Immunity
Receiving chemotherapy for bone marrow suppression?
"Bathe with an antimicrobial soap twice per day." The nurse should instruct the client to bathe twice per day with an antimicrobial soap to decrease their exposure to micro-organisms. A client who has bone marrow suppression is at increased risk for infection. Wrong "Clean your toothbrush with warm water weekly." The nurse should instruct the client to clean their toothbrush weekly with liquid bleach or run the toothbrush through the dishwasher to destroy micro-organisms. A client who has bone marrow suppression is at increased risk for infection. "Take aspirin for minor aches and pains." The nurse should instruct the client not to take aspirin or other platelet inhibitors because a client who has bone marrow suppression is at increased risk for bleeding. "Wear clothing that will minimize sun exposure." MY ANSWER Sun exposure does not pose a risk to a client who is receiving chemotherapy. However, the nurse should instruct the client to use skin protection when spending time in the sun. Furthermore, the nurse should instruct the client to wear clothing that does not rub to prevent bruising or bleeding.
A nurse is providing discharge teaching for a client who is HIV-positive. Which of the following instructions should the nurse include in the teaching?
"I should discard open beverages that have been unrefrigerated for 1 hr." The nurse should instruct the client to discard beverages that have been unrefrigerated for 1 hr. Bacteria can grow in open, unrefrigerated beverages, which places the client at risk for infection. WRONG "I will clean the bathroom surfaces with full-strength bleach." The nurse should instruct the client to clean bathroom surfaces with a 10% bleach solution. "I should wash laundry that is soiled with a body fluid in cool water."The nurse should instruct the client to wash laundry that is soiled by a body fluid in hot water. "I will work in the garden for exercise."The nurse should instruct the client to avoid working in the garden because it places the client in close proximity to the bacteria in plants and soil.
A nurse is providing teaching for a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?
"I should wear gloves when it is cold outside." Raynaud's phenomenon commonly accompanies SLE and can cause painful vasoconstriction in the client's fingers when exposed to cold temperatures. Wrong "SLE should not affect my lungs or breathing." SLE can affect all of a client's body systems. Therefore, SLE can cause pleural effusions and pneumonia. "Long-term immunosuppressive therapy could cure this disease." SLE is a lifelong chronic autoimmune disease. "I should use a sunscreen with an SPF of at least 15." The client should select a sunscreen with an SPF of at least 30.
A nurse is providing teaching for a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following should the nurse include in the teaching?
"I will avoid being in large crowds while taking this medication." The nurse should instruct the client to avoid crowds when taking methotrexate. Methotrexate can cause leukopenia due to bone marrow suppression, which can increase the client's risk for infection. WRONG "I should expect symptoms to subside in 1 to 2 weeks after starting this medication." The nurse should inform the client that it takes 4 to 6 weeks for the manifestations of rheumatoid arthritis to respond to methotrexate therapy. "I will increase my intake of vitamin D while taking this medication." The nurse should instruct the client to increase their intake of folic acid, not vitamin D, to help decrease the adverse effects of methotrexate. "I should expect to experience constipation while taking this medication." The nurse should inform the client that diarrhea is an adverse effect of methotrexate.
A nurse is providing teaching to a client who takes an oral contraceptive and has a new prescription for amoxicillin. Which of the following statements by the client indicates an understanding fo the teaching.
"I will use a backup method of birth control while I am taking this medication." The nurse should inform the client that antibiotics accelerate the elimination of oral contraceptives, making them less effective. Wrong "I should take this medication on an empty stomach."The nurse should inform the client that they should take the medication with food to decrease gastrointestinal side effects. "I should expect to have constipation while taking this medication."The nurse should inform the client that diarrhea is an adverse effect of amoxicillin. "I will keep taking this medication until I feel better."The nurse should instruct the client to take the full dose of antibiotics, even if the condition improves, to ensure the infection is eliminated.
A nurse is planning an education program for a group of high school teachers who will be taking students on a hike. Which of the following information should the nurse include regarding Lyme disease?
