Nur 255 B Adult Health 1 CBU
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Free Nur 255 B Adult Health 1 CBU Questions
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?
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Notify the patient's physician
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Stop the transfusion immediately
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Remove the patient's IV access
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Assess the patient's chest sounds and vital signs
Explanation
Correct Answer: Stop the transfusion immediately
When a patient exhibits signs of a transfusion reaction, such as difficulty breathing and severe chest tightness, it is crucial to stop the transfusion immediately.
This is because the patient may be having a severe allergic reaction or hemolytic transfusion reaction, both of which can be life-threatening.
Why the other options are incorrect:
Notify the patient's physician: While notifying the physician is important, it is not the initial action. The priority is to stop the transfusion to prevent further harm to the patient.
Remove the patient's IV access: Removing the IV access is not necessary at this point, as the focus should be on stopping the transfusion and then managing the reaction. The IV should remain open for emergency interventions if necessary.
Assess the patient's chest sounds and vital signs: Although it is important to assess the patient’s condition, the first priority is to stop the transfusion to prevent worsening of the reaction. Once the transfusion is stopped, the nurse can then assess the patient's vital signs and lung sounds.
Key Point:
The most immediate priority when a transfusion reaction is suspected is to stop the transfusion to prevent further exposure to the blood product. After stopping the transfusion, the nurse should notify the physician, assess the patient, and provide supportive care as needed.
Defense mechanisms such as skin, saliva, natural killer cells, and macrophages are components of which type of immune system?
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Innate immune system
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Adaptive immune system
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Pattern-recognition receptors
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Active immunity
Explanation
The innate immune system serves as the body’s first line of defense against invading pathogens. It is non-specific and immediate, meaning it does not require prior exposure to a pathogen to become activated. Components of the innate immune system include physical barriers such as skin, chemical barriers like enzymes in saliva, and cellular defenses such as natural killer (NK) cells and macrophages. These elements respond quickly to pathogens by recognizing general patterns and initiating an inflammatory response to contain and eliminate the threat.
For example, when a pathogen enters the body through a cut, macrophages are among the first responders that engulf and destroy the intruders, even if the body has never encountered that pathogen before.
Why the Other Options Are Incorrect:
Adaptive immune system:
This system provides a slower but highly specific response to pathogens. It involves B lymphocytes that produce antibodies and T lymphocytes that attack infected cells. The adaptive immune system develops memory after exposure, which allows for a faster and more effective response upon re-exposure. However, it is not responsible for the immediate responses involving physical and chemical barriers.
Pattern-recognition receptors (PRRs):
These are molecular structures found on cells of the innate immune system, such as macrophages and dendritic cells. They recognize pathogen-associated molecular patterns (PAMPs), which help trigger innate immune responses. PRRs are part of the innate immune system, not a separate system, so selecting this option reflects a misunderstanding of immune system classification.
Active immunity:
Active immunity refers to the acquired immune response that occurs after exposure to an antigen, either through infection or vaccination. It is part of the adaptive immune system and involves the generation of memory cells and antibodies. It does not include physical barriers like skin or chemical defenses such as saliva, and therefore is not part of the innate immune system.
Upon analysis, a patient's red blood cells (RBCs) appear microcytic (small) and hypochromic (pale). The nurse recognizes that the patient likely has which condition?
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Iron deficiency anemia
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Acute blood loss anemia
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Chronic blood loss anemia
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Vitamin B12 deficiency anemia
Explanation
Iron deficiency anemia is indeed the most common cause of microcytic (small) and hypochromic (pale) red blood cells. In this condition, there is insufficient iron in the body, which results in a reduced amount of hemoglobin in the red blood cells. Without enough hemoglobin, the cells are not as effective at carrying oxygen, and they become smaller (microcytic) and paler (hypochromic). These changes in the red blood cells are classic signs of iron deficiency anemia.
Why the Other Options Are Incorrect:
Acute blood loss anemia:
Acute blood loss anemia typically occurs due to significant, rapid blood loss (e.g., from trauma or surgery). However, it usually causes normocytic (normal-sized) and normochromic (normal color) red blood cells early on, as the body is still compensating for the blood loss. In the case of acute blood loss, the RBCs are not typically smaller or pale in the initial stages; the issue is more about reduced blood volume rather than abnormalities in RBC production. Microcytic and hypochromic RBCs would develop only if the blood loss leads to iron deficiency over time.
Chronic blood loss anemia:
While chronic blood loss (e.g., from a gastrointestinal bleed) can indeed lead to iron deficiency and result in microcytic, hypochromic anemia, the key distinction is that chronic blood loss is often associated with a history of gradual blood loss. If there is no clear evidence or history of chronic blood loss (like GI bleeding), the most likely diagnosis for microcytic, hypochromic anemia is iron deficiency anemia.
Vitamin B12 deficiency anemia:
Vitamin B12 deficiency causes macrocytic (large) red blood cells, which is opposite of what is seen in iron deficiency anemia. In B12 deficiency, RBCs are larger than normal, and the condition is typically classified as megaloblastic anemia, not microcytic and hypochromic anemia. The presence of large, abnormal RBCs rather than small, pale ones makes this diagnosis unlikely in the case of microcytic, hypochromic anemia.
The nurse is preparing to discharge a patient after having outpatient surgery. Which criteria should the nurse use to determine whether the patient is eligible to be discharged? Select All That Apply.
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Pain controlled
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Family member's eagerness to go home
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Stable vital signs
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No nausea or dizziness
- Adequate urine output
Explanation
Correct Answers:
Pain controlled
Stable vital signs
No nausea or dizziness
Adequate urine output
When preparing to discharge a patient after outpatient surgery, the nurse must assess whether the patient has met specific criteria indicating they are ready to safely leave the healthcare facility. These criteria include:
Pain controlled: The patient should have their pain under control, typically with the use of oral medications, and should be able to manage pain independently once at home.
Stable vital signs: Vital signs such as blood pressure, heart rate, respiratory rate, and temperature should be within normal limits and stable after surgery to ensure the patient is not at risk for immediate complications.
No nausea or dizziness: The absence of nausea or dizziness is crucial, as these symptoms could interfere with the patient's ability to safely leave the facility or manage self-care after surgery. Dizziness, in particular, could indicate issues like hypotension or sedation from anesthesia.
Adequate urine output: Adequate urine output indicates proper kidney function and the return of normal fluid balance post-surgery. This is particularly important in cases where surgery involved anesthesia or the use of fluids that could affect kidney function.
Why the Other Option is Not Correct:
Family member's eagerness to go home: While it's important to consider the patient's support system, the decision to discharge should be based on the patient's physical readiness to go home rather than the family member's desire to leave. The patient's well-being is the priority.
Summary:
The nurse must ensure the patient meets several criteria before discharge, focusing on physiological stability and ensuring the patient can safely manage at home.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select All That Apply
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Place the client in a prone position
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Contact the surgeon
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Instruct the client to remain still
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Place a sterile saline dressing over the wound
- Close the wound
Explanation
Correct Answers:
Contact the surgeon
Instruct the client to remain still
Place a sterile saline dressing over the wound
The scenario describes a dehiscence (a wound opening) and evisceration (the protrusion of bowel through the wound) following abdominal surgery. This is a medical emergency and requires immediate intervention.
Contact the surgeon:
The surgeon should be immediately notified when there is evisceration. This situation requires surgical intervention to repair the incision and prevent complications such as infection or further damage.
Instruct the client to remain still:
It is crucial that the client remains still to prevent further strain on the wound and the protruding bowel, which could worsen the condition or lead to additional complications.
Place a sterile saline dressing over the wound:
The exposed bowel should be covered with a sterile saline dressing to keep it moist and protected from infection. This dressing helps prevent drying and potential injury to the bowel until the client can be seen by the surgeon.
Why the Other Options Are Wrong:
Place the client in a prone position:
The client should not be placed in the prone position (lying face down). It would be uncomfortable, and it may worsen the evisceration. Instead, the client should be kept in a low Fowler’s position (head of the bed elevated slightly or flat) to relieve pressure on the abdominal incision.
Close the wound:
The nurse should not attempt to close the wound. The wound needs to be addressed by the surgeon, and trying to close it could result in further harm or infection. The priority is to protect the exposed bowel and prepare the client for surgical intervention.
Summary:
In the event of evisceration following abdominal surgery, the nurse should contact the surgeon, instruct the client to remain still, and cover the exposed bowel with a sterile saline dressing. The nurse should avoid placing the client in a prone position or attempting to close the wound.
A patient received lorazepam (Ativan), a benzodiazepine, a medication used to treat anxiety. What should the nurse assess when caring for this patient?
