Immunity

The patient was intubated in the field following a severe motor vehicle accident and is being managed in the intensive care unit. One day after the accident, increased oxygen requirement and diminished lung sounds are noted, and a radiograph is obtained. The chest x-ray reveals consolidation in bilateral lower lobes. The nurse anticipates which diagnosis for this patient?

The family practice nurse is reviewing telephone messages from patients. Which call is to be returned first?

The nurse caring for the child with beta-thalassemia is most concerned about which comorbidity?

The nurse is caring for the 3.7 kg neonate who was born at 38 weeks gestation after an uncomplicated pregnancy and delivery in the newborn nursery. Which immunization does the nurse administer to the patient prior to discharge from the hospital?

The patient is undergoing placement of an antibiotic-impregnated central line catheter for vancomycin infusions. Which statements are true about this type of catheter? Select all that apply.

A patient has a white blood cell (WBC) count of 17,000 cells per ml. What is the possible etiology? Select all that apply.

The nurse is assessing the elderly patient in the long-term care facility. Which findings suggest urinary catheter-associated urinary tract infection (CAUTI)? Select all that apply.

The nurse is caring for the patient with fever, chills, and a cough productive of green sputum. The chest X-ray shows a hazy opacity. The nurse checks the patient's medical history for sensitivity to which medication? 

The nurse is caring for the woman in labor whose body temperature is 102.8°F and heart rate is 114 bpm. Which order does the nurse carry out first?

The day after administering a blood product to the anemic patient, the nurse learns it was contaminated with a fungal pathogen due to improper processing. The nurse is vigilant for which symptom(s)?

The patient with advanced liver disease is being evaluated for moderate hematemesis, tachycardia, and hypotension. An esophagogastroduodenoscopy (EGD) confirms the patient has esophageal varices. Which is the priority action by the nurse?

The 7-day-old neonate born at 32-weeks’ gestation has an axillary temperature of 38.9°C. The nurse notes the infant is lethargic, with pale extremities and flash central capillary refill. Which nursing action is appropriate?

The 23-week gestation neonate is being cared for in a double-walled, heated isolette with ambient humidity set to 85%. The patient is at risk for sepsis due to which organism related to the care environment?

The nurse is preparing for an infant’s two-month well-baby check-up. Which immunizations does the nurse prepare? Select all that apply.

The nurse prepares a diphtheria, tetanus, and pertussis (DTaP) vaccination for a 6-year-old patient. The patient’s mother states, “Wait! He’s already gotten that vaccine, several times when he was younger. I have it written down in his records.” Which response by the nurse is appropriate?

The nurse is preparing a Haemophilus influenzae type b (Hib) immunization for the 2-month-old patient. The baby’s mother states, “I recently read the influenza vaccine isn’t given until at least a year. Are you sure he should be getting this now?” Which response by the nurse is most appropriate?

The nurse reviewing the vaccination record of a 12-month-old infant expects the infant to have completed which vaccine series?

The nurse is preparing for the well-baby visit of the 6-month-old who is up-to-date on vaccines. Which vaccinations does the nurse prepare for the visit? Select all that apply.

The 13-year-old female patient presents to the clinic in January to begin the vaccine series for human papillomavirus. The nurse instructs the patient’s mother to schedule an appointment for the next vaccine in the series during which month at the earliest?

The baby born at 32 weeks’ gestation to a mother who is hepatitis B surface antigen negative (HBsAg-negative) is taken to the Neonatal Intensive Care Unit (NICU) for care. The neonate, who weighs 1.8 kg, requires continuous positive airway pressure of 7 cm H20, intravenous fluids containing dextrose, and intravenous caffeine. After getting consent from the mother, when is the most appropriate time to administer the hepatitis B vaccine to the baby?

The 34-week-gestation neonate is born weighing 1.7 kg to a mother who is hepatitis B surface antigen (HBsAg) positive; all other infectious disease serologies are negative. Which orders are appropriate for this patient? Select all that apply.

The patient whose mother chose not to vaccinate him presents to the clinic the day after his 18th birthday to receive all eligible vaccinations. The nurse uses which statement to counsel the patient about the hepatitis B vaccine series?

The 19-year-old patient tells the nurse, “I was reviewing my vaccination records for school and noted I never received the varicella vaccination.” Which response by the nurse is most appropriate?

The 10-year-old female patient’s mother brings her to the clinic for a check-up and immunizations and requests that she receives the human papillomavirus (HPV) vaccination. Which question does the nurse ask first?

