ATI: Immune System
A nurse is instructing a client how to self-administer enfuvirtide. Which of the following instructions should the nurse include? "Allow the vial to sit until the solution is completely clear and without particulates." "After reconstituting with sterile water, vigorously shake the vial to mix the solution." "Use the medication immediately upon removing from the refrigerator." "Use the same location for five injections before rotating to a new site."
"Allow the vial to sit until the solution is completely clear and without particulates." When administering enfuvirtide, the client should inject sterile water to reconstitute it and gently roll the vial between the hands. Then, the client should let the vial sit until the solution is completely clear and without particulates, which might take up to 45 min. The client should allow the vial to warm to room temperature before the injection and refrigerate any unused portion.
A nurse is teaching a client about maraviroc. Which of the following instructions should the nurse include? "It is important to report any noticeable rash immediately as it might indicate an issue with your liver." "Make sure you take this medication without any other medications first thing in the morning." "You might experience flu-like symptoms for which you can take any over-the-counter medication." "The side effects of this medication are minimal, so you can continue to work and drive as normal."
"It is important to report any noticeable rash immediately as it might indicate an issue with your liver." Hepatic injury can manifest as a rash in clients who take maraviroc and should be reported to the provider regardless of how mild it appears.
A nurse is teaching a client about immunizations. Which of the following information should the nurse include about the teaching? "You should receive a tetanus booster every 10 years." "You should not receive the influenza immunization if you have a common cold." "You do not have to receive the shingles vaccine if you have received two doses of the varicella virus vaccine." "As long as you don't have risk factors, you will start receiving the pneumococcal vaccine when you are 50 years old."
"You should receive a tetanus booster every 10 years." The nurse should inform the client that the tetanus-diphtheria (Td) vaccine is recommended every 10 years.
A nurse is preparing to administer enfuvirtide to a client. Which of the following actions should the nurse plan to perform. (Select all that apply). Administer the drug subcutaneously. Discard the unused portion. Roll the vial gently to reconstitute the solution. Inject the solution at room temperature. Expect a cloudy solution.
-Administer the drug subcutaneously. -Roll the vial gently to reconstitute the solution. -Inject the solution at room temperature. The nurse should administer enfuvirtide, a fusion inhibitor, subcutaneously, twice per day. This is the only appropriate route of administration for the drug.The nurse should roll the vial of enfuvirtide gently between the palms of the hands after adding sterile water for injection. This reconstitutes the drug.The nurse can store unused solutions of enfuvirtide in a refrigerator up to 24 hr but should restore it to room temperature before injection.
A nurse is preparing to administer paclitaxel IV to a client who has ovarian cancer. Which of the following actions should the nurse take. (Select all that apply). Give the client an antihistamine. Infuse the drug over 1 hr. Administer the drug through non-PVC tubing. Use an in-line filter. Add heparin to the paclitaxel solution.
-Give the patient an antihistamine. -Administer the drug through non -PVC tubing.-Use an in-line filter. Prior to administering paclitaxel, an antimitotic drug, the nurse should give the client an antihistamine, such as diphenhydramine, a proton-pump inhibitor, such as cimetidine, and a glucocorticoid, such as dexamethasone, to prevent a hypersensitivity reaction.Paclitaxel is incompatible with PVC tubing.Paclitaxel requires administration through an in-line filter.
A nurse is preparing a client who has a new prescription for maraviroc therapy. The nurse should instruct the client to report which of the following adverse effects. (Select all that apply). Paresthesia Cough Tinnitus Jaundice Fever
-Paresthesia -Cough -Jaundice -Fever
A nurse is caring for a client who has a new prescription for cisplatin to treat testicular cancer. The nurse should instruct the client to report which of the following adverse effects? (Select all that apply). Paresthesia Sore throat Flank pain Tinnitus Conjunctivitis
-Paresthesia -Sore throat -Flank Pain -Tinnitus Cisplatin, a platinum compound, can cause peripheral neuropathy. The nurse should tell the client to report numbness, tingling, or decreased sensation in the hands or feet.Cisplatin can cause bone marrow depression. The nurse should tell the client to report fever, sore throat, bruising, or fatigue.Cisplatin can cause kidney toxicity. Prior to therapy, the nurse should hydrate the client with 1 to 2 L of IV fluid and continue for 24 hr following therapy to flush the kidneys and help prevent kidney toxicity.Cisplatin can cause ototoxicity. The nurse should monitor the client's hearing and instruct the client to report hearing loss, vertigo, or tinnitus.
