Med Surg - Chapter 13 & 14

The donor T cells are attacking the patients skin cells

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patients skin rash?

A patient who is recovering from an anaphylactic reaction to a bee sting

The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant?

Check for swelling of the patients lips and tongue.

The health care provider asks the nurse whether a patients angioedema has responded to prescribed therapies. Which assessment should the nurse perform?

Consult with the health care provider about giving a lower allergen dose

The nurse, who is reviewing a clinic patients medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate?

Stock the patients room with all the necessary personal protective equipment.

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?

Most infants born to HIV-positive mothers are not infected with the virus

A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, I am very nervous about making my baby sick. Which information will the nurse include when teaching the patient?

Administer skin testing by the cutaneous scratch method.

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Breastfeeding her infant

A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by passive immunity. Which example should the nurse use to explain this type of immunity?

Results of patient-donor cross matching are positive

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon?

Administration of immunosuppressant medications

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient?

IgE

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value?

Discuss a change in antiretroviral therapy.

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient?

I will plan to take oral antihistamines daily before going to work

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching?

The patient has developed acquired immunodeficiency syndrome (AIDS).

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4 + T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

Administer epinephrine.

A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first?

The EIA test will need to be repeated to verify the results.

A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient?

Assess the patients airway.

A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurses priority action?

Can you tell me more about the kind of thoughts that you are having?

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, I feel obsessed with thoughts about dying. Do you think I am just being morbid? Which response by the nurse is best?

Patients ability to comply with ART schedule

A patient who is human immunodeficiency virus (HIV)-infected has a CD4 + cell count of 400/L. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

A, E, C, B, D

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic infusion. b. Give diphenhydramine (Benadryl) IV. c. Inject epinephrine (Adrenalin) IM or IV. d. Prepare an infusion of dopamine (Intropin). e. Start 100% oxygen using a nonrebreather mask.

There is a 2-cm wheal at the site of the allergen injection.

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider?

It is important to participate in a needle-exchange program

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?

Remind the patient about the need to return for retesting to verify the results

A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

The patient will maintain intact perineal skin.

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?

Continue to use contraception while on this medication

A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

B, C

According to the Center for Disease Control (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium difficile (select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

Gamma globulin

An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer?

The patient has a glass of grapefruit juice every day for breakfast.

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patients health history has the most implications for planning patient teaching about the medication at this time?

Consequences of aging on cell-mediated immunity

An older adult patient who is having an annual check-up tells the nurse, I feel fine, and I don't want to pay for all these unnecessary cancer screening tests! Which information should the nurse plan to teach this patient?

Many medications have interactions with antiretroviral drugs

An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching?

Encourage adequate nutrition, exercise, and sleep.

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4 + cell count of 800/L and an undetectable viral load. What is the priority nursing intervention at this time?

Apply a tourniquet above the injection site.

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first?

A, B, C

The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

The patient states, Sometimes I miss a dose of zidovudine (AZT).

The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

Prevention of HIV transmission between sexual partners

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?

Numbness and tingling

The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation?

Explain to the patient that this is an expected finding

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take?

A, B, E

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Continue taking antibiotics until all the medication is gone. b. Antibiotics may sometimes be prescribed to prevent infection. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

Oral saquinavir (Invirase)

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time?

Screening for malignancy

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient?

After a couple of years, it is likely that I will be able to stop taking the cyclosporine.

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

Plasmapheresis will remove antibody-antigen complexes from circulation

The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan?

Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?

Plan to wait in the clinic for 20 to 30 minutes after the testing

Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies?

Viral load testing

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Patient age

Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing?

Check the patients class schedule to help decide when the drugs should be taken.

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Needle stick with a needle and syringe used to draw blood

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patients human immunodeficiency virus (HIV) status is unknown?

Patient who is sneezing after having subcutaneous immunotherapy

Which patient should the nurse assess first?

I had my spleen removed many years ago after a car accident.

Which statement by a patient would alert the nurse to a possible immunodeficiency disorder?

Document the patients allergy history and be alert for any clinical manifestations of a type I latex allergy.

While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate?