IMMUNITY EXAM

A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy? A) Quantitative RNA assay B) Platelet count C) Enzyme immunoassay (EIA) test D) Western blot

A

The nurse is caring for a renal transplant patient admitted with an acute rejection episode. The patient asks the nurse how the doctors will know if the kidney has been rejected. What is the best response by the nurse? a. "Your admission lab results will determine if your kidney is being rejected." b. "A procedure called a renal biopsy will be the best way to confirm rejection." c. "Monitoring over the next few days will determine if your kidney is failing." d. "An ultrasound of your kidney will determine if your kidney has failed."

"A procedure called a renal biopsy will be the best way to confirm rejection."

The transplant clinic nurse is conducting patient education on the importance of follow-up health screening activities important in detecting complications associated with long-term immunosuppressant therapy. Which statement is most important for the nurse to include in the discussion? a. "Application of sunscreen may cause a reaction." b. "Avoid sun exposure during peak hours of the day." c. "Melanoma is the most common type of cancer." d. "Skin examinations should occur every 5 years."

"Avoid sun exposure during peak hours of the day"

A client who had an organ transplant is receiving cyclosporine. The nurse should monitor for what serious adverse effect of cyclosporine? 1 Hirsutism 2 Constipation 3 Dysrhythmias 4 Increased creatinine level

4

The nurse is caring for a client who is newly diagnosed with human immunodeficiency virus (HIV) infection. The client asks the nurse whether there are ways to protect the client's life partner from getting the virus. After the nurse provides the client with teaching related to this topic, which statement on the part of the client would indicate a need for further education? A) "I know to use an oil-based lubricant to prevent spread of the virus to my partner." B) "I can still kiss and hug my partner to show affection." C) "I will not share my razor with my partner." D) "I know I have to practice safer sex with my partner by using a latex condom."

A

The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best protects against the development of a central line-associated bloodstream infection (CLABSI)? a) Documentation of insertion date b) Elevation of the HOB c) Assessment for weaning readiness d) Appropriate sedation management

A

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a) Dobutamine b) Furosemide c) Phenylephrine d) Sodium nitroprusside

A

The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a) Assess the blood pressure by Doppler b) Estimate the systolic pressure as 60 mmHg c) Obtain an electronic blood pressure monitor d) Record the blood pressure as "not assessable"

A

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung field

A

Which renal transplant patient being cared for in the ICU is exhibiting signs of acute rejection? A.Patient with tenderness over the graft site and a 15-lb weight gain over 3 days B.Patient with postoperative pain of 5/10 and a serum creatinine of 2 mg/dL C.Patient with a CVP of 8 mm Hg and hourly urine output of 100 mL D.Patient with a K+ of 4.2 mEq/L and a serum creatinine of 1.5 mg/dL

A

status of patients in the critical care unit. Regarding which patient the nurse should notify the organ procurement organization to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram b. A 68-year-old patient admitted with unstable atrial fibrillation who has suffered a stroke c. A 40-year-old brain-injured patient with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic with a history of unstable angina status postresuscitation

A

Your patient on Heparin develops Heparin-Induced Thrombocytopenia (HIT). What signs and symptoms in the patient confirm this diagnosis? Select all that apply:* A. Decrease in platelet level B. Increase in platelet level C. Development of a new thrombus D. Increase in hemoglobin level

A,C

The nurse is planning care for a patient with sepsis. Which is the priority intervention to help prevent renal failure? Administering prescribed intravenous fluids Elevating the head of the bed Providing prescribed mechanical ventilation Giving small, frequent meals

Administering prescribed intravenous fluids

postoperative after allogenic hematopoietic stem cell transplant presents with adenovirus and Candida infection. The critical care nurse suspects which of the following? A) Acute graft-versus-host disease B) Chronic graft-versus-host disease C) Neutropenia D) Stem cell rejection

Acute graft versus host disease

A client is diagnosed with septic shock. Which collaborative therapy should the nurse consider to be the priority? A.Administering vasoactive drugs B.Administering intravenous​ (IV) fluids C.Administering an inotropic drug D.Administering IV antibiotics

B

The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates that the client is at risk for acidosis? a. Decreased serum creatinine b. Increased serum lactic acid c. Increased urine specific gravity d. Decreased partial pressure of arterial carbon dioxide

B

The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention? a. Thirty-degree elevation of head of bed b. Endotracheal suctioning as needed c. Frequent side to side repositioning d. Sequential compression stockings

B

The nurse is caring for a patient in shock. Which is a priority action by the nurse? a. Ensure adequate cellular hydration. b. Maintain adequate tissue perfusion. c. Prevent third-spacing of fluids. d. Support mechanical ventilation.

