Question 1

The nurse explaining the procedure of indium imaging to a client with a bone infection would include which of the following?

Accepted Answer

Indium imaging involves tagging the patient's white blood cells with indium, which then accumulates in areas of infection, including infected bone, allowing for precise identification of infection sites.

Question 2

The client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which of the following changes in vital signs?

Accepted Answer

Tachycardia and hypotension are indicative of hypovolemic shock, which is a common and serious complication following multiple fractures and soft tissue injuries due to potential internal bleeding or fluid loss.

Question 3

Which of the following teaching points is the priority when the nurse i s teaching the client about caring for a plaster cast?

Accepted Answer

The priority teaching point for a client with a plaster cast is to immediately report any increase in drainage or interruption in cast integrity. This is crucial for preventing complications such as infection or further injury. The other options, while important, do not address potential immediate threats to the client's health.

Question 4

The nurse caring for a client who has undergone kidneytransplantation is monitoring the client for organ rejection. The nurse understands that in cases in which the recipient rejects transplanted organs, the cells of the transplanted organs are seen by the body as a(n):

Accepted Answer

In cases of organ transplantation, if the recipient's immune system rejects the transplanted organ, it is because the immune system recognizes the cells of the transplanted organ as foreign antigens. This recognition triggers an immune response against the transplanted organ.

Question 5

A client is admitted to the hospital with a diagnosis of parasitic worms. The nurse understands that the primary cell type that will attack these foreign particles is:

Accepted Answer

Eosinophils are primarily responsible for combating multicellular parasites, such as worms, and also play a role in allergic reactions. They are part of the immune system's response to these types of infections.

Question 6

Tetanus toxoid is prescribed for a client who has sustained a foot laceration from a piece of metal while walking barefoot on the beach. The nurse understands that the toxoid is a(n):

Accepted Answer

Tetanus toxoid is an inactivated toxin (toxoid) produced by the bacterium Clostridium tetani, which has been altered to be non-toxic but still elicits an immune response to protect against tetanus.

Question 7

The nursing instructor is questioning a nursing student about the organs of the immune system and asks the student where Kupffer's cells are located. The student responds correctly by stating that these types of cells are located in the:

Accepted Answer

Kupffer cells are specialized macrophages located in the liver, where they play a role in breaking down red blood cells and pathogens.

Question 8

The nursing student understands that the primary purpose of neutrophils in the inflammatory response is to:

Accepted Answer

Neutrophils are a type of white blood cell that play a crucial role in the immune response by phagocytizing, or engulfing and digesting, potentially harmful agents such as bacteria and debris at the site of injury or infection.

Question 9

The nursing student correctly describes the process of phagocytosis as:

Accepted Answer

Phagocytosis is the process by which cells, such as macrophages, ingest and digest particles, bacteria, or other small cells.

Question 10

The nurse is receiving a client from the postanesthesia care unit fol lowing left above-knee amputation. The priority nursing action at this time is which of the following?

Accepted Answer

Elevating the foot of the bed helps to reduce swelling and promote venous return, which is crucial immediately after an amputation surgery to prevent complications such as edema and to promote healing.

Question 11

The nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse would plan to teach the client which of the following pieces of information about positioning in the postoperative period?

Accepted Answer

After cataract surgery, it is important to avoid pressure on the operated eye, so the client should avoid sleeping on the left side to prevent any strain or pressure on the left eye.

Question 12

The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which of the following positions?

Accepted Answer

After a craniotomy with a supratentorial incision, the client is typically positioned in Semi-Fowler's position to promote venous drainage from the head and reduce intracranial pressure.

Question 13

The nurse is teaching a client with chronic airflow limitation ( CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching regarding positioning?

Accepted Answer

Lying on the back in a low Fowler's position can make breathing more difficult for someone with chronic airflow limitation, as it does not facilitate lung expansion or use gravity to aid in breathing.

Question 14

The nurse is assisting the physician with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse takes which of the following actions?

Accepted Answer

Fluctuation of the fluid level in the water seal chamber indicates that the chest tube is functioning properly, so the nurse should document this observation.

Question 15

The physician is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to:

Accepted Answer

The Valsalva maneuver is performed to increase intrathoracic pressure, which helps prevent air from entering the pleural space during chest tube removal.

Question 16

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube. Which of the following findings should be reported to the health care physician immediately?

Accepted Answer

Stridor is an indication of airway obstruction and can be a serious complication after the removal of an endotracheal tube, requiring immediate attention from a healthcare provider.

Question 17

A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that are most likely to have this taste for the client?

Accepted Answer

Chemotherapy can alter a patient's sense of taste, making certain foods taste bitter or metallic. Among the options provided, pork is more likely to be perceived as bitter by someone undergoing chemotherapy, compared to the other options which are milder in flavor.

Question 18

The client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed should plan to include which of the following in a list provided to the client?

Accepted Answer

Summer squash is a low-sodium option suitable for a client on a low-sodium diet. Tomato soup, boiled shrimp, and instant oatmeal often contain high levels of sodium, making them less appropriate choices for someone trying to manage hypertension through diet.

Question 19

The client has been diagnosed with gout. In developing a teaching plan for this client, the nurse should include a list that identifies which of the following foods to be avoided?

Accepted Answer

Chicken liver is high in purines, which can increase uric acid levels and exacerbate gout symptoms.

Question 20

The client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse gives the client suggestions for foods to aid in symptom management that are in which of the following diet types?

Accepted Answer

During an acute episode of diverticulitis, a low-fiber diet is recommended to decrease bowel stimulation and allow the colon to rest.

Quiz 1: Adult Health