"If you develop pain and stiffness in your joints, you should see your doctor." The nurse should inform the group that manifestations of stage 1 Lyme disease include influenza-like manifestations, a "bull's-eye" rash, muscle and joint pain, and stiffness. The nurse should instruct the group to report these findings to a provider. Wrong "If bitten by a tick, you should be tested immediately."The nurse should instruct the group to be tested for Lyme disease 4 to 6 weeks after being bitten by a tick because earlier testing is not reliable. "If you have a tick embedded in your skin, apply a lit match to remove it."The nurse should instruct the group not to use a lit match to remove a tick because this action can increase the risk for spreading an infection. The nurse should instruct the group to gently remove ticks with tweezers. "You should wear dark-colored clothing to deter ticks from biting."The nurse should instruct the group to wear light colors so ticks on the body can be seen easily.
A nurse is caring for a client who reports a skin change on her arm. Which of the following findings should the nurse report to the provider?
An asymmetrical papule that is pigmented The nurse should identify an asymmetrical papule that is pigmented as an indication of a malignant melanoma. The nurse should report the client's skin change to the provider. Wrong A patch of silvery-white scales with a red epidermal baseThe nurse should identify a patch of silvery-white scales with a red epidermal base as a manifestation of psoriasis, which does not need to be reported to the provider. A collection of irregular, dry papules that are blackThe nurse should identify a collection of irregular, dry papules that are black in color as a manifestation of seborrheic keratosis, which does not need to be reported to the provider. An elevated red lesion that arises from a scarThe nurse should identify an elevated red lesion that arises from a scar as a manifestation of a keloid, which does not need to be reported to the provider.
A nurse is providing care for four clients. Which of the following clients is at the greatest risk for pneumonia?
An older adult client who has dysphagia MY ANSWER An older adult client who has dysphagia is at the greatest risk for pneumonia due to the increased risk for aspiration when eating. Wrong A middle adult client who is using an incentive spirometer following surgery A middle adult client who is postoperative is at risk for pneumonia. However, since the client is using an incentive spirometer to prevent pneumonia, another client is at greater risk. A young adult client who is living in a college dormitory A young adult client who is living in a college dormitory is at risk for pneumonia, especially when in a crowded area during influenza season. However, another client is at greater risk. A school-age child who has a history of asthmaA school-age child who has a history of asthma is at risk for pneumonia, especially if the child's equipment is not well-maintained and decontaminated. However, another client is at greater risk.
A nurse is providing teaching for a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses by the nurse is appropriate?
Ask a friend or a family member to help with household chores." The nurse should instruct the client to allow others to assist with household chores to reduce the risk for joint injury and to give the client the opportunity to rest. Wrong "Take a cool bath in the evening."The nurse should instruct the client to take a warm shower instead of a tub bath due to the difficulty the client can experience getting in and out of the tub. A warm shower can also relax muscles and reduce pain. "Exercise every other day."The nurse should instruct the client to exercise daily but to balance activity with rest. "Use pillows to support your joints while in bed."The nurse should instruct the client to use only one small pillow, placed behind the head, while in bed to prevent flexion contractures.
A nurse is providing teaching for a client who has Hodgkin's lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include?
Avoid direct sun exposure to the skin. The nurse should instruct the client to avoid sun exposure because the client's skin is sensitive to sunburn due to the external radiation. WRONG Use an antibacterial soap to cleanse the skin.The nurse should instruct the client to cleanse their skin with mild soap and water because the client's skin is fragile due to the external radiation. The client should avoid antibacterial soaps because they can irritate the skin. Wash the ink marking off when showering.The nurse should instruct the client not to remove the ink or dye markings because they identify the location of the site that is being radiated. Rub the skin with a towel when drying.The nurse should instruct the client to pat, rather than rub, the skin dry to avoid damage to the skin.
A nurse is performing a breast examination on a female client who is pregnant. Which of the following findings should the nurse report to the provider?
Breast tissue with an orange-peel appearance The nurse should report an orange-peel appearance of the client's skin because this can indicate a blockage of lymph channels, which is a manifestation of advanced breast cancer. Wrong Slight asymmetrical breast size The nurse should identify that slight asymmetrical breast size is a common finding. The nurse should report a significant difference in breast size because this can indicate inflammation or a tumor. Nipple inversion of one breast since puberty The nurse should report a recent inversion of a client's nipple because it can indicate a malignant tumor; however, the nurse does not need to report a nipple inversion since puberty. Elevated Montgomery's glandsThe nurse should not report elevated Montgomery's glands because this is an expected finding for a client who is pregnant.
A nurse is providing teaching for a client who has an allergy to peanuts. Which of the following instructions is the priority to include in the teaching?
