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PCC Exam III Questions & Answers
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PCC Exam III Questions & Answers The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques...

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  • October 27, 2024
  • 45
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • pcc exam iii questions answers
  • the nurse is caring for a patient who is being dis
  • an 18 month old female patient is diagnosed with h

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PCC Exam III Questions & Answers
The nurse is caring for a patient who is being discharged home after a splenectomy.
What information on immune function needs to be included in this patient's discharge
planning?
a. The mechanisms of the inflammatory response
b. Basic infection control techniques
c. The importance of wearing a face mask in public
d. Limiting contact with the general population - answer ANS: B
The spleen is one of the major organs of the immune system. Without the spleen, the
patient is at higher risk for infection; so, the nurse must be sure that the patient
understands basic principles of infection control. The patient with a splenectomy does
not need to understand the mechanisms of inflammatory response. The patient with a
splenectomy does not need to wear a face mask in public as long as the patient
understands and maintains the basic principles of infection control. The patient who has
had a splenectomy does not need to limit contact with the general population as long as
the patient understands and maintains the basic principles of infection control.

REF: Page 219

An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10
months. The physician notes that the child's growth rate has decreased from the 60th
percentile for height and weight to the 15th percentile over that same time period. The
child has been treated for thrush consistently since the third ear infection. The nurse
understands that the patient is at risk for which condition?
a. Primary immunodeficiency
b. Secondary immunodeficiency
c. Cancer
d. Autoimmunity - answer ANS: A
Primary immunodeficiency is a risk for patients with two or more of the listed problems.
Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by
abnormal cells that will trigger an immune response. Autoimmune diseases are caused
by hyperimmunity.

REF: Page 221

The nurse is caring for a postoperative patient who had an open appendectomy. The
nurse understands that this patient should have some erythema and edema at the
incision site 12 to 24 hours post operation dependent on which condition?
a. His immune system is functioning properly.
b. He is properly vaccinated.
c. He has an infection.
d. The suppressor T-cells in his body are activated. - answer ANS: A

,Tissue integrity is closely associated with immunity. Openings in the integumentary
system allow for the entrance of pathogens. If the immune response is functioning
optimally, the body responds to the insult to the tissue by protecting the area from
invasion of microorganisms and pathogens with inflammation. Routine vaccinations
have no bearing on the body's response to intentional tissue impairment. The redness
and swelling at the incision site in the first 12 to 24 hours is part of optimal immune
functioning. A patient with erythema and edema that persist or worsen should be
evaluated for infection. Suppressor T-cells help to control the immune response in the
body.

REF: Page 225

While caring for a patient preparing for a kidney transplant, the nurse knows that the
patient understands teaching on immunosuppression when she makes which
statement?
a. "My body will treat the new kidney like my original kidney."
b. "I will have to make sure that I avoid being around people."
c. "The medications that I take will help prevent my body from attacking my new
kidney."
d. "My body will only have a problem with my new kidney if the donor is not directly
related to me." - answer ANS: C
Immunosuppressant therapy is initiated to inhibit optimal immune response. This is
necessary in the case of transplantation, because the normal immune response would
cause the body to recognize the new tissue as foreign and attack it. The body will
identify the new kidney as foreign and will not treat it as the original kidney. While
patients with transplants must be careful about exposure to others, especially those who
are or might be ill, and practice adequate and consistent infection control techniques,
they don't have to avoid people or social interaction. The new kidney brings foreign cells
regardless of relationship between donor and recipient.

REF: Page 222

The nurse is caring for a patient who was started on intravenous antibiotic therapy
earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy
and having difficulty breathing and talking. The nurse notes that the patient's
respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects
that the patient is experiencing which condition?
a. Suppressed immune response
b. Hyperimmune response
c. Allergic reaction
d. Anaphylactic reaction - answer ANS: D
The patient is exhibiting signs and symptoms of an anaphylactic reaction to the
medication. These signs and symptoms during administration of a medication do not
correspond to a suppressed immune response but a type of hyperimmune response.
While the patient is experiencing a hyperimmune response, the signs and symptoms
allow for a more specific response. While the patient is experiencing an allergic

,reaction, the signs and symptoms presented in the scenario allow for a more specific
response.

