CH 15, 35, 36, 46 Prep U (Immunity CC3)

The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care? a. Assist with chest physiotherapy every 2 to 4 hours. b. Maintain the client in a supine or side-lying position. c. Limit fluid intake to 1 1/2 to 2 liters per day. d. Encourage client to ambulate frequently in the halls.

a. Assist with chest physiotherapy every 2 to 4 hours.

A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client? a. Bank autologous blood. b. Sign a refusal of blood transfusion form so the client will not receive the transfusion. c. Using volume expanders in case blood is needed. d. Ask people to donate blood.

a. Bank autologous blood

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed? a. Hemorrhage b. Perforation c. Penetration d. Pyloric obstruction

a. Hemorrhage

According to the tumor-node-metastasis (TNM) classification system, T0 means there is a. No evidence of primary tumor b. Distant metastasis c. No regional lymph node metastasis d. No distant metastasis

a. No evidence of primary tumor

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive? a. Schick b. Enzyme-linked immunosorbent assay (ELISA) c. Western Blot d. Complete blood count (CBC)

b. Enzyme-linked immunosorbent assay (ELISA)

A hospital educator is reiterating the importance of Standard Precautions to a group of nursing students who will soon begin a clinical rotation on the unit. Which of the following statements best describes the application of Standard Precautions? a. Standard Precautions should be applied in the care of any patient who has an actual or suspected primary or secondary immunodeficiency. b. Standard Precautions should be applied to patients regardless of diagnosis or presumed infectious status. c. Standard Precautions should be used when providing care for any patient who has a white blood cell (WBC) count of 10.8 × 109/L or greater. d. Standard Precautions should be used in the care of any patient whose diagnosis is attributable to an infectious process.

b. Standard Precautions should be applied to patients regardless of diagnosis or presumed infectious status.

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? a. "I removed all the throw rugs from the house." b. "I use an electric razor to shave." c. "I floss my teeth every morning." d. "I take a stool softener every morning."

c. "I floss my teeth every morning."

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description? a. Coffee-ground-like b. Bright red c. Black and tarry d. Clay-colored

c. Black and tarry

A nurse is performing a home visit for a client who received chemotherapy within the past 24 hours. The nurse observes a small child playing in the bathroom, where the toilet lid has been left up. Based on these observations, the nurse modifies the client's teaching plan to include: a. Reinforcement of the client's medication regimen. b. Expected chemotherapy-related adverse effects. c. Chemotherapy exposure and risk factors. d. Signs and symptoms of infection.

c. Chemotherapy exposure and risk factors

Which of the following clients is at highest risk for peptic ulcer disease? a. Client with blood type AB b. Client with blood type A c. Client with blood type O d. Client with blood type B

c. Client with type O

A client calls the clinic and asks the nurse if using oxymetazoline nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications? a. Report white patches in the mouth because the medication can cause a fungal infection. b. Taper the dose when discontinuing the medication. c. Do not overuse the medication as rebound congestion can occur. d. Do not operate machinery or drive while using the medication.

c. Do not overuse the medication as rebound congestion can occur.

Which blood test confirms the presence of antibodies to HIV? a. Erythrocyte sedimentation rate (ESR) b. Reverse transcriptase c. Enzyme immunoassay (EIA) d. p24 antigen

c. Enzyme immunoassay (EIA)

A client with human immunodeficiency virus (HIV) develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this client? a. Community-acquired pneumonia b. Tuberculosis c. Pneumocystis pneumonia d. Mycobacterium avium complex (MAC)

c. Pneumocystis pneumonia

A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist? a. Stool antigen test b. Barium study of the upper gastrointestinal tract c. Gastric secretion study d. Endoscopy

d. Endoscopy

A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find? a. Proteinuria b. Hypernatremia c. Urine specific gravity of 1.010 d. Hypokalemia

d. Hypokalemia

A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? a. White blood cell (WBC) count of 9,000 cells/mm3 b. Ate 75% of all meals during the day c. Temperature of 98.3° F (36.8° C) d. Stage 3 pressure ulcer on the left heel

d. Stage 3 pressure ulcer on the left heel

Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client? a. Autologous b. Therapeutic c. Allogeneic d. Prophylactic

a. Autologous

Which medication classification represents a proton (gastric acid) pump inhibitor? a. Metronidazole b. Omeprazole c. Sucralfate d. Famotidine

b. Omeprazole

A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding? a. Instructing the client to wear cotton underwear b. Using a medicated douche in order to keep the vaginal pH normal c. Testing the client for the presence of HIV d Having the client abstain from sexual activity for 6 weeks while the medication is working

c. Testing the client for the presence of HIV

A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem? a. The patient cries openly when discussing her disease. b. The patient begins to discuss the future with her family. c. The patient requests that her family bring her makeup and wig. d. The patient reports less disruption from pain and discomfort.

c. The patient requests that her family bring her makeup and wig