Carry an emergency anaphylaxis kit. The greatest risk to the client is injury or death from an anaphylactic reaction. Therefore, the priority instruction for the client is to be prepared for emergency treatment by carrying an emergency anaphylaxis kit. Wrong Inform other health care professionals of the allergy. The nurse should instruct the client to inform other health care professionals of the allergy. However, this is not the priority instruction to include in the teaching. Wear a medical identification tag.The nurse should instruct the client to wear a medical identification tag. However, this is not the priority instruction to include in the teaching. Keep a food diary. The nurse should instruct the client to keep a food diary to identify other food allergies. However, this is not the priority instruction to include in the teaching.
A nurse is providing teaching for a client who is scheduled for a Papnicolaou (Pap) test. The nurse should instruct the client that she is being tested for which of the following?
Cervical cancer The nurse should inform the client that a Pap test is used to screen for cervical cancer. Wrong Uterine cancer The nurse should inform the client that a transvaginal ultrasound, along with an endometrial biopsy, is used to screen for uterine cancer. Ovarian cysts The nurse should inform the client that a pelvic examination, along with a transvaginal ultrasound, is used to screen for ovarian cysts. Fibroids The nurse should inform the client that a pelvic examination, along with a transvaginal ultrasound, is used to screen for fibroids.
A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to the nurse that medication therapy is effective?
Decreased viral load MY ANSWER The nurse should recognize that a client who has HIV and is receiving medication therapy should display a decreasing viral protein amount in the blood, indicating a positive response to the medication therapy. Wrong WBC count 3,500/mm3 The nurse should recognize that a WBC count of 3,500/mm3 is lower than the expected reference range for a client who has HIV and does not indicate that the medication therapy is effective. Lymphocyte 1,400/mm3 The nurse should recognize that a client who has HIV can have lymphocyte values below 1,500/mm3, which does not indicate that the medication therapy is effective. Low CD4/CD8 ratioThe nurse should recognize that a low or decreasing ratio of CD4/CD8 cells in a client who has HIV indicates disease progression and does not indicate that the medication therapy is effective
A nurse is caring for a client who has an elevated prostate-specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic tests?
Digital rectal examination The nurse should recognize that a digital rectal examination is used to determine the size and consistency of the prostate, assisting with the differentiation between benign prostatic hypertrophy and prostate cancer. Wrong Palpation of testes The nurse should recognize that palpation of a client's testes is used to screen for testicular cancer, not prostate cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer. Human chorionic gonadotropin level The nurse should recognize that human chorionic gonadotropin is used to diagnose testicular cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer. Pelvic ultrasound The nurse should recognize that a transrectal ultrasound, not a pelvic ultrasound, is used to screen for prostate cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer.
A nurse in the emergency department is assessing a newly admitted client. Which of the following places the client at risk for contracting hepatitis B?
Engaging in unprotected sexual intercourse MY ANSWER A client who engages in unprotected sexual intercourse is at increased risk because hepatitis B is transmitted by sexual contact. WRONG Residing in an institutional setting A client who resides in an institutional setting is not at increased risk because hepatitis B is not transmitted by casual contact or through contaminated food and water. Working with hazardous chemical waste materialsA client who works with hazardous chemical waste materials is not at increased risk because hepatitis B is not transmitted by chemical waste. Traveling to a foreign country A client who travels to foreign countries is not at increased risk because hepatitis B is not transmitted by casual contact or through contaminated food and water.
A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding?
Erythema at the IV insertion site MY ANSWER The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema at the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding. Wrong Mucositis of the oral cavity Sores in the mouth is an expected adverse effect of chemotherapy. Therefore, another assessment finding is the priority. Report of anorexia Anorexia and weight loss are expected adverse effects of chemotherapy. Therefore, another assessment finding is the priority. Loss of body hair Loss of body hair is an expected adverse effect of chemotherapy. Therefore, another assessment finding is the priority.
A nurse is planning an education program about testicular cancer for a group of male adolescents. Which of the following information should the nurse include?
Examine the testicles immediately after showering. The client should perform a testicular self-examination on a monthly basis by examining the testicles after a bath or shower to allow for easier palpation. Wrong Testicular cancer is more common in males who are older than 65.Males who are between the ages of 15 to 39 have an increased risk for developing testicular cancer. With early treatment, the survival rate is 50%.The survival rate for testicular cancer, when diagnosed and treated early, is nearly 100%. Schedule an annual ultrasound to screen for testicular cancer. Ultrasounds are not used to screen for testicular cancer. However, if there is a change in testicular size, shape, or texture, the provider might schedule an ultrasound.
