Question 1

A patient's white blood cell count is 11,000/mm³. What does the nurse understand this value to represent?

Accepted Answer

White blood cell count represents the total number of circulating leukocytes, which include neutrophils, eosinophils, basophils, lymphocytes, and monocytes. The given value of 11,000/mm³ represents the total count of all white blood cells in the blood.

Question 2

The nurse is instructing a patient on ways to prevent the onset of infection. What should the nurse include in these instructions?

Accepted Answer

Washing hands after using disposable tissues for nasal secretions helps prevent the spread of germs and viruses through hand contact.

Answer: C
 Taking prescribed antibiotics until symptoms subside helps ensure the infection is fully treated and reduces the risk of antibiotic resistance.

The nurse should NOT include options B or D as they both increase the risk of infection. Reusing disposable razors can lead to skin irritation and infection, while limiting interactions with people or crowds reduces exposure to germs and viruses.

Question 3

The nurse is caring for a patient recovering from a splenectomy. What should the nurse realize will occur regarding this patient's immunity?

Accepted Answer

After a splenectomy, the liver and bone marrow will take over the spleen's functions, such as filtering out old and damaged red blood cells and producing antibodies. However, the patient may be more susceptible to infections and should receive appropriate vaccinations and follow infection control measures. Swollen lymph glands are not a typical response after a splenectomy. The thymus gland is not directly involved in the spleen's functions.

Question 4

A patient sustains fractures to the ribs, both femurs, and one humerus. When planning care for this patient's immunologic status, what should the nurse include?

Accepted Answer

Monitoring the complete blood count daily can help detect any changes in the patient's white blood cell count, which can indicate an infection or changes in their immunologic status. Limiting iron-rich foods and performing passive range of motion are not directly related to immunologic status. Keeping the patient on bed rest may contribute to immunosuppression, so it is important to encourage mobility and activity as clinically indicated.

Question 5

The nurse is concerned that a patient is exhibiting signs and symptoms of inflammation. What did the nurse assess to come to this conclusion?

Accepted Answer

Inflammation is typically characterized by signs and symptoms such as edema (A), pain from swelling (B), and erythema or redness (C). These are classic indicators of the inflammatory response. Coolness to the touch (D) and decreased peripheral pulses (E) are not typical signs of inflammation; they might indicate other conditions such as poor circulation or peripheral artery disease.

Question 6

A patient recovering from knee surgery has a surgical infection. What findings indicate that the patient is experiencing a systemic reaction?

Accepted Answer

A WBC count of 14,200 mm³ and 10% bands (immature white blood cells) indicate a systemic reaction, as they suggest the body is responding to an infection throughout the body, not just locally.

Question 7

A patient is receiving intravenous vancomycin for the treatment of Clostridium difficile. Why should the nurse assess the patient for flushing, tachycardia, and hypotension during the infusion of this medication?

Accepted Answer

Flushing, tachycardia, and hypotension are signs and symptoms of red man syndrome, which can occur as a result of vancomycin infusion. Red man syndrome is a type of allergic reaction that can cause skin flushing, itching, hives, and difficulty breathing. It is important for the nurse to monitor the patient closely for the development of this syndrome during treatment.

Question 8

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?

Accepted Answer

Helper T cells play a key role in the adaptive immune response by recognizing and responding to specific pathogens. Once a helper T cell recognizes a pathogen, it can activate other immune cells, such as B cells, to produce specific antibodies against that pathogen. In addition, helper T cells develop a memory of the pathogen, which allows for a more rapid and effective response in the future. It is likely that the patient's wife was previously exposed to the same virus and developed immunity through the action of helper T cells, which prevented her from becoming ill when her husband was sick.

Question 9

The nurse believes that a patient is experiencing a systemic reaction associated with an inflammatory response. Which assessment finding supports this nurse's belief?

Accepted Answer

Edematous groin lymph nodes indicate a systemic reaction as lymph nodes swell in response to infection or inflammation in the body, suggesting a widespread inflammatory response rather than a localized one.

Question 10

An older patient has a small pressure ulcer on the coccyx. What should the nurse do to promote healing of the wound?