REF: Page 221 - Page 225

The nurse is preparing to administer medications to a patient with rheumatoid arthritis
(RA). The nurse should explain which goal of treatment to the patient?
a. Eradicate the disease
b. Enhance immune response
c. Control inflammation
d. Manage pain - answer ANS: C
Medications for RA are intended to control the inflammation that results from the body's
hyperimmune response. Autoimmune diseases like RA are chronic and currently have
no curative treatments. Autoimmune diseases like RA are caused by hyperimmune
response. The immune system needs to be suppressed, not enhanced. While the
medications used for RA might help with pain management, the goal of medication
intervention is to manage the inflammation.

REF: Page 223 - Page 224

The parents of a newborn question the nurse about the need for vaccinations: "Why
does our baby need all those shots? He's so small, and they have to cause him pain."
The nurse can explain to the parents that which of the following are true about
vaccinations? (Select all that apply.)

a. Are only required for infants
b. Are part of primary prevention for system disorders
c. Prevent the child from getting childhood diseases
d. Help protect individuals and communities
e. Are risk free
f. Are recommended by the Centers for Disease Control and Prevention (CDC) - answer
ANS: B, D, F
Immunizations are considered part of primary prevention, help protect individuals from
contracting specific diseases and from spreading them to the community at large, and
are recommended by the CDC. Immunizations are recommended for people at various
ages from infants to older adults. Vaccination does not guarantee that the recipient
won't get the disease, but it decreases the potential to contract the illness. No
medication is risk free.

REF: Page 224

The nurse is caring for a client who is hospitalized on a medical unit for a systemic
infection. The client asks the nurse what defenses the body has against infection. The
nurse responds that which physiological barrier helps defend the body against
microorganisms?
Select all that apply.

, A) Moisturizing the skin
B) Adequate urinary output
C) Intact skin
D) Occasional smoking
E) A surgical incision - answer Answer: B, C
Explanation: Voiding a sufficient quantity of urine is a form of barrier protection that
helps the body to defend itself against microorganisms. The act of voiding flushes those
organisms that might try to enter the body through the urinary meatus. Intact skin is also
a physiological barrier that helps defend the body against microorganisms. Occasional
smoking does not defend the body from microorganisms; it destroys the cilia in the nose
that helps to filter organisms. Moisturizing the skin and a surgical incision can both allow
microorganisms to enter the body.

A client, who has been given a yellow fever vaccine before traveling to the Amazon
Basin, asks the nurse to explain how the elements of the immune system will now
provide protection. Which is the appropriate response by the nurse?
Select all that apply.

A) "Human macrophages engulf the weakened vaccine virus as if it is dangerous and
antigens stimulate the immune system to attack it."
B) "In the lymph nodes, part of the lymphoid system, the macrophages present yellow
fever antigens to T cells and B cells."
C) "A response from yellow fever-specific T cells is activated. B cells secrete yellow
fever antibodies."
D) "The body's immune system eats away at the protective sheath (myelin) that covers
the nerves."
E) "The initial weak infection is eliminated and the client is left with a supply of memory
T and B cells for future protection against yellow fever." - answer Answer: A, B, C, E
Explanation: Macrophages ingest antigens and signal helper T cells that antigens are
present. Lymph nodes filter foreign products or antigens from the lymph system and
house and support proliferation of lymphocytes and macrophages. Antibodies directly
attack and destroy antigens either before or after antigens invade body cells. The
immune system damaging the myelin is an autoimmune response in MS. Memory B
cells and T cells remember how to identify the antigen and will reactivate at a future
time if the same type of antigen is present.

A nurse is volunteering in a health screening booth at the state fair. The nurse has
assessed several clients and determines that which client demonstrates the decline in
responsiveness of the immune system of an older adult?

A) An 88-year-old client with pneumonia who has a temperature of 99.5°F
B) A 70-year-old client who has swelling and redness around an abdominal incision
from an open appendectomy
C) A 58-year-old client who complains of redness and itching after developing a rash
from contact with poison ivy

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