IMMUNE
The client who received a kidney transplant is taking azathioprine, and the nurse reinforces instructions about the medication. Which statement by the client indicates a need for further teaching?
"I need to discontinue the medication after 14 days of use." (This medication is taken for life.)
A client arrives at the health care clinic requesting to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. The nurse would respond with which most appropriate action?
Arrange for the client to return in 4 to 6 weeks to be tested.
A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and would ask the child about a history of an allergy to which primary product?
Baker's yeast
The nurse notes that a client is receiving lamivudine. The nurse would determine that this medication has been prescribed to most likely treat which condition?
Human immunodeficiency virus (HIV) infection
Indinavir is prescribed for the client with a diagnosis of human immunodeficiency virus (HIV). Which medication instruction would the nurse reinforce to the client?
Increase fluid intake to at least 1.5 L/day. Rationale: It is an antiretroviral agent. This medication can cause kidney stones; therefore, the client is instructed to increase fluid intake to at least 1.5 L/day.
A client who is diagnosed positive for human immunodeficiency virus (HIV) has had a tuberculin skin test. The results show a 7-mm area of induration. The nurse would interpret the test results as which response?
It is positive. Rationale:The client with HIV is considered to have positive results on skin testing with an area of 5 mm of induration or greater. The client without tuberculin HIV is positive with induration greater than 10 or 15 mm if the client is at low risk.
Tacrolimus is prescribed for a client. Which disorder in the client's record would the nurse note that indicates the medication needs to be administered with caution?
Renal insufficiency used with caution in immunosuppressed clients and those with renal or hepatic function impairment.
Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse would instruct the client to report which symptom if it developed during the course of this medication therapy?
Sore throat (also fever and pallor)
Saquinavir is prescribed for a client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse would reinforce medication instructions about which health care measure to the client?
avoid sun exposure
Indinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse has reinforced instructions to the client regarding ways to maximize absorption of the medication. Which statement by the client indicates an adequate understanding of the use of this medication?
"I need to take the medication with water but on an empty stomach." The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar
The nurse determines that the client diagnosed with neutropenia needs further teaching if which statement is made by the client?
"I will include plenty of fresh fruits in my diet." Fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens
A client with a diagnosis of human immunodeficiency virus (HIV) who was prescribed an oral solution of ritonavir complains about the taste of the solution. Which response would the nurse give the client?
"Mix the oral solution with chocolate milk."
A client diagnosed with stage I Lyme disease asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which treatment would be included in the care plan?
A 3- to 4-week course of oral antibiotic therapy
The client with diagnosed acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to monitor the client, knowing that this sign would most likely indicate which condition?
A result of another infection caused by the leukopenic effects of the medication.
The nurse is assisting with the administration of immunizations at a health care clinic. The nurse would understand that immunization provides which protection?
Acquired immunity from disease
A client diagnosed with pemphigus is being seen in the clinic regularly. The nurse would plan care based on which description of this condition?
An autoimmune disease that causes blistering in the epidermis
The client calls the emergency department and tells the nurse that he received a bee sting to the arm. The client states that he has received bee stings in the past and is not allergic to bees, but the site is painful. The client asks the nurse how to alleviate the pain. Which primary action would the nurse instruct the client to take?
Apply ice and elevate the site.
Efavirenz, an antiviral medication, is prescribed for a client diagnosed with human immunodeficiency virus (HIV) infection. Which time would the nurse instruct the client is best to take this medication?
At bedtime
Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?
Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L) (Nephrotoxicity can occur)
The nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE). The nurse would most appropriately administer which prescribed medication to manage the condition?
Corticosteroid Treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants
The nurse would determine that which are risk factors for systemic lupus erythematous (SLE)?
Female gender, african american, and child bearing age
Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse would monitor for which side/adverse effects of the medication?
Flu-like syndrome, low neutrophil count, Ocular pain or blurred vision and signs of hepatitis
The nurse is assisting in preparing a plan of care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure would the nurse most likely include in the plan?
Foods that are at room temperature Rationale:The client with AIDS experiencing nausea should avoid fatty products, such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided because they aggravate nausea. Foods are best tolerated either cold or at room temperature.
The nurse is reinforcing dietary instructions to a client prescribed cyclosporine. Which priority food item would the nurse instruct the client to avoid?
Grapefruit juice
A client has been prescribed amikacin. Which priority baseline function would the nurse determine needs to be monitored?