Accepted Answer

Encouraging high-protein food choices in the diet is important for promoting wound healing because proteins are necessary for tissue repair and regeneration. It can also help to maintain overall nutritional status and immune function. Limiting carbohydrate intake or restricting caloric intake can result in a decrease in energy availability necessary for wound healing, and there is insufficient evidence to support a high intake of vitamin E for pressure ulcer healing.

Question 11

A patient is prescribed a trough blood level to evaluate the therapeutic effect of an antibiotic. When should the nurse schedule this blood test to be drawn?

Accepted Answer

Trough levels are measured just before the next dose of medication is due, to ensure that the drug concentration does not fall below the therapeutic range. This helps in adjusting the dose to maintain efficacy while minimizing toxicity.

Question 12

A patient is diagnosed with a positive tuberculosis skin test. The nurse understands that this response is due to what?

Accepted Answer

A positive tuberculosis skin test indicates that the patient’s immune system has recognized the antigens from the tuberculosis bacteria and has initiated a cell-mediated inflammatory response. This response involves activation of T cells, macrophages, and other immune cells that work together to attack and eliminate the invading bacteria.

Question 13

A patient diagnosed with active tuberculosis is being admitted to the hospital. For which type of isolation should the nurse prepare this patient?

Accepted Answer

Active tuberculosis is spread through the air when an infected person coughs or sneezes, making airborne precautions necessary. Standard precautions are recommended for all patients, droplet precautions are used for illnesses spread through respiratory secretions that are larger in size than those in airborne transmission, and contact precautions are used for illnesses spread through direct contact with the patient or their environment.

Question 14

The nurse is planning care for a patient at risk for developing an infection. Which intervention should the nurse include in the plan of care?

Accepted Answer

Washing hands prior to providing care is the most effective way to reduce the risk of infection transmission. Prophylactic antibiotics should only be used when there is an established indication for them. Wearing a mask or gown and gloves may be necessary depending on the specific situation, but hand hygiene is always a necessary and effective intervention.

Question 15

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?

Accepted Answer

Urinary catheterization increases the risk for urinary tract infections and other types of infections in older adults.

Question 16

The nurse is reviewing the white blood cell count differential for a patient and notes that the basophil count is elevated. What should this laboratory value indicate to the nurse?

Accepted Answer

An elevated basophil count is often indicative of an acute hypersensitivity or allergic reaction. Basophils contain histamine, which plays a role in allergic reactions. Therefore, an increase in basophils is a typical response to an allergic reaction.

Question 17

A patient is diagnosed with an antibiotic-resistant infection. Which action should the nurse take to reduce the spread of this infection?

Accepted Answer

Isolating the supplies used to care for the patient will help prevent the spread of the infection to other patients or individuals. The other options may not be enough to reduce the spread of an antibiotic-resistant infection.

Question 18

A patient who just delivered a newborn baby is concerned that the baby will "catch" a cold from a healthcare provider who was coughing and sneezing in the delivery room. How should the nurse respond?

Accepted Answer

The nurse should reassure the patient that the baby has some protection from infections from the time of birth. Newborns are born with some level of immunity to help protect them from infections. It is not necessary to isolate the baby or have everyone check the baby's temperature for signs of infection, as the baby is likely to be healthy and should not be exposed to unnecessary interventions. The healthcare provider may have been necessary for the patient's care and should have taken appropriate precautions (such as wearing a mask) if they were contagious.

Question 19

A patient has been intubated to receive care in the intensive care unit. The nurse recognizes that the patient is at risk of developing which types of infection?

Accepted Answer

Patients who are intubated are at risk of developing ventilator-associated pneumonia, which can lead to serious complications and prolonged hospitalization. The other options listed may be potential risks for infection as well, but pneumonia is the most common and significant risk in an intubated patient.

Question 20

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?

Accepted Answer

The answer of The nurse is caring for a patient...

Quiz 12: Nursing Care of Patients With Infections

A patient's white blood cell count is 11,000/mm3. What does the nurse understand this value to represent?