Sepsis Continuum and DIC

Question 1

A patient being admitted for knee surgery says, “Everyone in my office is sick all of the time, but I never get sick.” How would the nurse evaluate this statement?

1. The patient may have a strong antigen–antibody response.
2. This patient’s poorly differentiated histocompatibility antigens may be a problem during postoperative recovery.
3. The patient’s coworkers must have immune system compromise.
4. The patient must have strong passive immunity.

Answer 1

Correct Answer: 1

Rationale 1: Normally, an antibody circulates in the bloodstream until it encounters an appropriate antigen to bind. This binding results in antigen–antibody complexes, or immune complexes. The process of binding is such that the antibody binds to specifically conformed antigenic determinant sites on the antigen, which prevents the antigen from binding to receptors on host cells. The outcome is the host is protected from an infection.

Rationale 2: Histocompatibility antigens are surface antigens which are genetically determined and are proteins found on the surface of a cell. These antigens would not impact the patient’s inability to get colds or other illnesses, nor would they cause complications postoperatively.

Rationale 3: Immune system compromise does result in frequent illnesses, but there is not enough information for the nurse to make this determination.

Rationale 4: Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. Passive immunity can be transferred also through vaccination either of antiserum, an antitoxin, or as gamma globulin.

Question 1

A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate?

1. Decreasing the amount of oxygen being given
2. Immediate initiation of fluid resuscitation
3. Repeat of the testing in 4 hours
4. Bedside fingerstick level of blood glucose

Answer 1

Correct Answer: 2

Rationale 1: An increased serum lactate calls for increased oxygenation.

Rationale 2: A lactate level of 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation.

Rationale 3: There is no need to repeat this test before intervening.

Rationale 4: Measuring blood glucose is not indicated by this lab result.

Question 2

A patient admitted to the emergency department following chest trauma has tracheal deviation to the left. The nurse would prepare for which emergency medical intervention?

1. Open thoracotomy
2. Placement of a chest tube
3. Open excision of the pericardial sac
4. Immediate cardiopulmonary resuscitation

Answer 2

Correct Answer: 2

Rationale 1: Open thoracotomy is not indicated for this complication.

Rationale 2: Tracheal deviation can result from mediastinal shifting due to a tension pneumothorax. Treatment is placement of a chest tube or a needle thoracotomy.

Rationale 3: Excision of the pericardial sac may be indicated when cardiac tamponade exists. There is no indication that this complication has developed.

Rationale 4: There is no indication that cardiopulmonary resuscitation is needed at this point.

Question 4

The nurse caring for a patient with an infected leg wound realizes that neutrophils and macrophages will arrive to the wound as a part of the natural body response. How would the nurse explain this process to the patient?

1. “Your white blood cells will travel through your lymph system to the wound.”
2. “Chemical signals from the injured tissue help guide the white blood cells to where they are needed.”
3. “Only the white blood cells already in your system will be able to fight this infection.”
4. “The white blood cells attach to red blood cells for transport to the wound.”

Answer 4

Correct Answer: 2

Rationale 1: The white blood cells do not travel through the lymph system.

Rationale 2: Circulating neutrophils and monocytes have to arrive where they are needed and then they must be able to transfer from the blood vessels to the site of injury. After the leukocyte is outside the capillary, it requires guidance to move to the correct location. This is accomplished through chemotaxis, which refers to movement as a result of some type of chemical stimulus.

Rationale 3: Infection stimulates the production of additional white blood cells.

Rationale 4: White blood cells are independent of red blood cells.

Question 4

Which finding would cause the nurse to be concerned that a patient who sustained chest trauma is experiencing cardiac tamponade?

1. Distant heart sounds
2. Decrease of right arterial pressure
3. Sudden development of hypertension
4. Development of an S3 heart sound

Answer 4

Correct Answer: 1

Rationale 1: The presence of blood in the pericardial space makes the heart tones sound muffled or distant.

Rationale 2: Right arterial pressure increases with cardiac tamponade.

Rationale 3: Hypotension is associated with cardiac tamponade due to the heart’s inability to fill.

Rationale 4: S3 heart sounds are not associated with cardiac tamponade.

Question 5

A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy? (select all that apply)

1. Persistent hypotension
2. Heart rate 118
3. Development of a bundle branch block
4. Drop in urine output
5. Mottling of extremities

Answer 5

Correct Answer: 2,3,4,5

Rationale 1: The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring.

Rationale 2: Tachycardia can be an adverse effect of dopamine.

Rationale 3: Aberrant cardiac conduction may indicate an adverse drug effect is occurring.

Rationale 4: Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidney will cause decrease in urine output.

Rationale 5: Mottling of extremities indicates peripheral ischemia.

Question 6

A patient was admitted to the emergency room for treatment of severe infection. Which objective parameters would increase the nurse’s concern that shock is developing? (select all that apply)

1. Serum lactate level is 5.4 mmol/L.
2. Base deficit is -12 mmol/L.
3. SvO2 is 68%.
4. pHi is 6.9.
5. Arterial pH of 7.38.

Answer 6

Correct Answer: 1,2,4

Rationale 1: Lactate is the metabolic byproduct of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least to some part, on anaerobic metabolism rather than the normal aerobic metabolism.

Rationale 2: This is a moderate base deficit and indicates buildup of lactic acidosis resulting from impaired tissue oxygenation.

Rationale 3: Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues.

Rationale 4: Low mucosal pH indicates development of acidosis.

Rationale 5: This is a normal arterial pH.

Question 7

A patient was admitted through the emergency department with fractures of the skull, ribs, and both femurs sustained from a motor vehicle accident. The nurse provides care based upon changes in which pathophysiological process?

1. Formation of red blood cells
2. Cellular and humoral immune responses
3. Formation of plasma
4. Antigen–antibody formation

Answer 7

Correct Answer: 1

Rationale 1: Blood cells are formed in the bone marrow which exists within all bones. Because the patient sustained fractures to the skull, ribs, and both femurs, red blood cell formation will be impacted.

Rationale 2: Cellular and humoral immune responses occur in secondary lymphoid organs such as the tonsils, adenoids, lymph nodes, and spleen. This patient’s injuries are not focused in these areas.

Rationale 3: Plasma is a clear fluid that remains once all of the blood cells are removed. Formation of plasma should not be affected by these injuries.

Rationale 4: Antigen–antibody response is what occurs when an infectious organism is introduced into the body. The ability to mount this response will continue despite these injuries.

Question 8

A patient suffered severe trunk and lower extremity injury in a motor vehicle accident. Which injuries would indicate to the nurse that this patient may have dysfunction of normal hemostasis? (select all that apply)

1. Contusion of the spleen
2. Laceration of the liver
3. Femur fractures
4. Bruising of the heart
5. Pneumothorax

Answer 8

Correct Answer: 1,2,3

Rationale 1: The spleen provides storage for platelets. If the spleen is damaged and unable to hold or release platelets, normal hemostasis will be disrupted.

Rationale 2: The liver produces most of the clotting factors so injury would affect normal hemostasis.

Rationale 3: The marrow of long bones support blood cell development. This patient may have disruption of all three cell lines.

Rationale 4: Bruising of the heart should not affect hemostasis.

Rationale 5: Pneumothorax should not affect hemostasis.

Question 8

A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock?

1. Cold extremities
2. Increase in serum lactate levels
3. Decreased SCVO2
4. Widening of pulse pressure

Answer 8

Correct Answer: 4

Rationale 1: Cold and mottled extremities are associated with later stages of septic shock.

Rationale 2: Increased serum lactate levels indicate a later stage of shock.

Rationale 3: Decreased SCVO2 indicates a later stage of shock.

Rationale 4: Since the patient’s diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock.

Question 9

The nurse is assessing a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement?

1. Temperature of 97.8°F
2. Heart rate of 70 bmp
3. Resistance to ventilator-assisted breaths.
4. Pink skin tone

Answer 9

Correct Answer: 2

Rationale 1: Hypothermia is one of the triad of expected signs of neurogenic shock. This patient remains hypothermic.

Rationale 2: Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement.

Rationale 3: Respiratory rate is not one of the triad of expected findings associated with neurogenic shock. The patient may be mechanically ventilated, but a change in acceptance of this assistance is not indicative of an improved shock status.

Rationale 4: Peripheral vasodilation produces a pink skin tone so this finding does not indicate improvement.

Question 9

A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention?

1. Stop the infusion, but leave normal saline infusing at a rate to keep the vein open.
2. Stop the infusion and place an intermittent infusion cap on the IV access device.
3. Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion.
4. Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patient’s response

Answer 9

Correct Answer: 4

Rationale 1: Abrupt withdrawal of this medication is not indicated.

Rationale 2: Abrupt withdrawal of this drug is not indicated.

Rationale 3: The infusion rate should not be abruptly lowered.

Rationale 4: The nurse should decrease the infusion slowly, while monitoring the patient’s response. This is the only response that does not result in abrupt withdrawal of the medication

Question 11

A patient is being evaluated for a kidney transplant. Which individual is most likely the best candidate to donate this organ?

1. A live donor from a donor bank
2. Live kidney transplant from the patient’s spouse
3. Cadaver kidney transplant
4. Live kidney transplant from a brother

Answer 11

Correct Answer: 4

Rationale 1: A person willing to donate a kidney, but who is unrelated to the recipient, is not likely to be a match.

Rationale 2: A spouse may or may not be a match for this donation.

Rationale 3: Cadaver kidneys may or may not match the donor.

Rationale 4: Because full siblings share the same biological parents, they often have some degree of human leukocyte antigen matching. The closer the human leukocyte antigen combination matches between two people, the more the “fingerprint” is recognized as self.

Question 11

A patient’s admission laboratory work reveals a platelet count of 90,000/mcL. Which interventions should the nurse implement? (select all that apply)

1. Implement bleeding precautions.
2. Monitor urine output.
3. Limit the ingestion of green leafy vegetables.
4. Restrict fluids.
5. Review the patient’s medication history.

Answer 11

Correct Answer: 1,5

Rationale 1: Platelets play a crucial role in hemostasis or blood clotting. Since the normal platelet count in an adult is 150,000 to 400,000/mcL, a count of 90,000/mcL means the patient is prone to bleeding. Bleeding precautions should be implemented for this patient.

Rationale 2: There is no evidence that monitoring urine output is an essential part of this patient’s care.

Rationale 3: Green leafy vegetables contain vitamin K which is needed by the liver to form coagulation factors. Since these factors are needed for the coagulation cascade, vitamin K should not be limited in this patient.

Rationale 4: There is no evidence to suggest that fluids should be restricted for this patient.

Rationale 5: Medications can be implicated in low platelet counts, so reviewing medication history is indicated.

Question 12

A patient was admitted to the emergency department for treatment of a severe infection. Which subjective assessment would raise the nurse’s concern that this patient may be developing shock?

1. Hot, dry skin
2. Respiratory rate 11
3. Pulse rate 118 and weak
4. Anxiety

Answer 12

Correct Answer: 3

Rationale 1: Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection.

Rationale 2: Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system.

Rationale 3: Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues. Weak pulses occur as the contractility of the heart decreases.

Rationale 4: Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state.

Question 12

The nurse is monitoring a patient at risk for development of left ventricular failure and cardiogenic shock. Which findings would the nurse immediately discuss with the primary health care provider? (select all that apply)

1. Development of an S3 heart sound
2. Sustained systolic hypertension
3. Development of bilateral crackles
4. Decrease in PAWP
5. Decrease in cardiac index

Answer 12

Correct Answer: 1,3,5

Rationale 1: Development of third or fourth heart sounds may indicate development of left ventricular failure.

