ATI MED SURG IMMUNE & INFECTION

A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? A. Hypoglycemia B. Tendinitis C. Infection D. Weight loss

C. Infection

A nurse is caring for client who has human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? A. Protective isolation B. Droplet precautions C. Standard precautions D. Airborne precautions

C. Standard precautions

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? A. Confluent, honey-colored, crusted lesions B. A large, tender nodule located on a hair follicle C. Unilateral, localized, nodular skin lesions D. A fluid-filled vesicular rash in the genital region

C. Unilateral, localized, nodular skin lesions

A nurse is providing discharge instructions to a male client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent the transmission of this sexually transmitted infection (STI)? A. "I will bring my sexual partner for treatment." B. "Now that I've had my first dose of medicine, I can resume sexual activity." C. "Once I have been treated, I don't have to use condoms anymore." D. "Once treatment is complete and I am free of symptoms, I don't have to return to the clinic."

A. "I will bring my sexual partner for treatment."

A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to take methotrexate, even if I'm in remission." B. "I'm thankful that this type of lupus only affects the skin." C. "Each day, I should apply a sunblock with a sun protection factor of 15." D. "A mild fever is common with SLE and usually does not require medical intervention."

A. "I will need to take methotrexate, even if I'm in remission."

A nurse is providing teaching to a client who has a new prescription for alprazolam. Which of the following items is a priority for teaching? A. "This medication can affect your ability to drive or handle mechanical equipment." B. "You should avoid drinking beverages that contain caffeine with this medication." C. "You should avoid taking antacids within 2 hours of this medication." D. "This medication should be taken with or shortly after meals."

A. "This medication can affect your ability to drive or handle mechanical equipment."

A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? A. "Wash your genitalia using an antimicrobial soap." B. "Rinse your dishes with cold water." C. "Clean your toothbrush once per month." D. "Incorporate raw fruits and vegetables into your diet."

A. "Wash your genitalia using an antimicrobial soap."

A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching? A. "You can expect a persistent fever and swollen glands." B. "You can expect an elevated white blood cell count." C. "You can expect increased blood pressure and edema." D. "You can expect weight gain."

A. "You can expect a persistent fever and swollen glands."

A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching? A. "You can suck on popsicles to numb your mouth." B. "Season food with spices instead of salt." C. "Avoid the use of a straw to drink liquids." D. "Eat foods at hot temperatures."

A. "You can suck on popsicles to numb your mouth."

A nurse is providing discharge teaching to a client who has HIV. Which of the instructions about infection prevention should the nurse include? (Select all that apply.) A. Avoid large gatherings of people B. Clean toothbrush by running through the dishwasher C. Change pet litter boxes with disposable gloves D. Consume fresh fruit and raw vegetables E. Avoid digging in the garden

A. Avoid large gatherings of people B. Clean toothbrush by running through the dishwasher E. Avoid digging in the garden

A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is scheduled to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer? A. Corticosteroids B. Antimalarials C. Antidepressants D. Opioids

A. Corticosteroids

A nurse is teaching a female client with a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? A. Exercise B. Pregnancy C. Infection D. Sunlight

A. Exercise

A nurse is planning an educational program for a group of young adults about reducing the risk of cervical cancer. Which of the following interventions should the nurse include? A. Get the human papillomavirus (HPV) immunization B. Avoid the use of tampons on a routine basis C. Avoid drinking alcohol D. Get a Papanicolaou test every year starting at age 30

A. Get the human papillomavirus (HPV) immunization

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? A. Have the client wear a surgical mask. B. Wear a gown for protection from the client's infection. C. Ask the radiology staff to perform a portable chest X-ray in the client's room. D. Place an N-95 respirator on the client.

A. Have the client wear a surgical mask.

A nurse is teaching a client about the manifestations of an allergic reaction. The release of histamine causes which of the following reactions? A. Increased mucus secretion B. Bronchial dilation C. Bradycardia D. Vertigo

A. Increased mucus secretion

A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority? A. Initiate airborne precautions B. Administer antimicrobial therapy C. Tell the client that the infection will be communicable for 2-3 weeks from the start of medication therapy D. Teach the client about the manifestations of tuberculosis

A. Initiate airborne precautions

A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infection. Which of the following interventions is the nurse's priority? A. Performing hand hygiene before and after contact with the client B. Reducing the client's anxiety due to isolation procedures C. Assisting the client in making nutritional choices D. Monitoring the client's intake and output

A. Performing hand hygiene before and after contact with the client

A nurse is teaching a client who has Raynaud's disease. Which of the following pieces of information should the nurse include in the teaching? A. Protect against the cold by wearing layers of clothing B. Begin an exercise program of 2-mile walks once per week C. Increase vitamin A in the diet D. Elevate the hands above heart level when resting

A. Protect against the cold by wearing layers of clothing

A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make? A. The client has active tuberculosis. B. The client had an exposure to tuberculosis. C. The nurse must re-evaluate the result in 24 hr. D. The test is negative for tuberculosis.

