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Download Clinical Nursing Skills And Techniques 6th Edition Perry Test Bank all chapters
Download Clinical Nursing Skills And Techniques 6th Edition Perry Test Bank all chapters
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This online resource is from the US edition of Medical-Surgical Nursing: Assessment and Man-
agement of Clinical Problems 9e. Drug names and dosages should be checked carefully for ANZ
regulations and requirements.
Test Bank
MULTIPLE CHOICE
1. The nurse provides discharge instructions to a patient who has an immune deficiency
involving the T lymphocytes. Which screening should the nurse include in the teaching plan
for this patient?
ANS: B
Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Al-
lergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B
lymphocytes and humoral immunity.
2. A new mother expresses concern about her baby developing allergies and asks what the
health care provider meant by “passive immunity.” Which example should the nurse use to
explain this type of immunity?
a. Early immunization
b. Bone marrow donation
c. Breastfeeding her infant
d. Exposure to communicable diseases
ANS: C
Colostrum provides passive immunity through antibodies from the mother. These antibodies
protect the infant for a few months. However, memory cells are not retained, so the protection
is not permanent. Active immunity is acquired by being immunized with vaccinations or hav-
ing an infection. It requires that the infant has an immune response after exposure to an anti-
gen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active im-
munity.
3. A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of
which laboratory value?
a. IgE
b. IgA
c. Basophils
d. Neutrophils
ANS: A
Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosino-
phil level will be elevated rather than neutrophil or basophil counts. IgA is located in body
secretions and would not be tested when evaluating a patient who has symptoms of atopic
dermatitis.
4. An older adult patient who is having an annual check-up tells the nurse, “I feel fine, and I
don’t want to pay for all these unnecessary cancer screening tests!” Which information should
the nurse plan to teach this patient?
ANS: A
The primary impact of aging on immune function is on T cells, which are important for im-
mune surveillance and tumor immunity. Antibody function is not affected as much by aging.
Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a
contributing factor for this patient. Although some types of cancer are associated with specific
infections, this patient does not have an active infection.
5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to
bee stings. Which statement, if made by the patient, would indicate a need for additional
teaching?
ANS: C
Because the patient is at risk for bee stings and the severity of allergic reactions tends to in-
crease with added exposure to allergen, taking oral antihistamines will not adequately control
the patient’s hypersensitivity reaction. The other patient statements indicate a good under-
standing of management of the problem.
6. Which teaching should the nurse provide about intradermal skin testing to a patient with
possible allergies?
a. “Do not eat anything for about 6 hours before the testing.”
b. “Take an oral antihistamine about an hour before the testing.”
c. “Plan to wait in the clinic for 20 to 30 minutes after the testing.”
d. “Reaction to the testing will take about 48 to 72 hours to occur.”
ANS: C
Allergic reactions usually occur within minutes after injection of an allergen, and the patient
will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medica-
tions that might modify the response, such as antihistamines, should be avoided before allergy
testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur
within minutes.
7. The nurse, who is reviewing a clinic patient’s medical record, notes that the patient missed the
previous appointment for weekly immunotherapy. Which action by the nurse is most appro-
priate?
ANS: C
Because there is an increased risk for adverse reactions after a patient misses a scheduled dose
of allergen, the nurse should check with the health care provider before administration of the
injection. A skin test is used to identify the allergen and would not be used at this time. An
additional dose for the week may increase the risk for a reaction.
8. While obtaining a health history from a patient, the nurse learns that the patient has a history
of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate?
a. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex
develops.
b. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in
latex gloves.
c. Document the patient’s allergy history and be alert for any clinical manifestations of a type
I latex allergy.
d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing
blood-borne pathogen contact.
ANS: C
The patient’s allergy history and occupation indicate a risk of developing a latex allergy. The
nurse should be prepared to manage any symptoms that may occur. Epinephrine is not an ap-
propriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex.
Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are ap-
propriate to use when exposure to body fluids is unlikely.
9. The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about
plasmapheresis. What instructions about plasmapheresis should the nurse include in the
teaching plan?
ANS: B
plement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not di-
rectly contribute to the tissue damage in SLE.
10. The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the
patient for which clinical manifestation?
a. Shortness of breath
b. High blood pressure
c. Transfusion reaction
d. Numbness and tingling
ANS: D
Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used
to prevent coagulation. The other clinical manifestations are not associated with plasmaphere-
sis.
11. Which statement by a patient would alert the nurse to a possible immunodeficiency
disorder?
ANS: C
Splenectomy increases the risk for septicemia from bacterial infections. The patient’s protein
intake is good and should improve immune function. Daily aspirin use does not affect immune
function. A chest x-ray does not have enough radiation to suppress immune function.
