Saunders Immune Health Problems (81 questions)

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?

Can stain the skin and hair Rationale:Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It frequently can stain the skin and hair, and clients should be taught about this aspect of the medication. It has an unpleasant odor and can cause phototoxicity. It does not carry a risk for systemic effects.

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that the need for FURTHER teaching is necessary when the client makes which statement?

"I need to breastfeed my baby." Rationale:Breastfeeding may be contraindicated (depending on the primary health care provider's prescription) if the mother is positive for HIV because the virus may be spread to the infant in the breast milk. HIV is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for HIV for up to 2 years after birth because of placental transfer of maternal antibodies. It is vital that the nurse ascertain that the client has correct knowledge regarding the transmission of the disease and precautions necessary to prevent the spread of HIV.

The client who received a kidney transplant is taking azathioprine, and the nurse reinforces instructions about the medication. Which statement by the client indicates a need for FURTHER teaching?

"I need to discontinue the medication after 14 days of use." Rationale:Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must watch for signs of infection, which are reported immediately to the PHCP. The client should also call the PHCP if more than one dose is missed. The medication may be taken with meals to minimize nausea.

Saquinavir is prescribed for a client diagnosed as human immunodeficiency virus (HIV) seropositive. The nurse would reinforce medication instructions and determine that the client needs FURTHER teaching if the client makes which statement?

"I will take the medication on an empty stomach." Rationale:Saquinavir is an antiretroviral (protease inhibitor) used in combination with other antiretroviral medications in the management of HIV infection. It is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. It can cause photosensitivity, and the client is instructed to avoid sun exposure.

The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for FURTHER teaching?

"If the patch comes off, I need to reapply it." Rationale:The nurse instructs the client to keep the test site dry at all times. The nurse also discourages excessive physical activity that will result in sweating. Reapplying the patch can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later.

A client with a diagnosis of human immunodeficiency virus (HIV) who was prescribed an oral solution of ritonavir complains about the taste of the solution. Which response would the nurse give the client?

"Mix the oral solution with chocolate milk." Rationale:Ritonavir oral solution is preferably administered with a food substance. It may be mixed with chocolate milk or a dietary supplement to improve the taste. The client also is instructed to consume the dose within 1 hour of mixing. It is not necessary to notify the primary health care provider. Taking the medication at bedtime or refrigeration of the medication will not have an effect on the taste of the oral solution.

Zidovudine is prescribed for an adult client diagnosed with human immunodeficiency virus (HIV). Which statement by the nurse would provide the best instruction to the client about the medication?

"Space the medication doses evenly around the clock." Rationale:Zidovudine interferes with HIV replication, slowing the progression of HIV infection. The client is instructed to space the doses of the medication evenly around the clock. Food or milk does not affect the gastrointestinal absorption of the medication. The client is instructed to continue therapy for the full length of treatment. The client also is instructed not to take any medication, including aspirin, without the primary health care provider's approval.

The nurse notes that zidovudine (AZT) has recently been prescribed for the client. The client states, "I've been getting a little nauseated, and I've had a couple of headaches since I was prescribed the AZT. Does this mean I can't take the medicine?" The nurse should make which response to the client?

"These symptoms may become more tolerable as you adjust to ongoing therapy." Rationale:The initial adverse effects of zidovudine include headache, malaise, insomnia, rash, diarrhea, and fever. As zidovudine therapy proceeds, these symptoms become more tolerable. If anemia or neutropenia occurs, the medication will be discontinued or the therapy will be temporarily interrupted.

The nurse would plan to reinforce instructions to which clients about the risk for transmission of disease through blood and sexual contact? Select all that apply.

A client diagnosed with hepatitis A virus A client diagnosed with hepatitis B virus A client diagnosed with hepatitis C virus A client diagnosed with human immunodeficiency virus (HIV) Rationale:Clients who are diagnosed with hepatitis B, hepatitis C, and HIV, along with their close household members, need to be taught that the viruses are spread through blood and sexual contact. Hepatitis A can also be transmitted through sexual activity and is not limited to a fecal-oral route. Rocky Mountain spotted fever is spread through the bite of an infected wood tick. The reservoirs for Staphylococcus aureus include wound drainage, skin, hair, anterior nares, and mouth.

