Flashcards in Chapter 19 Deck (27):
A client has a reduction in immune function. What is the nurse’s priority action for this client?
a. Determine whether it is temporary or permanent.
b. Take the client’s vital signs every 4 hours.
c. Teach family members to receive the flu shot yearly.
d. Wash hands before entering the room.
D: The nurse should take precautions to prevent infection in the client who has a reduction in immune function. It does not matter whether it is temporary or permanent. Teaching the family what to do after the client is discharged from the hospital would not be the primary action. Taking vital signs would be an important action but would not prevent infection, which is the priority.
Which client is at highest risk of compromised immunity?
a. Client who has just had surgery
b. Client with extreme anxiety
c. Client who is awaiting surgery
d. Client who just delivered a baby
A: Intact skin is a defense to prevent infection; however, a client who has recently had surgery has a portal for organisms to enter the body and cause infection. p.303
A client who has an extensive burn injury develops inflammation that covers the entire body. What is the nurse’s best action?
a. Notify the health care provider immediately.
b. Document the assessment.
c. Take the client’s temperature.
d. Ask for an order for antibiotic therapy.
B: The inflammatory response depends on how severe the initiating event was. It would not be unexpected to have an extensive inflammatory reaction to a severe burn injury. The nurse would not have to notify the health care provider immediately, because this would not signal an emergency. This does not necessarily indicate a fever or an infection; however, the client with extensive burns would be prone to developing infection.
A client’s absolute neutrophil count (ANC) is 550/mm3. What is the nurse’s best action?
a. Use Standard Precautions.
b. Place the client on antibiotic therapy.
c. Place client on a low-sodium diet.
d. Administer chemotherapy.
A: The ANC is low. The client who has a low ANC is at risk of developing infection. The client would not need to be started on antibiotic therapy, and a low-salt diet would not help the client. Administering chemotherapy would further lower the ANC and would not be appropriate.
The nurse receives a report that a client’s laboratory results show a left shift or an increase in circulating band neutrophils. What is the nurse’s best action?
a. Keep the client on bedrest.
b. Prepare the client for surgery.
c. Increase the client’s oxygen flow rate.
d. Assess the client’s vital signs.
D: A left shift indicates that the client cannot produce a sufficient number of mature neutrophils. One condition that can cause this to happen is sepsis. Assessing vital signs, including temperature, can assist the nurse in planning the next action. There would be no reason to keep the client on bedrest, to prepare the client for surgery, or to increase the client’s oxygen at this point. The most appropriate action is assessing for a problem.
A client has an injury to the right ankle. On assessment, the nurse notes that it is red and inflamed. The nurse adds interventions to the care plan that address which factor?
a. An injury that is infected
b. Inflammation without infection
c. A secondary infection
d. Dermatitis around the ankle
B: Inflammation can occur without infection. A joint sprain or injury can cause inflammation of the joint. The nurse should not assume that there is an infection just because inflammation is evident.
The nurse is teaching a client with a leg injury and warmth around the injured area. Which statement by the client indicates a good understanding?
a. “The warmth indicates an infection.”
b. “The warmth indicates increased blood flow.”
c. “Warmth indicates that the tissues are rebuilding.”
d. “Warmth results from localized vasoconstriction.”
B: Injured tissues secrete histamine, serotonin, and kinins, which dilate the arterioles in the area of injury, increasing blood flow and delivery of nutrients and causing warmth.
A client enters the emergency department (ED) with an injury to the wrist. In assessment, the nurse notes that the area is red, warm, and edematous. What is the nurse’s best action?
a. Apply a heating pad to the area.
b. Inject pain medication directly at the site.
c. Start an IV infusion of a vasoconstrictive drug.
d. Assess circulation and elevate the extremity.
D: Blood flow to the area of injury is increased, causing edema. Edema at the site of injury protects the area from further injury by creating a cushion. A heating pad would enhance circulation to the area. Injecting pain medication and starting an IV infusion of a vasoconstricting drug would not be warranted. The best action is to elevate the extremity after ensuring adequate circulation.
The nurse is assessing a client who has a wound on the left calf. Drainage is coming from the wound. What does the nurse tell the client about this finding?
a. “Exudate or drainage is a natural occurrence with inflammation.”
b. “Exudate or drainage means the wound is infected.”
c. “Drainage from a wound is never a good sign.”
d. “All wounds result in bleeding and pus formation.”
A: Inflammation can lead to exudate or drainage, so it is an expected finding, not a bad sign. It does not mean the wound is infected. All wounds do not result in bleeding and pus formation. p. 308
The nurse is caring for a client who has undergone a kidney transplant. The client asks the nurse what will happen when his body realizes that the kidney is not “his.” What is the nurse’s best response?
a. “The immune system will try to destroy the kidney if we don’t suppress it.”
b. “As long as the kidney is a ‘match’ to your blood type, there will be no problem.”
c. “You will develop a fever or other complications from the transplant.”
d. “Within a week, your body will ‘adjust’ to the new organ.”
