P&P Immune system review questions

A 50-year-old Black patient is diagnosed with anemia. Where can the nurse best observe for pallor?

Conjunctivae

Which of the following is a common nursing diagnosis that the nurse will include in the plan of care for a patient with systemic lupus erythematosus?

Fatigue

The nurse recognizes that the patient may be having a reaction to abacavir sulfate (Ziagen) when which of the following occurs?

Flu-like symptoms

The nurse is caring for a patient with HIV who has diarrhea. Which of the following would be most therapeutic to explain to the patient to reduce diarrhea?

High-fiber foods

A patient with a history of hemophilia A arrives in the emergency department with a "funny feeling" in the elbow. The patient believes he is bleeding into the joint. Which response by the nurse is correct?

Notify the physician immediately and expect an order for factor VIII.

The nurse is teaching a patient about immune function. Which of the following would the nurse correctly include as stimulating antibody production? Select all that apply. 1. Cold virus 2. Plant pollen 3. Transplanted organ 4. Bacterial toxins 5. Measles vaccine 6. Influenza vaccine

1,2,4,5,6

The nurse is contributing to the teaching plan for a patient with HIV on how to reduce infection risks. Which of the following should the patient with HIV be taught to do to decrease risk of infections? Select all that apply. 1. Wash hands before eating. 2. Reuse dishes. 3. Wash toothbrush. 4. Report signs of infection. 5. Buy prepared deli foods. 6. Share razor if no visible blood.

1,3,4

The nurse is providing HIV risk-reduction reinforcement for a 55-year-old patient. Which of the following information should the nurse provide to the patient? Select all that apply. 1. Anal, oral, and vaginal sexual activity requires a latex barrier be used. 2. Condoms are needed only when a person discloses being HIV positive. 3. Having a sexually transmitted infection increases the risk of acquiring HIV. 4. A new condom is needed for each sexual activity. 5. Petroleum jelly can be used as a lubricant during condom use. 6. Condoms are only useful for birth control.

1,3,4

A patient who was walking in the woods disturbed a beehive, was stung two times, and was taken to the emergency department immediately due to allergies to bee stings. Which of the following data collected by the nurse would support a diagnosis of anaphylaxis? Select all that apply. 1. Pallor around the areas stung 2. Numbness and tingling in the extremities 3. Respiratory stridor 4. Retinal hemorrhage 5. Tachycardia 6. Dyspnea

3,5,6

The nurse is collecting data on a patient with suspected pernicious anemia. Which of these signs or symptoms would the nurse expect to find for this patient? Select all that apply. 1. Back spasms 2. Dry cough 3. Glossitis 4. Itching 5. Pallor 6. Weakness

3,5,6

Which of the following vaccines would the nurse correctly recommend be given annually during a teaching session on health maintenance with an older patient?

Influenza

A patient who is being tested for HIV asks what types of diagnostic tests are used. Which of the following diagnostic tests would the nurse state can be used to identify an HIV infection? Select all that apply. 1. CD4 T lymphocyte count 2. Genotyping 3. HIV antibody/antigen combination immunoassay 4. Nucleic acid test 5. Urinalysis

1,2,3,4

What should the nurse include in a teaching plan for a 27-year-old female patient who is 6 months pregnant in order to reduce the risk of HIV infection? Select all that apply. 1. Abstain from sexual intercourse. 2. Test for HIV at time of labor. 3. Avoid injection drug use. 4. Plan for autologous blood transfusion. 5. Avoid use of female condoms.

1,2,3,4

Which of the following activities should be carried out to keep the patient safe before starting a blood transfusion? Select all that apply. 1. Match the blood to the order. 2. Match the patient to the blood. 3. Match the room number to the order. 4. Check the patient's vital signs. 5. Check the temperature of the blood. 6. Check the patient's weight.

1,2,4

The nurse is taking the vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she needs to have an HIV test. Which of the following is the nurse's best response?

"After pretest counseling, you decide whether HIV testing should be done."

The nurse would evaluate that the patient understands what triggers allergic rhinitis by which of the following patient responses?

"Airborne pollens and molds."

The nurse is caring for a patient suspected to be infected with HIV. The patient asks what type of test will be done first to diagnose it. Which response by the nurse would be appropriate?

"Antigen/antibody combination immunoassay"

A mother brings her children into the clinic, and the children are diagnosed with chickenpox. The mother had chickenpox as a child. Which of the following statements should the nurse include in the patient teaching?

"Because you have an active natural immunity to chickenpox, you can safely take care of your children at home."

A patient has a long-standing history of allergies to pollen. Which of the following patient action statements indicates to the nurse that further teaching is necessary?

"I drive with the windows open."

A patient is admitted with an autoimmune disease and asks the nurse what autoimmune means. Which response by the nurse would be appropriate?

"Immune cells are not able to distinguish between 'self' and 'not self.'"

The nurse would evaluate a patient as understanding explanations about the definition of autoimmunity if the patient states which of the following?

"Inability to differentiate self from nonself"

The nurse is caring for a patient who asks what ankylosing spondylitis is. Which of the following responses by the nurse is appropriate?

"It is a chronic progressive inflammatory disease of the spine and large limb joints."

The nurse is teaching the parent of a child with hemophilia. Which of the following statements by the parent demonstrates understanding about preventing bleeding episodes?

"My son will have to avoid contact sports."

A mother asks if her baby is protected from infections, and the nurse explains that a baby has temporary immunity to the infections to which the mother is immune. The nurse would evaluate the mother as understanding if she stated that this is which of the following?

"Naturally acquired passive immunity"

A portion of a patient's stomach was removed, so the patient is to take vitamin B12. Which of the following patient statements would indicate patient understanding to the nurse after an educational session?

"Pernicious anemia is a complication of this surgery, so I need lifelong vitamin B12."

A patient asks the nurse how an allergy can develop to a medication that has been taken before without problems. Which of the following is the most appropriate response by the nurse?

"Viral illnesses and exposure to various chemicals and environmental substances can alter the immune system and its response to previously benign stimuli."

A nurse is caring for a patient admitted with gastrointestinal tract bleeding and a hemoglobin level of 6 g/dL. The patient asks the nurse why the low hemoglobin causes shortness of breath. Which response is best?

"You do not have enough hemoglobin to carry oxygen to your tissues."

Margo Haiken, age 22, is newly diagnosed as HIV positive. Her mother, who is seated at the bedside, is crying. Margo asks what to expect for her future health status. Which of the following is the nurse's best response?

"You will be able to chronically manage your disease."

A patient is receiving cefuroxime (Zinacef) intravenously. Fifteen minutes after the cefuroxime is started, the patient reports an uneasy feeling, as well as feeling very warm. Which actions would the nurse take now? Select all that apply. 1. Call for immediate assistance. 2. Discontinue the angiocath and apply pressure. 3. Stay with the patient. 4. Immediately turn off the intravenous infusion. 5. Offer the patient ice water. 6. Monitor vital signs frequently.

1,3,4,6

A patient who has been diagnosed with systemic lupus erythematosus is being discharged. The patient reports she is leaving shortly for a 3-week tour of the Grand Canyon and whitewater rafting. Which of the following patient statements would convey the patient's understanding of the plan of care to the nurse? Select all that apply. 1. "I will wear clothing on all exposed skin." 2. "As long as I wear sunscreen, I can be in the sun all day." 3. "I will use sunscreen on exposed skin at all times." 4. "If I develop a rash, I should avoid the sun." 5. "I will wear a hat." 6. "The early morning sun presents the strongest danger."

1,3,5

The nurse is caring for a patient who is HIV positive and prescribed antiretroviral therapy. At what timeframes does the nurse explain to the patient that CD4 T lymphocyte testing is recommended to be done? Select all that apply. 1. Before antiretroviral therapy 2. Every month 3. At 3 months 4. Every 2 months during antiretroviral therapy 5. Every 3 to 6 months for 2 years 6. Annually after 2 years

1,3,5,6

The nurse is reinforcing teaching on the frequency of viral load testing for a patient who has HIV and is to begin antiretroviral therapy. Which of the following general viral load testing recommendations, for those with consistently suppressed viral loads on antiretroviral therapy, would the nurse include? Select all that apply. 1. Before antiretroviral therapy 2. On day 1 of antiretroviral therapy 3. Within 1 month 4. Every 2 months during antiretroviral therapy 5. Every 3 to 4 months for 2 years 6. Every 6 months after 2 years

1,3,5,6

Which of the following nursing interventions are appropriate for a patient with thrombocytopenia? Select all that apply. 1. Avoid intramuscular injections. 2. Keep visitors who are ill away from the patient. 3. Encourage 4 liters of fluid daily. 4. Avoid use of aspirin and NSAIDs. 5. Allow rest between activities. 6. Encourage use of shoes or slippers.

