NCLEX-RN Immunity

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?

Correct response: a hemolytic allergic reaction caused by an antigen reaction

The nurse is caring for a 2-year-old child with cancer. The parents have been told that the child will need an allogeneic bone marrow transplant and want to know what this means. What is the best response by the nurse?

Correct response: "A donor is determined after testing for similar human leukocyte antigens."

A nurse is evaluating the parents' comprehension of their child's diagnosis of celiac disease. Which statements indicate a need for further teaching?

Correct response: "We will need to bring our child in for regular blood work to monitor the disease."

What should the nurse teach the parent of a 3-year-old child with eczema to remove from the child's environment at home?

Correct response: stuffed animals

A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity?

Correct response: swimming in rivers or lakes

The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?

Correct response: Reed-Sternberg cells.

The nurse is caring for a 68-year-old male client with new-onset fever, chills, and myalgia. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Action to Take: Monitor body temperature. Teach the client and family how to reduce risk of infection. Potential Conditions acute myeloid leukemia (AML) Parameter to Monitor neutrophil count platelet count

At a 6-month well-child check, an infant has a high fever and cold symptoms and is diagnosed with otitis media. The child is scheduled to receive the 6-month immunizations. The parent asks the nurse if the child will receive them. What is the nurse's best response?

Correct response: "Make an appointment to come back for the immunizations after your child has finished the antibiotics."

A 12-month-old child is seen in the neighborhood clinic for a regular checkup. Which statement by the child's mother about the influenza vaccine reflects the need for more teaching?

Correct response: "The Haemophilus influenzae vaccine my child has already received helps protect against some forms of the flu."

The parents of a toddler do not want their child to have a varicella immunization, stating, "My child will have better immunity if he or she gets the disease now." Which is the nurse's best response?

Correct response: "If the child contracts the disease, it could be very serious, even life threatening."

A preschooler with a history of repaired lumbar myelomeningocele is in the emergency department with wheezing and skin rash. Which question should the nurse ask the parent first?

Correct response: "Is your child allergic to bananas or any other food?"

The emergency department (ED) nurse is caring for a 48-year-old female client with anaphylaxis. For each potential intervention, click to specify whether the intervention is indicated or contraindicated.

Indicated: Teach about anaphylaxis prevention and treatment. Monitor airway for bronchospasm and edema. Teach family members how to use an epinephrine autoinjector. Advise the client to wear an allergy-alert bracelet. Contraindicated: Continue treatment of cellulitis with ampicillin. Prepare the client for imminent discharge.

When caring for a multiparous client who is human immunodeficiency virus (HIV) positive and asking to breastfeed her neonate as soon as possible, the nurse should include which instructions about breast milk in the teaching plan?

Correct response: It has been found to contain the retrovirus HIV.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?

Correct response: Pregnancy should be avoided for 4 weeks after the immunization.

A nurse is assessing whether a 6-year-old child has received all required immunizations. Which immunizations does the nurse expect to be documented?

Correct response: diphtheria, tetanus, and acellular pertussis (DTaP); measles, mumps, and rubella (MMR); and inactivated polio virus (IPV)

The nurse is teaching the parent of a preschool-age child with celiac disease about a gluten-free diet. The nurse determines that teaching has been successful when the parent tells the nurse she will prepare which breakfast for the child?

Correct response: eggs and orange juice

The nurse is instructing the mother of a child with asthma about noting food triggers for asthma attacks. Which foods would most likely be responsible for causing an allergic reaction?

Correct response: fish

Which family member exposed to tuberculosis would be at highest risk for contracting the disease?

Correct response: 76-year-old grandmother

A nurse is monitoring a client who developed facial edema after receiving a medication by tablet. What should the nurse do next?

Correct response: Assess for shortness of breath.

A nurse is reviewing the medication administration record and is getting ready to administer the flu vaccine. Prior to administering the vaccine, the client's spouse asks about getting the vaccine. Which locations will administer the flu vaccine to a client who does not have a primary care provider? Select all that apply.

Correct response: health department pharmacy urgent care clinic

A nurse is caring for a client with who is prescribed zidovudine. About which laboratory findings will the nurse alert the health care provider as a priority?

Correct response: hemoglobin of 11.2 g/dL (112 g/L) compared with 15.0 g/dL (150 g/L) 1 month ago

The nurse is developing a primary disease prevention program for older adults. Which topic is the most appropriate?

Correct response: immunizations for influenza

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?

You Selected: "I can eat whatever I want as long as it's low in fat."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

Correct response: "The paralysis caused by this disease is usually temporary."

The parents of a 12-year-old girl ask why their daughter, who is not sexually active, should receive the human papillomavirus (HPV) vaccine. What should the nurse should tell the parents?

Correct response: "The vaccine is most effective against cervical cancer if given before becoming sexually active."