Rationale 2: Sustained systolic hypotension would indicate development of left ventricular failure.

Rationale 3: Increased pulmonary congestion, as manifested by development of bilateral crackles, may indicate that left ventricular failure is developing.

Rationale 4: Left ventricular failure would be manifested by elevation of PAWP.

Rationale 5: Low cardiac index can indicate development of left ventricular failure.

Question 13

A patient is scheduled to have his tonsils removed. The nurse realizes that this procedure could result in deficiency of which immunoglobulin?

1. Immunoglobulin D
2. Immunoglobulin A
3. Immunoglobulin E
4. Immunoglobulin G

Answer 13

Correct Answer: 2

Rationale 1: Immunoglobulin D is a trace antibody found primarily in the blood.

Rationale 2: Immunoglobulin A protects mucous membranes from invading organisms and is found in the tonsils.

Rationale 3: Immunoglobulin E plays a role in the allergic response and is extremely powerful even though it is present in the body in very small quantities.

Rationale 4: Immunoglobulin G is the chief immunoglobulin and is produced on a secondary exposure to an antigen.

Question 14

A patient is admitted with iron deficiency anemia. The nurse assesses this patient for the presence of which most likely finding?

1. Hypoxia
2. Reduced urine output
3. Bleeding
4. Dehydration

Answer 14

Correct Answer: 1

Rationale 1: Each red blood cell contains hemoglobin. Hemoglobin has two parts: the heme portion that contains oxygen and iron and the globin part which is a protein. The oxygen will adhere to the portion of the hemoglobin with the iron molecule. In the event of iron deficiency anemia, the patient has reduced iron molecules which means less oxygen molecules will be available for body use. Because of this, the patient will most likely demonstrate signs of hypoxia.

Rationale 2: Iron deficiency anemia is not related to reduced urine output.

Rationale 3: Iron deficiency anemia will not result in bleeding.

Rationale 4: Iron deficiency anemia has not been linked to dehydration.

Question 15

An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurse’s priority intervention?

1. Benadryl (diphenhydramine) 50 mg intravenously
2. Oxygen at 3 liters via nasal cannula
3. Epinephrine 1:1000 0.5 mg sq
4. Normal saline at 150 mL/hr

Answer 15

Correct Answer: 3

Rationale 1: Administration of diphenhydramine is appropriate but is not the initial therapy.

Rationale 2: Oxygen should be administered, but is not the priority intervention.

Rationale 3: The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. This is the priority intervention.

Rationale 4: After experiencing anaphylaxis the patient will likely be hospitalized and given IV fluids. This is not the immediate priority.

Question 16

A wound on a patient’s leg has stopped bleeding. The nurse would attribute this to which physiologic occurrence?

1. Tumor necrosis factor has sealed the wound.
2. Neutrophils have invaded the wound.
3. Macrophages have been released into the general circulation.
4. Platelets retracted the clot, reducing leakage.

Answer 16

Correct Answer: 4

Rationale 1: Tumor necrosis factor will not seal a wound.

Rationale 2: Neutrophils do not impact the amount of bleeding from a wound.

Rationale 3: Macrophages in the general circulation do not impact the amount of bleeding from a wound.

Rationale 4: Shortly after bleeding has stopped and the clot has formed, it retracts, drawing the torn vessel walls into closer proximity, reducing leakage. Clot retraction is largely a function of platelets.

Question 18

A patient is being treated for anemia after a postpartum hemorrhage. The nurse would expect that this patient’s erythrocytes would have which appearance?

Standard Text: Select all that apply.

1. Microcytic
2. Normochromic
3. Macrocytic
4. Hypochromic
5. Normocytic

Answer 18

Correct Answer: 2,5

Rationale 1: Blood loss would not result in change in the size of the RBCs.