The client with diagnosed acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to monitor the client, knowing that this sign would most likely indicate which condition?

A result of another infection caused by the leukopenic effects of the medication. Rationale:Frequent side/adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection.

The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction?

Acute hemolytic Rationale:The client is experiencing an acute hemolytic reaction to the transfusion. The nurse in this instance would immediately stop the infusion and notify the primary health care provider. A delayed hemolytic reaction typically occurs from 2 to 14 days after transfusion. A hyperkalemic reaction occurs when blood is transfused that has been stored for too long, resulting in red blood cell hemolysis. The client experiencing a hyperkalemic reaction would exhibit nausea, muscle weakness or paresthesias, apprehension, bradycardia, electrocardiogram (ECG) changes, and possibly cardiac arrest. An allergic reaction is characterized by flushing, nausea and vomiting, respiratory stridor, hypotension, and other signs of anaphylaxis.

The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which would the nurse check before the procedure?

Allergy to iodine or shellfish Rationale:A client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. Allergy to salmon is not associated with this procedure. Claustrophobia and excessive weight are areas of concern with magnetic resonance imaging.

The nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client's record for which history?

Allergy to shellfish Rationale:Allergy to seafood, iodine, or iodine contrast media in the preprocedure period may necessitate a skin test for allergy severity and the use of prophylactic antihistamines to prevent an allergic response to the contrast medium.

A tuberculin skin test is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse checks the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which findings did the nurse identify to make this interpretation?

An area of induration at the test site measuring 7 mm Rationale:Normally, an area of induration greater than 15 mm is considered positive in low-risk individuals. However, an area of induration that measures 5 mm or greater in people with HIV infection is considered positive. Redness and swelling do not indicate a positive test result.

Which individual is LEAST likely to be at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible Rationale:Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder. It is a common acquired immunodeficiency syndrome (AIDS) indicator. Malignancy is seen most frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma but could be related to mesothelioma.

A client undergoing a computed tomography (CT) scan develops chest pain, wheezing, and stridor after injection of contrast media. Which type of shock is this client most likely exhibiting?

Anaphylactic Rationale:Injection of contrast media may result in anaphylaxis and most likely occurs as a result of mast cell degranulation. If not recognized and treated immediately, the client will progress to anaphylactic shock. Septic shock is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock occurs when there is loss of sympathetic tone. Cardiogenic shock occurs when the heart fails as a pump.

A client is brought into the emergency department by a family member with the following symptoms: erythematic rash on torso, audible wheezing, dyspnea, and abdominal cramping. The family member states, "we were at a party and all of a sudden, he was not feeling well." The nurse would consider which most likely complication?

Anaphylactic reaction Rationale:Anaphylaxis can produce systemic effects. Clinical manifestations that will be present may include neurological dysfunction such as headache or dizziness, skin irritation and erythema, airway narrowing, hoarseness or cough, hypotension, tachycardia, dysrhythmias, and nausea, vomiting, and diarrhea.

In reviewing anaphylaxis versus anaphylactic shock, the nurse understands that which statement is accurate?

Anaphylaxis, if left untreated, can become anaphylactic shock. Rationale:Anaphylaxis is a serious and immediate hypersensitivity reaction. Anaphylactic shock is untreated anaphylaxis where there is massive vasodilation causing impaired tissue perfusion. If either are not treated immediately, they can be life threatening.

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with the early stage of cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse would expect which assessment finding?

Appearance of reddish-blue lesions on the lower extremities Rationale: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 also can spread to the lymphatic system, lungs, and gastrointestinal (GI) tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions.

The nurse is caring for a client with a diagnosis of pemphigus. The nurse would include which interventions in the plan of care for the client? Select all that apply.

Applying prescribed topical antibiotic Administering prescribed corticosteroid Applying Domeboro solution to the affected skin Rationale:Pemphigus is a chronic autoimmune condition in which bullae (blisters) develop on the face, back, chest, groin, and umbilicus. The blisters rupture easily, releasing a foul-smelling drainage. Potassium permanganate baths, Domeboro solution, and oatmeal products with oil may be prescribed to soothe the affected areas, reduce odor, and decrease the risk of infection. Treatments may include corticosteroids, other immunosuppressants, and oral or topical antibiotics. Acyclovir is an antiviral medication used to treat chickenpox or shingles. Amphotericin B is an antifungal used to treat fungal infections.

Efavirenz, an antiviral medication, is prescribed for a client diagnosed with human immunodeficiency virus (HIV) infection. Which time would the nurse instruct the client is best to take this medication?

At bedtime Rationale:Because the medication causes temporary nervous system side effects during the first 2 to 4 weeks of therapy, the client is instructed to take the medication at bedtime.

Saquinavir is prescribed for a client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse would reinforce medication instructions about which health care measure to the client?

Avoid sun exposure. Rationale:Saquinavir is an antiretroviral (protease inhibitor) used with other antiretroviral medications to manage HIV infection. Saquinavir is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. Saquinavir can cause photosensitivity, and the nurse should instruct the client to avoid sun exposure.

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is important to immediately report which sign if it occurs?

Backache Rationale:The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include a backache among other signs such as chills, itching, or rash. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue, headache, and nausea are not specifically related to transfusion reaction; however, if these occur, the nurse should investigate their cause.

The nurse is caring for a postrenal transplantation client with prescription for cyclosporine. If the nurse notes an increase in one of the client's vital signs and the client is complaining of a headache, which vital sign is most likely increased?

Blood pressure Rationale:Hypertension can occur in a client taking cyclosporine, and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism.

A client comes to a primary health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick?

Bull's-eye rash Rationale:The classic characteristic of Lyme disease is a small bite with a bull's-eye rash, although not all individuals who sustain a bite develop this rash. A painful rash around a necrotic lesion is indicative of a brown recluse spider bite. Papules, vesicles, and oval lesions are not characteristics of Lyme disease.

A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions would the nurse include in planning care for this client? Select all that apply.

Check temperature at least every 4 hours. Monitor white blood cell count daily as prescribed. Remove fresh flowers or plants from the client's room. Rationale:Neutropenia is a decrease in neutrophils, one type of white blood cell needed to fight infection, especially bacterial infections. As the neutrophil count decreases, the susceptibility to infection increases. Fever is a common sign of infection, and the temperature should be monitored at least every 4 hours. A temperature greater than or equal to 100.4°F (38°C) may indicate an infection. A low white blood cell count increases the risk of infection, and the count should be monitored on a daily basis. Live plants and flowers should be removed from the room because the soil and standing water may harbor bacteria. Oxygen administration is not required for a client with neutropenia but may be indicated. Usually oxygen saturation levels of 92% to 95% are considered therapeutic. The client does not have to eliminate fruits and vegetables from the diet, but they should be cooked to destroy any bacteria present.

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse would tell the client that it is most important to report which signs immediately?

Chills, itching, or rash Rationale:The client is told to report chills, itching, or rash immediately, because these could be signs of a possible transfusion reaction. Mild discomfort at the catheter site may be indicative of a problem, or it could result from the size of the IV catheter required to infuse the blood product. Sore throat, earache, sleepiness, and fatigue are unrelated to a transfusion reaction.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) has begun therapy with zidovudine. The nurse would monitor which laboratory result during treatment with this medication?

Complete blood count Rationale:A common side/adverse effect of therapy with zidovudine is leukopenia and anemia. The nurse monitors the complete blood count results for these changes.

The client diagnosed with acquired immunodeficiency syndrome has been prescribed zidovudine. The nurse reviewing the primary health care provider's prescription, should expect to note that which laboratory test has been prescribed?

Complete blood count (CBC) Rationale:Zidovudine is a nucleoside-nucleotide reverse transcriptase. An adverse effect of this medication therapy is granulocytopenia and anemia. The nurse carefully monitors the CBC results for these changes. With early human immunodeficiency virus infection or in the client who is asymptomatic, CBC levels are monitored monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, these levels are monitored every 2 weeks for the first 2 months, and then once a month if the medication is tolerated well.

Mycophenolate mofetil is prescribed for the client as prophylaxis for organ rejection following an allogeneic renal transplant. Which instruction would the nurse most reinforce regarding administration of this medication?

Contact the primary health care provider (PHCP) if a sore throat occurs. Rationale:Mycophenolate mofetil should be administered on an empty stomach. The capsules should not be opened or crushed. The client should contact the PHCP if unusual bleeding or bruising, sore throat, mouth sores, abdominal pain, or fever occurs because these are adverse effects of the medication. Antacids containing magnesium and aluminum may decrease the absorption of the medication and therefore would not be taken with the medication. The medication may be given in combination with corticosteroids and cyclosporine.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) has an opportunistic respiratory fungal infection and is prescribed intravenous amphotericin B. The nurse assisting in caring for the client would primarily monitor for which sign that indicates an adverse effect of the medication?

Decreased urine output Rationale:Clients receiving amphotericin B may develop nephrotoxicity. Clients should be monitored for oliguria, hematuria, cloudy urine, decreased urine output, and elevated renal function laboratory values. Amphotericin B does not cause the urine to turn orange. Pale stools indicate hepatotoxicity, as does jaundice; hepatotoxicity is not an adverse effect.

A client is scheduled for intravenous pyelography (IVP). Which priority nursing action would the nurse take?

Determine if there is a history of allergies. Rationale:An iodine-based dye may be used during the IVP and can cause allergic reactions such as itching, hives, rash, tight feeling in the throat, shortness of breath, and bronchospasm. Checking for allergies is the priority

A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which manifestation of histoplasmosis?

Dyspnea Rationale:Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There also may be enlargement of the client's lymph nodes, liver, and spleen.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom would the nurse expect the client to experience?

Dyspnea Rationale:Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an enlargement of the client's lymph nodes, liver, and spleen as well.

The nurse is caring for a client diagnosed with Paget's disease. What abnormal laboratory values would the nurse specifically monitor in a client with Paget's disease? Select all that apply.

Elevated serum calcium Elevated serum alkaline phosphatase (ALP) Elevated 24-hour urinary hydroxyproline level Rationale:The laboratory values the nurse would expect to note in the client with Paget's disease of the bone include an elevated serum calcium, an elevated 24-hour urinary hydroxyproline level, and an elevated serum alkaline phosphatase (ALP). Increases in ALP and urinary hydroxyproline levels along with calcium are the primary laboratory findings indicating possible Paget's disease. Disorders of bone and the parathyroid gland are often reflected in an alteration of the serum calcium or phosphorus level. Therefore these electrolytes, especially calcium, are monitored. ALP can be further evaluated by alkaline phosphatase isoenzymes. Serum isoenzyme levels of bone ALP are used to monitor effectiveness of treatment. A 24-hour urinary hydroxyproline level reflects bone collagen turnover and indicates the degree of disease severity. The higher the hydroxyproline, the more severe is the disease.

A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse would obtain which medication from the emergency cart to have ready for use as prescribed?

Epinephrine Rationale:The symptoms exhibited by the client are compatible with an allergic reaction to the transfusion. Other common symptoms of allergic reaction are nausea and vomiting, diarrhea, and loss of consciousness. The nurse prepares to administer epinephrine and corticosteroid medications as prescribed. Norepinephrine is a sympathetic agonist used to treat hypotension but is not indicated in an allergic reaction. Lidocaine is an antidysrhythmic medication. Theophylline is a bronchodilator, which could be prescribed if needed to treat bronchospasm.

A client who is diagnosed with human immunodeficiency virus (HIV) seropositive has been taking stavudine. The nurse would monitor which parameter closely while the client is taking this medication?

Gait Rationale:Stavudine is an antiretroviral used to manage HIV infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse would monitor the client's gait closely and ask the client about paresthesia.

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which would the nurse wear to perform these tasks?

Gown and gloves Rationale:Gowns and gloves are required if the nurse anticipates contact with body fluids, such as wound drainage, diarrhea, or ileostomy or colostomy drainage. Masks are not required unless droplet or airborne precautions are necessary.

The nurse is taking a health history on a client seen in the health care clinic for the first time. When the nurse asks the client about current prescribed medications, the client tells the nurse that amprenavir is prescribed twice daily. Based on this finding, the nurse would elicit data from the client regarding the presence of which condition?

Human immunodeficiency virus (HIV) Rationale:Amprenavir is an antiretroviral agent, classified as a protease inhibitor, used to treat HIV infection.

The nurse notes that a client is receiving lamiVudine. The nurse would determine that this medication has been prescribed to most likely treat which condition?

Human immunodeficiency virus (HIV) infection Rationale:Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and is used for prophylaxis in health care workers at risk of acquiring HIV after occupational exposure to the virus. This medication is not used to treat pancreatitis, pharyngitis, or seizures.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is prescribed intravenous (IV) pentamidine isethionate. The nurse assigned to care for the client would primarily monitor for signs of which toxic effect related to the administration of this medication?

Hypoglycemia Rationale:Pentamidine isethionate causes severe hypoglycemia that may be fatal. Other toxic effects include hypotension, dysrhythmias, leukopenia, nephrotoxicity, Stevens-Johnson syndrome, hyperglycemia, and type 1 diabetes mellitus. Anorexia and dizziness are side effects that may occur with the administration of this medication, but they are not toxic effects. Hypertension is unrelated to the administration of this medication.

Indinavir is prescribed for the client with a diagnosis of human immunodeficiency virus (HIV). Which medication instruction would the nurse reinforce to the client?

Increase fluid intake to at least 1.5 L/day. Rationale:Indinavir is an antiretroviral agent. This medication can cause kidney stones; therefore, the client is instructed to increase fluid intake to at least 1.5 L/day. The client is also instructed to report sharp back pain or the presence of blood in the urine. The client is instructed to take the medication 1 hour before or 2 hours after a large meal. If the medication needs to be taken with food, the client should consume a light meal, such as dry toast, juice, or a bowl of cereal with milk. Unexplained weight loss must be reported to the primary health care provider.

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable. Rationale:There is a blood test available to detect Lyme disease; however, it is not reliable if performed before 4 to 6 weeks following the tick bite

The nurse is assisting in preparing a plan of care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who will be receiving ganciclovir. The nurse determines that which intervention would be included in the plan of care?

Instruct the client to use an electric razor for shaving. Rationale:Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. Thus, the client should be instructed to use an electric rather than a straight razor for shaving. The medication does not have to be taken on an empty stomach or without food. Additionally, the medication does not have to be taken with an antacid; in fact, an antacid may affect absorption. The medication may cause hypoglycemia but not hyperglycemia.

The nurse prepares to assist in instructing a client about Lyme disease. Which would the nurse include in the instructions?

It is caused by a tick carried by deer. Rationale:Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

A client diagnosed as human immunodeficiency virus (HIV) seropositive has been prescribed zalcitabine as a component of treatment. The nurse would instruct the client that which laboratory test will need to be monitored while taking this medication?

Liver function studies Rationale:Zalcitabine is an antiretroviral (nucleoside reverse transcriptase inhibitor) used in the management of HIV infection with other antiretrovirals. It also has been used as a single agent in clients who are intolerant of or who progress on other regimens. It can cause serious liver damage, and liver function studies should be monitored closely. Glucose level, platelet count, and red blood cell count are not specifically associated with the use of this medication.

The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse would implement which immediate action?

Maintaining a patent airway Rationale:If the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive epinephrine. Corticosteroids may also be prescribed. The client will need to be instructed about obtaining and wearing a Medic-Alert bracelet, but this is not the immediate action.

A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse would focus on which intervention first until additional help arrives?

Maintaining a patent airway Rationale:The initial priority of the nurse would be to maintain a patent airway. Once additional help arrives, the client would likely receive epinephrine and corticosteroids. The topic of the Medic-Alert bracelet should be deferred until the client is stable.

An oral powder form of nelfinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse would reinforce instructions regarding the preparation of the medication and instruct the client to mix the powder with which substance?

Milk Rationale:Nelfinavir is an antiviral medication used in the treatment of HIV infection when antiretroviral therapy is warranted. It is available in tablet and powder form. The powder form is prepared by mixing the dose with a small amount of water, milk, formula, soy milk, or dietary supplements. The powder is not mixed with acidic foods or juices such as apple juice or applesauce, orange juice, or grapefruit juice.

The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance?

Monitoring for decreased urine output and hypotension Rationale:With the loss of muscle mass and adipose tissue, the overlying skin loses its support. The usual elasticity of skin becomes a less reliable indicator of body fluid status. Vomiting and diarrhea may cause weight loss and electrolyte imbalances, but the amount that is vomited does not precisely correlate with the amount of fluid remaining in the body because systems such as the kidney can help reestablish equilibrium. Decreased urine output and hypotension more accurately correlate with loss of fluid and chronic illness in clients with HIV.

The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission would the nurse review? Select all that apply.

Needle-stick injuries Transmission by breast milk Inconsistent use of protective equipment Rationale:HIV can be contracted through infected blood and body fluids. A needle-stick injury is a potential source of HIV infection, and the person from whom the used needle came should be tested. HIV can be transmitted through breast milk. Inconsistent use of protective equipment and standard precautions can lead to HIV transmission. Use of latex condoms lowers the risk of transmission of HIV. A mutually monogamous relationship between two noninfected partners is considered safe.

The client, diagnosed with Lyme disease stage 2, asks the nurse "what is indicative of stage 2?" The nurse explains to the client that which sign or symptom is assessed in stage 2?

Neurological deficits Rationale:Stage 2 of Lyme disease develops within 1 to 6 months in most untreated individuals. The most serious problems include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. These problems are not usually permanent. Arthralgias and joint enlargements are noted in stage 3. A rash appears in stage 1.

The nurse has administered a dose of salmeterol to a client. Following administration, the client develops a generalized rash and urticaria, and the eyelids begin to swell. Which action would the nurse take?

Notify the registered nurse immediately. Rationale:Hypersensitivity reaction can occur in clients taking ephedrine, epinephrine, isoproterenol, or salmeterol. Signs and symptoms include rash, urticaria, and swelling of the face, lips, or eyelids. The nurse would notify the registered nurse immediately, who would then contact the primary health care provider.

A client who underwent kidney transplant 6 months earlier is seen in the clinic for a routine monthly appointment. The nurse reviews how the client has been doing and observes for signs/symptoms of acute rejection. Which signs/symptoms suggest acute rejection of the transplanted kidney? Select all that apply.

Oliguria Elevation of blood pressure over baseline Abdominal tenderness on the side of the kidney transplant Elevation of serum blood urea nitrogen (BUN) and creatinine Rationale:Acute rejection occurs 1 week to 2 years after a kidney transplant. Antibodies and white blood cells cause inflammation and vasculitis within the transplanted organ. Diagnosis is made by laboratory tests demonstrating impaired function of the organ and by changes in the donated organs found upon biopsy. Acute rejection is treated with increased immunosuppressant medication. Signs/symptoms of acute rejection of a transplanted kidney include abdominal tenderness over the transplanted kidney and decrease in organ function. Signs of decreased kidney function include oliguria (urine output between 100 and 400 mL in 24 hours), elevation in blood pressure, and elevation in the BUN and creatinine levels. Swelling of the lips is a sign of angioedema that occurs with an acute hypersensitivity reaction or anaphylaxis. Tachypnea (rapid breathing) with wheezing, the sound resulting from airway inflammation, occurs with many types of respiratory distress. It is not specific to acute rejection in a transplanted kidney.

The nurse is caring for a child with human immunodeficiency virus (HIV). It is most important that the nurse use which precautions to protect herself and her other clients from infection with HIV? Select all that apply.

Perform hand hygiene before and after contact with the client. Use biohazard bags for items saturated with blood and bodily fluids. Wear personal protective equipment when contact with blood and other bodily fluids are anticipated. Rationale:Standard precautions are sufficient to protect the nurse and her other clients from infection with HIV. Standard precautions include the use of personal protective equipment, performance of hand hygiene, and disposal of items saturated with blood and bodily fluids in biohazard bags. Needles should not be recapped. N95 respirators are used in the care of clients with diseases such as tuberculosis and are not a part of standard precautions.

The client is prescribed tacrolimus to prevent organ rejection. The nurse would expect to administer the dose with which medication that is also normally prescribed?

Prednisone Rationale:Tacrolimus is used for the prevention of organ rejection in clients receiving an organ transplant. Concurrent use of glucocorticoids is recommended during administration of this medication. Prednisone is a glucocorticoid. Fluconazole is an antifungal agent. Carbamazepine is an anticonvulsant. Erythromycin is an antibiotic.

One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The primary health care provider prescribes diphenhydramine to be administered before the administration of the transfusion. Why is this medication being given?

Prevent a rash and pruritus Rationale:An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine. All other options are incorrect. Acetaminophen, however, may be prescribed before the administration to assist in preventing an elevated temperature.

A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure?

Prior reaction to contrast media Rationale:This procedure requires a signed informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure.

A client is coming into the emergency department with a severe anaphylactic reaction. In preparation for the client's arrival, the nurse would anticipate performing which intervention first?

Quickly assess for airway patency Rationale:Anaphylactic reactions are emergencies that must be dealt with quickly. Maintaining a patent airway and assessing the client's respiratory status should be managed first. Management of airway supersedes other interventions. Then, quick action, support and help from the primary healthcare provider (PHCP) and rapid response team will allow the other interventions to be performed in a timely manner.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse would monitor for which side/adverse effects of the medication? Select all that apply.

Rash Hepatotoxicity Rationale:Nevirapine is a nonnucleoside reverse transcriptase inhibitor that is used to treat HIV infection. It is used in combination with other antiretroviral medications to treat HIV. Adverse effects include rash, Stevens-Johnson syndrome, hepatitis, and increased transaminase levels.

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

The blood bank Rationale:The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented.

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Respiratory distress Rationale:Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction. Discomfort is expected.

The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted?

Serum amylase Rationale:Didanosine can cause pancreatitis. A serum amylase level that is increased 1.5 to 2 times the normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client, which would be the appropriate form of isolation to use to prevent the spread of infection to others?

Standard precautions Rationale:The acquired immunodeficiency syndrome (AIDS) virus is transmitted through anal, vaginal, or oral sexual contact with infected semen or vaginal secretions; contact with infected blood or blood products; from mother to fetus during childbirth; or during breast-feeding. P. jiroveci pneumonia is an opportunistic infection seen in clients with compromised immune function. Standard precautions include blood and body fluid precautions and are used for contact with all clients including those who are HIV-positive. Pneumocystis jiroveci is normally not pathogenic for persons with a healthy immune system, so no extra precautions are necessary for the nurse to follow. Droplet, enteric, and contact precautions are not indicated for the client in the question. If the client would develop another disease, some precautions may be needed.

The nurse is assigned to care for a client with a diagnosis of toxoplasmosis. The primary health care provider has prescribed sulfasalazine. The nurse preparing to administer the medication would determine that this medication is in which drug category?

Sulfonamide Rationale:Sulfasalazine is a sulfonamide and produces anti-inflammatory and antibacterial effects.

During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study further supports the presence of HIV?

T lymphocyte levels Rationale:HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T lymphocytes leads to significant cell destruction. Platelet count is important and may be an indicator of HIV, but this laboratory test already has been identified in the data of the question. Angiotensin is produced in the kidney. Glomerular filtration rate indicates kidney function.

After pleading for information, a visitor learns from the nurse that his friend (the client) has died from human immunodeficiency virus (HIV). Inadvertently, the visitor informs the client's family about the client's HIV diagnosis. Which is the most serious potential consequence of possible damages caused by these events?

The state convicts the nurse for invasion of privacy. Rationale:Nursing ethics include the nurse's promise to perform care with nonmaleficence and to maintain client privacy. The nurse's duty was to avoid releasing information about a client to others; however, the nurse released personal client information to a third party. This is an action that is a violation of nursing ethics, clients' rights, and civil law. As a result, the nurse could face civil action for invasion of privacy if the family can prove damages. The family can confront the friend about the veracity of the statement, the agency can issue an internal reprimand against the nurse, and the state board can issue an ethical reprimand; however, option 3 is the most serious consequence of the nurse's action because it most likely involves an award for the family.

