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BSN 266 Test

Enter the letter for the matching Answer
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1.
A nurse is caring for a patient who spilled boiling soup on her legs. Which type of burn will the nurse see?
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2.
A patient with facial burns frequently asks the nurse, “When will I look normal again?” Which is an appropriate response by the nurse?
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3.
Which theories characterize the mechanisms involved in autoimmunity?
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4.
A student nurse is caring for a patient with severe thermal burns. Which statement made by the student nurse to the charge nurse indicates that additional teaching is needed?
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5.
A family member of a patient with a severe facial burn asks the nurse why the patient’s face is swollen. Which statement made by the nurse is appropriate?
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6.
Which interventions are appropriate for the nurse to include in the plan of care for a patient who underwent organ transplantation 2 days ago?
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7.
The nurse determines the patient’s prescribed Basilximab (monoclonal antibody) is acting to prevent T cell activation based on which finding?
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8.
The nurse is caring for a patient who was just transported by EMS to the hospital for burns to the legs, chest, arms, and face. Which nursing interventions are appropriate at this time?
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9.
What does the nurse determine is the most important reason for teaching patients on immune suppressive therapy to weigh weekly?
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10.
The nurse is caring for a patient who had a liver transplant 3 months ago. Which nursing intervention can prevent acute rejection in this patient?
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11.
What will the nurse include in the discharge teaching for a patient who has received a prescription for prednisone after liver transplantation?
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12.
A nurse is caring for a newly admitted patient in the emergent phase after a severe electrical burn. Which provider orders should the nurse question?
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13.
The nurse is caring for a patient who underwent kidney transplantation 8 hours ago. Which finding would indicate that the patient is developing hyperacute rejection?
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14.
A female transplant recipient asks the nurse to explain why she is receiving a cytotoxic drug even though she does not have cancer. What is the nurse’s best response?
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15.
Which nursing intervention does the nurse determine addresses the goal of “verbalizing strategies for effective self-care”?
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16.
A patient who underwent organ transplantation 2 months ago is admitted to the hospital with acute rejection. Which order would the nurse anticipate from the health care provider?
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17.
The nurse determines that which action takes priority for a newly admitted patient with an autoimmune disorder who is acutely ill with fever and pain?
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18.
The nurse is caring for a patient who received an organ transplant 3 days ago. Which nursing assessments and interventions will decrease the risk for infection?
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19.
Type I: Anaphylaxis Wheezing, dysrhythmias, cyanosis Type II: Acute hemolytic reaction Fever, hypotension, chills
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20.
The nurse determines which patient problem will take priority when the patient is experiencing a type III antigen-antibody complex hypersensitivity disorder?
A.
Type III: Post streptococcal glomerulonephritis Hypertension, proteinuria, edema Type IV: Contact dermatitis Vesiculated blisters, itching, burning
B.
“The use of chemotherapy medications can play an important role in preventing organ rejection.”
C.
Decreased lymphocyte count
D.
“Swelling is an expected inflammatory response of the body to a burn injury.”
E.
Controlling current acute exacerbation
F.
Administer prophylactic antibiotics Auscultate the patient’s lung sounds
G.
Obtain an ECG in 8 hours Administer PO pain medication
H.
Administering the immunosuppressant medications as prescribed
I.
Decreased to no urine output
J.
Leakage of protected self-antigens Epitope immune system evasion Loss of T suppressor function Failure of T cell programming
K.
Facilitating periods of uninterrupted rest
L.
Insert urinary catheter to monitor intake and output Monitor oxygen status and provide supplemental oxygen as needed
M.
“I will check my patient hourly to make sure that he does not experience an inflammatory response from his burns.”
N.
“Weigh yourself daily.” “Take daily calcium supplements.” “Do not suddenly stop taking the drug.”
O.
Increased doses of monoclonal antibodies
P.
Thermal
Q.
Give immunosuppressant drugs Assist the patient with ambulation Administer intravenous (IV) fluids Change the surgical site dressing as prescribed
R.
“You seem to be very anxious. Would you like to talk about how you’re feeling?”
S.
monitor for weight change
T.
Continue activities and being productive, seeking assistance if needed.
Type the Answer that corresponds to the displayed Question.
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21.
What is the proper classification for a thermal burn involving only the epidermis and superficial structures of the dermis?
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22.
The nurse determines which action will take priority upon recognizing a patient experiencing a febrile, non-hemolytic transfusion reaction?
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23.
Which finding associated with use of corticosteroids as collaborative treatment for type I hypersensitivity (allergy) will the nurse report to the patient’s health care provider?
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24.
Which diagnostic test differentiates the level of autoimmune disease activity from the presence of disease?
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25.
Which assessment component will the nurse check when administering a dose of lymphocyte immune globulin to a patient with acute rejection?
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26.
A nurse is caring for a patient with a first-degree thermal burn injury. Which symptom can the nurse expect to see on assessment?
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27.
What is the total 24-hour fluid requirement in milliliters for a 55-kg adult patient with 75% TBSA burned?
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28.
Which step does the nurse determine is first when caring for a patient with an autoimmune disorder?
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29.
Which classic characteristic is most often noted in patients with the autoimmune disorder systemic lupus erythematosus?
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30.
The nurse determines the effectiveness of placing cold on the autoimmune patient’s acutely inflamed knee after noting which finding?

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