HCC III Immunity- ATI

A nurse is caring for a client who had an anaphylatic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity. Which of the following information should the nurse confirm about AMI?

AMI is mediated by antibodies produced by B-lymphocytes. AMI is mediated by antibodies produced by B-lymphocytes in response to an invading allergen or antigen.

A nurse is providing discharge instructions to a parent and his school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include?

Administer prednisone on an alternate-day schedule. Prednisone is an effective anti-inflammatory agent that can have serious adverse effects. Taking prednisone on an alternate-day schedule can help maintain joint mobility and minimize adverse effects.

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include?

Both are inflammatory The nurse should inform the client that both disease processes are an inflammatory process of the gastrointestinal tract.

A nurse is teaching a client who is to begin long-term therapy with prednisone to treat rheumatoid arthritis. The nurse should instruct the client to take which of the following supplements while taking this medication?

Calcium and vitamin D Long-term use of glucocorticoids, such as prednisone, places the client at risk for osteoporosis. The nurse should instruct the client to take calcium and vitamin D supplements to reduce this risk.

A nurse is preparing to administer cephalexin oral suspension to an older adult who has difficulty swallowing pills. Which of the following actions should the nurse take?

Check the client for a penicillin allergy. The nurse should check the client for a penicillin allergy because cephalexin is a beta-lactam antibiotic that is similar in actions and structure to penicillin.

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine, a bronchodilator and vasopressor used for allergic reactions to reverse severe manifestations of anaphylactic shock.

A nurse is teaching a client who has a new prescription for cyclosporine oral solution to treat rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Mix with chocolate milk The client may combine cyclosporine with milk, chocolate milk, or orange juice to make the medication more palatable.

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select All That Apply) Night sweats Low-grade fever Weight gain Flushed cheeks Blood in the sputum

Night sweats is correct. Night sweats are a manifestation of tuberculosis. Low-grade fever is correct. Low-grade fever is a manifestation of tuberculosis. Weight gain is incorrect. Weight loss, not weight gain, is a manifestation of tuberculosis. Flushed cheeks is incorrect. Flushed cheeks are a manifestation of pneumonia, not tuberculosis. Blood in the sputum is correct. Blood-streaked sputum is a manifestation of tuberculosis.

A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first?

Nucleic acid amplification test (NAAT) The CDC recommends that the NAAT test replace other diagnostic screening tests for tuberculosis. The test is performed on a client's sputum.

A nurse is caring for a client who has active pulmonary tuberculosis and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication?

Red-colored urine Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.

A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client?

Reduced joint stress Rheumatoid arthritis in an autoimmune disease in which the cartilage and bone of the joints are destroyed resulting in increased pain and limited range of motion. The nurse should instruct the client that rest reduces stress on the joints and can be an effective intervention for relieving pain associated with rheumatoid arthritis.

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

Review the client's electrolyte values. The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea.

A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions?

The nurse should first assess the client's airway and oxygen saturation to determine the need for respiratory support. Intubation or tracheotomy is considered if adequate oxygenation is not maintained. The second step the nurse should take is to call the rapid response team to provide emergency treatment in case of cardiac or respiratory arrest. Next, the nurse should apply high-flow oxygen to increase oxygenation and then initiate an IV site, if one is not present, and administer isotonic IV fluids to prevent hypotension and provide access for IV medications. The nurse should then administer IV epinephrine to constrict blood vessels, dilate bronchioles, and increase cardiac function. And finally, the nurse should administer IV antihistamines and corticosteroids to block the effects of histamine and decrease edema.

A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body

​Connective tissue SLE originates in the connective tissues of the body and affects all organ systems.

A nurse is preparing to teach about communicable diseases. During which of the following stages in the period in which a diseases is contagious?

Communicability period The communicability period is the time when a disease is contagious and can be transmitted to others.

A nurse is teaching a client who has rheumatoid arthritis about taking methotrexate. Which of the following information should the nurse include?