A nurse is teaching a client who has a new prescription for mercaptopurine to treat leukemia. Which of the following instructions should the nurse include? (Select all that apply). Use contraception if pregnancy is a risk. Perform oral hygiene frequently. Avoid activities that require mental alertness. Perform hand hygiene frequently. Avoid activities that can cause injury.
-Use contraception if pregnancy is a risk -Perform oral hygiene frequently. -Perform hand hygiene frequently. -Avoid activities that can cause injury. Mercaptopurine, a purine analog, is a pregnancy risk category D drug. Clients of childbearing age who take the drug should use contraception, and the nurse should confirm nonpregnancy before starting therapy.Mercaptopurine can cause stomatitis. The nurse should instruct the client to perform frequent oral hygiene to help prevent or minimize this adverse effect.Mercaptopurine can cause neutropenia. The nurse should instruct the client to wash hands thoroughly or use an alcohol-based hand rub frequently and to avoid crowds and contact with people who have communicable infections.Mercaptopurine can cause thrombocytopenia. The nurse should monitor the client's CBC throughout treatment and instruct the client to avoid activities that can cause injury and report any unexplained bruising or bleeding.
A nurse is teaching a guardian of a child about the recommended age range to receive the human papillomavirus (HPV) vaccine. Which of the following age ranges should the nurse include? 11 to 12 years old 7 to 9 years old 13 to 15 years old 15 to 17 years old
11 to 12 years old
A nurse should recognize that enfuvirtide can be prescribed to clients who have which of the following conditions? Advanced prostate cancer Primary brain tumors Advanced HIV Metastatic ovarian cancer
Advanced HIV Enfuvirtide, a fusion inhibitor, treats HIV that is advanced or resistant to other types of treatment. The nurse should always administer the drug with other antiretroviral drugs.
A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a child. The nurse should recognize that the MMR vaccine provides which of the following types of immunity? Artificial active immunity Active Passive Artificial passive immunity
Artificial active immunity The nurse should recognize that the MMR vaccine provides artificial active immunity to the child. A vaccine contains a form of the disease that is live, attenuated, or killed, which will allow the body to build up an active immunity against the disease.
A nurse should recognize that maraviroc is used in the treatment of which of the following conditions? Diabetes mellitus Meningeal infection Pancreatitis Chemokine receptor 5 (CCR5)-tropic HIV-1
Chemokine receptor 5 (CCR5)-tropic HIV-1 Maraviroc, a CCR5 antagonist, acts by binding to CCR5 and preventing HIV-1 from entering the cell. It is used in the treatment of clients who have CCR5-tropic HIV-1.
A nurse is teaching a client who has a new prescription for imatinib to treat chronic myeloid leukemia. Which of the following instructions should the nurse include? (Select all that apply). Clean fruits and vegetables thoroughly. Increase calcium intake. Weigh yourself daily. Perform hand hygiene frequently. Avoid grapefruit and grapefruit juice.
Clean fruits and vegetables thoroughly. Weigh yourself daily. Perform hand hygiene frequently. Avoid grapefruit and grapefruit juice. Imatinib, a targeted antineoplastic drug, can cause bone marrow suppression. The nurse should instruct the client to clean fruits and vegetables carefully and completely to prevent transmission of bacteria.Imatinib can cause fluid retention and weight gain. The nurse should instruct the client to record daily weights and monitor for edema.Imatinib can cause bone marrow suppression. The nurse should instruct the client to wash hands or use an alcohol-based hand rub frequently and to avoid exposure to illness. Grapefruit and grapefruit juice can cause the blood levels of imatinib to be higher than normal. The nurse should instruct the client to avoid grapefruit and grapefruit juice during therapy.
A nurse is teaching a client who has a new diagnosis of breast cancer about the drug tamoxifen. The nurse should tell the client that which of the following conditions is a contraindication for taking tamoxifen? Deep-vein thrombosis COPD Diabetes mellitus Alcohol use disorder
Deep Vein Thrombosis Tamoxifen, an estrogen receptor blocker, can cause thromboembolism. Its use requires cautious use with clients who have deep-vein thrombosis.
A nurse is caring for a client who has a new prescription for intrathecal cytarabine therapy to treat meningeal leukemia. The nurse should inform the client that they will also receive which of the following drugs to reduce the risk of neurotoxicity? Diphenhydramine Leucovorin Folic acid Dexamethasone
Dexamethasone Clients who have a prescription for the intrathecal form of cytarabine should also receive dexamethasone, a glucocorticoid, to help decrease the inflammation of the arachnoid that the drug can cause. IV dexamethasone reduces the client's risk for neurotoxicity.
