NU216 Fall 25 Final

Correct Answer:

Type IV - Delayed cell-mediated hypersensitivity

Explanation of Correct Answer:

Poison ivy reactions are classic examples of Type IV hypersensitivity, which is mediated by T lymphocytes rather than antibodies. This reaction develops 24–72 hours after exposure and involves localized inflammation, redness, and itching. The delay occurs because T cells must recognize the antigen and release cytokines that recruit immune cells, causing the skin reaction.

Why Other Options Are Incorrect:

Type I - Immediate hypersensitivity

This is IgE-mediated and occurs within minutes of exposure to allergens like pollen or insect venom, causing symptoms such as hives, anaphylaxis, or asthma—not a delayed rash.

Type II - Cytotoxic hypersensitivity

This involves IgG or IgM antibodies binding to cell surfaces, leading to cell destruction. Examples include hemolytic anemia or transfusion reactions, not contact dermatitis.

Type III - Immune complex hypersensitivity

This occurs when antigen-antibody complexes deposit in tissues, leading to inflammation, such as in lupus or serum sickness, not in poison ivy reactions.

Correct Answers:

"Call 911 immediately after using the injector"

"Inject into the outer thigh and hold for 10 seconds"

"Store the injector at room temperature and check the expiration date."

"You may need a second dose if symptoms do not improve."

Explanation of Correct Answers:

Call 911 immediately after using the injector

Epinephrine provides temporary relief from severe allergic reactions, but emergency medical care is still required as symptoms can return.

Inject into the outer thigh and hold for 10 seconds

The correct site for administration is the mid-outer thigh, even through clothing if necessary. Holding for 10 seconds ensures full medication delivery.

Store the injector at room temperature and check the expiration date.

Proper storage maintains drug potency, and expired injectors may not be effective during an emergency.

You may need a second dose if symptoms do not improve.

If symptoms persist or recur before emergency help arrives, a second dose can be given according to provider or manufacturer instructions.

Why Other Option Is Incorrect:

Massage the injection site vigorously after administration

Massaging is no longer recommended as it can cause local irritation and is unnecessary for drug absorption.

Correct Answer:

Usually occurs with physical exertion, lasting 3–5 minutes and relieved by rest

Explanation:

Stable angina is caused by myocardial ischemia due to increased oxygen demand during exertion. It is predictable, typically triggered by exercise or stress, lasts a few minutes, and is relieved by rest or nitroglycerin. Unlike unstable angina, it does not usually occur at rest. Recognizing this predictable pattern is key to distinguishing stable angina from other chest pain syndromes.

Why Other Options Are Wrong:

Severe, persistent and occurs with rest or while ambulating

This is incorrect because pain at rest that is severe and persistent suggests unstable angina or myocardial infarction, not stable angina. Stable angina is exertional and relieved by rest.

Aggravated by inspiration, coughing, and movement of the upper body

This is incorrect because pain worsened by respiration or movement is more likely musculoskeletal or pleuritic in origin, not cardiac ischemia. Stable angina is not influenced by breathing or body movement.

Occurs primarily at rest and is triggered by smoking or alcoholic beverages

This is incorrect because angina at rest is characteristic of variant (Prinzmetal’s) or unstable angina, not stable angina. Stable angina is exertional, not primarily triggered by smoking or alcohol intake.

Correct Answers:

Avoid pregnant women and children for a minimum 5 days after therapy

Avoid preparing meals for others using bare hands

Perform oral care two to three times daily with a salt and soda solution

Use a private toilet and flush at least 3 times after each use

Notify the provider if extreme fatigue and shortness of breath occur

Explanation of Correct Answers:

Avoid pregnant women and children for a minimum 5 days after therapy

Radioactive iodine emits radiation that can be harmful to developing fetuses and children. Close contact should be avoided for at least 5 days to minimize radiation exposure.

Avoid preparing meals for others using bare hands

Saliva and sweat can contain small amounts of radioiodine, so using utensils or gloves while preparing food helps prevent radiation exposure to others.

Perform oral care two to three times daily with a salt and soda solution

RAI can cause inflammation of salivary glands and dry mouth. Salt and soda rinses help keep the mouth clean and reduce discomfort.

Use a private toilet and flush at least 3 times after each use

Radioactive iodine is excreted in urine and other body fluids. Multiple flushes help reduce contamination and protect others from radiation exposure.

Notify the provider if extreme fatigue and shortness of breath occur

These symptoms may indicate hypothyroidism or other complications after RAI and require prompt evaluation and treatment.

Why Other Option Is Incorrect:

Visitors are allowed after the first follow-up care with HCP

This is incorrect. Restrictions on visitors, especially pregnant women and children, are based on radiation safety timelines, not on follow-up visits. Close contact precautions typically apply immediately after treatment and for several days, not only after follow-up.