A nurse who is 6 months pregnant is assigned to a client with a diagnosis of HIV. The nurse tells the manager that she is unable to care for the client because it would be a risk to her baby. Which is the most appropriate statement by the manager?

Correct response: "You will be OK if you follow standard precautions and use protective equipment to avoid contact with blood and body fluids when providing care."

A nurse is providing health teaching about pediatric immunizations to the parents of a child. Which of the following is the most appropriate information for the nurse to give the parents about immunizations?

Correct response: "Your child may need medication for a low-grade fever."

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

Correct response: A positive reaction indicates that the client has been exposed to the disease.

A nurse is preparing immunizations for a child being treated for leukemia. Which immunization will the nurse hold at this time?

Correct response: chickenpox

The client who is 28 weeks gestation is at the obstetric (OB) clinic reviewing lab work. The human immunodeficiency virus (HIV) test is positive, and treatment is indicated. Which medication should the nurse expect to administer that will help to prevent transmission of the virus to the fetus?

Correct response: zidovudine

The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use?

Correct response: Contact the health care provider at first signs of an infection.

A healthy 2-month-old infant is being seen in the local clinic for a well-child checkup and initial immunizations. When analyzing the pediatric record, which immunizations would the nurse anticipate administering at this appointment? Select all that apply.

Correct response: DTaP (diphtheria, tetanus, and acellular pertussis) IPV (inactivated polio vaccine) Hib (Haemophilus influenzae vaccine) PCV (pneumococcal vaccine)

When developing a teaching plan for the parent of an asthmatic child concerning measures to reduce allergic triggers, which suggestion should the nurse include?

Correct response: Have the child bring his or her own pillow when sleeping away from home.

A normal, healthy 2-month old infant is brought to the clinic for the first diphtheria, tetanus, and acellular pertussis (DTaP) immunization. Which route is appropriate to administer this vaccine?

Correct response: IM

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?

Correct response: IgE

Which would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia?

Correct response: Obtain influenza and pneumococcal vaccines.

Propylthiouracil (PTU) is prescribed for a client with Graves' disease. Which symptom should the nurse teach the client to report?

Correct response: sore throat

When explaining the long-term toxic effects of cancer treatments on the immune system, what should the nurse tell the client? You Selected: The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment.

Correct response: The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment.

The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. What information should the nurse give to the clients?

Correct response: Two parents who are carriers may produce a child who has the disease.

A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis (RA). Which medical facts about RA are essential in developing a plan of care? Select all that apply.

Correct response: The client experiences stiff, swollen joints bilaterally. Erythrocyte sedimentation rate (ESR) is elevated, and x-rays show erosions and decalcification of involved joints. Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators.

A client diagnosed with leukemia is now experiencing neutropenia. Which assessment related to neutropenia is a priority for the nurse?

Correct response: Breath sounds

A client infected with human immunodeficiency virus (HIV) has a low CD4+ level. What intervention should the nurse implement?

Correct response: Place the client in reverse isolation.

A 12-year-old child sustains a moderate burn injury. The parent reports that the child last received a tetanus injection at 5 years of age. Which immunization would the nurse anticipate for this child?

Correct response: 0.5 ml of tetanus toxoid I.M.

An infant is to receive the diphtheria, tetanus, and acellular pertussis (DTaP) and inactivated polio vaccine (IPV) immunizations. The child is recovering from a cold and is afebrile. The child's sibling has cancer and is receiving chemotherapy. Which action is most appropriate?

Correct response: Administer the DTaP and IPV immunizations.

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Correct response: Administration of Rho(D) immune globulin I.M. to the mother within 72 hours

A client is experiencing an allergic response. The nurse should perform the actions in which order from first to last? All options must be used.

Correct response: Assess the airway and breathing pattern. Assess for urticaria. Activate the rapid response team. Notify the health care provider (HCP).

A school-age child with leukemia is taking immunosuppressive drugs. What health maintenance recommendation should the nurse include in the teaching plan?

Correct response: Avoid any live attenuated vaccines.

Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium?

Correct response: rubella counseling and immunization with live rubella virus vaccine

The nurse is working in the mother-baby unit. To which client would the nurse anticipate giving Rho(D) immune globulin (human)?

Correct response: the Rh-negative mother with an Rh-positive baby

The nurse is preparing to administer a flu shot to an adult client. How would the nurse proceed? Place the steps in sequential order. All options must be used.

Correct response: Put gloves on. Locate the deltoid muscle. Clean the injection site with an alcohol pad. Gently stretch the skin taut at the site. Inject it into the muscle at a 90-degree angle. Wait 10 seconds before removing needle.

A client is diagnosed with human immunodeficiency virus (HIV). What information does the nurse provide to best protect the client from advancing to the acquired immunodeficiency syndrome (AIDS) phase of this infection?

Correct response: Strictly adhere to antiviral medication therapy.

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client?

Correct response: The client will need Rh immunoglobulin injection within 72 hours

When explaining the long-term toxic effects of cancer treatments on the immune system, what should the nurse tell the client?