A: Because a solid organ transplanted into a host is seldom a perfectly identical match of human leukocyte antigens (unless the organ is obtained from an identical sibling) between the donated organ and the recipient host, the client’s immune system cells recognize a newly transplanted organ as non-self. Without intervention, the host’s immune system starts inflammatory and immunologic actions to destroy or eliminate these non-self cells. The immune response is suppressed so that the body will not attack the new organ. p.318
The nurse assesses a cut that is 24 hours old and finds that the site is swollen, red, and tender to the touch. Which cell types are responsible for these assessment findings?
a. Erythrocytes and platelets
b. Basophils and eosinophils
c. Plasma cells and B-lymphocytes
d. Natural killer cells
B: Basophils and eosinophils release histamine, kinins, and other substances that cause the manifestations of inflammation. Erythrocytes carry oxygen, and platelets help stop bleeding. Plasma cells and B-lymphocytes produce antibodies to help fight infection, and natural killer cells destroy invading bacteria.
A client had a splenectomy. Which fact is most important to teach the client regarding immune function?
a. “You won’t get a fever with infection, so you need to learn to identify other symptoms.”
b. “It will no longer be necessary for you to worry about developing allergies.”
c. “Avoid people who are ill because it will be harder for you to develop antibodies.”
d. “You will need to be assessed yearly for the risk of developing cancer.”
C: The spleen is involved in B-lymphocyte maturation. People who undergo splenectomies for any reason may have a decreased antibody-mediated immune response and thus would be more susceptible to infection. Clients will still develop fever after splenectomy and are not at increased risk for allergies or fever.
A client’s white blood cell (WBC) count value is 10,000 cells/mm3. The nurse reviews the differential. Which counts or percentages is the nurse sure to report to the provider?
a. Eosinophils, 200/mm3
b. A left shift in the white count
c. Segmented neutrophils, 6000/mm3
d. Basophils 100/mm3
B: A left shift in the WBC count indicates that the client is experiencing a continuing infection and that the client’s bone marrow cannot produce the required neutrophils, so it is now releasing immature neutrophils into the blood. The eosinophil count, the segmented neutrophil count, and the basophil count are all within normal ranges.
The nurse is assessing a client who cannot synthesize suppressor T-cells. For what other condition does the nurse assess the client?
a. Increased seasonal allergies
b. Multiple sclerosis
d. Graft-versus-host disease
A: Suppressor T-cells function to limit the actions of general and specific responses. These cells prevent overreactions to the presence of “foreign proteins” within a person’s environment. People who are deficient in suppressor T-cell activity have more severe hypersensitivity reactions, allergies, and autoimmune responses. Low numbers of T-suppressor lymphocytes would not increase the client’s risk for multiple sclerosis (MS), leukemia, or graft-versus-host disease.
An older adult client tells the nurse that her granddaughter has chickenpox. The client is afraid to visit because she is afraid of getting shingles from her granddaughter. What is the nurse’s best response?
a. “If you already had chickenpox, you cannot get shingles.”
b. “If you already had shingles, you cannot get them again.”
c. “If you already had chickenpox, you can safely visit your granddaughter.”
d. “Shingles is caused by a different virus than the chickenpox virus.”
C: Shingles is not transmitted from a person with chickenpox. Shingles (herpes zoster) is an infection that manifests later in life because of residual virus retained in the dorsal root ganglia of sensory nerves after a client has had chickenpox.
A client recovering from hepatitis A asks whether he should take the vaccine to avoid contracting the disease again. What does the nurse say?
a. “Yes, because now you are more susceptible to this infection.”
b. “Yes, because the hepatitis A virus changes from year to year.”
c. “No, your liver and immune system are too impaired at this time.”
d. “No, having the infection has done the same thing a vaccination would.”
D: Vaccination with hepatitis A vaccine is an artificial way of stimulating the immune system to make antibodies against hepatitis A (artificially acquired active immunity). This client’s immune system has responded to an actual infection with hepatitis A by making many antibodies to hepatitis A (naturally acquired active immunity); therefore he does not need a vaccination for this virus.
A client reports severe hay fever and allergic rhinitis. Which finding does the nurse expect to see in this client’s laboratory results?
a. Band neutrophils outnumber segmented neutrophils.
b. The basophil count is 50/mm3.
c. The eosinophil count is 20%.
d. The white count is 7500/mm3.
C: During allergic episodes, the eosinophil count is elevated both to respond to the presence of allergens and to limit the tissue level responses of inflammatory cells by releasing enzymes capable of degrading the vasoactive amines secreted by other leukocytes.
A client has been diagnosed with a deficiency of complement proteins. Which assessment is the item of highest priority for the nurse to perform?
a. Joint stiffness and range of motion
b. Enlarged lymph nodes and night sweats
c. Rhinorrhea and conjunctivitis
d. Lung sounds, cough, and oxygen saturation
D: The complement system attaches to viruses and bacteria so that they are more easily phagocytosed by white blood cells (WBCs). Without an effective complement system, the client is susceptible to bacterial and viral infections such as pneumonia. Pneumonia might manifest with abnormal lung sounds, productive cough, and decreased oxygen saturation. Joint stiffness and limited range of motion would suggest arthritis; enlarged lymph nodes and night sweats might indicate lymphoma; rhinorrhea and conjunctivitis might indicate seasonal allergies.
The nurse prepares to administer a tetanus toxoid vaccination to a client who has suffered a puncture wound. The client reports that he had a tetanus shot just 1 year ago. What is the nurse’s best action?
a. Give the vaccination because strains of tetanus change yearly.
b. Refrain from giving the vaccination if the client is reliable.
c. Give a smaller dose because antibody production slows down with aging.
d. Give the shot because it won’t hurt to receive an extra dose of the toxoid.
B: Tetanus toxoid boosters should be administered routinely every 10 years. In some cases, emergency departments use 5 years as the cutoff for re-vaccination. If the client’s medical records substantiate that he did indeed receive a tetanus toxoid booster 1 year ago, or if the client seems to be a reliable historian, he does not need another one now.
The nurse is caring for an older postoperative client. Which assessment finding causes the nurse to assess further for a wound infection?
a. Moderate serosanguineous drainage is seen on the dressing.
b. The client is now confused but was not confused previously.
c. The white blood cell differential indicates a right shift.
d. The white blood cell count is 8000/mm3.
B: Older adult clients often do not demonstrate typical signs and symptoms of infection because of the diminished immune function seen with aging. Often, the first sign of infection is mental status changes. Any change in mental status in the older postoperative client should lead the nurse to assess for a wound infection.
The nurse is providing discharge teaching for a client following a liver transplant. Which statement by the client indicates that additional teaching is needed?
a. “If I develop an infection, I should stop taking the steroid preparation.”
b. “If I have tenderness in my abdomen, I will call the physician.”
c. “I should avoid people who are ill or who have an infection.”
d. “Cyclosporine (Sandimmune) won’t work as well if I change the routine.”
A: Immunosuppressive agents should not be stopped without consultation with the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ.
The nurse is caring for a client who is depressed because of acute rejection following a kidney transplant. What is the nurse’s best response?
a. “This is what happens when you don’t take your transplant medications.”
b. “At least you can still have dialysis, unlike people who receive liver transplants.”
c. “One acute rejection episode does not mean that you will lose the new kidney.”
d. “You can always find another donor and get another kidney transplant.”
C: An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained.
When an antibody titer to varicella zoster virus is performed on a nurse, the titer is negative. Which result and action by the nurse’s supervisor are most appropriate?
a. The nurse has chickenpox and is contagious. The supervisor sends the nurse home.
b. The nurse has never been infected with varicella zoster virus. The supervisor assigns another nurse to care for clients with chickenpox.
c. The nurse had a subclinical case of herpes at least 5 years ago and is now immune to the disease. The supervisor assigns the nurse to a client with chickenpox.
d. The nurse has never been infected with varicella zoster virus and is susceptible to herpes. The supervisor assigns another nurse to a client with herpes.
B: The nurse does not have detectable levels of antibodies to the varicella zoster virus. The most likely explanation for this is that she or he has never been infected with the virus, although it is possible the infection occurred at such a young age that the nurse was unable to generate sufficient antibodies.
Which type of immunity does the hepatitis B immune globulin provide for the nurse?
b. Artificial active
c. Natural active
A: Passive immunity occurs when the individual is given antibodies that were created in the laboratory or by another person. Active immunity occurs after exposure of the host to an antigen or vaccination. Cell-mediated immunity is carried out by T-cells in response to specific antigens
The nurse is teaching a client who has recently given birth about immunity that has been passed to the newborn. Which statement by the client indicates that additional teaching is needed?
a. “My baby received some antibodies from me before birth, and I will give him more when I breast-feed.”
b. “I had the measles, so my baby will be protected against it until he is old enough to receive the MMR vaccine.”
c. “I had chickenpox and am immune to it, so my baby will not need to have the chickenpox vaccine.”
d. “Only certain antibodies were able to cross the placenta to protect my baby.”
C: The baby receives passive immunity from antibodies that are passed through the placenta in utero. Maternal passive immunity is temporary and will last for only a short time after birth.
The nurse reviews the laboratory results of a client and finds that the white blood cell (WBC) count is 1500/mm3. What is the priority action of the nurse?
a. Have the client wear a mask at all times.
b. Obtain a urine sample for culture and sensitivity.
c. Administer two units of fresh-frozen plasma.
d. Institute reverse isolation precautions.
D: A white cell count of 1500/mm3 indicates that the client is severely neutropenic and does not have sufficient protection against invasion by bacteria and other organisms. Reverse isolation should be initiated for his or her protection. A urine sample is not needed because the client is not being evaluated for infection with a low WBC, but would be with a high one. Fresh-frozen plasma will not increase the client’s WBC count. In reverse isolation, the client does not need to wear a mask.