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Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. The nurse recognizes which term to identify the second line of defense that leads to local capillary dilation and leukocyte infiltration? A. Normal flora B. Inflammatory response C. Immune response D. Humoral immunity ____ 2. The nurse knows that the antigen-antibody reaction is an example of what type of immunity? A. Humoral B. Cellular C. Innate D. Passive ____ 3. The nurse uses ...

1. The nurse knows which description would be classified as a closed wound? A. A large bruise on the side of the face B. A surgical incision that is sutured closed C. A puncture wound that is healing D. An abrasion on the leg ____ 2. The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education? A. “The wound will be red.” B. “The wound will have pus.” C. “The wound will be warm.” D. “The wound...

STROKE — PRIORITY ASSESSMENT A patient arrives in the ED with sudden right-sided weakness and slurred speech that began 1 hour ago. Which assessment is the highest priority? A. Blood glucose level B. NIH Stroke Scale C. Non-contrast CT of the head D. Vital signs t-PA DECISION MAKING A patient with suspected ischemic stroke is being evaluated for alteplase (t-PA). Which finding would immediately contraindicate administration? A. Blood pressure of 178/96 mmHg B. History of ischemic s...

1. A nurse is reviewing the medical record of a client who has a blood glucose of 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply.) A. Diuretics B. Corticosteroids C. Oral anticoagulants D. Opioid analgesics E. Antipsychotics 2. A nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferrin...

A patient reports “a curtain coming down over my vision” in the right eye. What is the nurse’s priority action? A. Assess visual acuity B. Administer prescribed eye drops C. Notify the provider immediately D. Reassure the patient this is age-related Narrow-Angle Glaucoma – Emergency Recognition Which assessment finding suggests acute narrow-angle glaucoma requiring immediate intervention? A. Gradual peripheral vision loss B. Severe eye pain with nausea and halos around lights ...

Question #1 The nurse manager is preparing an in-service regarding legal issues and client care. Which of the following is a correct example for the nurse manager to give during the in-service? a. Battery is having security keep a client in their room when they want to leave against medical advice (AMA). b. Using a recliner’s attached lap tray to keep the client in the chair is considered assault. c. Malpractice is applying restraints without an order from the primary health care provi...

Management of Care 1. A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers 2. A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the...

Question 1 A client has been admitted to the hospital with draining foot lesions. What should the nurse do? Select all that apply. Place the client in a room with negative air pressure. Admit the client to a semi-private room. Admit the client to a private room. Post a "contact isolation" sign on the door. Wear a protective gown when in the client's room. Wear gloves when providing direct care. Explanation: Infection control policies must be followed to prevent the spre...

Strategy Reminders: ● Never delegate assessments, teachings, or evaluation ● Always check for airway, breathing, circulation (ABCs) ● Use Maslow when prioritizing (physiological needs first) ○ Physiological → Safety → Love/Belonging → Esteem → Self-Actualization ● Watch for infections, falls, and safety issues Drug Alerts: ● Digoxin: Hold if HR <60, toxicity = visual changes, bradycardia ● Furosemide: Watch K+, dehydration ● Warfarin: PT/INR monitoring, antido...

Hemoglobin (Hgb) Male: 14-18 g/dL | Female: 12-16 g/dL | Pregnant: >11 g/dL Low = anemia | Transfuse if critically low Hematocrit (Hct) Male: 42-52% | Female: 37-47% | Pregnant: >33% Hct ≈ 3× Hgb value WBC 5,000-10,000 mm³ High = infection | Low = immunosuppression Platelets 150,000-400,000 mm³ Low <150K = bleeding risk Sodium (Na+) 135-145 mEq/L <135 = hyponatremia | >145 = hypernatremia Potassium (K+) 3.5-5.0 mEq/L <3.5 = hypokalemia | >5.0 = hyperkalemia Calc...