B

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute

B

The nurse is providing discharge teaching to a client recovering from deep venous thrombosis (DVT). Which instructions are appropriate for the nurse to include in the teaching session? Select all that apply. A. Avoid long car trips B. Avoid prolonged standing or sitting C. Avoid crossing the legs D. Take frequent walks E. Take a daily aspirin dose of 650 mg

BCD

The nurse is caring for a client diagnosed with septic shock. Which neurologic assessment finding requires immediate nursing intervention? (Select all that apply.) A: Hypothermia B: Lethargy C: Disorientation D: Acidosis E: Restlessness

BCE

A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock? a. "Are you more thirsty than normal?" b. "When was the last time you urinated?" c. "What is your normal heart rate?" d. "Is your skin usually cool and pale?"

C

The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of greater than or equal to 2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? a) Obtain a stat serum potassium level b) Order a stat 12-lead electrocardiogram c) Reduce the rate of dobutamine d) Assess the patient's hourly urine output

C

The nurse is educating a renal transplant patient about his immunosuppressant medication therapy. Which statement by the patient best indicates an appropriate understanding? a. "I will be gradually weaned off my medications during my lifetime." b. "After 6 months, I will be down to taking one medication for life." c. "Complications of these medications include diabetes, infection, hypertension, and bone loss." d. "I will only need to take my mediations every other day for life."

C

The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a) Breath sounds and capillary refill b) BP and oral temperature c) Oral temperature and capillary refill d) Right Arterial Pressure and urine output

D

The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)? Sharp pain in both legs B. Two-plus palpable pedal pulses C. Shortness of breath after activity D. Swelling in one leg with edema

D

The nurse obtains initial vital signs on a patient 2 weeks post-liver transplant who presents for follow-up monitoring to the outpatient transplant clinic. Which assessment finding by the a. Blood pressure of 100/60 mm Hg b. Serum creatinine of 1.5 mg/dL c. Hemoglobin of 9.2 gm/dL d. Tenderness over graft site

D

When caring for an obtunded ED client with shock of unknown origin, which action should the nurse take first? A. Establish IV access and hang prescribed infusion B. Apply the automatic BP cuff C. Assess level of consciousness and pupil response to light D. Check the airway and respiratory status

D

Which liver transplant patient being cared for in the ICU is exhibiting signs of acute rejection? A.Patient with postoperative pain 6/10 B.Patient with a CVP of 6 mm Hg C.Patient with temp of 99.0° F and thirst D.Patient with dark urine and jaundice

D

A patient receiving a direct thrombin inhibitor begins to bleed. For which medication should the nurse expect idarucizumab (Praxbind) to be prescribed? Dabigatran (Pradaxa)

Dabigatran (Pradaxa)

A client is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this client? Select all that apply. Hypotension Tachycardia Fever Edema Pain

Hypotension Tachycardia Fever

The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? a) Insertion of an 18-gauge peripheral intravenous line b) Application of cushioned heel protectors c) Implementation of fall precautions d) Implementation of universal precautions

Insertion of an 18-gauge peripheral intravenous line

Which lung transplant patient being cared for in the ICU is exhibiting signs of acute rejection? Pt with postoperative pain level of 5/10 Pt who is short of breath on exertion Pt with congestion and dyspnea Pt with spo2 of 94% on 3L of oxygen

Pt with congestion and dyspnea

What is the gold standard diagnostic test to dx HIT-II? Serotonin Release Assay

Serotonin Release Assay

The nurse is caring for a premature newborn admitted with poor feeding, lethargy, and respiratory distress. Which early assessment finding would indicate possible sepsis? Apical pulse 140 beats/min Cyanosis Temperature 100.4°F (38.8°C) Blood pressure 65/45 mmHg

Temperature 100.4°F (38.8°C)

The nurse is caring for a client diagnosed with septic shock. Which assessment finding should the nurse report immediately to the healthcare provider? Urine output of 15 mL/hr. and BP of 82/45

Urine output of 15 mL/hr. and BP of 82/45

A patient presents to the outpatient transplant clinic stating, "I would like to donate one of my kidneys." What is the best response by the nurse?

"Let us orient you to the process required to become a donor

The transplant clinic nurse is educating a group of transplant recipients on health promotion and maintenance. What is the priority statement by the nurse? a. "Adhere to all future scheduled appointments with the clinic." b. "Obtain annual vaccinations for pneumonia from your physician." c. "Report all routine lab results to your primary care physician." d. "Notify the transplant clinic of all future hospital admissions."

"Obtain annual vaccinations for pneumonia from your physician."

