Saunders Chapter 63. Immune problems & Chapter 64 Immune Medications

3. A client develops an anaphylactic reaction after receiving morphine. The nurse would take which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a primary health care provider (PHCP). 5. Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

- Administer oxygen. - Quickly assess the client's respiratory status. - Document the event, interventions, and client's response. An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the PHCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per PHCP prescription. Documentation of the event, actions taken, and client outcomes needs to be performed. The head of the bed needs to be elevated if the client's blood pressure is normal.

11. A client arrives at the health care clinic and tells the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that the tick was removed and flushed down the toilet. Which actions are most appropriate? Select all that apply. 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client that if this happens again, to never remove the tick but to vigorously scrub the area with an antiseptic.

- Tell the client to avoid any woody, grassy areas that may contain ticks. - Instruct the client to immediately start to take the antibiotics that are prescribed. - Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.

3. Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions would the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

-Monitor liver function studies. -Instruct the client to avoid alcohol. -Instruct the client to avoid exposure to the sun. Ketoconazole is an antifungal medication. There is no reason for the client to restrict fluid intake; in fact, this could be harmful to the client. The medication is hepatotoxic, and the nurse monitors liver function. It is administered with food (not on an empty stomach), and antacids are avoided for 2 hours after taking the medication to ensure absorption. The client is also instructed to avoid alcohol. In addition, the client is instructed to avoid exposure to the sun, because the medication increases photosensitivity

4. The nurse is caring for a client who has been taking a Sulfonamide and would monitor for signs and symptoms of which adverse effects of the medication? Select all that apply. 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects 6. Increased white blood cell (WBC) count

-Nephrotoxicity -Bone marrow suppression -Gastrointestinal (GI) effects Adverse effects of Sulfonamides include nephrotoxicity, bone marrow suppression, GI effects, hepatotoxicity, dermatological effects, and some neurological symptoms including headache, dizziness, vertigo, ataxia, depression, and seizures. Options 1, 2, and 6 are unrelated to these medications.

2. The nurse caring for a client who is taking an Aminoglycoside would monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

-Ototoxicity -Renal toxicity -Dysrhythmias Aminoglycosides are administered to inhibit the growth of bacteria. Adverse effects of this medication include confusion, ototoxicity, renal toxicity, gastrointestinal irritation, palpitations, blood pressure changes, and hypersensitivity reactions. Therefore, the remaining options are incorrect.

13. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

-Record site, date, and time of the test. -Give the client a list of potential allergens if identified.

8. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use only a blood pressure cuff from an electronic device to measure the blood pressure.

-Use nonlatex gloves. -Use medications from glass ampules. -Keep a latex-safe supply cart available in the client's area. -Avoid the use of medication vials that have rubber stoppers.

7. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

1. Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

8. A client who is human immunodeficiency virus seropositive has been taking Stavudine. The nurse would monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Gastrointestinal function

1. Stavudine is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse would monitor the client's gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to this medication.

5. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and would incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1. The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

2. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? 1. "I need to take hot baths because they are relaxing." 2. "I need to sit whenever possible to conserve my energy." 3. "I need to avoid long periods of rest because it causes joint stiffness." 4. "I need to do some exercises, such as walking, when I am not fatigued."

1. To help reduce fatigue in the client with systemic lupus erythematosus, the nurse would instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

1. The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens, and gloves only for the bath

2. Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or if the nurse is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

6. A client calls the nurse in the emergency department and reports being just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action would the nurse take? 1. Advise the client to soak the site in hydrogen peroxide. 2. Ask the client if they ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency department. 4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

2. In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if they ever experienced a bee sting in the past. Option 1 is inappropriate advice. Option 3 is unnecessary. The client would not be told "not to worry."

10. A client is diagnosed with scleroderma. Which intervention would the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

2. Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated, and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present.

9. A client presents at the primary health care provider's office with complaints of a ringlike rash on the upper leg. Which question would the nurse ask first? 1. "Do you have any cats in your home?" 2. "Have you been camping in the last month?" 3. "Have you or close contacts had any flulike symptoms within the last few weeks?" 4. "Have you been in physical contact with anyone who has the same type of rash?"

2. The nurse would ask questions to assist in identifying a cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ringlike rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

7. Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches

3. Amikacin is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the PHCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the PHCP immediately if nausea occurs. If nausea persists or results in vomiting, the PHCP would be notified.

5. The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving Didanosine. The nurse interprets that the client may have the medication discontinued by the primary health care provider if which elevated result is noted? 1. Serum protein level 2. Blood glucose level 3. Serum amylase level 4. Serum creatinine level

3. Didanosine can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

6. The nurse is caring for a postrenal transplantation client taking Cyclosporine. The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. What vital sign is most likely increased? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry

3. Hypertension can occur in a client taking cyclosporine, and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.

12. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3. Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

4. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1. "My skin will have tiny red vesicles." 2. "The presence of the skin vesicles is caused by a virus." 3. "I have an autoimmune disease that causes blistering in the skin." 4. "Red, raised papules and large plaques covered by silvery scales will be present on my skin."

3. Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis.

1. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving Pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of the medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

4. Frequent adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client would be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

14. The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse would question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

4. Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy.