Dr. DeSimone Exam#1 Immune system

When a transfusion is completed, flush the line with: A. normal saline solution B. Sterile water for injection C. Lactated ringers solution D. 5% dextrose and water solution

A- normal saline solution

On inspection, a unit of blood from the blood bank shows several clots clinging to the bag. what is the best course of action? A. notify the blood bank B. administer the block as ordered C. dilute the blood with saline solution D. shake the bag to help

A- notify the blood bank

If you suspect a transfusion reaction, what action should you take first? A. stop the transfusion B. notify the transfusion C. administer epinephrine D. take vital signs

A- stop the transfusion

What is the priority nursing diagnosis for the person with AIDS that has shingles? A. Disturbed body image B. Deficient fluid volume C. potential for injury D. Acute pain

D- Acute Pain

if the patients platelet count doesn't rise as anticipated after a platelet transfusion, what is most likely the cause? A. Febrile reaction B. Hemolytic reaction C. Graft-versus-host disease D. an immune-mediated reaction

D- An immune-mediated reaction

when beginning a transfusion, you should: A. notify the blood bank B. place patient in isolation C. administer oxygen to the patient D. stay with the patient for at least 15 min

D- stay with the patient for at least 15 minutes

The nurse is assisting in planning care for a client with a diagnosis of immunodefciency 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- protecting the client from infection 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.

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.

1-administer oxygen 2-quickly assess the clients respiratory status 3-document the event, interventions, and the clients 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.

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- Have you been camping in the last month? 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.

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 difculty with breathing occurs.

2- ask the client if they sustained a bee sting in the past 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.

The client with acquired immunodefciency 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

4- appearance of reddish-blue lesions noted on the skin 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

Which activity among relatives or friends in a household could spread HIV? A. Sharing a safety razor with an HIV+ person B. Using the same toilet as an HIV+ person C. Eating a meal prepared by an HIV+ person D. Wearing a hat of an HIV+ person

A- sharing a safety razor with an HIV+ person

Before transfusing blood, you should check the providers orders for the: A. transfusion amount, duration and expiration date B. Blood component, additives, and transfusion duration C. blood component, transfusion amount, and duration D. Transfusion amount, type of administrative set, and expiration date

C- blood component, transfusion amount, and duration

The client with AIDS has chronic diarrhea. What dietary change should you suggest to this client? A. Avoid fatty foods B. Increase your fiber intake C. Take an antiacid 30 min before each meal D. Restrict your fluid intake to 1 liter per day

A- Avoid fatty foods

which blood cells play a key role in oxygen exchange and delivery? A. RBC's B. Platelets C. Neutrophils D. Lymphocytes

A- RBC's

What is the major mechanism for immunodeficiency found among people undergoing chemotherapy for cancer? A. Reduction of the bone marrow production of WBC's B. Loss of the ability to recognize and tolerate healthy self cells C. suppression of antibody production from sensitized B lymphocytes D. Protein calorie malnutrition as a result of chemotherapy induced nausea and vomiting,

A- Reduction of the bone marrow production of WBC's

what type of paper work must be completed before a blood transfusion? A. consent form B. incident report C. vital sign flow sheet D. transfusion reaction report

A- consent form

Which of these solutions is compatible with packed RBC's? A. normal saline B. lactated ringers C. dextrose 5% water D. dextrose 5% is half-normal saline

A- normal saline

Your client requires a platelet transfusion. When the blood arrives from the bank, it looks light pink. What does this appearance suggest? A. contamination B. Normal platelets C. Excessive clotting D. Incompatible blood type

B- Normal platelets

The HIV+ client has a bout of pneumocystis pneumonia and must take Bactrim. What do you teach this client? A. If you miss one dose, take two at the next scheduled dose B. Drink at least 4 liters of fluid a day when taking this medication C. Do not take the Bactrim within 4 hours of taking another medication D. Avoid direct sunlight and wear SPF during and for two weeks after taking this medication.

B- drink at least 4 liters a day while taking this medication

Because your patient has a hemoglobin level of 6g/dl and a hematocrit of 18%, he received 2 units of packed RBC's. Blood tests are repeated 4 hours after the transfusion. With effective therapy, what test results are expected? A. hemoglobin of 7g/dl and hematocrit of 26% B. hemoglobin of 8g/dl and hematocrit of 24% C. hemoglobin of 9g/dl and hematocrit of 21% D. hemoglobin of 9g/dl and hematocrit of 26%

B- hemoglobin of 8g/dl and hematocrit of 24%

From what potentially fatal complication should the nurse protect the client who has any type of temporary or permanent immunodeficiency? A. anaphylaxis B. infection C. Autoimmune disease D. coronary artery disease

B- infection

FFP is prescribed to: A. treat anemia B. replace clotting factors C. treat thrombocytopenia D. prevent graft-versus-host disease

B- replace clotting factors

In the blood, platelets usually appear? A. White and frothy B. small and colorless C. red and disk shaped D. watery and straw colored

B- small and colorless

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? A. Wearing gloves B. Wearing a gown and gloves C. Wearing a gown, gloves, and a mask D. Wearing a gown and gloves to change the bed linens, and gloves only for the bath

B- wearing a gown and gloves 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.