Correct Answer:

21 mL/hr

Explanation:

Using the formula:

$\mathrm{mL}/\mathrm{hr} =\frac{\mathrm{Desired} \mathrm{dose} (\mathrm{units}/\mathrm{hr}) \times \mathrm{Volume} \left(\mathrm{mL}\right)}{\mathrm{Total} \mathrm{units} \mathrm{available}}$

$\mathrm{mL}/\mathrm{hr} = \frac{1,050 \times 500}{25000}$

The nurse should program the IV pump at 21 mL/hr.

Why Other Options Are Wrong:

18 mL/hr – Would deliver fewer units (900 units/hr), which underdoses the patient.

25 mL/hr – Would deliver 1,250 units/hr, overdosing the patient.

30 mL/hr – Would deliver 1,500 units/hr, significantly overdosing the patient.

Correct Answers:

Notify the primary care provider immediately

Perform neurovascular checks

Remove or loosen restrictive dressings

Explanation of Correct Answers:

Notify the primary care provider immediately

These findings are consistent with compartment syndrome, a surgical emergency. The nurse must notify the provider at once, as delayed intervention could result in permanent tissue damage, loss of limb, or death. Timely communication is essential.

Perform neurovascular checks

Ongoing neurovascular checks are critical to monitor for worsening ischemia and nerve injury. Assessing pulses, sensation, skin color, and movement ensures early recognition of changes and guides urgent interventions.

Remove or loosen restrictive dressings

If restrictive dressings are contributing to impaired circulation, loosening them can help relieve pressure while awaiting definitive treatment. This step helps protect circulation and prevent further injury.

Why Other Options Are Wrong:

Reassure patient this is a normal finding

This is incorrect because severe pain unrelieved by medication, pallor, paresthesia, delayed capillary refill, and absent pulses are not normal postoperative findings. Reassuring the patient falsely delays emergency intervention.

Apply ice to the affected area

This is incorrect because while ice may reduce swelling in minor injuries, it does not treat compartment syndrome. Relying on ice alone would delay the urgent interventions required, such as fasciotomy, putting the patient at serious risk.

Correct Answer:

"I will only drink clear liquids the morning of my surgery."

Explanation:

NPO means “nothing by mouth” after midnight before surgery, including food, liquids, gum, and candy. Drinking clear liquids the morning of surgery increases the risk of aspiration during anesthesia and shows that the patient did not fully understand the instructions. This statement indicates a need for further teaching to ensure compliance and patient safety.

Why Other Options Are Wrong:

"My surgery may be canceled if I do not follow these instructions."

This is correct understanding. If the patient eats or drinks after midnight, the anesthesiologist may cancel surgery to reduce aspiration risk. This demonstrates the patient is aware of the consequences.

"Following these instructions will reduce nausea after surgery."

This is correct understanding. NPO status reduces stomach contents, lowering the risk of aspiration during surgery and helping decrease postoperative nausea. The patient is correctly linking the instruction with its benefits.

"I will not eat any food after midnight before my surgery."

This is correct understanding. This statement shows the patient comprehends the NPO order and the importance of not consuming food after midnight. No further teaching is needed here.

Correct Answer:

Graves' Disease

Explanation of Correct Answer:

Graves’ disease is an autoimmune disorder that causes hyperthyroidism. Classic symptoms include heat intolerance, palpitations, excessive sweating, weight loss, and anxiety due to increased metabolic rate. The hallmark sign is exophthalmos (bulging eyes), caused by autoimmune-mediated inflammation of the eye tissues.

Why Other Options Are Incorrect:

Deficiency of iodine consumption

Iodine deficiency can lead to hypothyroidism and goiter, not hyperthyroidism with exophthalmos.

Thyroiditis

Thyroid inflammation can cause temporary hyperthyroidism but typically does not cause exophthalmos, which is specific to Graves’ disease.

Hypothyroidism

Characterized by fatigue, weight gain, cold intolerance, and bradycardia—not palpitations, heat intolerance, or bulging eyes.

Correct Answer:

Active immunity

Explanation:

Vaccines stimulate the body’s immune system to produce antibodies and memory cells against a specific pathogen. This is active immunity, because the patient’s own immune system is activated to provide long-term protection. Unlike passive immunity, which is temporary, vaccine-induced active immunity can last for years or even a lifetime depending on the vaccine.

Why Other Options Are Wrong:

Titer

This is incorrect because a titer is a blood test used to measure the amount of antibodies present in the blood. It does not describe a type of immunity, but rather an assessment tool to check immunity levels.

Passive immunity

This is incorrect because passive immunity involves the transfer of preformed antibodies from another source, such as maternal antibodies through breast milk or immunoglobulin therapy. It provides immediate but short-term protection, not what vaccines provide.

Vaccine

This is incorrect because a vaccine is the method used to achieve immunity, not the type of immunity itself. The type of immunity achieved through vaccination is specifically active immunity.