The nurse should recognize which response is the immune system's reaction to a source of inflammation?

Activation of exocytosis.

Vasoconstriction.

Decreased histamine production.

Increased vascular permeability.

Answer and Explanation

The Correct Answer is D

A. Activation of exocytosis. Exocytosis is a cellular process used for releasing substances such as neurotransmitters or hormones, but it is not the primary response to inflammation. The immune response involves chemical mediators like histamine, prostaglandins, and cytokines, which increase vascular permeability.
B. Vasoconstriction. Vasodilation, not vasoconstriction, is a hallmark of inflammation. Initially, there may be a brief period of vasoconstriction, but the primary response is vasodilation, which increases blood flow to the inflamed area.
C. Decreased histamine production. Histamine production increases during inflammation, leading to vasodilation and increased vascular permeability. This allows immune cells to travel to the site of injury or infection.
D. Increased vascular permeability. The inflammatory response involves increased vascular permeability, allowing immune cells, proteins, and fluid to move from the bloodstream into tissues to fight infection and promote healing. This process leads to swelling (edema), redness, and warmth, which are classic signs of inflammation.

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Correct Answer is B

Explanation

A. Peripheral neurovascular dysfunction. While some chemotherapy agents can cause neuropathy, the immediate risk of a vesicant (a drug that can cause severe tissue damage if it leaks) is extravasation, leading to skin and tissue damage, rather than direct neurovascular impairment.
B. Impaired skin integrity. Vesicants can cause severe tissue necrosis if they extravasate (leak into surrounding tissues). Leaving an IV in place for 72 hours increases the risk of infiltration or extravasation, which can lead to serious complications, including blistering, necrosis, and deep tissue injury. Proper IV site rotation and monitoring are essential to prevent skin and tissue damage.
C. Fluid volume excess. Fluid volume excess is not a direct risk related to vesicant chemotherapy. While some IV fluids can contribute to fluid overload, the primary concern with vesicants is extravasation and tissue damage.
D. Acute pain and anxiety. While pain and anxiety can occur if extravasation happens, the greatest clinical risk is the physical damage caused by tissue necrosis. Pain is a symptom of extravasation, but preventing skin and tissue injury is the priority.

A. Enzyme immunoassay. B. Western Blot. C. White blood cell differential. D. CD4+ cell count.

Correct Answer is B

Explanation

A. Enzyme immunoassay. The enzyme immunoassay (EIA), also known as the ELISA test, is used as a primary screening test for HIV. If the EIA test is positive, a confirmatory test, such as the Western Blot, is performed to ensure accuracy.

B. Western Blot. The Western Blot is a confirmatory test for HIV used to verify positive results from an initial screening test. It detects specific HIV antibodies and is highly specific, reducing the likelihood of false positives.

C. White blood cell differential. A white blood cell (WBC) differential assesses the overall immune response but does not diagnose HIV. While some HIV patients may show low WBC counts, this test is not specific for HIV infection.

D. CD4+ cell count. CD4+ cell count is used to monitor disease progression and immune function in HIV-positive patients, but it is not a confirmatory test for diagnosing HIV. A low CD4+ count suggests HIV progression toward AIDS rather than initial diagnosis.

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The nurse should recognize which response is the immune system's reaction to a source of inflammation?

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Naxlex Comprehensive Predictor Exams

A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. Which is the greatest clinical risk related to this situation?

Correct Answer is B

Explanation

Which test for HIV is used primarily as a confirmatory test rather than a generalized screening test?

Correct Answer is B

Explanation

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