CoursePoint - Chapter 32: Management of Patients with Immune Deficiency Disorders

A client is infected with human immunodeficiency virus (HIV) after sharing needles with another intravenous (IV) drug abuser. Upon infection with HIV, the immune system responds by making antibodies against the virus, usually within how many weeks after infection? A. 1 to 2 weeks B. 3 to 6 weeks C. 6 to 18 weeks D. 3 to 12 weeks

D. 3 to 12 weeks When a person is infected with HIV, the immune system responds by producing antibodies against the virus, usually within 3 to 12 weeks after infection.

A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately? A. Sneezing B. Mouth sores C. Constipation D. Tickle in the throat

D. Tickle in the throat Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction.

The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is: A. Chronic diarrhea B. Oral candida C. Anorexia D. Nausea and vomiting

A. Chronic diarrhea Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of AIDS can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.

A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize what intervention? A. Educational programs that focus on control and prevention B. Screening programs for youth and young adults C. Appropriate use of standard precautions D. Lifestyle actions that improve immune function

A. Educational programs that focus on control and prevention Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions applies to very few cases of HIV infection.

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: A. Western blot test for confirmation of diagnosis B. p24 antigen test for confirmation of diagnosis C. T4-cell count for confirmation of diagnosis D. polymerase chain reaction test for confirmation of diagnosis

A. Western blot test for confirmation of diagnosis The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.

The nurse is instructing a client about safer sexual behaviors. Which client statement indicates a need for additional instruction? A. "My partner and I should avoid manual-anal intercourse" B. "After having sex, I should hold onto the condom when pulling out" C. "I will apply baby oil to lubricate the condom" D. "I should use a new condom each time I have sex"

C. "I will apply baby oil to lubricate the condom" The client should use only water-soluble lubricant, such as K-Y jelly or glycerin. Baby oil can cause the condom to break. The client should use a new condom for each sexual activity and hold onto the condom so that it does not come off when pulling out. Manual-anal intercourse should be avoided.

A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection? A. Trimethoprim-sulfamethoxazole B. Amphotericin B C. Nystatin D. Fluconazole

A. Trimethoprim-sulfamethoxazole To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat candidiasis.

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse? A. "I.V. drug users can get HIV from sharing needles." B. "I won't donate blood because I don't want to get AIDS." C. "I've heard about people who got AIDS from blood transfusions." D. "A latex condom should be used during intimate sexual contact."

B. "I won't donate blood because I don't want to get AIDS." HIV is transmitted through infected blood, semen, and certain other body fluids. Although a transfusion with infected blood may cause HIV infection in the recipient, a person can't become infected by donating blood. The other options reflect accurate understanding of HIV transmission.

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse knows which body fluid is not a means of transmission? A. Breast milk B. Blood C. Urine D. Semen

C. Urine HIV is transmitted in body fluids that contain free virions and infected CD4+ T cells. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. Urine is not a body fluid responsible for HIV transmission.

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive? A. Complete blood count (CBC) B. Western Blot C. Schick D. Enzyme-linked immunosorbent assay (ELISA)

D. Enzyme-linked immunosorbent assay (ELISA) The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. If the ELISA is positive twice then the Western Blot test is run. A CBC and a Schick test are not screening tests for HIV.

Which blood test confirms the presence of antibodies to HIV? A. p24 antigen B. Enzyme immunoassay (EIA) C. Reverse transcriptase D. Erythrocyte sedimentation rate (ESR)

B. Enzyme immunoassay (EIA) EIA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is A. Hypocalcemia B. Malnutrition C. Chronic diarrhea D. Neutropenia

B. Malnutrition The most prevalent cause of immunodeficiency worldwide is severe malnutrition.

A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? A. "When you take this drug, eat a high-fat meal immediately afterwards" B. "You should take the drug with an antacid" C. "Be sure to take this drug about 1/2 hour before or 2 hours after you eat" D. "It doesn't matter if you take this drug with or without food"

C. "Be sure to take this drug about 1/2 hour before or 2 hours after you eat" Didanosine (Videx) should be taken 30 to 60 minutes before or 2 hours after meals. Other antiretroviral agents, such as abacavir, emtricitabine, or lamivudine can be taken without regard to meals. High-fat meals should be avoided when taking amprenavir. Atazanavir should be taken with food and not with antacids.

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis? A. Vascular lesions B. Thrombocytopenia C. Eczema D. Thrush

A. Vascular lesions Ataxia-telangiectasis is characterized by loss of muscle coordination and vascular lesions. Thrombocytopenia and eczema are associated with Wiskott-Aldrich syndrome. Thrush is a manifestation associated with severe combined immunodeficiency (SCID).

Telangiectasia is the term that refers to A. Vascular lesions caused by dilated blood vessels B. Uncoordinated muscle movement C. Difficulty swallowing D. Inability to understand the spoken word

A. Vascular lesions caused by dilated blood vessels Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia-telangiectasia is an autosomal-recessive disorder affecting both T-cell and B-cell immunity. Receptive aphasia is an inability to understand the spoken word. Dysphagia refers to difficulty swallowing.

A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find? A. Urine specific gravity of 1.010 B. Hypernatremia C. Proteinuria D. Hypokalemia

D. Hypokalemia Electrolyte imbalances such as decreased sodium, potassium, calcium, magnesium, and chloride typically result from profuse diarrhea. A urine specific gravity of 1.010 would indicate dilute urine. The client with severe diarrhea most likely would be dehydrated, leading to a high urine specific gravity. Proteinuria may suggest renal dysfunction and would not be associated with severe diarrhea unless the client was developing renal failure.

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which symptoms? Select all that apply. A. Tightness in the chest B. Shaking chills C. Hunger D. Fatigue E. Flank pain

A, B, E Adverse reactions can include reports of flank and back pain, shaking chills, dyspnea, and tightness in the chest, as well as headache, fever, and local reaction at the infusion site.

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. A. urine B. blood C. semen D. breast milk E. vaginal secretions

A, C, D, E There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.

Which condition is an early manifestation of HIV encephalopathy? A. Headache B. Hallucinations C. Hyperreflexia D. Vacant stare

A. Headache Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.

Which substance may be used to lubricate a condom? A. K-Y jelly B. Skin lotion C. Baby oil D. Petroleum jelly

A. K-Y jelly K-Y jelly is water-based and will provide lubrication while not damaging the condom. The oils in skin lotion and petroleum jelly, and baby oil, will cause a latex condom to break.

A client with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this client? A. Meticulous infection control precautions B. Daily oral assessment and oral care every 4 hours C. Daily weight measurements and strict monitoring of intake and output D. Continuous monitoring of cardiac status

A. Meticulous infection control precautions Nursing care must be meticulous. Appropriate infection control precautions and thorough hand hygiene are essential. Institutional policies and procedures related to protective care must be followed scrupulously until definitive evidence demonstrates that precautions are unnecessary. Continual monitoring of the patient's condition is critical, so early signs of impending infection may be detected and treated before they seriously compromise the patient's status. It also is imperative that nurses appropriately apply standard precautions (previously known as universal precautions), which have become one of the first-line tools for decreasing transmission of disease.

Thirty minutes after the nurse begins an intravenous immunoglobulin (IVIG) infusion, the client reports itching at the site and a lump in the throat. Which action should the nurse take first? A. Stop the infusion B. Apply a tourniquet above the infusion site C. Administer subcutaneous epinephrine D. Notify the physician

A. Stop the infusion Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat as the precursor to laryngospasm that precedes bronchoconstriction. Stop the infusions at the first sign of reaction and initiate the institutional protocol to be followed in this emergent situation.

Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives? A. The female condom B. A diaphragm C. An intrauterine device (IUD) D. Oral estrogen contraceptives

A. The female condom The female condom, the first barrier method controlled by women, is the only proven, effective method to prevent the transmission of HIV and sexually transmitted infections (STI).

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? A. "I stopped smoking last year; this year I'll quit drinking alcohol" B. "I can eat whatever I want as long as it's low in fat" C. "I won't go to see my nephew right after he gets his vaccines" D. "I won't go to see my sister while she has a cold"

B. "I can eat whatever I want as long as it's low in fat" The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client.

When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic? A. cure rate B. HIV-1 is more prevalent than HIV-2 subtypes C. the fact that it is a mutated virus originally thought to be bovine in nature D. means of transmission

B. HIV-1 is more prevalent than HIV-2 subtypes Two HIV subtypes have been identified: HIV-1 and HIV-2. HIV-1 mutates easily and frequently, producing multiple substrains that are identified by letters from A through O. HIV-2 is less transmittable, and the interval between initial infection with HIV-2 and development of AIDS is longer. HIV-1 is more prevalent in the United States and in the rest of the world. Western Africa is the primary site of infection with HIV-2. There is no cure for HIV/AIDS; hence, no cure rate. The virus is thought to be a mutation of a simian virus. Transmission of the virus is not a characteristic.

The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about their medications. What is essential for the nurse to include in the teaching of this client regarding medications? A. The action of each antiretroviral drug B. Side effects of drug therapy C. What vaccinations to have D. The use of condoms

B. Side effects of drug therapy Describing the side effects of drug therapy is essential, with the admonition to refrain from discontinuing any of the prescribed drugs without first consulting the prescribing physician. Although the client may want to know how the drugs work in general, the specific action of each antiretroviral drug is not essential information. Teaching about condoms and vaccinations may be appropriate, but these topics are not directly related to the client's HIV medications.