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Respiratory depression
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Nausea and vomiting
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Confusion
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Rash
Explanation
Correct Answer: Respiratory depression
Lorazepam (Ativan) is a benzodiazepine commonly used to treat anxiety, agitation, and sometimes seizures. As a CNS depressant, lorazepam can cause various side effects, but respiratory depression is one of the most significant and potentially dangerous effects.
Respiratory depression is a known risk of benzodiazepines, particularly if used in high doses, if the patient has pre-existing respiratory conditions, or if the drug is combined with other CNS depressants (e.g., opioids, alcohol). Benzodiazepines like lorazepam depress the respiratory centers in the brain, which can lead to shallow or slowed breathing, posing a risk for hypoxia.
Why the Other Answers are Not Correct:
Nausea and vomiting: While nausea and vomiting can occur with lorazepam, they are less common compared to respiratory depression, and they are not the primary concerns associated with this medication.
Confusion: Confusion or sedation can occur with lorazepam, especially in elderly patients, but respiratory depression is a more immediate and dangerous concern for this class of drugs.
Rash: Although a rash can be a side effect of lorazepam, it is rare. The most concerning side effects are typically related to the CNS and respiratory system.
Key point:
When caring for a patient on lorazepam, the nurse should monitor for signs of respiratory depression, especially if the patient is receiving other CNS depressants or has underlying respiratory issues. Other side effects like confusion and sedation are also important to monitor but are generally less life-threatening than respiratory depression.
A postoperative client asks the nurse why it is so important to perform deep breathing and to cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?
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Pneumonia
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Hypoxemia
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Fluid imbalance
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Pulmonary embolism
Explanation
Correct Answer: Pneumonia.
Pneumonia: After surgery, patients are at an increased risk of retaining pulmonary secretions due to immobility and reduced respiratory effort.
This can lead to the development of atelectasis (collapse of lung tissue) and create an environment conducive to bacterial growth in the lungs, potentially leading to pneumonia.
Deep breathing and coughing exercises help to mobilize secretions, expand the lungs, and reduce the risk of pneumonia.
Why the other options are wrong:
Hypoxemia: While retained secretions can impair oxygen exchange and contribute to hypoxemia, the primary concern when emphasizing deep breathing and coughing is preventing pneumonia, not directly correcting low oxygen levels. Hypoxemia may result from complications like atelectasis, but it is not the most direct result of retained secretions compared to pneumonia.
Fluid imbalance: Retained pulmonary secretions are not directly linked to fluid imbalance. Fluid imbalance usually refers to changes in electrolytes, water retention, or dehydration, which are unrelated to secretions in the lungs.
Pulmonary embolism: A pulmonary embolism (PE) occurs when a blood clot blocks a pulmonary artery, typically due to venous thromboembolism. While post-operative patients are at risk for PE, the primary concern with retained secretions is preventing pneumonia rather than embolism. Deep breathing and coughing help promote lung expansion, but do not directly prevent a pulmonary embolism.
Summary:
Retained pulmonary secretions after surgery increase the risk of pneumonia by promoting bacterial growth in the lungs. Deep breathing and coughing exercises help prevent this complication by improving lung ventilation, mobilizing secretions, and reducing the risk of infection.
The nurse is caring for a patient who is nearing death from a terminal illness. The patient is experiencing secretions in the back of the throat and dyspnea. Which medications should the nurse provide to assist this patient? (Select One Combination Response)
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Atenolol, Losartan, Lisinopril, Hydrochlorothiazide
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Oxygen, Morphine, Atropine, Scopolamine
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Oxygen, Demerol, Atropine, Scopolamine
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Lasix, calcium gluconate, regular insulin, D50
Explanation
Correct Answer: Oxygen, Morphine, Atropine, Scopolamine
When a patient is nearing death from a terminal illness and experiencing symptoms like secretions in the back of the throat (often referred to as "death rattle") and dyspnea (difficulty breathing), the goal is to manage comfort and ease the symptoms.
Here’s how each medication helps with these symptoms:
Oxygen: Although oxygen is not always effective in terminal stages, it is often given to relieve the feeling of breathlessness or dyspnea.
Morphine: Morphine is used to relieve dyspnea and to manage pain. It helps reduce respiratory effort and eases the sensation of air hunger.
Atropine: Atropine is used to reduce secretions, including the "death rattle" caused by the accumulation of mucus in the airways. It dries up excess saliva and secretions in the throat.
Scopolamine: Like atropine, scopolamine helps reduce secretions, which can alleviate the discomfort associated with the "death rattle."
