A client had a bowel resection 5 days ago. The nurse assesses the client and finds that the client's temperature is 103 degrees F, pulse is 88, respirations are 20, and the blood pressure is 146/72. Urine output has been 160cc for the last 4 hours. The incision is erythemic and warm to touch. The nurse determines that the client's fever is most likely due to what condition?

Wound infection

Urinary tract infection

Respiratory infection

Dehydration

Answer and Explanation

The Correct Answer is A

A.   The combination of fever, tachycardia, decreased urine output, and erythema and warmth at the incision site suggests the possibility of a wound infection.
B.   While a urinary tract infection could cause fever and decreased urine output, the presence of erythema and warmth at the incision site suggests a localized wound infection.
C.   Respiratory infection may cause fever and tachycardia but would not typically present with erythema and warmth at the incision site.
D.   Dehydration may cause decreased urine output but would not typically present with fever and erythema at the incision site.

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Correct Answer is C

Explanation

A. Naturally acquired active immunity refers to immunity acquired through natural exposure to a pathogen or antigen, leading to the production of antibodies by the individual's immune system.
B. Artificially acquired passive immunity refers to the transfer of antibodies produced by another individual or animal, such as through administration of immune globulin.
C. Naturally acquired passive immunity occurs when antibodies are transferred from mother to baby through the placenta or breast milk, providing temporary protection to the baby.
D. Artificially acquired active immunity refers to immunity acquired through vaccination, where the individual's immune system is stimulated to produce antibodies in response to an antigen.

A. Use sterile gloves when handling soiled linens B. Place a surgical mask on the client if transportation to another department is needed C. Wear a gown when providing all client cares D. Wear a mask when providing care within 10 ft of the client

Correct Answer is D

Explanation

A. While standard precautions should be followed, the use of sterile gloves for routine care related to pertussis is not necessary.
B. Placing a surgical mask on the client during transportation may help prevent the spread of respiratory droplets but is not a comprehensive infection control measure.
C. Wearing a gown for all client cares is unnecessary and may not be practical.
D. Wearing a mask when providing care within 10 feet of the client helps reduce the risk of droplet transmission of pertussis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A baby is born temporarily immune to the diseases to which the mother is immune. The nurse would explain this to the mother as being which of the following types of immunity?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse is planning care for a client who has been placed on airborne precautions. Which of the following in an appropriate nursing precaution?

The nurse is caring for a client who was recently diagnosed with Ankylosing Spondylitis. Which of the following symptoms would the nurse expect in this client?

A client who reports they are an avid outdoorsman and enjoys hiking, camping, and backpacking, has been admitted for Lyme's Disease. Lyme's Disease is spread by a tick. What is the mode of transmission?

The nurse is preparing to administer furosemide 80 mg PO daily. The amount available is furosemide oral solution 10mg/1mL. How many mL should the nurse administer? (Round to the nearest whole number and label your answer.)

A nurse is completing a head-to-toe assessment on a client who is 3 days post-operative from a right mastectomy. Which of the following should the nurse recognize as a sign of possible infection? Select all that apply.

A client is admitted with a severe allergic response to a bee sting. Which lab would the nurse expect to be the most elevated on the white blood count (WBC) differential?

A nurse is instructing an unlicensed assistive personnel (UAP) on the use of personal protective equipment while caring for clients. Which of the following statements made by the UAP indicates an understanding of standard precaution techniques?