B. The client had an exposure to tuberculosis.

A nurse is conducting dietary teaching for a client who has AIDS. Which of the following instructions should the nurse include in the teaching? A. Discard leftovers after 8 hr B. Use a separate cutting board for poultry C. Thaw frozen foods at room temperature D. Store cold foods at 10°C (50°F) or less

B. Use a separate cutting board for poultry

A nurse is teaching a client who has human immunodeficiency virus (HIV) about how the virus is transmitted. Which of the following statements should the nurse include the teaching? A. "HIV can be transmitted as soon as a person develops manifestations." B. "HIV can be transmitted to anyone who has had contact with infected blood." C. "HIV is transmitted through the respiratory route via droplets." D. "HIV is transmitted only during the active phase of the virus."

B. "HIV can be transmitted to anyone who has had contact with infected blood."

A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome (AIDS). Which of the following statements by the client's partner indicates a need for further teaching? A. "I will dispose of soiled tissues in separate plastic bags." B. "I'll clean up blood spills immediately with hot water." C. "I know that handwashing is an important preventive measure." D. "I will wash soiled clothes in hot water."

B. "I'll clean up blood spills immediately with hot water."

A nurse is caring for a client who is 2 days postoperative. Which of the following findings indicates that the client is developing an infection? A. Temperature 37.8°C (100°F) B. Erythema at the incision site C. WBC count 9,000/mm^3 D. Pain reported as 6 on a scale of 0 to 10

B. Erythema at the incision site

A nurse is teaching a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? A. Maternal-fetal B. Fecal-oral contamination C. Genital sexual contact D. Blood to blood

B. Fecal-oral contamination

A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? A. Excessive salivation B. Finger contractures C. Periorbital edema D. Alopecia

B. Finger contractures

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? A. An assistive device when the client is ambulating B. Heat paraffin therapy applied to the client's joints C. Gentle massage of the client's hands D. Active range-of-motion exercises on the client's affected joints

B. Heat paraffin therapy applied to the client's joints

A nurse is caring for a male client who reports a thick urethral discharge. Which of the following actions should the nurse take? A. Contact the client's sexual partners B. Obtain a urethral specimen for culture C. Prepare to administer penicillin to the client D. Obtain blood for a rapid plasma reagin test

B. Obtain a urethral specimen for culture

A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory values can indicate arthritis? A. Reticulocyte count B. Rheumatoid factor C. Direct Coombs' test D. Platelet count

B. Rheumatoid factor

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses should the nurse give? A. "Keep the lesions covered with a light sterile dressing when going outdoors." B. "Rub lesions with a washcloth to dry after washing." C. "Apply moisturizer after bathing the lesions with warm water." D. "Apply antibiotic cream twice per day until scabs form on the lesions."

C. "Apply moisturizer after bathing the lesions with warm water."

A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take this medication with food." B. "I need to take a B-complex vitamin while using this medication." C. "I can expect this medication to turn my skin orange." D. "I can expect this medication to make my vision blurry."

C. "I can expect this medication to turn my skin orange."

A nurse in a provider's office is teaching a client with a recent diagnosis of rheumatoid arthritis who has a new prescription for naproxen tablets. Which of the following statements by the client indicates the need for further teaching? A. "After taking this medication for 4 weeks, I'll start to notice relief in my joints." B. "I can take an antacid with this medication for indigestion." C. "I can take this medication with aspirin." D. "The naproxen goes down easier when I crush it and put it in applesauce."

C. "I can take this medication with aspirin."

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my exposure to sunlight." B. "I should avoid drinking alcohol." C. "I should not smoke." D. "I should limit of intake of foods that are high in purine."

C. "I should not smoke."

A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? A. "I am unable to donate blood." B. "I will need to get a booster shot of immune serum globulin every year." C. "I should stop eating raw clams." D. "I can develop this disease by getting a tattoo."

C. "I should stop eating raw clams."

A nurse is teaching a client who tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen through which of the following statements? A. "I will begin vacuuming once a week." B. "Carpeting the entire house will be very expensive, but it will be worth it." C. "I will put a mattress cover on my bed." D. "Installing curtains on the windows will help control the dust in my house."

C. "I will put a mattress cover on my bed."

A nurse is providing discharge teaching about foot care to a client who has diabetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I can use a heating pad on my feet to keep them warm." B. "I can go barefoot as long as I stay inside the house." C. "I will wash my feet daily and apply lotion, except between my toes." D. "I will trim my toenails every morning by rounding the corners."

C. "I will wash my feet daily and apply lotion, except between my toes."

A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse provide? A. "That is your decision alone." B. "I would if I were you." C. "It sounds like you are unsure what to say to your partner." D. "Your provider is required by law to notify your partner."

C. "It sounds like you are unsure what to say to your partner."

A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following pieces of information should the nurse include in the teaching? A. "PCP is sexually transmitted from person to person." B. "You were most likely exposed to a contaminated surface such as a drinking glass." C. "PCP results from an impaired immune system." D. "You might have contracted PCP from a family pet."

