not associated with nosocomial infections
3. A patient tells the nurse that she used to get the “common cold” at least three times a year but now can’t
remember the last time she had one. What should the nurse realize this patient is describing?
1. Healthy B cell functioning
2. Healthy helper T cell functioning
3. T cell secretion of antibodies
4. Healthy regulator T cell functioning
Answer: 1 Global Rationale: B cells produce antibodies, also known as immunoglobulins, that inactivate an
invading antigen. Memory cells “remember” an antigen, and, when exposed to it a second time, immediately initiate
the immune response. T cells do not secrete antibodies. T cells are subdivided into effector cells and regulator cells.
Regulator T cells are divided into two subsets known as helper T cells and suppressor T cells. In addition to
destroying viruses within cells marked as “non self,” cytotoxic T cells also attack malignant cells and are
responsible for the rejection of transplanted organs and grafted tissues (LM Ch. 13)
25. A patient diagnosed with HIV has an HIV viral load test of 9,000 copies/mL. What should this test result
suggest to the nurse?
1. The current prescribed medication therapy is not effective
2. The current prescribed medication therapy is effective
3. The dose of prescribed medication can be reduced
4. A less toxic medication needs to be prescribed
Answer: 1 Rationale 1: HIV viral load tests measure the amount of actively replicating HIV. Levels correlate with
disease progression and response to antiretroviral medications. Levels greater than 5,000 to 10,000 copies/mL
indicate the need for treatment. 2: The patient’s current prescribed medication is not effective. 3: The patient’s
medication dose should not be reduced. 4: This laboratory value does not indicate toxicity (LM Ch. 13)
