Immunity

The patient presents to the urgent care clinic with a hand laceration sustained while using pruning shears in the garden. Which vaccine is most important for this patient?

The patient presents to the clinic following being bitten by a bat while cleaning out a barn. The nurse anticipates administering which vaccine?

The nurse is reviewing the results of a patient’s sputum culture as part of a sepsis evaluation. The culture tested positive for Acinetobacter baumannii. Which is the most appropriate interpretation of these results?

A patient presents to the dermatology office with complaints of several areas of pruritic silver-gray patches on the elbows, knees, and trunk. The nurse anticipates which diagnosis will be made?

The 3-year-old patient is diagnosed with atopic dermatitis. The nurse provides information to the parents about which condition(s) the patient is likely to experience as he ages? Select all that apply. 

The nurse is admitting a patient positive for human immunodeficiency virus (HIV). A fellow nurse states, “This patient is on contact precautions for his HIV status. You need to wear an isolation gown in addition to your gloves.” Which response by the nurse is most appropriate?

A 12-year-old male patient has received the first dose of the human papillomavirus vaccine in May of this year. When will the nurse schedule an appointment for him to come back to receive his second and third doses?

The nurse is providing education to a patient with localized shingles. Which statement by the patient indicates the teaching was effective?

The 8-year-old presents with a generalized rash. The patient's mother reports that some areas of the rash have developed into pimples that are oozing clear fluid. The nurse places this patient on which type of precaution(s)? Select all that apply.

Which statement by a patient with mumps indicates an understanding of the diagnosis?

Which statement by the family member of a patient who has Guillain-Barré Syndrome indicates that they understand the nurse’s teaching on the disease process?

Which complication is of greatest concern for the patient with nephrotic syndrome?

The patient receiving levothyroxine for hypothyroidism reports treatment failure after the third dose increase. The nurse anticipates the provider to order which test for this patient?

The 6-month-old infant is admitted to the pediatric intensive care unit with a diffuse purpuric rash and prolonged bleeding. The nurse notes the fingers on the right hand are pale and cool to the touch. Which question asked of the parents will be the most helpful in diagnosing this patient’s condition?

Which lab value is consistent with acute disseminated intravascular coagulopathy (DIC)?

The patient with type I diabetes mellitus has contracted influenza A. Which lab must be most closely monitored in this patient to prevent a life-threatening complication?

The pregnant patient has experienced preterm premature rupture of membranes (PPROM) at 32 weeks. The patient is not in active labor. The nurse is aware this patient is most at risk for which complication?

A unit has experienced a significant rise in the incidence of hospital-acquired urinary tract infections (UTIs). Which action item will be most effective to reduce the incidence of hospital-acquired UTIs?

A paper cut represents which step in the chain of infection?

Which nursing intervention will be most effective in preventing the spread of Clostridium difficile between patients?

Which interventions does the nurse implement for the patient diagnosed with Clostridium difficile? Select all that apply.

Which patient does the nurse assess first following shift change report?

The 50-year-old patient receiving chemotherapy for breast cancer has developed a fungal bloodstream infection. Which intervention is the nurse’s first consideration?

The nurse is caring for a 21-year-old diagnosed with Lyme disease. Which feature suggests this is early localized disease?

The patient who will be travelling out of the country soon is concerned about traveler's diarrhea. How does the nurse counsel the patient? 

The nurse is caring for a 12-year-old being evaluated for juvenile rheumatoid arthritis (JRA). Which characteristic is required for the diagnosis? 

The patient with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (AZT). The nurse requests an order for which lab test to monitor adverse effects of the drug?

The patient with Guillain-Barre Syndrome is ordered to undergo plasmapheresis. Which rationale for the procedure does the nurse provide to the patient and family? 

The nurse observes the affected eye of the patient with newly diagnosed Bell's palsy is not closing fully and performs which interventions? Select all that apply.

The 5-year-old boy with measles cries when the nurse enters the room and turns on the lights. The nurse is most concerned about which reason behind the patient's behavior?