C. "PCP results from an impaired immune system."

A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following findings should the nurse report to the provider immediately? A. Headache and fatigue B. Swollen lymph nodes in the neck C. Abdominal pain in the left upper quadrant D. Fever and sore throat

C. Abdominal pain in the left upper quadrant

A nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. Which of the following actions should the nurse perform? A. Instruct visitors to maintain a distance of at least 1 m (3 ft) from the client. B. Wash hands with antimicrobial soap after leaving the client's room. C. Use dedicated equipment for the client. D. Keep the doors to the client's room closed at all times.

C. Use dedicated equipment for the client.

A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client? A. Diffuse maculopapular rash B. Dyspnea C. Double vision D. Progressive circular rash

D. Progressive circular rash

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision C. Onset of progressive dementia D. Reddish-purple skin lesions

D. Reddish-purple skin lesions

A nurse is planning care for a client. Which of the following interventions should the nurse include in the plan? (Click on "Exhibit NCLEX 2" under Resources on the right-hand side for additional information about the client) A. Advance diet to soft B. Perform active and passive range-of-motion (ROM) exercises twice daily C. Apply compression garments 23 hr daily D. Restrict visitors

D. Restrict visitors

A nurse is preparing to administer a Mantoux skin test to a client. What is the purpose of a Mantoux skin test using purified protein derivative (PPD)? A. To identify if a client lacks immunity to tuberculosis B. To find out if a client has active tuberculosis C. To decrease the hypersensitivity of the client's reaction to PPD D. To identify if a client has been infected with Mycobacterium tuberculosis

D. To identify if a client has been infected with Mycobacterium tuberculosis

A nurse is working with an assistive personnel (AP) who is assigned to bathe a client with herpes zoster. The AP asks the nurse if herpes zoster is contagious. Which of the following responses should the nurse make? A. "Adults receive natural immunity to herpes zoster from casual exposure to children who have had chickenpox." B. "Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant." C. "A client who has herpes zoster is not contagious if blisters are present on the skin." D. "Herpes zoster is not contagious to people who have had chickenpox."

D. "Herpes zoster is not contagious to people who have had chickenpox."

A nurse is assessing a 66-year-old client during a routine physical examination. This is the client's first clinic visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I've had any immunizations." Which of the following responses should the nurse provide? A. "In case you had the immunization before, we can't give you another one." B. "You'll need a series of 3 injections." C. "This immunization is unsafe for people over the age of 65 years old." D. "Let's go ahead and give you this immunization."

D. "Let's go ahead and give you this immunization."

A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? A. "Avoid the use of NSAIDs." B. "Stop taking the corticosteroids when your symptoms resolve." C. "Exposure to ultraviolet light will help control the skin rashes." D. "Monitor your body temperature and report any elevations promptly."

D. "Monitor your body temperature and report any elevations promptly."

A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following pieces of information should the nurse include in the teaching? A. "Wear nylon socks with shoes." B. "Wear flip flops instead of going barefoot when outside." C. "Apply moisturizing cream between your toes." D. "Wash your feet daily using lukewarm water and soap."

D. "Wash your feet daily using lukewarm water and soap."

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching? A. Use an alcohol-based soap to clean lesions B. Wear a condom during sexual activity when lesions are present C. Take a sitz bath once per day D. Apply a warm compress to the lesions

D. Apply a warm compress to the lesions

A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care? A. Rinse the mouth with chlorhexidine solution every 2 hr B. Limit fluid intake with meals C. Provide oral hygiene with a firm-bristled toothbrush after each meal D. Avoid salty foods

D. Avoid salty foods

A home health nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following foods should the nurse include in the client's plan of care? A. Soft-boiled eggs B. Brie cheese made with unpasteurized milk C. Cold deli-meat sandwiches D. Baked chicken

D. Baked chicken

A nurse is performing a preoperative assessment of a client about to undergo a cholecystectomy. The nurse should identify a risk for a latex allergy when the client reports an allergy to which of the following foods? A. Cabbage B. Oatmeal C. Milk D. Bananas

D. Bananas

A nurse is caring for a client who is suspected to have tuberculosis. Which of the following findings should the nurse expect? A. Recent weight gain B. High fever C. Rhinitis D. Blood-streaked sputum

D. Blood-streaked sputum

A nurse is reviewing the laboratory data of a client who reports manifestations suggesting systemic lupus erythematosus (SLE). The nurse should expect an increase in which of the following parameters for a client who has SLE? A. Platelet count B. RBC count C. Hct D. Erythrocyte sedimentation rate (ESR)

D. Erythrocyte sedimentation rate (ESR)

A nurse is caring for a client who underwent radioallergosorbent (RAST) testing due to seasonal allergies. The nurse should anticipate an elevation in which of the following immunoglobulin laboratory values? A. IgM B. IgA C. IgG D. IgE

D. IgE