Drink 2 to 3 L of water per day. Methotrexate can cause renal toxicity. The client should drink 2 to 3 L of water per day to promote excretion of the medication.

A nurse is caring for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Which of the following laboratory tests should the nurse instruct the client will be required while on the medication regimen?

Liver function tests Pyrazinamide and rifampin can both cause hepatotoxicity, thus the provider will monitor liver function regularly.

A nurse is reviewing laboratory values for a client who has sytemic lupu erythematosis. which of the following values should give the nurse the best indication of the client's rnela function?

Serum creatinine A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function.

A nurse is teaching a client who is starting to take methotrexate to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

"Drink at least 2 liters of water daily." The client should drink 2 to 3 L of water per day because methotrexate can cause kidney damage. Adequate hydration optimizes drug excretion and helps prevent renal damage.

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

"I will be certain to take enteric-coated medications." This is not an appropriate statement and indicates a need for additional teaching. Enteric-coated medications should be avoided to reduce the risk of blockage caused by the coating.

A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make?

"These organs support immunity." The nurse should inform the client that the function of the thymus, spleen, and lymph nodes is to support immunity and fight infection.

A nurse is teaching a client about the intradermal purified protein derivative (PPD). Which of the following information should the nurse include?

"This test is performed if previous results are negative." The nurse should assess whether the client has tested positive to a prior PPD test. For clients who have tested positive, chest x-ray is performed to determine exposure.

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following information should the nurse provide?

"Urine and other secretions might turn orange." Rifampin might turn the urine and other secretions reddish-orange. This includes sputum, tears, and sweat.

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus. Which of the following instructions should the nurse include?

"Wash your hair with a mild protein shampoo." Clients who have SLE are prone to hair loss and should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A clinic nurse is preforming a physical assessment on a client who has systemic lupus erthematosus. Which of the following findings should the nurse expect?

A dry, red rash across the bridge of the nose and on the cheeks. MY ANSWER A "butterfly" rash that is dry, red, and raised is characteristic of SLE.

A nurse is teaching a client who has a new prescription for aspirin to treat rheumatoid arthritis. the nurse should include monitoring for which of the following adverse effects of this mdeication?

Bleeding Aspirin can cause bleeding, tinnitus, gastric ulceration, nausea, and heartburn. The client should monitor and report manifestations of bleeding, such as black tarry stools.

A nurse is assessing a client who has systemic lupus erythematosus an dis taking hydroxychloroquine. The nurse should report which of the following adverse effects to the provider immediately?

Blurred vision When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding to report to the provider is blurred vision, as this is a manifestation of hydroxychloroquine toxicity and can be an indication of retinal damage.

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurses priority intervention?

Count the respiratory rate. Checking the client's respiratory status is the priority action when following the nursing process approach to client care.

A nurse is teaching a client who has a new prescription for prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication?

Decreases inflammation Prednisone is used to treat rheumatoid arthritis because it produces anti-inflammatory and immunosuppressive effects, which reduces inflammation, decreases pain, and increases mobility.

A nurse is assessing a client for early manifestations of rheumatoid arthritis. Which of the following changes is an early manifestation of RA?

Fatigue Fatigue, weakness, and anorexia are early manifestations of RA.

A nurse is caring for a female client who has rheumatoid arthritis and asks the nurse if it is safe for her to take aspirin. The nurse should recognize which of the following findings in the client's history is a contraindication to the medication?

History of gastric ulcers Aspirin is contraindicated for clients who have a history of gastrointestinal bleeding and peptic ulcer disease because it impedes platelet aggregation. An adverse effect of aspirin is gastric bleeding.

A nurse is assessing a client who has systemic lupus erythematosus. Which of the following findings is the highest priority for the nurse to report to the provider?

Presence of peripheral edema. The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to the safety and risk reduction priority setting framework, findings that indicate an impairment of renal function are the highest priority to report.