Rationale 2: Since the RBCs are lost, not changed due to a physiological problem, they will have a normal color.

Rationale 3: There is no reason for these RBCs to be bigger than normal.

Rationale 4: The cells should not appear hypochromic.

Rationale 5: The RBCs should be of normal size.

Question 19

A patient diagnosed with leukemia has minimal white blood cells. The nurse realizes which intervention may be indicated for this patient?

1. Infusion of fresh frozen plasma
2. Infusion of red blood cells
3. Bone marrow transplant
4. Immunizations

Answer 19

Correct Answer: 3

Rationale 1: Infusion of fresh frozen plasma would expand intravascular volume but would not add white blood cells.

Rationale 2: There is no indication that this patient needs additional red blood cells.

Rationale 3: Blood cells include red cells, white cells, and platelets. All three of these elements of blood are created in the bone marrow. The patient with low white blood cells would benefit from a bone marrow transplant since each of these types of cells originates from a stem cell.

Rationale 4: Individuals with low white blood cell counts usually do not receive immunizations.

Question 21

A patient is admitted to the emergency department with severe burn injuries. The nurse’s priority actions are to prevent development of which type of shock?

1. Cardiogenic
2. Hypovolemic
3. Distributive
4. Obstructive

Answer 21

Correct Answer: 2

Rationale 1: Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock.

Rationale 2: Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority.

Rationale 3: Distributive shock, particularly septic shock, is a potential complication for patients with burn injury and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care.

Rationale 4: Depending upon other injuries the patient with burns may develop obstructive shock, but this is not the nurse’s highest priority in emergent care

Question 22

A patient is admitted with left lower thoracic rib injuries. The nurse realizes this injury could result in which problem for this patient?

1. Decrease in platelet maturation
2. Decreased availability of B cells
3. Reduction in T cell formation
4. Reduction in filtering of foreign matter in the blood

Answer 22

Correct Answer: 2

Rationale 1: Platelet maturation does not occur in this area.

Rationale 2: The spleen sits behind the 9th, 10th, and 11th left ribs and serves three functions: destroy injured or worn out red blood cells, store extra blood for use by the body, and store B cells. With an injury to the left lower thoracic rib area, the patient could have an injury to the spleen.

Rationale 3: There is a possibility of splenic injury. Splenic injuries do not cause a reduction in T cell formation.

Rationale 4: Lymph tissue is where the blood is filtered of foreign matter.

Question 22

A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patient’s mental status?

1. Temporarily discontinue the drip and assess mental status within a few minutes.
2. Temporarily discontinue the drug and plan to assess mental status in an hour.
3. Use “train of four” testing while the medication is still infusing.
4. This assessment will have to wait until the sedating drug is no longer needed.

Answer 22

Correct Answer: 1

Rationale 1: Propofol has a very short half-life, so assessment of mental status can occur within a few minutes of the drugs discontinuation.

Rationale 2: Benzodiazepines used for sedation require discontinuation of the drug for a longer time in order for mental status assessment to be valid.

Rationale 3: “Train of four” testing is used when the patient is receiving neuromuscular blocking agents.

Rationale 4: Mental status should be assessed frequently and cannot be safely deferred until sedation is no longer needed.

Question 23

A man with assessment findings associated with prostate cancer is having the tumor-associated antigen PSA drawn. The nurse anticipates this level will be used for which purposes? (select all that apply)

1. To confirm the diagnosis of prostate cancer
2. To rule out the presence of prostate cancer
3. To screen for the probability of prostate cancer
4. To assess efficacy of treatment
5. To determine presence of metastasis

Answer 23

Correct Answer: 3,4

Rationale 1: PSA levels are not diagnostic of prostate cancer.

Rationale 2: Even if the level of PSA is low, it does not rule out prostate cancer.

