Immune Quiz
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take?
Explain to the patient that this is an expected finding.
Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patients human immunodeficiency virus (HIV) status is unknown
Needle stick with a needle and syringe used to draw blood
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time?
Oral saquinavir (Invirase)
The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan?
Plasmapheresis will remove antibody-antigen complexes from circulation.
The nurse plans a presentation for community members about how to decrease the risk for antibiotic- resistant infections. Which information will the nurse include in the teaching plan (select all that apply)?
1. Continue taking antibiotics until all the medication is gone. 2. Antibiotics may sometimes be prescribed to prevent infection 3. Hand washing is effective in preventing many viral and bacterial infections.
The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)?
1. Hepatitis B vaccine 2. Pneumococcal vaccine 3. Influenza virus vaccine
The nurse should plan to use a wet-to-dry dressing for which patient?
A patient who has a wound with purulent drainage and dry brown areas
A patient who has an infected abdominal wound develops a temperature of 104 F (40 C). All the following interventions are included in the patients plan of care. In which order should the nurse perform the following actions?(Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics.b. Sponge patient with cool water.c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).
A, D, B, C
A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first?
Administer epinephrine.
The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?
Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient?
Administration of immunosuppressant medications
The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?
After a couple of years, it is likely that I will be able to stop taking the cyclosporine.
Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first?
Apply a tourniquet above the injection site.
A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient?
Ask about feeling of malaise
A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, I am very nervous about making my baby sick. Which information will the nurse include when teaching the patient?
Because she is at an early stage of HIV infection, the infant will not contract HIV
Monitor to see if prednisone has been effective
C-reactive protein
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother?
Change position at least every 2 hrs
Which finding will the nurse expect when assessing a 58-year-old patient who has osteoarthritis (OA) of the knee?
Discomfort with joint movement
The nurse assesses a patients surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
Document the assessment.
While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate?
Document the patients allergy history and be alert for any clinical manifestations of a type I latex allergy.
A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate?
Elevate the ankle above heart level
An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. . To provide immediate protection from infection, what medication will the nurse administer?
Gamma globulin
Which statement by a patient would alert the nurse to a possible immunodeficiency disorder?
I had my spleen removed many years ago after a car accident.
A 40-year-old African American patient has scleroderma manifested by CREST (calcinosis, Raynauds phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care
Keep environment warm and draft free.
A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by passive immunity. Which example should the nurse use to explain this type of immunity?
Passive immunity
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
Patient taking insulin
Which patient should the nurse assess first?
Patient who is sneezing after having subcutaneous immunotherapy
which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies?
Plan to wait in the clinic for 20 to 30 minutes after the testing
A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound?
Red wound
A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon?
Results of patient-donor cross matching are positive
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
Stage III
Which action will the nurse include in the plan of care for a 33-year-old patient with a new diagnosis of rheumatoid arthritis?
Suggest that the patient nap in the afternoon
Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patients skin rash?
The donor T cells are attacking the patients skin cells.
After the home health nurse teaches a patients family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?
The family member dries the wound using a hair dryer set on a low setting.
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?
The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.
Which assessment finding about a patient who has been using naproxen (Naprosyn) for 6 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider?
The patient has dark-colored stools.
After receiving a change-of-shift report, which patient should the nurse assess first?
The patient who has been receiving chemotherapy and has a temperature of 102 F
A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider?
There is a 2-cm wheal at the site of the allergen injection
Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurses teaching about the condition?
Use sunscreen outside
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?
Viral load testing
Methotrexate for RA
WBC OF 1500/L
When counseling a couple in which the man has an autosomal recessive disorder and the woman has no gene for the disorder, the nurse uses Punnett squares to show the couple the probability of their having a child with the disorder. Which statement by the nurse is most appropriate?
Your children will be carriers
Rheumatoid arthritis:
avoid activities that require repetitive use of the same muscles and joints
Atopic dermatitis
elevated IgE
Systemic lupus erythematosus (SLE) important to communicate
elevated blood urea nitrogen (BUN)
Important to communicate with MD for patient using negative pressure therapy:
low serum albumin level
The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestations
numbness and tingling
A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, I never leave my house because I hate the way I look. An appropriate nursing diagnosis for the patient is
social isolation related to embarrassment about the effects of SLE.
The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with :
warm bath followed by a nap