When preparing a site for venipunctures with alcohol, how long must the area be cleaned?

Correct Answer: C

Rationale: When preparing a site for venipunctures with alcohol, it is important to clean the area for at least 30 seconds. This ensures that the alcohol thoroughly disinfects the skin and reduces the risk of introducing infections during the procedure. Cleaning the area for a full 30 seconds allows the alcohol to effectively kill any bacteria present on the skin's surface, creating a safe environment for the venipuncture to take place. Shortening the cleaning time may compromise the cleanliness of the site and increase the chances of contamination. Therefore, 30 seconds is the recommended duration for cleaning the site with alcohol before a venipuncture.

Correct Answer: D

Rationale: When auscultating the lungs of a client with pleural effusion, the examiner would note sounds consistent with fluid accumulation in the pleural space. This includes decreased or absent breath sounds over the area where the effusion is present. The presence of fluid in the involved area may cause a dullness to percussion as well. Pronounced breath sounds and expiratory wheezes are not typically associated with pleural effusion. While a friction rub may be heard in conditions such as pleurisy, it is not specific to pleural effusion.

Correct Answer: B

Rationale: An INR of 4 is higher than the normal therapeutic range for patients receiving warfarin therapy, which is typically between 2-3. An INR value above the therapeutic range indicates that the patient is at an increased risk of bleeding complications. Therefore, it is essential to report this finding to the physician for further evaluation and possible adjustment of the warfarin dosage to prevent excessive bleeding. The other values provided (A and C) are within or close to the normal ranges, so they would not warrant immediate concern compared to the elevated INR level.

Correct Answer: C

Rationale: The humoral immune response involves the activation of B cells, which are stimulated by T helper cells or macrophages. When B cells are activated, they differentiate into plasma cells that produce antibodies specific to the foreign antigen. These antibodies can neutralize pathogens, tag them for destruction by other immune cells, or activate the complement system. In addition to producing antibodies, memory B cells are also generated during this process, providing long-lasting immunity upon re-exposure to the same antigen. This coordinated response is an essential part of the adaptive immune system's defense mechanism against foreign invaders.

Correct Answer: A

Rationale: Age-related changes contribute significantly to the vulnerability of older clients with an immune system disorder. As people age, their immune system undergoes various alterations that can compromise its effectiveness in fighting off infections and diseases. These changes include thymic involution (decrease in thymus size and function), decrease in T-cell production, impaired immune response to infections, and decline in overall immune function. Older individuals are more susceptible to infections due to these age-related changes, which makes it essential for nurses to provide special care tailored to their specific needs. By understanding and considering these age-related immune system changes, nurses can develop appropriate care plans to support the health and well-being of older clients with immune system disorders.