The nurse is caring for a patient with AIDS who has come to the clinic for an HIV viral load test. The patient asks, "What is a viral load test?" Which response by the nurse is accurate? "This test is the most widely used screening test for HIV infection." "This test is used to detect HIV antibodies." "This test detects anemia, leukopenia, and thrombocytopenia." "This test measures the amount of actively replicating HIV."

"This test measures the amount of actively replicating HIV."

The nurse has just completed administration of a 500 mL bolus of 0.9% normal saline in a patient with hypovolemic shock. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a) Patient response to therapy is appropriate b) Additional interventions are indicated c) More time is needed to assess response d) Values are normal for the patient condition

- Additional interventions are indicated

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a) Blood cultures b) Chest x-ray c) Foley insertion d) Serum electrolytes

- Blood cultures

A 22-year-old woman has received an organ transplant and is on cyclosporine therapy. The nurse will encourage her to avoid crowds and limit social activities while on the medication due to: - Episodes of extreme dizziness - Increased risk of infections - Frequent migraine headaches - Increased sedation

- Increased risk of infections

A patient is on a continuous IV Heparin drip. As the nurse you are monitoring for any adverse reactions. Select all the signs and symptoms that would indicate this patient is having an adverse reaction to this medication:

-Hematuria _Decreasing platelets _Low hemoglobin and hematocrit _ Positive stool guaiac test

The nurse is providing induction therapy to a client to prevent rejectino after an organ transplant. Which medication will the nurse most likely administer? 1 Atgam 2 Mycophenolate 3 Acetaminophen 4 Diphenhydramine

1

A patient recovering from a liver transplant is at risk for malnutrition. What would the nurse include when planning care for this patient?Select all that apply. 1. Consult with a dietician to plan for adequate energy from carbohydrates or fats. 2. Provide nutritional supplements enterally. 3. Prepare for placement of a central line for parenteral nutrition. 4. Encourage high-protein foods. 5. Restrict fruits and vegetables.

1, 2

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? A. Report chest heaviness B. Pedal pulses 1+/4+ bilaterally C. Blood pressure 98/68 mmHg D. Urine output of 32 mL/hr

A

A client is at risk for MODS. In caring for this client, the nurse should place the highest priority on a. assisting with incentive spirometry. b. hourly monitoring of urinary output c. maintaining adequate oral intake. d. performing range-of-motion exercises

A

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin when the client is not a diabetic. What response by the nurse is best? A. High glucose is common in shock and needs to be treated B. The stress of this illness has made your spouse diabetic C. The IV solution has lot's of glucose which raises blood sugar. D. Some of the medications we are giving are to raise blood sugar.

A

The nurse is caring for a renal transplant recipient in the post anesthesia care unit. Blood pressure is 125/70 mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO2) is 95% on 3 L/min of oxygen via nasal cannula; temperature is 97.8° F; and the central venous pressure a. Administer fluid replacement therapy; monitor intake and output closely. b. Increase supplemental oxygen to 100% non-rebreather mask; notify physician. c. Apply thermal warming blanket; administer all fluids through warming device. d. Assess the patient for pain; administer pain medications as ordered.

A

The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a) The patient is developing neurogenic shock. b) The patient is experiencing an allergic reaction. c) The patient most likely has an elevated temperature. d) The vital signs are normal for this patient.

A

What assessment findings would a nurse expect in a patient experiencing septic shock? Select all that apply. A. Tachycardia B. Bradycardia C. Hypertension D. Hypotension E. Bradypnea

A D

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Advocate for parenteral nutrition for patients who cannot take oral feedings. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis

ABCE

What are signs of Sepsis/Septic shock? a. tachycardia b. hypotension c. fever d. bradycardia e. polyuria f. malaise g. tachypnea

ABCFG

A patient is on a continuous IV Heparin drip. As the nurse you are monitoring for any adverse reactions. Select all the signs and symptoms that would indicate this patient is having an adverse reaction to this medication: A. Hematuria B. Decreasing platelets C. Increased blood glucose D. Low hemoglobin and hematocrit E. Positive stool guaiac test

ABDE

The family of a critically ill patient has asked to discuss organ donation with the patient's nurse. When preparing to answer the family's questions, the nurse understands which concern(s) most often influence a family's decision to donate? (Select all that apply.) a. Donor disfigurement influences on funeral care b. Fear of inferior medical care provided to donor c. Age and location of all possible organ recipients d. Concern that donated organs will not be used e. Fear that the potential donor may not be deceased f. Concern over financial costs associated with donation

ABEF

Your patient on Heparin develops Heparin-Induced Thrombocytopenia (HIT). What signs and symptoms in the patient confirm this diagnosis? Select all that apply: A. Decrease in platelet level B. Increase in platelet level C. Development of a new thrombus D. Increase in hemoglobin level

AC

Which clinical scenario best represents hyperacute rejection? a. A cardiac transplant patient with a 3-month history of shortness of breath b. A lung transplant patient with small pustules that follow a dermatome c. A liver transplant patient with several small lumps under the skin d. An implanted renal transplant that, upon reperfusion, becomes cyanotic

An implanted renal transplant that, upon reperfusion, becomes cyanotic.