Rationale 3: PSA is best used as a screening tool. If levels are high, additional assessment should be done. If levels are low, but other findings indicate strong suspicion of prostate cancer, additional assessment should be done.

Rationale 4: Monitoring PSA levels after treatment for prostate cancer has begun can help to monitor the effects of treatment.

Rationale 5: PSA does not help to identify metastasis.

Question 24

A patient is prescribed vitamin B12 injections. What information should the nurse provide when starting this medication?

1. “Vitamin B12 will strengthen the red blood cells’ membranes and prevent them from being damaged so easily.”
2. “Vitamin B12 is needed for normal manufacture of red blood cells.”
3. “Vitamin B12 will increase the ability of your blood to carry oxygen.”
4. “Vitamin B12 helps build the components of white blood cells.”

Answer 24

Correct Answer: 2

Rationale 1: Iron and copper strengthen the plasma membrane.

Rationale 2: Vitamin B12 is one vitamin needed for normal red blood cell synthesis, development of DNA and RNA, and cell maturation.

Rationale 3: Iron increases the oxygen-carrying capacity of the blood.

Rationale 4: Vitamin B12 does not impact white blood cell synthesis.

Question 26

A nurse is providing care to a patient with progressive shock. Which nursing diagnosis is priority in guiding the selection of interventions for this patient?

1. Ineffective Airway Clearance
2. Ineffective Tissue Perfusion
3. Stress Overload
4. Impaired Skin Integrity

Answer 26

Correct Answer: 2

Rationale 1: Without additional assessment findings, it is not possible to determine if this patient has ineffective airway clearance.

Rationale 2: Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority nursing diagnosis for all patients in shock.

Rationale 3: Undoubtedly this patient is experiencing stress, but this is not the highest priority nursing diagnosis.

Rationale 4: This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination.

Question 27

A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive?

1. The patient complains of a severe headache.
2. The patient’s urine output has dropped.
3. The patient begins to shiver.
4. The patient develops a cough.

Answer 27

Correct Answer: 3

Rationale 1: Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia.

Rationale 2: Decreased urine output is not associated with treatment for hyperthermia.

Rationale 3: Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified.

Rationale 4: Development of a cough is not associated with treatment for hyperthermia.

Question 28

The mother of a young child tells the nurse that when she was breastfeeding her baby, he never had any colds or infections but now that he is weaned, he seems to be sick all of the time. What should the nurse explain to the mother?

1. The breast milk provided passive immunity to the baby that he no longer is receiving.
2. The child should be immunized to prevent these common illnesses.
3. Some children are just prone to getting more infections than others.
4. Most babies won’t get sick until they are past the age of 12 months.

Answer 28

Correct Answer: 1

Rationale 1: Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. An infant receives passive immunity both in utero and from breast milk.

Rationale 2: There are no immunizations against many of these common illnesses.

Rationale 3: This information is not accurate and should not be provided to the mother

Rationale 4: This information is not accurate and should not be provided to the mother.

Question 29

A patient tells the nurse that he thought he had a varicella vaccine as a child. His daughter has just developed varicella. What information should the nurse provide? (select all that apply)

1. “Since you were vaccinated you won’t contract varicella from your daughter.”
2. “Your innate immunity will protect you from contracting this disease.”
3. “It is dangerous to give a second injection of vaccines.”
4. “You may need an injection to boost your immunity.”
5. “We can check your blood titer to check your immunity.”

Answer 29

Correct Answer: 4,5

Rationale 1: Vaccinations do not always provide life-long immunity.

Rationale 2: The immunity that this patient may have against varicella is not innate immunity.

Rationale 3: There is no indication that a second injection of vaccines is dangerous if it is needed.

Rationale 4: In some cases, there is need for a second injection.

Rationale 5: Antibody titers can be compared to pre-established norms to see if repeated immunizations are necessary.

