Title: ASN 210 Week 4 Post Quiz (Remotely Proctored)
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I > Section: Week 4

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Q: What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement?
- Administer preoperative antibiotic as ordered.
- Assess the client’s white blood cell count.
- Instruct the client to shower the night before.
- Monitor the client’s temperature postoperatively.
A: Administer preoperative antibiotic as ordered.
If right: To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.
If wrong: To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

Q: The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? <b>(Select all that apply.)</b>
- It affects single joints only.
- Antibodies lead to inflammation.
- It consists of an autoimmune process.
- Morning stiffness is rare.
- Permanent damage is inevitable.
A: Antibodies lead to inflammation.; It consists of an autoimmune process.
If right: RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.
If wrong: RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

Q: The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren’s syndrome?
- Abdominal assessment
- Oxygen saturation
- Renal function studies
- Visual acuity
A: Visual acuity
If right: Sjögren’s syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjögren’s syndrome.
If wrong: Sjögren’s syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjögren’s syndrome.

Q: The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? <b>(Select all that apply.)</b>
- Anorexia
- Felty’s syndrome
- Joint deformity
- Low-grade fever
- Weight loss
A: Felty’s syndrome; Joint deformity; Weight loss
If right: Late manifestations of RA include Felty’s syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.
If wrong: Late manifestations of RA include Felty’s syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

Q: The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?
- Needs multiple dental fillings
- Over age 85
- Severe osteoporosis
- Urinary tract infection
A: Severe osteoporosis
If right: Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.
If wrong: Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

Q: The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client’s surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best?
- Assess neurovascular status in both legs.
- Elevate the affected leg and apply ice.
- Prepare to administer pain medication.
- Try to place the affected leg in abduction.
A: Assess neurovascular status in both legs.
If right: This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.
If wrong: This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

Q: The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further?
- Creatinine: 3.9 mg/dL
- Platelet count: 210,000/mm<sup>3</sup>
- Red blood cell count: 5.2/mm<sup>3</sup>
- White blood cell count: 4400/mm<sup>3</sup>
A: Creatinine: 3.9 mg/dL
If right: Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.
If wrong: Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

Q: The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? <b>(Select all that apply.)</b>
- Type I –<sup> </sup>Examples include hay fever and anaphylaxis
- Type II – Mediated by action of immunoglobulin M (IgM)
- Type III – Immune complex deposits in blood vessel walls
- Type IV – Examples are poison ivy and transplant rejection
- Type V – Examples include a positive tuberculosis test and sarcoidosis
A: Type I –<sup> </sup>Examples include hay fever and anaphylaxis; Type III – Immune complex deposits in blood vessel walls; Type IV – Examples are poison ivy and transplant rejection
If right: Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves’ disease and B-cell gammopathies.
If wrong: Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves’ disease and B-cell gammopathies.

Q: The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?
- Administering steroids for severe serum sickness
- Correctly identifying the client prior to a blood transfusion
- Keeping the client free of the offending agent
- Providing a latex-free environment for the client
A: Correctly identifying the client prior to a blood transfusion
If right: A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.
If wrong: A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.

Q: A nurse works in an allergy clinic. What task performed by the nurse takes priority?
- Checking emergency equipment each morning
- Ensuring informed consent is obtained as needed
- Providing educational materials in several languages
- Teaching clients how to manage their allergies
A: Checking emergency equipment each morning
If right: All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.
If wrong: All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.

Q: A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?
- Blood urea nitrogen: 12 mg/dL
- Creatinine: 3.2 mg/dL
- Hemoglobin: 8.2 mg/dL
- White blood cell count: 12,000/mm<sup>3</sup>
A: Creatinine: 3.2 mg/dL
If right: The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related.
If wrong: The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related.

Q: A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
- “I don’t need to go to the hospital after using it.”
- “I must carry two EpiPens with me at all times.”
- “I will write the expiration date on my calendar.”
- “This can be injected right through my clothes.”
A: “I don’t need to go to the hospital after using it.”
If right: Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.
If wrong: Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.

Q: A client with Sjögren’s syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?
- Frequent eyedrops
- Home humidifier
- Strong moisturizer
- Tear duct plugs
A: Home humidifier
If right: A humidifier will help relieve many of the client’s Sjögren’s syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.
If wrong: A humidifier will help relieve many of the client’s Sjögren’s syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.

Q: Which statements are true regarding Standard Precautions? <b>(Select all that apply.)</b>
- Always wear a gown when performing hygiene on clients.
- Sneeze into your sleeve or into a tissue that you throw away.
- Remain 3 feet away from any client who has an infection.
- Use personal protective equipment as needed for client care.
- Wear gloves when touching client excretions or secretions.
A: Use personal protective equipment as needed for client care.; Wear gloves when touching client excretions or secretions.
If right: Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you should also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet away from clients is also not part of Standard Precautions.
If wrong: Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you should also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet away from clients is also not part of Standard Precautions.

Q: Which findings are AIDS-defining characteristics? <b>(Select all that apply.)</b>
- CD4+ cell count less than 200/mm<sup>3</sup> or less than 14%
- Infection with <i>Pneumocystis jiroveci</i>
- Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV)
- Presence of HIV wasting syndrome
- Taking antiretroviral medications
A: CD4+ cell count less than 200/mm<sup>3</sup> or less than 14%; Infection with <i>Pneumocystis jiroveci</i>; Presence of HIV wasting syndrome
If right: A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm<sup>3 </sup>or less than 14% (even if the total CD4+ count is above 200 cells/mm<sup>3</sup>) or an opportunistic infection such as <i>Pneumocystis jiroveci </i>and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.
If wrong: A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm<sup>3 </sup>or less than 14% (even if the total CD4+ count is above 200 cells/mm<sup>3</sup>) or an opportunistic infection such as <i>Pneumocystis jiroveci </i>and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

Q: Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?
- Assessing skin and mucous membranes
- Consistently using appropriate hand hygiene
- Monitoring daily white blood cell counts
- Teaching visitors not to visit if they are ill
A: Consistently using appropriate hand hygiene
If right: Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare-associated infections are due to staff members’ contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come see the client when they are ill will also help prevent infection, but not to the degree that hand hygiene will.
If wrong: Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare-associated infections are due to staff members’ contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come see the client when they are ill will also help prevent infection, but not to the degree that hand hygiene will.

Q: The student nurse learns that effective antimicrobial therapy requires which factors to be present? <b>(Select all that apply.)</b>
- Appropriate drug
- Proper route of administration
- Standardized peak levels
- Sufficient dose
- Sufficient length of treatment
A: Appropriate drug; Proper route of administration; Sufficient dose; Sufficient length of treatment
If right: In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.
If wrong: In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.

Q: The student nurse caring for clients understands that which factors must be present to transmit infection? <b>(Select all that apply.)</b>
- Colonization
- Host
- Mode of transmission
- Portal of entry
- Reservoir
A: Host; Mode of transmission; Portal of entry; Reservoir
If right: Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors.
If wrong: Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors.

Q: The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection?
- Colonization by host bacteria
- Gastrointestinal secretions
- Inflammatory processes
- Skin and mucous membranes
A: Skin and mucous membranes
If right: The skin and mucous membranes are the <i>most</i> important barrier against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.
If wrong: The skin and mucous membranes are the <i>most</i> important barrier against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.

Q: The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?
- Consistent use of Standard Precautions
- Double-gloving before body fluid exposure
- Labeling charts and armbands “HIV+”
- Wearing a mask within 3 feet of the client
A: Consistent use of Standard Precautions
If right: According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.
If wrong: According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.