Hearing acuity (This med is an antibiotic, This medication can cause ototoxicity and nephrotoxicity; therefore, hearing acuity tests and kidney function studies should be performed before the initiation of therapy.)
The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?
Individuals with spina bifida
The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse would plan care considering which factor regarding this diagnosis?
It is an inflammatory disease of collagen contained in connective tissue.
A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse would determine that this has been confirmed by which finding?
Punch biopsy of the cutaneous lesions
The nurse is reinforcing dietary instructions to a client diagnosed with systemic lupus erythematosus. Which dietary item would the nurse most instruct the client to avoid?
Steak The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension.
Stavudine is prescribed for a client diagnosed with advanced human immunodeficiency virus (HIV). The nurse reinforcing medication instructions to the client would instruct the client about the importance of reporting which sign/symptom to the primary health care provider?
Tingling in the extremities Rationale:Peripheral neuropathy,
The nurse is caring for the client diagnosed with a skin infection who is prescribed amoxicillin 500 mg every 8 hours. Which sign/symptom would indicate to the nurse that the client is experiencing a frequent side effect related to the medication?
Vaginal drainage
The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking didanosine. The nurse reinforces instructions to the client to watch for which signs/symptoms that the medication may have caused the adverse effect of pancreatitis?
Vomiting and abdominal pain
Which precautions would the nurse specifically take during the administration of ribavirin to a child with respiratory syncytial virus (RSV)?
Wearing goggles Rationale:Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration.
The nurse is reinforcing medication instructions to a client with a diagnosis of human immunodeficiency virus (HIV) who is prescribed saquinavir. Which instruction would the nurse most appropriately provide the client in regard to taking this medication?
Within 2 hours after a full meal
What is kaposi's sarcoma?
a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator
The client is diagnosed with stage I of Lyme disease. The nurse would check the client for which characteristic of this stage?
flu-like symptoms
The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse would question the client about an allergy to which food items?
kiwis and bananas
Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions would the nurse include when administering this medication?
monitor liver function studies, instruct to avoid alcohol, instruct the client to avoid exposure to the sun
The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse would monitor for which side/adverse effects of the medication?
rash and hepatotoxicity
A client diagnosed with Lyme disease tells the nurse, "I heard this disease can affect the heart. Is this true?" The nurse would make which response to the client?
"It can, but you will be monitored closely for cardiac complications." Stage II of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The serious problems that occur in this stage include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis
The nurse reads the chart of the client who has been diagnosed with stage III Lyme disease. The nurse would determine that which sign/symptom best supports this diagnosis?
Complaints of joint pain
The nurse is assisting in developing a plan of care for the pregnant client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse would determine that which is the priority concern for this client?
Development of an infection
A client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking zidovudine 200 mg orally 3 times daily. The client reports to the health care clinic for follow-up blood studies, and the results indicate severe neutropenia. Which would the nurse next anticipate to be prescribed for the client?
Discontinuation of the medication Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery.
A client began taking amantadine approximately 2 weeks ago. Which would the nurse expect to decrease if the medication is having a therapeutic effect?
Rigidity and akinesia an antiparkinson agent
The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted?
Serum amylase (The med can cause pancreatitis)
Zidovudine is prescribed for an adult client diagnosed with human immunodeficiency virus (HIV). Which statement by the nurse would provide the best instruction to the client about the medication?
Space the medication doses evenly around the clock." Rationale: This med interferes with HIV replication, slowing the progression of HIV infection. The client is instructed to space the doses of the medication evenly around the clock
A client diagnosed with diabetes mellitus has a foot infection and is prescribed antibiotic therapy with an aminoglycoside. The nurse collects data from the client and notes that the client has a hearing loss. The nurse would take which action next?
Inform the registered nurse (RN) about the hearing loss. A preexisting hearing loss is a contraindication for the administration of aminoglycosides because these medications can cause ototoxicity and irreversible hearing loss.
The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?
Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.
The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which would be included in the plan of care for instructions?
Maintain a high fluid intake.
An oral powder form of nelfinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse would reinforce instructions regarding the preparation of the medication and instruct the client to mix the powder with which substance?
Milk rationale:The powder form is prepared by mixing the dose with a small amount of water, milk, formula, soy milk, or dietary supplements.
A client is diagnosed with stage II Lyme disease. The nurse would check the client for which characteristic of this stage?