Which of the following blood products usually is prescribed to replace blood loss, as in hemorrhage? A. platelets B. Whole blood C. Fresh frozen plasma D. Packed red blood cells

B- whole blood

For the patient with low hemoglobin and hematocrit values, the physician is most likely to order a transfusion of: A. FFP B. Platelets C. Packed RBC's D. Clotting factors

C- Packed RBC's

What is the priority nursing diagnosis for a client with HIV/AIDS who has severe oral candisis? A. Risk for infection B. Disturbed body image C. Risk for imbalanced nutrition D. Risk for impaired skin integrity

C- Risk for imbalanced nutrition

You have been occupationally exposed through a needle stick to a HIV+ patient who has a low viral load. What drug regimen should you initiate? A. None B. Zidovudine (retrovir) 100mg q 4hrs C. Zidovudine (retrovir) 300mg BID and Lamivudine (epivir) 150mg BID for 4 weeks D. Zidovudine (retrovir) 300mg BID and Lamivudine (epivir) 150mg BID for one year

C- Zidovudine (retrovir) 300mg BID and Lamivudine (epivir) 150mg BID for 4 weeks

After a platelet transfusion, when should you expect to check the patients platelet count? A. At 30 min and at 12 hours B. at 1 hour and at 12 hours C. at 1 hour and at 24 hours D. at 12 hours and at 24 hours

C- at 1 hour and at 24 hours

After a transfusion reaction, expect to obtain blood samples for which test? A. sodium level B. potassium level C. cross-matching D. creatinine kinase level

C- cross matching

Whenever you transfuse FFP, you should assess for which potential complication? A. sepsis B. Dehydration C. fluid overload D. thrombocytopenia

C- fluid overload

Which transfusion reactions result from administering ABO incompatible blood? A. febrile reaction B. allergic reaction C. hemolytic reaction D. Graft-versus-host disease

C- hemolytic reaction

If blood typing and screening detect no antigens on the surface of a patients RBC's, which blood type does this patient have? A. A B. B C. AB D. O

D- Type O

the client with AIDS and CD4+ count of 100 cells/uL is admitted with a compound fracture of the left leg. In addition, the client has a productive cough, fever, chills and history of night sweats. The clients PPD test is negative. What is your best action? A. Use standard precautions alone because client doesn't have tuberculosis B. Use airborne precautions alone because the client is taking appropriate therapy for HIV C. Use standard and airborne precautions because patient has TB D. Use standard and airborne precautions until client has chest Xray and shows no TB

D- Use standard and airborne precautions until client has chest Xray and shows no TB

During a blood transfusion, you should plan to check the patients vital signs: A. once per shift until transfusion is complete B. once every hour until transfusion is completed C. every 10 min for the first hour and then once every 4 hours D. as soon as the transfusion begins, 15 min in, and then once every hour

D- as soon as the transfusion begins, 15 min in, and then once every hour

How should FFP normally appear? A. Clear and dark red B. cloudy and yellow C. cloudy and dark red D. clear and pale yellow

D- clear and pale yellow

You should transfuse platelets using a: A. Buretrol B. Pump tubing set C. Y Type blood transfusion set D. standard infusion administration set

D- standard infusion administration set

The client who is HIV positive is classified at CDC clinical category al, in which persistent lymphadenopathy is present. The client tells you "If I progress to category B I will be capable of transmitting the virus to others". Which is your best response? A. At this point you can only transmit the disease through donation of blood B. If your CD4+ T cells drop below 200/ul you would be considered infectious C. You cannot transmit the virus if you are taking your prescribed drugs D. The virus can be transmitted at all stages and all categories of HIV+

D- the virus can be transmitted at all stages and all categories of HIV+

A febrile transfusion typically occurs when the patients antibodies react to transfused: A. FFP B. RBC's C. platelets D. white blood cells

D- white blood cells

A cocktail of protease inhibitors, nucleo- and nonnucleoside analogue reverse transcriptase kills the virus and eliminates the worry of transmitting it. True OR False

False