A nurse is caring for a client who has viral pneumonia and a history of COPD. Which of the following findings should the nurse report to the provider?
Left shift in WBC differential When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a left shift in the client's WBC differential, which indicates that the pneumonia is of bacterial origin, rather than viral. The left shift can be a manifestation of sepsis, and the nurse should report this finding to the provider. Wrong Crackles heard on auscultation MY ANSWER Crackles heard on auscultation is nonurgent because it is an expected finding for a client who has pneumonia. Therefore, the nurse should report another finding first. Oxygen saturation 93% An oxygen saturation of 93% is nonurgent because it is an expected finding for a client who has pneumonia. Tissues are adequately provided with oxygen when a client has an oxygen saturation of 92% to 100%. Therefore, the nurse should report another finding first. Negative blood culture A negative blood culture is nonurgent because it indicates that the client does not have a systemic infection caused by the pneumonia. Therefore, the nurse should report another finding first.
A nurse is providing teaching for a group of clients regarding prevention of skin cancer. Which of the following risk factors should the nurse include in the teaching?
Light skin pigmentation The nurse should inform the clients that light skin pigmentation is a risk factor for the development of skin cancer. WRONG Psoriasis The nurse should inform the clients that psoriasis is not a risk factor for the development of skin cancer. History of frostbite The nurse should inform the clients that a history of frostbite is not a risk factor for the development of skin cancer. Immunodeficiency disorder The nurse should inform the clients that having an immunodeficiency disorder is not a risk factor for the development of skin cancer.
A nurse is caring for a client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect?
Reed-Sternberg cells The nurse should expect to find Reed-Sternberg cells, which are cancer cells specific to a client who has Hodgkin's lymphoma, in the client's lymph nodes. Wrong Overgrowth of B-lymphocyte plasma cells The nurse should expect a client who has multiple myeloma to have an overgrowth of B-lymphocyte plasma cells. Epstein-Barr virus The nurse should recognize that the Epstein-Barr virus is associated with the development of Burkitt's lymphoma and Hodgkin's lymphoma. However, it is not a diagnostic finding after the disease has occurred. Overproduction of blast phase cells The nurse should expect a client who has leukemia to have an overproduction of blast phase cells.
A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS?
Small, purple-colored skin lesions MY ANSWER The nurse should identify the presence of small, purple-colored skin lesions as an indication that the client has acquired Kaposi's sarcoma, which is an AIDS-defining illness. WRONG Fever and diarrhea lasting longer than 1 monthThe nurse should identify fever and diarrhea as manifestations of HIV. Persistent, generalized lymphadenopathy The nurse should identify persistent, generalized lymphadenopathy as a manifestation of HIV. CD4-T-cells decreased to 750 cells/mm3 The nurse should identify a CD4-T-cell count of 750 cells/mm3 as an indication that the client has HIV. A diagnosis of AIDS requires the CD4-T-cell count to be below 200 cells/mm3.
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? (Select all that apply.)
Subcutaneous nodules is incorrect. Subcutaneous nodules are manifestations of rheumatoid arthritis. Decreased urine output is correct. Decreased urine output, due to kidney damage, is a manifestation of SLE. Renal calculi is incorrect. Lupus nephritis, not renal calculi, is a manifestation of SLE. Butterfly rash is correct. A scaly rash on the face, commonly known as the "butterfly rash," is a common manifestation of SLE .Joint inflammation is correct. Joint inflammation is a common manifestation of SLE.
A nurse is caring for a client who has leukemia and a platelet count of 48,000/mm3. Which of the following actions should the nurse take?
Test the client's urine and stool for occult blood. A client who is thrombocytopenic is at risk for occult bleeding. Therefore, the nurse should test the client's urine and stool for occult blood. Wrong Administer subcutaneous epoetin alfa. The nurse should not administer epoetin alfa because it is used to treat anemia and is not effective in increasing platelet production. Place the client on contact precautions.The nurse should recognize that thrombocytopenia does not require contact precautions. However, the client might require neutropenic precautions and a private room. Provide the client with a diet that is low in vitamin K. The nurse should not provide the client with a diet that is low in vitamin K because this can further decrease coagulation.