Question 31

A patient is concerned that the disease that has affected his horses will cause him to become ill. What information should the nurse provide?

1. “You will probably contract the same illness but in a milder form.”
2. “Many illnesses are species specific and it is not likely that you will contract the same illness as your horses.”
3. “All illnesses can be transmitted between animals and humans, so I am glad you came in to be checked.”
4. “There are vaccinations against diseases caused by horses. I would talk with the veterinarian.”

Answer 31

Correct Answer: 2

Rationale 1: There is no way of knowing if the patient will contract the same illness as the horses or if the illness will be in a milder form.

Rationale 2: Innate immunity is species specific which means that human beings are immune to a variety of diseases to which certain animals are susceptible, and vice versa. The nurse should explain this concept to the patient.

Rationale 3: All illnesses cannot be transmitted between animals and humans.

Rationale 4: It is unknown if there is a vaccine to provide immunity against diseases caused by horses.

Question 32

A patient with cardiac decompensation is started on dobutamine at 1 mcg/kg/min with an order to titrate to effect. After receiving this dose for several minutes the patient develops tachycardia and occasional premature ventricular contractions. What nursing intervention is indicated?

1. Increase the dose to 1.5 mcg/kg/min.
2. Discontinue the infusion.
3. Decrease the infusion to 0.5 mcg/kg/min.
4. Contact the prescriber immediately.

Answer 32

Correct Answer: 3

Rationale 1: There is no indication to increase the dose.

Rationale 2: Discontinuing the infusion is not the first intervention.

Rationale 3: Decreasing the infusion rate may reverse these adverse cardiac effects.

Rationale 4: The order is given to titrate the drug to effect. There is no reason to contact the prescriber at this point.

Question 34

A patient being treated for a severe infection has a temperature of 35.8°C. Which additional finding would indicate to the nurse that initiation of treatment for sepsis is likely?

1. A shift to the left on the white blood cell differential
2. Heart rate 88
3. Respiratory rate 10
4. Acute alteration in mental status

Answer 34

Correct Answer: 1

Rationale 1: Greater than 10% bands on the white blood cell differential, or a shift to the left, along with this temperature would indicate sepsis has developed.

Rationale 2: Heart rate over 90, along with this temperature, indicates sepsis is present.

Rationale 3: Respiratory rate greater than 20, along with this temperature, indicate sepsis is present.

Rationale 4: Acute alteration in mental status is related to development of septic shock.

Question 35

A patient who sustained a gunshot wound walks into the emergency department and collapses. Which priority directions should the nurse who assumes this patient’s care give to those coming to assist? (select all that apply)

1. Check the airway.
2. Bring a wheelchair.
3. Put direct pressure on the leg wound.
4. Check for identification.
5. Check the pulse.

Answer 35

Correct Answer: 1,3,5

Rationale 1: Airway patency is the most important intervention for this patient.

Rationale 2: This patient will likely need to be transported by stretcher.

Rationale 3: Controlling the source of the fluid loss is imperative.

Rationale 4: Checking for identification can wait until more pertinent interventions are performed.

Rationale 5: The patient may have collapsed due to cardiac arrest from hypovolemia. Checking the pulse is part of the immediate assessment.

Question 36

The patient has developed a “shift to the left.” The nurse would expect which value on the complete blood count?

1. Increased bands
2. Increased eosinophils
3. Decreased lymphocytes
4. Increased monocytes

Answer 36

Correct Answer: 1

Rationale 1: When an infection exists and the body needs neutrophils, the production is increased, but many immature cells or “bands” are released. This release results in a “shift to the left.”

Rationale 2: Eosinophils are not involved in the “shift to the left.”

Rationale 3: A decrease in lymphocytes is not reported as a shift.

Rationale 4: An increase in monocytes is not reported as a shift.

Question 37

A patient is admitted with a leg wound with a large amount of pus exudate. The nurse assesses that which part of the immune process is functioning?