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic dynes/sec/cm−5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a) Furosemide 20 mg intravenous (IV) every 4 hours as needed for CVP greater than or equal to ≥20 mm Hg b) Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain c) Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as needed for CI less than 2 L/min/m2 d) Dopamine infusion at a rate of 5 to 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

B

The nurse is managing a donor patient six hours before the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse? a. Morning serum blood glucose of 128 mg/dL b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L c. Pulmonary artery temperature of 97.8° F d. Central venous pressure of 8 mm Hg

B

What is the most commonly observed opportunistic infection in clients with AIDS? A) Tuberculosis B) Pneumocystis jiroveci pneumonia C) Candida albicans infection D) Mycobacterium avium complex

B

A family member approaches the nurse caring for their gravely ill son and states, "We want to donate our sons' organs." What is the best action by the a. Arrange a multidisciplinary meeting with physicians. b. Consult the hospitals ethics committee for a ruling. c. Notify the organ procurement organization (OPO). d. Obtain family consent to withdraw life support.

C

A nurse is developing a plan of care for a client who was recently diagnosed with human immunodeficiency virus (HIV). The client states, "I don't plan on giving up sex just because I am HIV positive." Based on this data, which nursing diagnosis is the priority for this client? A) Risk for Infection B) Death Anxiety C) Deficient Knowledge D) Social Isolation

C

The nurse is caring for a patient in the critical care unit who, after being declared brain dead, is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO2) is 99% and core temperature 93.8° F. Which provider prescription should the nurse implement first? a. Apply forced-air warming device to keep temperature 96.8 F. b. Obtain basic metabolic panel every 4 hours until surgery. c. Begin phenylephrine (Neo-Synephrine) for systolic BP <90 mm Hg. d. Draw arterial blood gas every 4 hours until surgery.

C

The nurse is caring for a renal transplant recipient in the post anesthesia care unit (PACU). One hour after the transplant recipient was admitted to the PACU, the RN notes the patient's blood pressure has dropped to 82/60 mm Hg and the pulse is 138 beats/min. Which physician order should the nurse implement first? a. Administer 20 mg furosemide intravenous (IV) every 4 hours as needed for urine output < 30 mL/hr. b. Administer a 500-mL bolus of 0.9% normal saline intravenously over 2 hours. c. Irrigate the indwelling urinary catheter gently with 30 mL 0.9% normal saline. d. Provide maintenance IV fluids of D5 NS to infuse at 100 mL/hr. c. Irrigate the indwelling urinary catheter gently with 30 mL 0.9% normal saline.

C

The nurse is educating a renal transplant patient about his immunosuppressant medication therapy. Which statement by the patient best indicates an appropriate understanding? a. "I will be gradually weaned off my medications during my lifetime." b. "After 6 months, I will be down to taking one medication for life." c. "My doctors may try to stop my steroids soon after my transplant." d. "I will only need to take my mediations every other day for life."

C

The charge nurse of a transplant unit is reviewing the clinical course of several transplant patients being cared for in the unit. Which patient assessed by the charge nurse requires immediate action? a. Renal transplant recipient, 1 day post op with a 3/10 pain level b. Lung transplant recipient, 1 day post op with a productive cough c. Heart transplant recipient, 1 day post op with a cardiac output of 4 L/min d. Liver transplant recipient, 12 hours post op with a serum glucose of 58 mg/dL

D

The nurse is providing postoperative care to a kidney transplant recipient. What is the nurse's first priority during this period? Teaching signs of rejection to the client Maintaining fluid and electrolyte balance Providing emotional support to the recipient Advising the client to have frequent blood testing

Maintaining fluid and electrolyte balance

Type 2 HIT can be caused by both unfractionated heparin or low molecular weight heparin, but which is it more common with?

More common with unfractionated heparin

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? A) Positive western blot test B) CD4-T-cell count 180 cells/mm C) Platelets 150,000/mm D) WBC 5,000/mm

b

The nurse notices that the latest laboratory report of a patient with a history of HIV indicates a CD4 T-cell count of less than 200/mm3. Which condition should the nurse assess for during the patient's examination? Rheumatoid arthritis Dysmenorrhea Psoriasis Candidiasis

candidiasis

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions? A) Dehydration B) Fungal infection C) Compartment syndrome D) Pleural effusion

fungal infection