A nurse is caring for a client who has neutropenia. Which of the following findings indicates a need for intervention?
The client's grandchild is visiting and telling the client about the first day of kindergarten. The nurse should limit the client's visitors to healthy adults. A visit from a child who is attending school can place the client at risk for infection due to the client's immunocompromised status. Wrong The client has a grilled ham and cheese sandwich, a banana, and yogurt on their lunch tray.The nurse should recognize that these foods are part of a low-bacteria diet and are acceptable for a client who is immunocompromised. The client's family brings in a silk flower arrangement.The nurse should recognize that the client can have an artificial flower arrangement because it does not pose a risk of infection. The client's assistive personnel places paper cups and plastic utensils in the client's room.The nurse should ensure that the client is provided with individually-wrapped paper and plastic utensils.
A nurse is educating a client who is scheduled for a kidney transplant. Which of the following information regarding hyperacute rejection should the nurse include in the teaching?
The organ will need to be removed if hyperacute rejection occurs. Removing the transplanted organ is the only treatment for hyperacute rejection, due to the widespread clotting cascade that leads to ischemic necrosis of the transplant kidney. Wrong Immunosuppressive therapy is given to reverse hyperacute rejection. Immunosuppressive therapy is not used to reverse hyperacute rejection, but it can prevent chronic rejection of the transplanted kidney. Hyperacute rejection can occur during the first few weeks after the transplant.Hyperacute rejection occurs immediately following transplantation. Acute rejection occurs during the first few weeks following the client's transplant. If hyperacute rejection occurs, the kidney can become enlarged.Enlargement of the transplant kidney due to an inflammatory response is consistent with an acute rejection.
A nurse is providing education for the parent of a child about administration guidelines for the human papilloma virus (HPV) vaccine. Which of the following information should the nurse include?
Three doses are administered to adolescents who start the series after age 15. The nurse should inform the parent that the HPV vaccine is recommended for children beginning at age 11 or 12 years. Children who receive the first dose before age 15 should receive two doses of the HPV vaccine. Adolescents who receive the first dose after age 15 should receive three doses of the HPV vaccine. wrong The vaccine protects against chlamydia. The nurse should inform the parent that the HPV vaccine is not effective against chlamydia. The vaccine does not protect males.The nurse should inform the parent that the HPV vaccine is equally effective for both males and females. One dose is administered at birth and another is administered at age 5. The nurse should inform the parent that the HPV vaccine is recommended for children beginning at 11 or 12 years of age.
A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. To confirm a diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic tests?
Throat culture The nurse should recognize that a throat culture is used to confirm a diagnosis of bacterial pharyngitis by identifying specific micro-organisms present in the pharynx. Wrong Indirect laryngoscopyThe nurse should recognize that an indirect laryngoscopy is used to visually assess pharyngeal structures. Chest x-rayThe nurse should recognize that a chest x-ray is used to identify disorders such as pneumonia and pleural effusions. Monospot test The nurse should recognize that a monospot test is used to detect mononucleosis, which is a viral infection.
A nurse is reviewing the daily laboratory results for a female client who has acute leukemia. Which of the following values is an expected finding?
WBC count 21,000/mm3 The nurse should expect a client who has acute leukemia to have an elevated WBC count. Wrong Hgb 14 g/dL The nurse should expect a client who has acute leukemia to have a decreased Hgb level. Hct 40% The nurse should expect a client who has acute leukemia to have a decreased Hct level. Platelets 170,000/mm3 The nurse should expect a client who has acute leukemia to have a decreased platelet count.
A nurse is caring for a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. The nurse should monitor for and report which of the following findings immediately to the provider?
Watery diarrhea MY ANSWER The greatest risk to this client is pseudomembranous colitis, which is manifested by watery diarrhea. Therefore, the priority finding is diarrhea. The nurse should report this finding to the provider immediately and discontinue the medication. WRONG Vaginitis Vaginitis can indicate the client has developed a superinfection such as Candida albicans, which is an adverse effect of clindamycin. However, another finding is the priority. Furry tongueFurry tongue can indicate the client has developed a superinfection such as Candida albicans, which is an adverse effect of clindamycin. However, another finding is the priority. Nausea and vomitingNausea and vomiting are adverse effects of clindamycin. However, another finding is the priority.