1,4,6

A patient diagnosed with lymphoma is discharged from the hospital. Which statements should the nurse include in the patient teaching? Select all that apply. 1. "It is important to avoid crowds to reduce your risk of infection." 2. "Avoid exposure to the sun, and wear sunscreen if you go outside." 3. "It is important for you to increase your dietary intake of iron." 4. "Your disease can affect the eyes, so screen viewing should be minimized." 5. "Be sure to wash all fruits and vegetables thoroughly before eating them."

1,5

The nurse would evaluate the patient as understanding modes of HIV transmission if the patient stated that the modes of HIV transmission for a person who has a detectable viral load include which of the following? Select all that apply. 1. Contact with infected blood products 2. Fecal-oral contact 3. Sharing towels and eating utensils 4. Mosquito bites 5. Unprotected sex 6. Saliva and tears

1,5

A patient with hypercalcemia needs to drink at least 3 liters of fluid per day. Today, the patient had 1 measuring cup of coffee, 1 liter of water, a can of soda that says it has 355 milliliters, and a half cup of juice. How many milliliters has he had so far today?

1,715 mL

The nurse is caring for a patient with allergic rhinitis. Which of the following interventions should the nurse anticipate will be included in the treatment plan for this patient? Select all that apply. 1. Anticholinergics 2. Antihistamines 3. Avoiding environmental stimuli 4. Decongestants 5. Immunotherapy 6. Steroids

2,3,4,5,6

The nurse would recognize that the patient understands antiretroviral therapy if the patient states that the goals of highly active antiretroviral therapy are which of these? Select all that apply. 1. "To increase viral load." 2. "To improve survival rates." 3. "To decrease CD4 T lymphocytes." 4. "To delay progression of HIV disease." 5. "To reduce HIV load to undetectable levels." 6. "To suppress the immune system."

2,4,5

The nurse is caring for a client who has iron-deficiency anemia. Which foods will add the most iron to this patient's diet? Select all that apply. 1. Berries 2. Roast beef 3. Yogurt 4. Crackers 5. Bean soup 6. Kale salad

2,5,6

The nurse is caring for a patient with HIV. Which of the following foods would the nurse inform the patient are safe to eat to reduce the risk of an infection? Select all that apply. 1. Caesar dressing 2. Cooked vegetables 3. Feta cheese 4. Raw fruits 5. Raw vegetables 6. Self-peeled fruits

2,6

During data collection, the patient reports tenderness in the cervical lymph nodes. The nurse recognizes that enlarged and tender lymph nodes usually indicate which of these problems? Select all that apply. 1. Arthritis 2. Cancer 3. Infection 4. Inflammation 5. Tetanus

3,4

In planning an educational session for a patient with HIV, the nurse would include that contact with which of the following body fluids can transmit HIV? Select all that apply. 1. Saliva 2. Tears 3. Breast milk 4. Semen 5. Blood 6. Sweat

3,4,5

The LPN/LVN is assisting the registered nurse in caring for a patient who is receiving a transfusion of two units of packed red blood cells. After checking the patient, the LPN/LVN is leaving the unit for a break. What information is essential to include in a focused SBAR handoff report to the registered nurse? Select all that apply. 1. Results of a complete head-to-toe examination 2. A report of the patient's pain on a 0 to 10 scale 3. The ABO blood type and Rh factor 4. Current vital signs 5. Status of patient's comfort level 6. Allergies

4,5

The nurse is assisting with data collection on a patient. Which of the following past surgeries found in the patient's history would alert the nurse to possible immune system dysfunction when planning care? Select all that apply. 1. Appendectomy 2. Parathyroidectomy 3. Pneumonectomy 4. Splenectomy 5. Thymectomy 6. Thyroidectomy

4,5

Which of the following patient test results would the nurse review to identify if inflammation is present? Select all that apply. 1. IgM assay 2. CD4+ count 3. Western blot 4. C-reactive protein 5. Erythrocyte sedimentation rate

4,5

Clarithromycin (Biaxin) 200 mg oral suspension is ordered for a patient. The nurse has 125 mg/5 mL available. How many milliliters should the nurse give?

8mL

The nurse is explaining to a patient newly diagnosed with AIDS about complications of the disease. Which of the following would the nurse explain is a more common opportunistic infection in AIDS?

Candidiasis

The nurse is preparing to assist the physician with a bone marrow biopsy. Which intervention is most important for the nurse to carry out before the procedure?

Administer an analgesic to the patient.

The nurse is providing care for patients on a medical-surgical unit. Which of the following patients is at increased risk for infection?

An 88-year-old with a neutrophil count of 32%.