A nurse is teaching the guardian of a 4- month- old infant about recommended immunizations for the infant. Which of the following immunizations should the nurse include? Haemophilus influenzae type B vaccine (Hib) Varicella vaccine Meningococcal conjugate vaccine (MCV4) Tetanus-diphtheria-acelluar pertussis vaccine (Tdap)
Haemophilus influenza type B vaccine (Hib) The nurse should inform the guardian that the Haemophilus influenzae type B vaccine (Hib) is recommended for infants and children to prevent a serious type of meningitis commonly seen in young children.
A nurse is caring for a client who is prescribed zidovudine. Which of the following laboratory values should the nurse report to the provider? Hemoglobin 7.1 g/dL RBC count 5.2/mm3 Neutrophil 57% Triglycerides 125 mg/dL
Hemoglobin 7.1 g/dL The provider might consider dose reduction, discontinuation of therapy, or blood transfusions if the client's hemoglobin is less than 7.5 g/dL or has a reduction of greater than 25% from baseline.
A nurse is teaching a client about recommended immunizations. Which of the following immunizations should the nurse recommend the client receive starting at 50 years of age? Herpes zoster vaccine Human papillomavirus vaccine (HPV) Pneumococcal vaccine Haemophilus influenzae type B vaccine (Hib)
Herpes zoster vaccine The herpes zoster, or shingles vaccine, is recommended for adults older than 50 years of age.
A nurse is caring for a client who has a new prescription for topotecan therapy to treat resistant, small-cell lung cancer. The nurse should advise the client against taking which of the following types of over-the-counter drugs while receiving the therapy? Folic acid St. John's wort Ibuprofen Aluminum hydroxide
Ibuprofen NSAIDs, anticoagulants, and antiplatelet drugs increase the client's risk for bleeding while receiving topotecan, a topoisomerase inhibitor. The nurse should advise the client against taking aspirin, ibuprofen, and other NSAIDs during therapy.
A nurse is caring for a client who has a new prescription for delavirdine therapy to treat HIV-1. The nurse should instruct the client to report which of the following adverse reactions to this drug? Rash Insomnia Rhinitis Alopecia
Rash Delavirdine, a non-nucleoside reverse transcriptase inhibitor, can cause a rash. The nurse should instruct the client to report a rash, which can occur 1 to 3 weeks after therapy, because it can develop into Stevens-Johnson syndrome, a potentially life-threatening complication.
A nurse should recognize that raltegravir is used to treat clients who have which of the following conditions? Hairy cell leukemia Thyroid cancer Kaposi's sarcoma Resistant HIV
Resistant HIV Raltegravir, an integrase inhibitor, along with other antiretroviral drugs, treats HIV that is resistant to other drugs. The nurse should administer raltegravir with other antiretroviral drugs.
A nurse is caring for a client who has a new prescription for ritonavir and zidovudine therapy to treat HIV-1. The nurse should inform the client that zidovudine is prescribed with ritonavir for which of the following reasons? To prevent an infusion reaction To increase platelet production To protect healthy cells from the toxic effects of ritonavir To prevent drug resistance
To prevent drug resistance The nurse should explain that zidovudine, a nucleoside reverse transcriptase inhibitor, is administered along with ritonavir, a protease inhibitor, to reduce the risk for drug resistance and to increase drug effectiveness. Monotherapy with zidovudine quickly results in drug resistance, as is also the case with monotherapy with ritonavir.
A nurse is considering drug therapy options for a client who has metastatic breast cancer that is positive for human epidermal growth factor receptor 2 (HER2). Which of the following drugs should the nurse expect the provider to prescribe? Trastuzumab Imatinib Leuprolide Flutamide
Trastuzumab Trastuzumab, a monoclonal antibody and a pregnancy risk category D drug, treats and helps control the cell growth of metastatic breast cancer with tumors that overexpress HER2. This form of breast cancer accounts for up to 30% of metastatic breast tumors.
A nurse is caring for a client who is receiving vincristine to treat lung cancer. The nurse should monitor the client and recognize which of the following manifestations as an indication that the client is experiencing an adverse reaction to the drug. Weak hand grasps Constricted pupils Bradycardia Crackles
Weak hand grasps Vincristine, a vinca alkaloid, can cause peripheral neuropathy. The nurse should monitor deep-tendon reflexes and the strength and movement of the hands and feet. The nurse should instruct the client to report paresthesia or reduced sensation in the hands or feet.
A nurse is assessing a client following trastuzumab infusion to treat metastatic breast cancer. Which of the following should the nurse recognize as an indication that the client is experiencing an adverse reaction to the drug. (Select all that apply). Wheezing Dysrhythmias Hypotension Fever Ascites
Wheezing Dysrhythmias Hypotension Fever