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

Soy milk Soy milk is the best choice for this client because soy milk is lactose-free.

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

Sputum culture for acid-fast bacillus Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.

A nurse is caring for a client who has Crohn's disease. Which of the following food choices would follow the recommended diet for the clients who have Crohn's disease?

Toast with jelly Toast with jelly is an appropriate food choice by the client. It does not contain large amounts of lactose, fat, or fiber.

A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethamnutol therapy. The nurse should understand that which of the following should be monitored?

Visual acuity A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of color discrimination, especially red and green. Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals.

A nurse is providing discharge teaching ot a client who has systemic lupus erythematosis. Which of the following instructions should the nurse include?

Wash the hair with a mild protein shampoo. Clients who have SLE are prone to hair loss. They should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Wipe perianal area with warm water and apply a barrier cream The nurse should instruct the client to wipe the perianal area and apply a barrier cream to decrease skin breakdown when in contact with fecal material.

A nurse is teaching a client who has rheumatoid arthritis about self-care strategies for managing the diseases. Which of the following activities should the nurse include in the teaching?

Press water from a sponge rather than wringing it. The nurse should instruct the client to modify fine motor activities, such as wringing out a sponge, by using larger joints or body surfaces, such as the palm of the hand, to substitute for smaller ones.

A nurse is teaching with a client about taking high doses of oral glucocorticoids for an extended period of time to treat rheumatoid arthritis. Which of the following instructions should the nurse include in teaching?

"Monitor for compression fractures of the back and neck." High-dose, long-term use of glucocorticoids can result in bone loss in the back and neck within weeks of starting the medication. Clients experience an increase in parathyroid hormone, which causes calcium to move out of the bones can result in fractures.

A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin, pyrazinamide. Which of the following instructions should the nurse include?

"Drink at least 8 ounces of water when you take the pyrazinamide tablet." A client who has tuberculosis usually takes pyrazinamide for the first 2 months of therapy and can shorten the entire course of therapy to 6 months. The nurse should instruct the client to drink at least 240 mL (8 oz) of fluid when taking the medication and to protect himself from the sun with cotton clothing and sunscreen.

A nurse is reviewing discharge instructions with a client who has rheumatoid arthritis and a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching?

"I should eat more bananas while taking this medication." The nurse should instruct the client to eat more potassium-rich foods such as bananas and citrus fruits while taking this medication. Prednisone can cause a loss of potassium, and the nurse should instruct the about the manifestations of hypokalemia such as muscle weakness and cramping and to notify the provider should these occur.

A nurse is caring for a client who is taking naproxen following an exacerbation of rheumatoid arthritis. Which of the following statements by the client requires further discussion by the nurse?

"I've been taking an antacid to help with indigestion." NSAIDs, like naproxen, can cause serious adverse gastrointestinal reactions such as ulceration, bleeding, and perforation. Warning manifestations such as nausea or vomiting, gastrointestinal burning, and blood in the stool reported by the client require further investigation by the nurse. The client might be taking an antacid because he is experiencing one or more of these manifestations.

A nurse is preparing a presentation at a community center about systemic lupus erythematosus. The nurse should plan to include which of the following findings as a manifestation of SLE?

A raised rash A dry, raised rash (butterfly rash) on the face or on sun exposed areas of the body is a manifestation of SLE.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A room with air exhaust directly to the outdoor environment A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?

A typical course of treatment involves 6 to 9 months of consistent medication use. Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which the organisms are susceptible. Such therapy is continued until the disease is controlled. A 6- to 9-month regimen consisting of two, and often four, different medications is used. The client should not drink alcohol during this time.

A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurse's priority to report to the provider?

Audible inspiratory stridor When using the airway, breathing, circulation approach to client care the nurse determines the priority finding is inspiratory strider. The client is at risk for bronchospasms, hypotension and circulatory collapse due to anaphylaxis. The nurse should contact the rapid response team, discontinue the vancomycin, and administer epinephrine.