The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what? A. Uncoordinated muscle movement B. Vascular lesions caused by dilated blood vessels C. Peripheral edema D. A condition marked by development of urticaria

B. Vascular lesions caused by dilated blood vessels Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia refers to uncoordinated muscle movement and is a clinical manifestation of combined B-cell and T-cell deficiencies. Telangiectasia is not peripheral edema, vascular lesions, or urticaria.

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate? A. "We need to do some more testing before we will know if your child's condition is AIDS" B. "Your child's condition is extremely serious. Like AIDS, it will most likely be fatal" C. "Although AIDS is an immune deficiency, your child's condition is different from AIDS" D. "Your child does not have AIDS but this condition puts your child at risk for it later in life"

C. "Although AIDS is an immune deficiency, your child's condition is different from AIDS" Primary immune deficiencies should be not be confused with AIDS. They are not the same condition. In addition, a primary immune disorder does not increase the child's risk for developing AIDS later in life. Primary immune deficiency diseases are serious, but they are rarely fatal and can be controlled. Testing will reveal the evidence of a primary immune disease, not AIDS. AIDS is classified as a secondary immunodeficiency.

Which is usually the most important consideration in the decision to initiate antiretroviral therapy? A. ELISA B. Western blotting assay C. CD4+ counts D. HIV RNA

C. CD4+ counts The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts.

A client with acquired immune deficiency syndrome (AIDS) informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the client has developed? A. Kaposi's sarcoma B. Wasting syndrome C. Candidiasis D. MAC

C. Candidiasis Candidiasis, a fungal infection, occurs in almost all clients with AIDS and immune depression. Oral candidiasis is characterized by creamy-white patches in the oral cavity and, if left untreated, can progress to involve the esophagus and stomach. Associated signs and symptoms include difficult and painful swallowing and retrosternal pain.

Which blood test confirms the presence of antibodies to HIV? A. p24 antigen B. Erythrocyte sedimentation rate (ESR) C. Enzyme-linked immunosorbent assay (ELISA) D. Reverse transcriptase

C. Enzyme-linked immunosorbent assay (ELISA) ELISA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. The p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.

The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family? A. How to choose antibiotics based on the client's symptoms B. The importance of maintaining the client's vaccination status C. The need to report any slight changes in the client's health status D. How to promote immune function through nutrition

C. The need to report any slight changes in the client's health status They must be informed of the need for continuous monitoring for subtle changes in the client's physical health status and of the importance of seeking immediate health care if changes are detected. Nutrition is important, but infection control is the priority. Clients and families do not choose antibiotics independently. Vaccinations are often contraindicated in immunocompromised clients.

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time? A. 24 weeks B. 18 weeks C. 12 weeks D. 6 weeks

D. 6 weeks Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels.

More than 50% of individuals with this disease develop pernicious anemia: A. DiGeorge syndrome B. Bruton disease C. Nezel of syndrome D. Common variable immunodeficiency (CVID)

D. Common variable immunodeficiency (CVID) More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions.

A nurse is caring for a client who is HIV positive and is taking zidovudine. Which side effects should the nurse expect in this client? A. decreased cognition and memory loss B. renal dysfunction C. kidney/bladder stones D. diarrhea and abdominal pain

D. diarrhea and abdominal pain Common side effects associated with the administration of zidovudine and other NRTIs include headache, nausea, rash, vomiting, peripheral neuropathy, abdominal pain, and diarrhea. The nurse should also monitor for pancreatitis and liver dysfunction (not renal dysfunction). The drug does not cause decreased cognition, memory loss, or kidney/bladder stones.

A nurse is caring for a client with human immunodeficiency virus (HIV). What would the nurse expect the health care provider to order to determine the effectiveness of treatment? A. enzyme-linked immunosorbent assay (ELISA) B. ELISA with Western blot test C. E-rosette immunofluorescence D. quantification of T-lymphocytes

D. quantification of T-lymphocytes Quantification of T-lymphocytes is used to monitor the effectiveness of treatment for HIV. E-rosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test. The Western blot test — electrophoresis of antibody proteins — detects HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone and doesn't monitor the effectiveness of treatment.

The lower the client's viral load, A. the longer the time immunity B. the shorter the survival time C. the shorter the time to AIDS diagnosis D. the longer the survival time

D. the longer the survival time The lower the client's viral load, the longer the time to AIDS diagnosis and the longer the survival time. The key goal of antiretroviral therapy is to achieve and maintain durable viral suppression.

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)? A. Radiation therapy B. Bone marrow transplantation C. Removal of the thymus gland D. Antibiotics

B. Bone marrow transplantation Treatment options for SCID include stem cell and bone marrow transplantation.

A nurse is teaching the parents of an infant about primary immunodeficiencies. Which statement verifies that the parents understand the teaching? A. "The primary immunodeficiency will disappear with age" B. "The majority of primary immunodeficiencies are diagnosed in infancy" C. "My baby cannot survive into childhood with a diagnosis of primary immunodeficiency" D. "Girls are diagnosed with primary immunodeficiencies more often than boys"

B. "The majority of primary immunodeficiencies are diagnosed in infancy" The majority of primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1.