The 18-year-old patient calls the clinic two weeks after receiving the 2nd vaccination in the three-dose series for human papillomavirus (HPV). She states, “I didn’t realize it when I got the vaccine, but I was 6 weeks pregnant. Will my baby be okay?” Which response by the nurse is most appropriate?

The nurse is providing discharge education to the patient regarding immunizations following a hematopoietic stem cell transplant. When does the nurse instruct the patient to visit the clinic for the Haemophilus influenzae type b (Hib) vaccine?

The public health nurse encourages which individuals to receive the hepatitis A vaccine? Select all that apply.

The 18-year-old healthy female presents to the clinic requesting to receive the vaccinations her mother refused for her when she was a child. Reviewing the chart, the nurse notes the patient never received the measles, mumps, rubella (MMR) vaccine. Prior to administering the vaccination, which test is most important?

The nurse assists with a pericardiocentesis to drain a pericardial effusion and notes serosanguinous fluid. The nurse suspects which condition?

The patient presents to the emergency department (ED) with nausea, vomiting, fever, severe knee and wrist pain, nosebleed, and lymphadenopathy. A new murmur is noted, as well. The nurse asks the patient about a recent history of which infection?

Which neurologic alteration is associated with acute rheumatic fever?

Which medication is a member of the biologic pharmacologic class?

Which comorbidities increase the risk for refeeding syndrome in the chronically ill patient who is started on total parenteral nutrition (TPN)? Select all that apply.

A man who has remediated water-damaged basements for over thirty years presents to an acute care clinic for ongoing breathing problems. He has never smoked, has never been exposed to asbestos, and is afebrile. The nurse knows the man is most likely suffering from what condition?

The patient with a severe peanut allergy was inadvertently exposed to peanuts at work. Dyspnea persists despite the patient using the epinephrine autoinjector and emergency medical services was contacted. Which concentration of epinephrine does the first responder prepare for intramuscular injection?

The nurse planning care for the neonate with myelomeningocele plans interventions to ensure the child does not develop an allergy to which substance?

The registered nurse is caring for a 48-year-old patient with a surgical wound infected with methicillin-resistant Staphylococcus aureus (MRSA) requiring q6h intravenous antibiotic infusions and dressing changes twice per shift. The patient with which diagnosis is most appropriate to be added to this nurse’s assignment?

The charge nurse is planning room assignments during an outbreak of Shiga toxin-producing Escherichia coli (STEC). Due to the influx of patients, only one private room is available. Which patient with STEC must be placed in this private room?

The patient presents to the emergency room complaining of fever, malaise, and nuchal rigidity. Which personal protective equipment does the nurse don prior to assessing the patient? Select all that apply.

The 6-month-old patient is admitted to the pediatric intensive care unit for treatment of a pertussis infection. The donning of which personal protective equipment by the unlicensed assistive personnel (UAP) entering this patient’s room would prompt the nurse to intervene and provide additional education?

The nurse is providing discharge teaching to the patient admitted with anaphylaxis after blowing up a rubber balloon. Which foods, if selected by the patient as safe to eat, indicate a need for further teaching? Select all that apply.

The nurse is counseling the parents of an 8-month-old child born with myelomeningocele on appropriate baby foods to introduce to the child. Which foods, if selected by the parents, indicate teaching was effective? Select all that apply.

The nurse is assisting the provider in lancing the abscess of a patient whose medical history is notable for anaphylaxis after ingestion of oysters. The nurse enters the room as the provider begins swabbing the affected skin with povidone-iodine solution. Which response by the nurse is appropriate?

The nurse is planning care for the patient receiving adalimumab. Which nursing intervention does the nurse utilize to prevent complications of the medication?

The patient is receiving alefacept. Which finding indicates the patient is having the desired response to therapy?

The nurse advocates for the use of secukinumab in which patient?

Which symptom can occur following vertical transmission of Neisseria gonorrhoeae?

The female patient tells the nurse, “I think the man I had unprotected sex with last night might have herpes. I’m so afraid I’m going to get it, too.” Which response by the nurse is most appropriate?

The patient is admitted to the hospital with systemic syphilis infection. The patient is ordered to receive a 14-day course of penicillin G 20 million units/day intravenously. Prior to administering the medication, the nurse checks the patient’s allergies and learns the patient experienced anaphylaxis after receiving ampicillin. Which action does the nurse take?

Which cell is responsible for cleaning wounds of microorganisms?