ANS: C
Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and as-
sessment and emergency measures should be initiated. The other patients also have findings
that need assessment and intervention by the nurse, but do not have evidence of
life-threatening complications.
13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What
would the nurse suspect is the cause of this patient’s skin rash?
ANS: A
The patient’s history and symptoms indicate that the patient is experiencing graft-versus-host
disease, in which the donated T cells attack the patient’s tissues. The history and symptoms
are not consistent with rejection or delayed hypersensitivity.
14. An adolescent patient seeks care in the emergency department after sharing needles for
heroin injection with a friend who has hepatitis B. To provide immediate protection from in-
fection, what medication will the nurse administer?
a. Corticosteroids
b. Gamma globulin
c. Hepatitis B vaccine
d. Fresh frozen plasma
ANS: B
The patient should first receive antibodies for hepatitis B from injection of gamma globulin.
The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen
plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.
15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by
the patient would indicate a need for further instructions?
a. “After a couple of years, it is likely that I will be able to stop taking the cyclosporine.”
b. “If I develop an acute rejection episode, I will need to have other types of drugs given IV.”
c. “I need to be monitored closely because I have a greater chance of developing malignant
tumors.”
d. “The drugs are given in combination because they inhibit different ways the kidney can be
rejected.”
ANS: A
Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient
statements are accurate and indicate that no further teaching is necessary about those topics.
16. An older adult patient has a prescription for cyclosporine following a kidney transplant.
Which information in the patient’s health history has the most implications for planning pa-
tient teaching about the medication at this time?
ANS: D
Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to
avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function.
Cyclosporine may cause hypertension, and the patient’s many concerns should be addressed,
but these are not potentially life-threatening problems.
17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which
intervention will the nurse prepare for this patient?
ANS: A
Acute rejection is treated with the administration of additional immunosuppressant drugs such
as corticosteroids. Because acute rejection is potentially reversible, there is no indication that
the patient will require another transplant or hemodialysis. There is no indication for repeat
HLA testing.
18. The charge nurse is assigning rooms for new admissions. Which patient would be the most
appropriate roommate for a patient who has acute rejection of an organ transplant?
ANS: C
Treatment for a patient with acute rejection includes administration of additional immunosup-
pressants, and the patient should not be exposed to increased risk for infection as would occur
from patients with viral pneumonia, graft-versus-host disease, and burns. There is no in-
creased exposure to infection from a patient who had an anaphylactic reaction.
19. A patient who has received allergen testing using the cutaneous scratch method has
developed itching and swelling at the skin site. Which action should the nurse take first?
a. Administer epinephrine.
b. Apply topical hydrocortisone.
c. Monitor the patient for lower extremity edema.
d. Ask the patient about exposure to any new lotions or soaps.
ANS: A
The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypo-
tension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epineph-
rine when excessive itching or swelling at the skin site is observed can prevent the progression
to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction. Exposure to
lotions and soaps does not address the immediate concern of a possible anaphylactic reaction.
The nurse should not wait and observe for edema. The nurse should act immediately in order
to prevent progression to anaphylaxis.
20. A patient who is anxious and has difficulty breathing seeks treatment after being stung by a
wasp. What is the nurse’s priority action?
ANS: B
The initial action with any patient with difficulty breathing is to assess and maintain the air-
way. The other actions also are part of the emergency management protocol for anaphylaxis,
but the priority is airway maintenance.
21. Immediately after the nurse administers an intracutaneous injection of an allergen on the
forearm, a patient complains of itching at the site and of weakness and dizziness. What action
should the nurse take first?
ANS: C
Application of a tourniquet will decrease systemic circulation of the allergen and should be
the first reaction. A local antiinflammatory cream may be applied to the site of a cutaneous
test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to
anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate
initial nursing action.
22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is
most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational
nurse (LPN/LVN)?
ANS: D
LPN/LVNs are educated and licensed to administer medications under the supervision of an
RN. RN-level education and the scope of practice include assessment of health history, fo-
cused physical assessment, and patient teaching.
23. The health care provider asks the nurse whether a patient’s angioedema has responded to
prescribed therapies. Which assessment should the nurse perform?
ANS: C
Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare le-
sions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic
reactions.
24. A nurse has obtained donor tissue typing information about a patient who is waiting for a
kidney transplant. Which results should be reported to the transplant surgeon?
ANS: C
25. A patient who is receiving immunotherapy has just received an allergen injection. Which
assessment finding is most important to communicate to the health care provider?
ANS: D
A local reaction larger than quarter size may indicate that a decrease in the allergen dose is
needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the
site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect,
an improvement in the patient’s symptoms is not expected after a few months.
OTHER
1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order
should the nurse implement these prescribed actions? (Put a comma and a space between
each answer choice [A, B, C, D, E]).
