Saunders Immune Disorders & Medications

A client who is HIV seropositive has been taking stavudine (d4T, Zerit). The nurse should monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Gastrointestinal function

1.

A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing action are most appropriate? Select all 1. Tell the client that testing is not necessary unless arthralgia develops 2. Tell the client to avoid any woody, grassy areas that may contain ticks 3. Instruct the client to immediately start to take the antibodies that are prescribed 4. Inform the client to plant to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease 5. Tell the client if this happens again to never remove the tick but vigorously scrub the area with an antiseptic

2, 3, 4

The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

2, 3, 4

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3.

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicated a need for further instructions? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled over my pants."

3.

The nurse is reviewing the results of serum laboratory studies drawn on a client with AIDS who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted? 1. Serum protein level 2. Blood glucose level 3. Serum amylase level 4. Serum creatinine level

3.

The nurse is conducting allergy skin testing on a client. Which post procedure interventions are most appropriate for the nurse to perform? Select all 1. Record site, date, and time of the test 2. Give the client a list of potential allergens if identified 3. Estimate the size of the wheal and document the finding 4. Tell the client to return to have the site inspected only if there is a reaction 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection

1, 2

A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all 1. Administer oxygen 2. Quickly assess the client's respiratory status 3. Document the event, interventions, and client's response 4. Leave the client briefly to contact a health care provider 5. Keep the client supine regardless of the blood pressure readings 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus

1, 2, 3

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all 1. Use nonlatex gloves 2. Use medications from glass ampules 3. Place the client in a private room only 4. Keep a latex-safe supply cart available in the client's area 5. Avoid the use of medication vials that have rubber stoppers 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure

1, 2, 4, 5

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions? 1. Lyme disease is caused by a tick carried by deer 2. Lyme disease is caused by contamination from cat feces 3. Lyme disease can be caused by the inhalation of spores from bird droppings 4. Lyme disease can be contagious through skin contact with an infected individual

1.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1.

The nurse provides home care instructions to a client with SLE and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1.

Ketoconazole is prescribed for a client with a diagnosis of a candidiasis. Which interventions should the nurse include when administering this medication? 1. Restrict fluid intake 2. Monitor liver function studies 3. Instruct the client to avoid alcohol 4. Administer the medication with an antacid 5. Instruct the client to avoid exposure to the sun 6. Administer the medication on an empty stomach

2, 3, 5

A client calls the nurse in the ED and states that he was just stung by a bumble bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which nursing action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide 2. Ask the client if he ever sustained a bee sting in the past 3. Tell the client to call an ambulance for transport to the emergency department 4. Tell the client not to worry about the sting unless difficulty with breathing occurs

2.

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible 2. Administer corticosteroids as prescribed for inflammation 3. Advise the client to remain supine for 1 to 2 hours after meals 4. Keep the room temperature warm during the day and cool at night

2.

A client with pemiphigus is being seen in the clinic regular. The nurse plans care based on which description of this condition? 1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales

2.

The client with AIDS and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300). The client develops a temperature of 101 degrees F. The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

4.

The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

4.

The nurse is assigned to care for a client with cytomegalovirus retains and AIDS who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication? 1. CD4 cell count 2. Lymphocyte count 3. Serum albumin level 4. Serum creatinine level

4.

The community health nurse is conducting a research study and is identifying clients in the community as risk for latex allergy. Which client population is at most risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

1.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wear a gown and gloves to change the bed linens and gloves only for the bath

2.

The nurse is caring for a postern transplantation client taking cyclosporine (Sandimmune). The nurse notes an increase in one of the client's vital signs and the client is complaining a headache. What vital signs most likely increased? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry

3

The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs/symptoms of which side/adverse effects of the medication? Select all 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow depression 5. Gastrointestinal effects 6. Increased white blood cell count

3, 4, 5

Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the HCP immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches

3.