ATI RN
Immune System Quiz Quizlet Questions
Question 1 of 5
A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine (Sandimmune) and methylprednisolone (Solu-Medrol). Which staff member is best to assign to care for this patient?
Correct Answer: C
Rationale: An experienced RN who is familiar with the medical unit and its protocols is the best choice for caring for a patient with acute rejection. This patient requires close monitoring and skilled care which an experienced RN can provide. The other options involve RNs who may not be as familiar with the unit or are less experienced.
Question 2 of 5
In a patient with a CD4 count less than 200, the most important nursing assessment would include:
Correct Answer: C
Rationale: In a patient with a CD4 count less than 200, the most important nursing assessment would include monitoring for fever (option C). This is because a CD4 count below 200 indicates severe immunosuppression, specifically defining AIDS. Fever in this context could indicate an opportunistic infection, which is a common complication in patients with advanced HIV/AIDS. Monitoring for fever allows for early detection and timely intervention, which is crucial in preventing further complications and improving patient outcomes. Option A, bowel movements, is not the priority assessment in this case because while changes in bowel movements can occur with some infections, fever is a more specific and critical assessment in an immunocompromised patient. Option B, urinary output, is important for assessing hydration status and kidney function but is not the priority when considering the risk of opportunistic infections in a patient with severe immunosuppression. Option D, blood pressure, is essential for monitoring overall hemodynamic status, but it is not the most crucial assessment in a patient with a CD4 count less than 200, where infection surveillance is paramount. Educationally, understanding the significance of CD4 counts and their implications on a patient's immune status is vital in pharmacology and nursing practice. This scenario highlights the importance of prioritizing assessments based on the patient's condition and the potential complications they may be at risk for due to their immunocompromised state. It emphasizes the need for comprehensive and targeted assessments to provide holistic care to patients with complex medical conditions like HIV/AIDS.
Question 3 of 5
A patient had a complicated vaginal hysterectomy. The student nurse provided perineal care after the patient had a bowel movement. The student nurse tells the nurse there was a lot of light brown, smelly drainage seeping from the perianal area. What should the nurse suspect when assessing this patient?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Fistula formation. A fistula is an abnormal connection between two body parts that usually develops as a result of infection, inflammation, or injury. In the context of a patient with light brown, smelly drainage seeping from the perianal area after perineal care following a hysterectomy, this presentation is indicative of a fistula forming between the bowel and the vagina. Option A) Dehiscence refers to the separation of previously joined wound edges, which typically presents with a gaping wound rather than drainage from a different body part. Option B) Hemorrhage would manifest as significant bleeding and not foul-smelling drainage. Option C) Keloid formation is a type of raised scar that forms at the site of a wound and is not related to the symptoms described in the scenario. From an educational perspective, understanding the signs and symptoms of potential complications post-surgery is crucial for student nurses to provide prompt and appropriate care. Recognizing the specific characteristics of different complications, such as fistula formation in this case, enables healthcare providers to intervene effectively and prevent further complications for the patient.
Question 4 of 5
A patient’s documentation indicates he has a stage III pressure ulcer on his right hip. What should the nurse expect to find on assessment of the patient’s right hip?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C) Deep crater through subcutaneous tissue to fascia. A stage III pressure ulcer involves damage to the skin and the tissue beneath the skin, extending through the subcutaneous tissue to the fascia. This indicates a more severe level of tissue damage compared to the other options. Option A) Exposed bone, tendon, or muscle is more indicative of a stage IV pressure ulcer, which is even more severe than a stage III ulcer. Option B) An abrasion, blister, or shallow crater describes characteristics of a stage II pressure ulcer, which is less severe than a stage III ulcer. Option D) Persistent redness (or bluish color in darker skin tones) is more typical of a stage I pressure ulcer, which involves non-blanchable erythema of intact skin. In an educational context, understanding the different stages of pressure ulcers is crucial for healthcare professionals, especially nurses, as it helps in proper assessment, treatment, and prevention of pressure ulcers. Recognizing the specific characteristics of each stage enables appropriate interventions to promote healing and prevent further complications. Nurses need to be able to accurately assess and stage pressure ulcers to provide optimal care for patients with compromised skin integrity.
Question 5 of 5
The physician plans to prescribe trastuzumab (Herceptin) for the patient with breast cancer. What testing will the physician order before prescribing this medication?
Correct Answer: A
Rationale: Rationale: The correct answer is A) HER2 protein levels. Trastuzumab (Herceptin) is a targeted therapy used in the treatment of breast cancer, specifically in patients who overexpress the HER2 protein. Before prescribing trastuzumab, it is crucial to test for HER2 protein levels to determine if the patient is a suitable candidate for this medication. Option B) BRCA2 gene mutation and C) BRCA1 gene mutation are related to genetic mutations that increase the risk of developing breast cancer but are not directly relevant to the decision of prescribing trastuzumab. These genetic tests are more commonly used in assessing the risk of developing breast cancer rather than guiding treatment decisions. Option D) Stage II cancer identification is important for determining the extent of the disease and planning the overall treatment strategy. However, it does not specifically inform the decision to prescribe trastuzumab based on HER2 protein expression. In an educational context, understanding the rationale behind pre-treatment testing for medications like trastuzumab enhances students' knowledge of personalized medicine and targeted therapies in oncology. It emphasizes the importance of conducting appropriate tests to tailor treatment plans to individual patients, ultimately improving outcomes and minimizing adverse effects.