A hospital client is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? A. Send the client to the x-ray department, and have the staff in the department wear masks. B. Arrange for a portable x-ray machine to be used. C. Have the client wear a mask to the x-ray department. D. Ensure that the radiology department has been disinfected prior to the test.

B. Arrange for a portable x-ray machine to be used. A client who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the client's room. This confers more protection than disinfecting the radiology department or using masks.

A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed? A. Hyperthyroidism B. Pernicious anemia C. Gastric ulcer D. Sickle cell anemia

B. Pernicious anemia More than 50% of clients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur.

Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment? A. Depression B. Lack of social support C. Active substance abuse D. Past substance abuse

D. Past substance abuse Factors associated with nonadherence include active substance abuse, depression, and lack of social support, as well as neurocognitive impairment, low health literacy, stressful life events, high levels of alcohol consumption, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment.

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? A. "I will make sure to have my own toothbrush and tube of toothpaste at home" B. "I will avoid contact with people who are sick or who have recently been vaccinated" C. "I will be sure to eat lots of fresh fruits and vegetables every day" D. "I will wash my hands whenever I get home from work"

C. "I will be sure to eat lots of fresh fruits and vegetables every day" The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started? A. Chest physiotherapy B. Antibiotic therapy C. Immunosuppressive agents D. Anticoagulation

C. Immunosuppressive agents For a client undergoing a hematopoietic stem cell transplant, immunosuppression is started to ensure engraftment of depleted bone marrow. Antibiotic therapy may or may not be indicated. Chest physiotherapy would be appropriate for clients with ataxia-telangiectasis who have chronic lung disease. Anticoagulation would not be used.

A patient presents to a clinic on May 1 and tells the nurse practitioner that he had a 1-month sexual relationship with a friend who did not disclose that he was HIV positive. The relationship ended last week. The nurse tells the patient that after infection with HIV, the immune system responds by making antibodies against the virus; therefore the patient should expect this to happen by: A. May 20 B. July 1 C. June 5 D. May 8

C. June 5 An antibody response to an HIV infection usually occurs 4 to 6 weeks after exposure.

The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurrence) in persons with AIDS? A. Legionnaire's disease B. Cytomegalovirus C. Pneumocystis pneumonia D. Mycobacterium tuberculosis

C. Pneumocystis pneumonia Pneumocystic pneumonia (PCP) is one of the first and most common opportunistic infections associated with AIDS. It may be present despite the absence of crackles. If untreated, PCP progresses to cause significant pulmonary impairment and respiratory failure.

A client taking abacavir has developed fever and rash. What is the priority nursing action? A. Administer acetaminophen B. Document the information C. Report to the health care provider D. Administer lidocaine cream for the rash

C. Report to the health care provider Fever and a rash could be indicative of a hypersensitivity reaction. Hypersensitivity reactions are also known as anaphylactic reactions and often involve skin rashes, fever, and bronchopulmonary issues such as bronchial constriction. The health care provider should be notified immediately and the medication stopped. Interventions need to be taken to assure that the client's airway is not compromised. Administering acetaminophen and documentation and treating the rash are not the priority and would be completed after the client is stabilized.

Kaposi sarcoma (KS) is diagnosed through A. visual assessment B. computed tomography C. biopsy D. skin scraping

C. biopsy KS is diagnosed through biopsy of the suspected lesions. Visual assessment will not confirm a diagnosis. A computed tomography scan will not assist in determining skin cell changes. Skin scraping is a procedure to collect cells, not to evaluate cells.

A hospital nurse has experienced percutaneous exposure to an HIV-positive client's blood because of a needlestick injury. The nurse has informed the supervisor and identified the client. What action should the nurse take next? A. Flush the wound site with chlorhexidine B. Follow up with the nurse's primary care provider C. Apply a hydrocolloid dressing to the wound site D. Report to the emergency department or employee health department

D. Report to the emergency department or employee health department After initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. Flushing is recommended, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended. Following up with the nurse's own primary provider would require an unacceptable delay.

A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client? A. Bank autologous blood B. Sign a refusal of blood transfusion form so the client will not receive the transfusion C. Use volume expanders in case blood is needed D. Ask people to donate blood

A. Bank autologous blood Banking autologous blood that is self-donated is the safest option for the client. Signing the refusal form does not give the client any information about the options that are available and places the client at risk. Directed donor blood may be no safer than blood collected from public donors. Those who support this belief say that directed donors may not reveal their high-risk behaviors that put the potential recipient at risk for blood-borne pathogens such as HIV.