Immunity

The nurse is caring for a client with systemic lupus erythematosus (SLE). What clinical manifestations will the nurse expect to find during assessment? 1. Expiratory wheezing 2. Pericardial friction rub 3. Enlarged lymph nodes 4. Watery diarrhea

2

The immune system can mistakenly react to itself. This is known as which of the following? 1. Passive immunity 2. Autoimmune disease 3. Cell-mediated immunity 4. Anaphylactic reaction

2

The nurse is assessing a client and notes cervical lymph nodes are enlarged, moveable, and painful upon palpation. Which of the following can the nurse conclude from these findings? 1. Cancer 2. Infection 3. Renal failure 4. Arthritis

2

The nurse is caring for a client exhibiting symptoms of nasal itching, watery rhinorrhea, itchy red eyes, and sneezing. The nurse suspects this client has which of the following diagnoses? 1. Atopic dermatitis 2. Allergic rhinitis 3. Urticaria 4. Serum sickness

2

The nurse is caring for a client with a latex allergy. Which of the following requires correction by the nurse? 1. The unlicensed assistive personnel (UAP) places a cart with latex-free supplies outside the client's room. 2. The UAP wears powdered latex gloves when bathing the client. 3. The UAP removes the avocado and banana from the lunch tray. 4. The UAP places a "latex allergy" sign on the client's door.

2

The nurse is caring for a client admitted with atopic dermatitis (eczema). Which of the following interventions should the nurse implement? 1. Suggest a lukewarm soak followed with application of emollients. 2. Administer antiretroviral drugs as ordered. 3. Place the client in isolation. 4. Prepare the client for debridement.

1

The nurse is caring for a client admitted with urticaria. Which clinical manifestations will the nurse expect to see during assessment? 1. Raised, pruritic, nontender, erythematous wheals on the skin 2. Pruritis, edema, and extremely dry skin 3. Sneezing, itching, rhinorrhea, and itchy eyes 4. Fever, malaise, muscle soreness, arthralgia, and splenomegaly

1

The nurse is caring for a client with an allergy to bee stings. Which of the following is most important for the nurse to teach the client? 1. Carry an epinephrine pen at all times. 2. Avoid going outdoors in the summer. 3. Take 50 mg of diphenhydramine (Benadryl) 2 hours before going outside. 4. Encourage the client to remove all bee hives from their home.

1

The nurse is caring for a client with pernicious anemia. The nurse can expect to implement which intervention? 1. Administer vitamin B12 as prescribed. 2. Strict 1500 mL/day fluid restriction. 3. Place the client in protective isolation. 4. Teach the client to use a brown soap.

1

The nurse is discussing immunity with a client. The client asks what type of immunity her child will receive if she breastfeeds. The nurse will reply with which of the following? 1. Naturally acquired passive immunity 2. Artificially acquired active immunity 3. Naturally acquired active immunity 4. Artificially acquired passive immunity

1

The nurse is evaluating if teaching was effective for a client with a prescription of diphenhydramine for itching. Which statement made by the client indicates an understanding? 1. "I should be careful when driving while taking this medication." 2. "I can still take my loratadine while taking this medication." 3. "I must take this medication with food." 4. "I can drink alcohol in moderation."

1

The nurse is reviewing orders for a client with systemic lupus erythematosus (SLE). Which medication will the nurse question? 1. Phenytoin 2. Belimumab 3. Methylprednisolone 4. Acetaminophen

1

The nurse is taking a medication history of a client who reports an allergy to penicillin. The nurse asks what happens when they take penicillin, and the client states, "My stomach gets upset and I have diarrhea." Which of the following responses by the nurse is best? 1. "What you are experiencing is a side effect to the medication, not an allergy." 2. "You need to carry an EpiPen with you in case this happens while taking the medication." 3. "You should wear a medical alert bracelet listing penicillin allergy." 4. "You should not take cephalosporins because you can have a reaction to drugs from this class too."

1

Which is an administration priority for epinephrine? 1. Oral 2. Intravenous (IV) 3. Topical 4. Injection

1

The nurse is caring for a client with allergic rhinitis. Which interventions will the nurse anticipate implementing? Select all that apply. 1. Administration of a prescribed antihistamine. 2. Teach client to avoid environmental stimuli. 3. Administration of corticosteroids as ordered. 4. Administration of antibiotics as ordered. 5. Routinely check vital signs every 2 hours.

1, 2, 3

The nurse is educating a client diagnosed with systemic lupus erythematosus (SLE) about triggers for the condition. Which triggers will the nurse include in the teaching? Select all that apply. 1. Infection 2. Surgery 3. Stress 4. Emotional crisis 5. Immunizations

1, 2, 3, 4, 5

The nurse is teaching a client who returned to the unit after an appendectomy to report clinical manifestations of infection. Which of the following will the nurse encourage the client to report? Select all that apply. 1. Fever 2. Redness of the incision site 3. Swelling of the incision site 4. Cool to touch 5. Pain of the incision site

1, 2, 3, 5

A client presents to the emergency department with stridor, wheezing, dyspnea, and facial edema. The nurse concludes this client is experiencing an anaphylactic reaction. Which interventions will the nurse implement? Select all that apply. 1. Administer oxygen as prescribed. 2. Place an endotracheal (ET) intubation kit at the bedside. 3. Administer the prescribed antibiotic. 4. Place the client on a cardiac monitor. 5. Obtain the prescribed intravenous (IV) access.

1, 2, 4, 5

The nurse is teaching a client with contact dermatitis about skin care and prevention of infection. What will the nurse include in the teaching? Select all that apply. 1. Wear clean, white cotton gloves at night. 2. Keep fingernails short and clean. 3. Use topical corticosteroids on dry skin. 4. Take oral antihistamines to reduce itching. 5. Rub skin gently instead of scratching.

1, 2, 4, 5

After an infection, a client develops antibodies and memory cells specific to the pathogen that caused the infection. What type of immunity will the client receive? 1. Artificially acquired passive immunity 2. Naturally acquired active immunity 3. Naturally acquired passive immunity 4. Artificially acquired active immunity

2

The nurse is discussing vaccinations with an older adult. Which of the following statements made by the client indicates an understanding regarding the teaching? 1. "I should get a flu shot every other year so I don't get the flu." 2. "I should get a shingles vaccine because I am over 60." 3. "I had a tetanus shot 15 years ago, so I don't need another one." 4. "I should get a shot for pneumonia every 5 years."

2

The nurse is preparing to administer a cephalosporin intravenously to a client. Which information is most important for the nurse to ask before administering the medication? 1. Is the client allergic to shellfish? 2. Does the client have an allergy to penicillin? 3. Is the client taking any other medications? 4. Has the client experienced diarrhea in the past from antibiotics?

2

The nurse is reviewing orders for a group of clients. Which client might the nurse see a prescription for a CD4 count? 1. A client with renal failure 2. A client with HIV 3. A client with anemia 4. A client with arthritis

2

The nurse is teaching a client who underwent a renal transplant about immunosuppressants. The nurse will include which information in the teaching? 1. Take on an empty stomach. 2. Report signs of infection. 3. This medication will take weeks for effects to be noticed. 4. Severe itching is a normal occurrence while taking this medication.

2

The nurse is teaching a daycare about planning a peanut-free menu for a class with children with peanut allergies. Which of the following food choices indicates a need for further teaching? 1. Fresh carrots 2. Trail mix 3. Cheddar snack crackers 4. Oranges

2

Which is an administration priority for epinephrine? 1. Oral 2. Intravenous (IV) 3. Topical 4. Injection

2

. A client receiving a blood transfusion experiences a sudden onset of chest pain, tachycardia, tachypnea, dyspnea, and urticaria. The nurse concludes this client is experiencing a hemolytic transfusion reaction. Which of the following actions will the nurse take? Select all that apply. 1. Double-check the patient's blood type in the medical record 2. Notify the health care provider (HCP) 3. Stop the blood transfusion immediately 4. Monitor symptoms and vital signs 5. Inform the blood bank

2, 3, 4, 5

A client receiving a blood transfusion experiences a sudden onset of chest pain, tachycardia, tachypnea, dyspnea, and urticaria. The nurse concludes this client is experiencing a hemolytic transfusion reaction. Which of the following actions will the nurse take? Select all that apply. 1. Double-check the patient's blood type in the medical record 2. Notify the health care provider (HCP) 3. Stop the blood transfusion immediately 4. Monitor symptoms and vital signs 5. Inform the blood bank

2, 3, 4, 5

The nurse is caring for a client with hypothyroidism. Which clinical manifestations can the nurse expect the client to exhibit? Select all that apply. 1. Hypertension 2. Dyspnea 3. Diarrhea 4. Slow mental processes 5. Sensitivity to heat

2, 4

The nurse is caring for a client with hypothyroidism. Which clinical manifestations can the nurse expect the client to exhibit? Select all that apply. 1. Hypertension 2. Dyspnea 3. Diarrhea 4. Slow mental processes 5. Sensitivity to heat

2, 4, 5

The nurse is caring for a client who is diagnosed with goiter secondary to Hashimoto's thyroiditis. Which interventions will the nurse expect to implement? 1. Encourage frequent activity. 2. Provide a regular diet. 3. Apply antiembolic stockings while client is in bed. 4. Encourage client to consume food high in iodine.