ANS: A, E, C, B, D
The nurse should initially discontinue the antibiotic because it is the likely cause of the aller-
gic reaction. Next, oxygen delivery should be maximized, followed by treatment of broncho-
constriction with epinephrine administered IM or IV. Diphenhydramine will work more
slowly than epinephrine, but will help prevent progression of the reaction. Because the patient
currently does not have evidence of hypotension, the dopamine infusion can be prepared last.
Pasé por Vitoria y por la Puebla de Arganzón, como los días felices
por la vida del hombre: a escape. No miraba a ningún lado, por miedo
a mis malos recuerdos, que salían a detenerme.
En los pueblos todos del norte, la intervención vencía sin batallas; y
antes de que asomara el morrión del primer francés de la vanguardia
la Constitución estaba humillada. Los mozos todos comprendidos en la
quinta ordenada por el gobierno, se unían a las facciones, y eran muy
pocos los milicianos que se aventuraban a seguir a los liberales. No he
visto una propagación más rápida de las ideas absolutistas. Era
aquello como un incendio que de punta a punta se desarrolla
rápidamente y todo lo devora. En medio de las plazas los frailes
predicaban mañana y tarde, con pretexto de la Cuaresma
presentando a los franceses como enviados de Dios, y a los liberales
como alumnos de Satanás que debían ser exterminados.
El general Ballesteros mandaba el ejército que debía operar en e
norte y línea del Ebro para alejar a los franceses. No viendo yo a dicho
ejército por ninguna parte, sino inmensas plagas de partidas, pregunté
por él, y me dijeron en Briviesca que Ballesteros, convencido de no
poder hacer nada de provecho, se había retirado nada menos que a
Valencia. Movimiento tan disparatado no podía explicarse en
circunstancias normales; pero entonces todo lo que fuera desastres y
yerros del liberalismo tenía explicación.
Viendo crecer en los pueblos la aversión a las Cortes y al gobierno
el ejército perdía el entusiasmo. A su paso, como se levanta polvo de
camino, levantábanse nubes de facciosos, que al instante eran
soldados aguerridos. Así se explica que el ejército de Ballesteros
compuesto de dieciséis mil hombres, se retirara sin combati
emprendiendo la inverosímil marcha a Valencia, donde podía adquiri
algún prestigio derrotando a Sempere, al Locho y al carretero Chambó
tres nuevos generales o arcángeles guerreros que le habían salido a la
fe.
En Dueñas me adelanté, dejando atrás a los franceses; tenía tanta
prisa como ellos y menos estorbos en el camino, aunque los suyos no
eran tampoco grandes. ¡Cuánto deseaba yo ver por alguna parte
tropas regulares españolas! En verdad, me avergonzaba que los hijos
de San Luis, a pesar de que nos traían orden y catolicismo, se
internaran en España tan fácilmente. Con todo mi absolutismo, yo
habría visto con gusto una batalla en que aquellos liberales tan
aborrecidos dieran una buena tunda a los que yo llamaba entonces
mis aliados. Española antes que todo, distaba mucho de parecerme a
los señores frailes y sacristanes que en 1808 llamaban judíos a los
franceses y ahora ministros de Dios.
En Somosierra encontré tropas. Eran las del ejército de La Bisbal
destinado por las Cortes a cerrar el paso del Guadarrama, amparando
de este modo a Madrid. Mis dudas acerca del éxito de aquella
empresa fueron grandes. Yo conocía a La Bisbal. ¿Cómo no, si era
conocido de todo el mundo? Fue el que el año 14 se presentó al rey
llevando dos discursos en el bolsillo, uno en sentido realista, otro en
sentido liberal, para pronunciar el que mejor cuadrase a las
circunstancias. Fue el que en 1820 hizo también el doble papel de
ordenancista y de sedicioso. La inseguridad de sus opiniones había
llegado a ser proverbial. Era hombre altamente penetrado del axioma
italiano ma per troppo variar natura è bella. Yo no comprendía en qué
estaba pensando el gobierno cuando le nombró. Si los ministros se
hubieran propuesto elegir para mandar el ejército más importante a
hombre más a propósito para perderlo, no habrían elegido a otro que a
La Bisbal.
Pasé con tristeza por entre su ejército. Aquellos soldados, capaces
del más grande heroísmo, me inspiraban lástima, viéndoles destinados
a desempeñar un papel irrisorio, como leones a quienes se obliga a
bailar. Sentía yo impulsos de arengarles: «¡Que os engañan, pobres
muchachos! No dejéis las armas sin combatir. Si os hablan de
capitulación, degollad a vuestros generales.»
En Madrid hallé un abatimiento superior a lo que esperaba. Se
hablaba allí de capitular, como de la cosa más natural del mundo. Solo
tenían entusiasmo algunos infelices que no servían para nada, e