1. The complement system causing cellular destruction
2. The natural killer lymphocytes circulating through the lymph
3. The neutrophils arriving at the wound as the first line of defense
4. The macrophages circulating in the blood

Answer 37

Correct Answer: 3

Rationale 1: The complement system is an immune mechanism that resembles the blood coagulation cascade by progressing through several sequential stages, each contributing to the immune response and resulting in cellular destruction or cytolysis. Activation of the complement system does not result in pus formation.

Rationale 2: Natural killer lymphocytes protect the body from pathologic cells such as microbes and cancer cells through cytolytic activities and secretion of cytokines. They do not produce pus.

Rationale 3: Neutrophils are responsible for the formation of pus. As they die, the neutrophil-degrading enzymes are released, causing breakdown and liquefaction of local cells as well as foreign substances. This forms pus, a thin liquid residue that is an important indicator of inflammation.

Rationale 4: Mobile macrophages circulate in the blood supply and migrate out of the vessels into the tissues when required through the process of chemotaxis. They do not produce pus.

Question 38

A patient who had a myocardial infarction this morning is now developing cardiogenic shock. Which nursing intervention is indicated?

1. Increase IV fluids.
2. Administer vasoconstricting drugs.
3. Provide care in a calm, reassuring manner.
4. Withhold oral fluids and nutrition.

Answer 38

Correct Answer: 3

Rationale 1: Increasing IV fluids is not indicated when the patient’s heart is already damaged. The physiological issue is not lack of fluid, but inability to pump fluid efficiently.

Rationale 2: It is more likely that vasodilating drugs like nitroglycerin will be administered.

Rationale 3: Providing care in a calm and quiet manner helps to decrease the patient’s anxiety, thereby reducing oxygen consumption.

Rationale 4: There is no reason to withhold oral fluids and nutrition that is evidenced by this scenario. If the patient appears to be deteriorating rapidly, withholding food may be indicated.

Question 39

A patient has been admitted to the emergency department with bleeding from a traumatic amputation of the leg. Which findings would the nurse interpret as indicating this patient’s blood loss is severe? (select all that apply)

1. Heart rate is 120.
2. Blood has soaked the dressing applied by first responders.
3. Blood pressure is 78/50.
4. Mild anxiety is present.
5. Heart rate is 50.

Answer 39

Correct Answer: 1,3

Rationale 1: Marked tachycardia, greater than 110 bpm, indicates severe volume loss.

Rationale 2: It is not possible to characterize blood loss by the appearance of a bandage. Blood may have been lost prior to the application of the bandage.

Rationale 3: Marked hypotension indicates severe blood loss.

Rationale 4: Presence of mild anxiety indicates moderate hypovolemia.

Rationale 5: As exsanguination occurs, heart rate will drop and the condition becomes life-threatening. This indicates massive blood loss.

Question 40

A patient is diagnosed with a low red blood cell count. The nurse should assess this patient for which finding?

1. History of fractures
2. Carbohydrate intake
3. Location of joint replacements
4. Renal functioning

Answer 40

Correct Answer: 4

Rationale 1: A history of fractures will not impact the patient’s current red blood cell formation.

Rationale 2: Production of red blood cells requires certain levels of adequate nutrients which include protein, multivitamins, and nutrients. The patient’s carbohydrate intake will not affect red blood cell production.

Rationale 3: Even though red blood cells do originate in the marrow of the ribs, sternum, and femur, joint replacements will most likely not impact red blood cell formation.

Rationale 4: Red blood cells arise from the myeloid cell line in the red bone marrow and mature in the blood or spleen. Erythrocyte production is tightly regulated by erythropoietin, a circulating hormone that is primarily produced by the kidneys. It is believed that erythropoietin may be produced in the renal tubular cells, which are major consumers of oxygen that are particularly sensitive to lowering oxygen levels. In a patient with a low red blood cell count, the patient’s renal function should be further assessed.