3

The nurse is caring for a client who presents with severe shortness of breath, wheezing, and hives. Which of the following medications would the nurse expect to administer as ordered? 1. Proton-pump inhibitor (PPI) 2. Antibiotic 3. Epinephrine 4. Opioid analgesic

3

The nurse is caring for a client with systemic lupus erythematosus (SLE). The nurse will be most concerned with which finding? 1. Complaints of joint stiffness 2. A "butterfly" rash on the face 3. Foamy, brown-colored urine 4. Drowsiness during the day

3

The nurse is caring for a group of clients. Which client will the nurse see first? 1. A client who has pernicious anemia receiving B12 injections 2. A client with allergic rhinitis who has developed sinusitis 3. A client who got admitted for angioedema from a bee sting 4. A client with systemic lupus erythematosus (SLE) who is crying

3

The nurse is providing teaching to a client receiving methylprednisolone (Solu-Medrol). Which statement made by the client indicates a need for further teaching? 1. "I need to take this medication with food." 2. "I should monitor my weight while taking this medicine." 3. "I can stop taking this medication as soon as I feel better." 4. "This medicine might make my blood sugar high."

3

The nurse is reviewing laboratory test results for a client who developed a potential hemolytic reaction. Which laboratory test will the nurse expect to read to confirm this reaction? 1. C-reactive protein (CRP) 2. Erythrocyte sedimentation rate (ESR) 3. Direct Coombs test 4. Antinuclear antibody (ANA)

3

The nurse is reviewing risk factors for a latex allergy. Which of the following individuals is at high risk for developing a latex allergy? 1. A teacher 2. An airplane pilot 3. A dental assistant 4. A farmer

3

Which of the following antibodies is produced first during an infection? 1. IgG 2. IgA 3. IgM 4. IgD

3

The nurse is monitoring a client who is receiving a blood transfusion. The client suddenly reports chills, low back pain, tachycardia, and dyspnea. Aside from remaining with the client, place the nursing actions in order from first to last. 1. Transfuse normal saline as ordered. 2. Notify the health-care provider. 3. Stop the transfusion. 4. Return the unused blood and tubing to the blood bank.

3, 1, 2, 4

The nurse is taking a surgical history. Which of the following surgeries place a client at risk for a weakened immune system? Select all that apply. 1. Appendectomy 2. Lobectomy 3. Splenectomy 4. Thymectomy 5. Tonsillectomy

3, 4

A client is diagnosed with ankylosing spondylitis. Which intervention will the nurse implement? 1. Encourage a diet high in starch. 2. Discourage range-of-motion exercises. 3. Provide a soft mattress for sleeping. 4. Give the prescribed ibuprofen.

4

A client with type O blood is about to undergo surgery. Which blood type will the nurse ensure is on hand? 1. A 2. B 3. AB 4. O

4

The nurse is caring for a client with pernicious anemia. Which clinical manifestations will the nurse expect during assessment? 1. Lower back stiffness, lordosis, and fatigue 2. Sensitivity to cold, facial edema, and anorexia 3. Hypotension, dyspnea, and jaundice 4. Weakness, tongue inflammation, and pallor

4

The nurse is caring for a group of clients. Which client will the nurse see first? 1. A client with contact dermatitis who reports redness and itching to both hands 2. A client receiving the fifth dose of antibiotic who reports of watery diarrhea 3. A client with ankylosing spondylitis who reports joint pains in early mornings 4. A client receiving a blood transfusion who reports fever, low back pain, and itching

4

The nurse is reviewing vaccination records for an older adult. Which of the following vaccinations should the nurse suggest the client receive? 1. Varicella vaccine 2. Rotavirus vaccine 3. Hepatitis B vaccine 4. Pneumococcal vaccine

4

The nurse is teaching a client with systemic lupus erythematosus (SLE) how to prevent exacerbations of the illness. What should the nurse include in teaching? 1. Sleep for 6 hours every night. 2. Cool baths for joint stiffness. 3. Eat a high-carbohydrate diet. 4. Wear protection from the sun.

4