A 25-year-old female with burns is about to undergo skin autologous graft procedure. Which could be a source of the skin tissue to be transplanted to the patient?

The nurse is assigned to care for a 45-year-old patient who presents with a three-day history of fever, sore throat, chills, and myalgia. On physical assessment, the nurse notes the patient has multiple erythematous macular areas surrounding bullous lesions, some of which have ruptured and desquamated. Past medical history is significant for a recently diagnosed seizure disorder, managed with lamotrigine. Which intervention will be performed first?

The nurse is assigned to a 45-year-old HIV-positive male patient who is admitted with a MRSA skin infection on his right arm secondary to intravenous drug use. The patient is prescribed intravenous vancomycin. Twenty minutes after starting the vancomycin infusion, the patient develops a mild erythematous macular rash on the face, trunk and extremities. Which action is performed first?

The nurse is assigned to care for a patient who presents with fever, chills, lethargy, and sore throat. Past medical history is significant for schizophrenia diagnosed three months ago for which clozapine was prescribed. Which additional laboratory finding does the nurse expect to see in this patient?

The nurse is taking care of a patient who is prescribed chloramphenicol. After three days, the patient develops fatigue and dyspnea on exertion. Physical assessment reveals tachycardia, pallor and multiple petechiae on the trunk and extremities. The nurse anticipates which laboratory result(s)?

The nurse is assigned to a 52-year-old patient who is admitted for elective cholecystectomy. While undergoing preoperative evaluation, the patient mentions to the nurse an allergy that is not documented in the health record. Which action by the nurse is most appropriate?

The nurse learns the patient uses nasal irrigation to help prevent sickness during flu season. Which statement by the nurse is the most important?

The patient brought to the emergency department following a motor vehicle accident is found to be brain dead. An organ donor card is found on this person and the organ procurement team is contacted. Which medical history, if found in the patient’s chart, would prompt the nurse to stop the line in the organ procurement process?

The nurse knows which immunoglobulins are passed to the neonate through breastfeeding? Select all that apply.

How frequently does the nurse clean the toys of a pediatric patient with measles?

The nurse caring for the patient with pulmonary tuberculosis requests which personal protective equipment?

A 30-year-old female presents in the emergency room with symptoms of a lower respiratory infection with a productive cough, but there are no N95 respirators for the staff to utilize. Which action by the nurse is appropriate?

Which personal hygiene interventions will increase the patient’s risk for infection? Select all that apply.

A 23-year-old pregnant woman presents to the clinic stating, “I am a teacher and have heard there is a measles outbreak in my community. I want to get the measles vaccine to protect my baby and myself. Which response by the nurse is most appropriate?

The patient has a peripherally inserted central catheter (PICC) for the long-term administration of parenteral nutrition, oxacillin, and gentamicin. Which assessment findings, if present in the patient, indicate the patient is experiencing a complication of the PICC line? Select all that apply.

The 10-year-old patient presents to the emergency room following a fever as high as 105°F for 5 days. The patient’s mother reports the child has had red, watery eyes, poor appetite, and has felt ill during this time. The child was brought to the emergency room upon the appearance of a red rash that started on the child’s face and spread to the neck and chest. Which question will be most helpful in order to determine the cause of this patient’s symptoms?

The unvaccinated child presents to the emergency department with a fever lasting 6 days, malaise, and a new, diffuse, maculopapular rash that started on the face and has spread to the chest and arms. Prior to entering the room to assess the patient, the nurse dons which personal protective equipment (PPE)? Select all that apply.

The school nurse who works in an area with poor vaccination compliance learns a child has developed measles after being in class for the past week. Twenty other children in the class have not received the measles vaccine. The nurse anticipates how many of these children will contract measles?

A patient who was admitted with measles infection spent 4 hours in the busy emergency department. Each hour the patient was in the emergency department, 10 new patients entered the room. This trend continued for six hours after the patient was admitted to a room. How many patients are at risk for contracting the measles virus?

The 4-year-old child is admitted with measles. Which medication does the nurse prepare to administer initially?