While working with patients in an autoimmune disease clinic, the nurse recognizes that which of the following individuals is at most risk for systemic lupus erythematosus?

An Asian female who is attending college

In collecting data for a patient with angioedema, the nurse understands angioedema differs from urticaria because angioedema is characterized by which of the following?

Angioedema has a deeper and more widespread edema.

The nurse is educating the patient on his newly diagnosed disease process characterized by a chronic progressive inflammation of the sacroiliac and costovertebral joints and adjacent soft tissue. The nurse would evaluate the patient as understanding the educational session if he stated the name of the condition as which of these?

Ankylosing spondylitis

The nurse is collecting data from a patient with contact dermatitis. Which data is essential for the nurse to obtain?

Appearance of skin lesions

The nurse teaches a patient about vaccines. The nurse would evaluate the patient as understanding the presented information if the patient states that a vaccine provides which of these types of immunity?

Artificially acquired active immunity

A patient is diagnosed with Hashimoto thyroiditis and asks what causes it. The nurse would respond that destruction of thyroid cells in this condition is due to which of the following?

Autoantibodies

Which circumstance places the patient at most risk for postoperative pneumonia following a splenectomy?

Location of surgical incision

A patient is taking warfarin (Coumadin) after an artificial heart valve replacement procedure. The international normalized ratio result is 2.6. Which action by the nurse is correct?

No action needs to be taken at this time.

A patient reports on admission being "very sick" after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding the antibiotic?

Do not give the antibiotic.

A patient with multiple myeloma develops hypercalcemia. Which intervention can help minimize complications related to hypercalcemia?

Encourage 3 to 4 liters of fluid daily.

The nurse is caring for a patient undergoing a biopsy. Which action is appropriate for the nurse to take?

Ensure that informed consent is obtained before the procedure.

The nurse is reinforcing teaching to a 36-year-old patient who was working in the garden and was stung by a bee about always having which of these medications on hand in the event of another incident?

Epinephrine

Which of the following actions should the nurse prioritize when taking care of a patient with a platelet count of 23,000/mm3?

Protect the patient from injury.

What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?

Receive a yearly flu vaccine.

A patient is admitted with a 2-month history of fatigue, shortness of breath, pallor, and dizziness. The patient is diagnosed with idiopathic autoimmune hemolytic anemia. On reviewing the laboratory results, the nurse notes the presence of which of the following that would confirm this diagnosis?

Red blood cell fragments

A nurse is collecting patient data and finds small red-purple dots over most skin surfaces. The patient denies noticing them before. Which action should the nurse take first?

Report the findings immediately to the registered nurse or health-care provider.

In planning care for a patient who has allergic rhinitis, the nurse understands that without adherence to the treatment regimen, the patient is at risk for developing which of the following?

Sinusitis

A nurse is monitoring a patient during a blood transfusion. After the blood has been hanging for 30 minutes, the patient's temperature rises from 98.6°F (37°C) at baseline to 101°F (38.3°C). The patient also experiences severe chills. Which action should the nurse take first?

Stop the transfusion and hang normal saline solution.

The nurse is caring for a patient receiving packed red blood cells. They are piggybacked into an IV of dextrose and water. A separate IV site is being used for antibiotic administration and appears to be clotted. What should the LPN/LVN immediately report to the RN?

The blood is piggybacked into dextrose and water solution.

The nurse instructed a patient with thrombocytopenia on methods to prevent bleeding. Which is the best evidence that the teaching has been effective?

The patient uses an electric razor instead of a safety razor.

A 27-year-old male patient is admitted in sickle cell crisis. Which of the following events most likely contributed to the onset of the crisis?

The patient walked home in a cold rain yesterday.

A patient is admitted to the hospital for a splenectomy. The nurse understands that the health-care provider prescribes an injection of vitamin K prior to surgery for which action?

To correct a clotting problem

A patient is being given penicillin via intravenous infusion and develops signs and symptoms of an anaphylactic reaction. Which of the following should be the nurse's first action?

Turn off the antibiotic.

A patient has hand-foot syndrome related to sickle cell anemia. Which finding does the nurse expect to see during physical examination?

Unequal growth of fingers and toes

The nurse is teaching a patient with multiple myeloma how to remain safe in the home. Which problem should be a priority for this patient?

Unsteady gait

The nurse is caring for a patient with AIDS. Which of the following interventions should the nurse implement for infection control?

Wear gloves for blood/body fluid contact.

As the nurse collects data on a patient experiencing anaphylaxis, which of the following would require the nurse to take immediate action?

Wheezing