Stavudine is prescribed for a client diagnosed with advanced human immunodeficiency virus (HIV). The nurse reinforcing medication instructions to the client would instruct the client about the importance of reporting which sign/symptom to the primary health care provider?

Tingling in the extremities Rationale:Peripheral neuropathy, characterized by numbness, tingling, or pain in the hands or feet, can occur frequently with this medication and is an adverse effect. Headache, diarrhea (not constipation), and fatigue are side effects of the medication.

Lamivudine is prescribed for a client diagnosed with human immunodeficiency virus (HIV) who is prescribed zidovudine. Which would the nurse reinforce in the medication instructions to the client?

To report vomiting or abdominal pain to the primary health care provider Rationale:Lamivudine is an antiretroviral agent administered in combination with zidovudine to delay the appearance of zidovudine resistance. Lamivudine is well absorbed orally with or without food. Peripheral neuropathy can occur with its use, and the client is instructed to notify the primary health care provider if burning, numbness, or tingling of the hands, arms, feet, or legs occurs. Pancreatitis, evidenced by nausea, vomiting, and abdominal pain, is also an adverse effect of the medication and requires primary health care provider notification.

The nurse is assigned to care for a client who has been diagnosed with human immunodeficiency virus (HIV). In planning care for the client, the nurse understands that educating staff concerning which instruction will have the greatest impact on minimizing the spread of the virus?

Using personal protective equipment appropriately Rationale:HIV is a blood-borne illness with a long latency period between the introduction of the virus and positive results on a blood test. The disease is spread through blood and body fluids so standard precautions in place should control spread of the virus. It is unrealistic and unreliable to test every client on a hospital unit. Testing every client is also questionable from an ethical perspective. Protective isolation is meant to protect the client with a decreased immune function, not to protect the nurse. HIV is not a virus that is transmitted by the airborne route. The Centers for Disease Control and Prevention guidelines are specific regarding when and how to use protective equipment and are the nurse's best protection.

A caregiver of a client with an advanced case of acquired immune deficiency syndrome (AIDS) asks the nurse to review instructions in order to take care of the client. Which instructions would be appropriate for the nurse to reinforce? Select all that apply.

Wash soiled clothes in hot water. Use gloves when handling body fluids. Soak cleaning rags, sponges and mops in a 1:10 bleach solution for 5 minutes. Rationale:Caregivers of clients with advanced AIDS should follow measures included in standard precautions and use bleach solutions for disinfections. The caregiver should also perform frequent hand washing. Soiled clothes should be washed in hot water with 1 cup of bleach. Gloves should be worn whenever there is risk of contact with blood or body fluids. Sponges, mops, and cleaning rags should be disinfected in the 1:10 bleach solution for 5 minutes. Using 100% bleach on surfaces is unnecessary and may corrode some surfaces. Twelve hours of sleep is unnecessary; recommending 8 hours and naps as needed is more appropriate. The bathroom may be shared with proper cleaning.

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse would include which actions to safely administer the medication? Select all that apply.

Wear gloves while administering the injected medication. Dispose of the needle and syringe in a puncture-resistant container. Rationale:Standard precautions must be used while caring for all clients, including those who are diagnosed with AIDS. The nurse must wear gloves while administering the injection. The correct procedure for needle disposal is to dispose of uncapped needles and sharps in a hard-wall, puncture-resistant container (sharps) immediately after use. Gowns and goggles are not normally necessary to administer an injection unless the client has other problems requiring the nurse to take additional precautions. The client should not dispose of the needle. An enteral form may not be available, and this action is unnecessary because the injection can be safely administered.

The nurse is reinforcing medication instructions to a client with a diagnosis of human immunodeficiency virus (HIV) who is prescribed saquinavir. Which instruction would the nurse most appropriately provide the client in regard to taking this medication?

Within 2 hours after a full meal Rationale:Saquinavir is an antiviral medication. It is administered within 2 hours after a full meal. If the medication is taken without food in the stomach, it may result in no antiviral activity.