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Auscultate for wheezing. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.

A nurse is assessing a client who has a new diagnosis of systemic lupus erythematosus. The nurse should identify which of the following a cutaneous manifestation of SLE?

Butterfly rash on face The "butterfly" rash, a reddened, scaly, raised facial rash, is a cutaneous manifestation of SLE.

A nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. Which of the following foods should be eliminated from the client's diet?

Dried apricots A nurse should instruct a client who has ulcerative colitis to consume a diet low in fiber and should eliminate dried apricots from his diet. Dried apricots are high in fiber and may cause an exacerbation of the client's disease process.

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription of methotrexate. Which of the following information should the nurse provide?

Drink 2 to 3 L of water per day while on the medication. Methotrexate can cause renal toxicity. Adequate hydration promotes its excretion and helps prevent this adverse effect.

A nurse is caring for an older adult client who has rheumatoid arthritis and is taking aspirin 650 mg every 4 hrs. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Erythrocyte sedimentation rate (ESR) Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases.

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus. The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

Exercise Deconditioning and muscle atrophy occurs as a result of lack of mobility. The nurse should encourage client to engage in conditioning exercises alternated with periods of rest.

A nurse is providing teaching a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following instructions should the nurse include? Expect to feel the medication's effects immediately. Do not drink alcoholic beverages while taking this medication. Report unexplained bruising to the provider. Avoid people who have infections. Take NSAIDS to help minimize the adverse effects of the medication.

Expect to feel the medication's effects immediately is incorrect. It may take 3 to 6 weeks to achieve the medication's therapeutic effects. Do not drink alcoholic beverages while taking this medication is correct. Report unexplained bruising to the provider is correct. Avoid people who have infections is correct. Take NSAIDs to help minimize the adverse effects of the medication is incorrect. NSAIDs interact with methotrexate and should be avoided. Providers sometimes prescribe folic acid to help minimize the side effects of methotrexate.

A nurse is assessing a client who has systematic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Facial rash SLE causes a characteristic facial "butterfly" rash that is dry, scaly, red, and raised.

A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result?

Immunoglobulin E (IgE) A RAST involves measuring the quantity of IgE present in the serum after exposure to specific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST.

A nurse in a provider's office is assessing a client who has rheumatoid arthritis. Which of the following findings is a late manifestation of this condition?

Knuckle deformity Joint deformity is a late manifestation of RA.

A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

Lethargy Manifestations of pulmonary tuberculosis include lethargy and fatigue.

A nurse is preparing for admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?

Place the client in a private room with a special ventilation system. Clients who have active tuberculosis should be assigned to private rooms with negative-pressure airflow via HEPA filtration systems. In these rooms, the air is not returned to the inside ventilation system but is filtered and exhausted directly to the outside.

A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications shold the nurse plan to administer? Select All That Apply Rifampin Isoniazid Acyclovir Pyrazinamide Montelukast

Rifampin is correct. Isoniazid is correct. Acyclovir is incorrect. A client should take acyclovir treat a viral infection, such as herpes simplex virus and herpes zoster. Pyrazinamide is correct. Montelukast is incorrect. A client should take montelukast to manage chronic asthma, seasonal allergic rhinitis, or for prophylaxis of bronchospasms.

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the findings should the nurse intervene first?

Stridor When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance.

A nurse is caring for a female client who has rheumatoid arthritis and a new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give the client?

The medication should be discontinued 3 months prior to a planned pregnancy. Methotrexate should be discontinued 3 months prior to planning a pregnancy because of the risk of birth defects.

A nurse is providing teaching to a client who has a new prescription for hydroxychloroquine to treat mild manifestations of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Wear sunglasses when out in bright sunshine. The nurse should instruct the client to wear sunglasses to decrease photophobia when taking hydroxychloroquine. Clients should have an ophthalmologic examination before treatment because the medication can cause retinopathy.