Why the other options are incorrect:
Atenolol, Losartan, Lisinopril, Hydrochlorothiazide: These are medications used for managing hypertension and heart conditions, but they are not appropriate for managing symptoms in the terminal phase of life, such as secretions or dyspnea.
Oxygen, Demerol, Atropine, Scopolamine: While oxygen, atropine, and scopolamine are appropriate for managing symptoms, Demerol (meperidine) is not typically used for symptom management at the end of life due to its potential for causing confusion or seizures in older adults or those with kidney impairment. Morphine is preferred over Demerol for managing pain and dyspnea in end-of-life care.
Lasix, calcium gluconate, regular insulin, D50: These medications are used to manage conditions like fluid overload, electrolyte imbalances, and diabetic emergencies. They do not address symptoms related to dying, such as secretions or dyspnea.
Summary:
The most appropriate combination of medications to assist a terminally ill patient with secretions and dyspnea is Oxygen, Morphine, Atropine, and Scopolamine. These medications work together to reduce discomfort, ease breathing, and manage secretions in the final stages of life.
The nurse is caring for a patient who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting?
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Using antibacterial soap when bathing patients with MRSA
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Conducting culture surveys on a regularly scheduled basis
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Performing hand hygiene before and after contact with every patent
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Using aseptic housekeeping practices for environmental cleaning
Explanation
Correct Answer: Performing hand hygiene before and after contact with every patient
Hand hygiene is the most effective and fundamental infection control measure for reducing the transmission of MRSA and other nosocomial (hospital-acquired) pathogens.
The hands of healthcare workers are the most common vectors for transmitting infections between patients. Proper hand hygiene, including washing with soap and water or using alcohol-based hand sanitizers, significantly reduces the risk of spreading MRSA, as well as other harmful pathogens.
Why the other options Are Not Correct:
Using antibacterial soap when bathing patients with MRSA: While antibacterial soap can be useful in reducing the bacterial load on the skin, it is not as effective as hand hygiene in preventing the transmission of MRSA in healthcare settings. Hand hygiene is the primary measure for infection prevention.
Conducting culture surveys on a regularly scheduled basis: Although surveillance cultures can help identify carriers of MRSA, they do not actively reduce transmission. Regular hand hygiene and other preventive measures are more important for reducing the spread of MRSA in real time.
Using aseptic housekeeping practices for environmental cleaning: While proper cleaning and disinfecting of the environment is important, it is secondary to hand hygiene in preventing transmission. Many pathogens, including MRSA, are primarily spread through direct contact with healthcare workers' hands, making hand hygiene the top priority.
Key Point:
Hand hygiene is a critical practice in preventing the spread of healthcare-associated infections, including MRSA. It is recommended to perform hand hygiene before and after patient contact to minimize the risk of transmission.
The client has a hematocrit of 22.3% and hemoglobin of 7.7 g/dL. The doctor has ordered two units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select All That Apply.
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Obtain a signed consent
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Initiate a 22-gauge IV
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Perform a baseline assessment
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Hang an IV of D5W
- Check for allergies
Explanation
Correct Answers: Obtain a signed consent, Perform a baseline assessment, and Check for allergies.
Obtain a signed consent: A blood transfusion requires informed consent. The nurse must ensure that the client has signed the consent form, acknowledging that they understand the risks, benefits, and alternatives to the procedure.
Perform a baseline assessment: Before starting the transfusion, it is crucial to obtain baseline vital signs (temperature, pulse, blood pressure, respiratory rate, oxygen saturation) and assess the client for any signs or symptoms of fluid overload or pre-existing reactions.
Check for allergies: The nurse must check the client's medical history for any known allergies or previous reactions to blood products. This is critical for identifying patients at higher risk of transfusion-related complications.
Explanation of Incorrect Answers:
Initiate a 22-gauge IV: A larger bore IV (18- or 20-gauge) is recommended for blood transfusion to ensure adequate flow and prevent hemolysis of red blood cells. A 22-gauge IV is too small for transfusing packed red blood cells efficiently.
Hang an IV of D5W: Blood products must be infused using normal saline (0.9% sodium chloride) as it is isotonic and does not cause hemolysis or clotting of red blood cells. D5W is contraindicated for blood transfusions.
Summary:
For a safe blood transfusion, the nurse should obtain consent, perform a baseline assessment, and check for allergies. The IV gauge must be large enough (18-20 gauge), and normal saline should be used as the compatible solution for blood product administration.
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