Correct response: The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment.

The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply.

Correct response: Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times.

The nurse is preparing to administer the measles-mumps-rubella (MMR) and varicella vaccines to an infant who has an egg allergy and a wheat allergy. Which is the appropriate action by the nurse?

Correct response: administer both vaccines

A 7-year-old has been diagnosed with bacterial meningitis. Who should receive chemoprophylaxis?

Correct response: all household contacts and close contacts

A nurse practicing in a clinic cares for an 8-year-old client with an upper respiratory tract infection, sinusitis, and elevated immunoglobulin (Ig) E levels. What is the next action by the nurse?

Correct response: ask about allergy history

When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem?

Correct response: aspiration

A client is Rh(D)-negative and D-negative and hasn't formed Rh antibodies. When should the client receive RHO(D) immune globulin (RhoGAM) to prevent isoimmunization?

Correct response: at about 28 weeks' gestation and again within 72 hours after birth

A client has a positive reaction to the Mantoux test. How should the nurse interpret this reaction? The client has:

Correct response: been exposed to Mycobacterium tuberculosis.

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child?

Correct response: being an infant

The nurse reviews the laboratory report of a child with leukemia (see exhibit). What does the nurse determine is the priority problem for this client?

Correct response: bleeding

A client has given birth to a preterm neonate. The client tells the nurse that she wants to breast-feed her neonate. The nurse should explain to the mother that

Correct response: breast milk contains antibodies that help protect her neonate.

Which clients will the nurse place in reverse isolation? Select all that apply.

Correct response: client with a white blood cell count (WBC) of 600 µL with a granulocyte count of 100 µL client with a burn injury involving > 30% of the total body surface area (TBSA)

The nurse is assigning a room for a client admitted with hepatitis A. Which diagnosis would be an appropriate roommate for this client?

Correct response: congestive heart failure

While attending a support group, the parents of a child with hemophilia become concerned because they heard stories about how many children with hemophilia have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which as the most likely route of transmission of AIDS to these children?

Correct response: contamination of the factor VIII replacement received during bleeding episodes

After determining that a pregnant client is Rh-negative, a physician orders an indirect Coombs' test. The purpose of performing this test with a pregnant client is to:

Correct response: detect maternal antibodies against fetal Rh-positive factor.

A nurse is teaching a client who has a severe allergy to bee stings how to manage a reaction. What medication does the nurse encourage the client to take first after being stung by a bee?

Correct response: epinephrine

After teaching the parents of a child with celiac disease about diet, the nurse understands the teaching has been effective if the parents state that which foods should be avoided? Select all that apply.

Correct response: hot dog buns bologna on rye sandwich

A parent tells the nurse that the parent's preschool-aged child with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently the child had an allergic reaction after eating kiwi fruit and bananas. Based on the parent's report, the nurse suspects that the child may have an allergy to

Correct response: latex.

A client was diagnosed with AIDS several years ago and now has a CD4 T-lymphocyte count of 110 units/L. Which outcome is appropriate for this client?

Correct response: no development of opportunistic infections

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information?

Correct response: presence of maternal antibodies

A client's blood test results are: white blood cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which goal is most important for this client?

Correct response: prevent infection

Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for

Correct response: removal of the transplanted kidney.

A client with severe arthritis has been receiving maintenance therapy of prednisone 10 mg/day for the past 6 weeks. The nurse should instruct the client to immediately report which symptom?

Correct response: respiratory infection

A nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity

Correct response: results from exposure of an antigen through immunization or disease contact.

An 8-year-old child has been admitted to the oncology unit with a suspected diagnosis of acute lymphoblastic leukemia. The nurse is obtaining a health history from the parents. During the interview, the parents ask the nurse if any of the factors discussed would make their child more at risk for this type of leukemia. What information about potential risk factors is correct for the nurse to share with the parents?

Correct response: the diagnosis of Down's syndrome at birth

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason?

Correct response: to prevent Rh-positive sensitization with the next pregnancy

A multidisciplinary oncology team of health care providers, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply.

Correct response: decreased white blood cells decreased platelets decreased RBCs

A client with AIDS develops a fever, severe headache, and stiff neck and begins to vomit. Family members state they have noticed that the client does not seem to be as alert and oriented as before. What is the nurse's priority intervention?

Correct response: protecting the client's airway

When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which factor as the basis for the discussion?

Correct response: autosomal recessive gene

During a well-baby visit, a 2-month-old infant receives a diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. How does the nurse respond?

Correct response: "This vaccine protects against serious bacterial infections, such as meningitis."

The nurse in the dermatology clinic is caring for a 32-year-old female client with skin lesions. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to Take: Use birth control while taking methotrexate and for 3 months after stopping it. Do not drink alcohol while taking methotrexate. Potential Conditions psoriasis Parameters to Monitor liver function tests complete blood count