NCLEX 3000-IMMUNE – Flashcards
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(SELECT ALL THAT APPLY) A client has undergone total gastrectomy due to stomach cancer. Which nursing interventions are necessary for this client immediately after surgery?
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(3) Observe the wound for redness, swelling, and warmth, (4) Encourage incentive spirometry use every hour during the client's waking hours., (5) Administer opioid analgesics as prescribed.
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A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide?
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Take ferrous sulfate and the antacid at least 2 hours apart."
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A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?
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Aplastic anemia
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Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
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Lamb and peaches
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The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
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Take piroxicam with food or an antacid.
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After undergoing testing, a client comes to a physician's office for a follow-up appointment. During the appointment, the physician informs the client that she has systemic lupus erythematosus (SLE) . Which resource might be helpful for a nurse to recommend to this client?
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A support group for clients with SLE
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A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:
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autonomy.
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A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
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"I won't donate blood because I don't want to get AIDS."
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(SELECT ALL THAT APPLY) The nurse is planning care for a client with human immunodeficiency virus (HIV). Which statement by the nurse indicates her understanding of HIV transmission?
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(4) "I will wear a mask, gown, and gloves when splashing of bodily fluids is likely.", (5) "I will wash my hands after client care."
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A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
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Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
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A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
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bilateral hearing loss.
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The nurse is teaching the parents of a child with hemophilia about how to provide a safe home environment throughout the child's life. Which nursing instruction is most appropriate?
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"Establish a written emergency plan that includes what to do in specific situations and the names and phone numbers of emergency contacts."
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The physician prescribes didanosine (ddI [Videx]), 200 mg by mouth every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine, AZT [Retrovir]). Which condition in the client's history warrants cautious use of this drug?
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Peripheral neuropathy
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The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?
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Infection
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The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
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Urine output of 20 ml/hour
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Which factor is most important when providing care for a client with hemophilia?
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Ensuring client safety
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Which action should the nurse take when a client diagnosed with human immunodeficiency virus (HIV) infection refuses treatment?
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Recognize that the client might not be ready to make treatment decisions.
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A nurse delegates the task of obtaining a blood sample to a nursing assistant trained in venipuncture. When delegating this task, the nurse should understand which delegation principle?
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The nurse may delegate the task but she remains accountable for the delegated task.
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(SELECT ALL THAT APPLY) The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions should the nurse include in the teaching plan?
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(1) Stay out of direct sunlight., (3) Monitor body temperature., (4) Taper the corticosteroid dosage as ordered by the physician when symptoms are under control.
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Two days after a client undergoes splenectomy, a nurse changes his abdominal dressings according to the physician's order. How should the nurse proceed with the dressing change?
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Remove the soiled dressings using clean gloves.
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A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
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Listen and show interest as the client expresses feelings.
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A clinical nurse specialist (CNS) is orienting a new licensed practical nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
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A-positive blood to an A-negative client.
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A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300 mg by mouth daily. Before initiating iron therapy, the nurse reviews the client's medical history. Which condition would contraindicate the use of ferrous sulfate?
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Ulcerative colitis
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After an extensive diagnostic workup, a client is diagnosed with systemic lupus erythematosus (SLE). Which statement about the incidence of SLE is true?
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SLE tends to occur in families.
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The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for:
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diarrhea
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A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia. Good oral hygiene also is essential to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drugs falls into this category?
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Phenytoin (Dilantin)
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A client with allergic rhinitis is prescribed loratadine (Claritin). On a follow-up visit, the client tells the nurse, "I take one 10-mg tablet of Claritin with a glass of water two times daily." The nurse concludes that the client requires additional teaching about this medication because:
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loratadine should be taken once daily for allergic rhinitis.
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While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
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diphenhydramine hydrochloride (Benadryl)
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How can a nurse best ensure the safety of a client who has a latex allergy?
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Make sure that the latex allergy is properly documented.
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The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
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fat.
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A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:
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fluid replacement.
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During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
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joint abnormalities.
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When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
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Strawberries
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A client with human immunodeficiency virus (HIV) infection is preparing for discharge from the hospital when he complains to a nurse that he continually feels weak. How should the nurse intervene?
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Explain to the client that he should schedule periods of rest throughout the day.
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The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
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"Client will exhibit no signs or symptoms of aspiration."
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Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
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...
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In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
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extent of immune system damage.
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A client weighing 158 lb is ordered to receive 5 mg/kg of cyclosporine (Sandimmune) daily. How many milligrams should the client receive?
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360
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Which factor is most important when planning care for a client with a bleeding disorder?
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Prioritization
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How should a nurse respond when asked by a family member of a client with human immunodeficiency virus (HIV) infection why she's performing passive range-of-motion (ROM) exercises on the client?
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"These exercises help prevent contractures by keeping his joints mobile."
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Which nursing intervention is appropriate for a client diagnosed with idiopathic thrombocytopenia purpura (ITP)?
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Administering stool softeners, as ordered, to prevent straining during defecation
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In teaching a female client who is HIV-positive about pregnancy and the human immunodeficiency virus (HIV), the nurse would know more teaching is necessary when the client says:
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"I'll need to have a C-section if I become pregnant and have a baby."
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After being admitted to the hospital with sickle cell crisis, a client asks a nurse how he can prevent another crisis. Which response by the nurse is best?
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"Make sure that you drink plenty of fluids."
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A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [Retrovir]), 200 mg by mouth every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
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"Take zidovudine every 4 hours around the clock."
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A client who is hospitalized with scleroderma signs a document that provides instructions concerning the provision of care if he is unable to make his own treatment decisions. The document is known as:
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an advance directive.
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Which of the following blood types would the nurse identify as the rarest?
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AB
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A client with blood type B needs a blood transfusion. Which type of blood can this client receive?
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Type B or type O blood
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A nurse administers etanercept (Enbrel) by subcutaneous injection to a client with ankylosing spondylitis. Which action should the nurse take to prevent a needle-stick injury?
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Place the uncapped needle in the designated puncture-resistant container.
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A nurse is caring for a client who is experiencing the end-stage of acquired immunodeficiency syndrome (AIDS) . What is the goal of treatment for this client?
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Promoting client comfort
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The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction?
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Bronchospasm
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The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
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Use the smallest needle possible for injections.
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For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
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Increased weight, hypertension, and insomnia
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A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
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Compatible blood and tissue types
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A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safe sex practices for persons with HIV is accurate?
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A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.
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Which nursing intervention takes priority for a client infected with Pneumocystis carinii pneumonia?
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Auscultating breath sounds
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A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
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sit upright, leaning slightly forward.
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A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
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Reduced sneezing
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A 33-year-old client who tested positive for the human immunodeficiency virus (HIV) is admitted to the medical unit with pancreatitis. A nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director, who says that the client is her neighbor's son. What should the nurse do to protect the client's right to privacy?
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Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart.
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Which immunoglobulin is specific to an allergic response?
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IgE
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How can a nurse best protect herself after she experiences a minor allergic reaction to latex?
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Avoid use of all latex products.
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Which nursing intervention takes priority for a client with human immunodeficiency virus (HIV) infection?
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Protecting the client from infection
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A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
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Western blot test with ELISA.
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A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
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Bluish urine
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The nurse is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when collecting data on the client?
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Pallor, tachycardia, and a sore tongue
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The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
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Following safe-sex practices
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A 40-year-old client with mild dementia related to end-stage acquired immunodeficiency syndrome (AIDS) is preparing for discharge. She has decided against further curative treatment. Before discharge, she develops ocular cytomegalovirus (CMV). Her physician recommends treatment with a ganciclovir-impregnated implant (Vitrasert), which requires a surgical procedure. The client's husband feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which response best answers the husband's question while promoting client advocacy?
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"The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult."
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When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
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"Avoid sharing such articles as toothbrushes and razors."
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Which action takes priority for a client who is experiencing a hypersensitivity reaction to latex?
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Administering supplemental oxygen
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A licensed practical nurse (LPN) is coassigned with a registered nurse (RN) for the care of a client with hemophilia. The physician prescribes a blood transfusion for this client. Which task associated with blood transfusion is the responsibility of the LPN?
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Monitoring the client during the transfusion
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A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
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Autoimmune disorders include connective tissue (collagen) disorders.
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A 27-year-old client with end-stage acquired immunodeficiency syndrome (AIDS) is being cared for by his wife at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about advance directives. At the next visit, the client states that since he and his wife filled out the advance directive form he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client 's concerns?
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"Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself."
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A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
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Risk for injury
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A client is admitted to an acute care facility with a myocardial infarction. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to assist in formulating which nursing diagnosis?
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Risk for impaired skin integrity
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In an individual with Sjögren's syndrome, nursing care should focus on:
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moisture replacement.
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A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone (Deltasone) daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
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Osteoporosis
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A client is admitted to the medical-surgical floor with a suspected diagnosis of acute myeloid leukemia. A nurse discusses the client's condition in the hallway. This action by the nurse jeopardizes which of the following principles?
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Confidentiality
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A 56-year-old client diagnosed with acquired immunodeficiency syndrome (AIDS) is admitted with a closed head injury after being found unconscious on the kitchen floor by her neighbor. The staff suspects domestic abuse, based on information supplied by the neighbor that the client has a restraining order against the husband, who repeatedly tries to visit the client. Which nursing action ensures client safety?
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Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client.
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The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
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An above-normal anti-deoxyribonucleic acid (DNA) test
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The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:
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wear gloves when providing mouth care.
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The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client?
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Volume overload
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A client with anemia has been admitted to the medical-surgical unit. Which data collection findings are characteristic of iron-deficiency anemia?
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Dyspnea, tachycardia, and pallor
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A client takes prednisone (Deltasone), as prescribed, for rheumatoid arthritis. The nurse should tell the client to look for common adverse reactions to this drug, such as:
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fluid retention and weight gain.
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A client diagnosed with human immunodeficiency virus (HIV) infection states, "I'm afraid of gaining weight, so I always supplement my diet with vitamins." Which response by the nurse is appropriate?
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"Eating a variety of healthy foods is the best source of vitamins."
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Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse's suspicions are:
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drop in blood pressure and rise in heart rate.
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A nurse is preparing a teaching plan for a client with sickle cell disease. She includes periods of rest in her plan. Why is this point important to include?
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Rest relieves stress, which may precipitate sickle cell crisis.
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A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600 mg by mouth every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?
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Tinnitus
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A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
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"I will receive parenteral vitamin B12 therapy for the rest of my life."
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The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
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Monitor body temperature.
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Which of the following is the most numerous type of white blood cell (WBC)?
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Neutrophil
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A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The nurse's most appropriate response to her would be:
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"You seem angry. Would you like to talk about it?"