Nervous system disorders If untreated, stage II of Lyme disease begins 2 to 12 weeks after the first stage with carditis and nervous system disorders such as meningitis, peripheral neuritis, or a facial paralysis similar to Bell palsy.
The clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to the child. The nurse would administer this vaccine by which method?
Subcutaneously in the outer aspect of the upper arm
The nurse is assisting in caring for a client diagnosed with a respiratory tract infection who is prescribed intravenous tobramycin sulfate. The nurse is instructed to monitor for adverse effects of the medication. The nurse would determine that which finding is most indicative of an adverse effect of this medication?
Vertigo Rationale:Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of cranial nerve VIII.q
The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which would be the appropriate nursing action?
Ask the client if they ever sustained a bee sting in the past.
The nurse is assisting in developing a plan of care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. Which nursing intervention would be included in the plan of care to manage this symptom?
Administer an antipyretic at bedtime. For clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Administering sedatives, keeping the call bell within reach of the client, and providing back rubs and comfort measures before bedtime are important interventions, but they are unrelated to the subject of fever and night sweats.
The nurse is reviewing the laboratory results for a client receiving tacrolimus. Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication?
Blood glucose of 200 mg/dL Other adverse effects include neurotoxicity evidenced by headache; tremor; insomnia; gastrointestinal (GI) effects such as diarrhea, nausea, and vomiting; hypertension; and hyperkalemia.
The nurse is assigned to care for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the primary health care provider's prescriptions. Which medication would the nurse expect to be prescribed to aid in long-term control?
Hydroxychloroquine
A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student would include which correct item in the discussion?
HIV virus attacks the immune system by destroying T lymphocytes.
The nurse is taking a health history on a client seen in the health care clinic for the first time. When the nurse asks the client about current prescribed medications, the client tells the nurse that amprenavir is prescribed twice daily. Based on this finding, the nurse would elicit data from the client regarding the presence of which condition?
Human immunodeficiency virus (HIV)
Diphenhydramine hydrochloride 25 mg orally every 6 hours is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. What would the nurse determine about the medication dosage?
The dosage is within the safe range. Calculate the dosage parameters using the safe dosage range identified in the question and the child's weight in kilograms. Next, determine the total daily dosage. Dosage parameters: 5 mg/kg × 25 kg = 125 mg/day. Dosage frequency: 25 mg × 4 doses = 100 mg/day. The dosage is safe.
The nurse has reinforced discharge instructions to the mother of a child who is prescribed tetracycline to treat Rocky Mountain spotted fever (RMSF). Which statement by the mother indicates the best understanding regarding the administration of the medication?
"I need to use a straw when I give the medication." Rationale: cause staining of the teeth, straws should be used, and the mouth should be rinsed after administration.
Moxifloxacin is prescribed for the client with a diagnosis of community-acquired pneumonia. The client needs to take the medication for 10 days, and the nurse reinforces instructions to the client about the medication. Which statement by the client best indicates an understanding of the medication instructions?
"I need to wear sunscreen and protective clothing when outdoors." The med is a fluoroquinolone. Increased sensitivity of the skin to sunlight can occur, and the client is instructed to avoid excessive sunlight and artificial ultraviolet light.
The nurse is assessing the client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection?
"Did you have chicken pox as a child?" The client has the symptoms of herpes zoster, or shingles, which is caused by the same organism as chicken pox
The nurse is instructing a client with a diagnosis of systemic lupus erythematosus (SLE) about dietary alterations. The nurse would remind the client to avoid which primary foods? Select all that apply.
Beef and cheese at risk for cardiovascular disorders, such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce intake of salt, fat, and cholesterol.
The primary health care provider aspirates synovial fluid from a knee joint of a client diagnosed with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to best indicate which finding?
Cloudy synovial fluid Cloudy synovial fluid is diagnostic of rheumatoid arthritis.
The nurse is assisting in preparing a plan of care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who will be receiving ganciclovir. The nurse determines that which intervention would be included in the plan of care?
Instruct the client to use an electric razor for shaving. Rationale: causes neutropenia and thrombocytopenia as the most frequent side effects.
The nurse is assisting in caring for a client receiving amphotericin B intravenously (IV) to treat disseminated candidiasis. The nurse reviews the plan of care and would implement which priority action during the administration of the medication?
Monitor urinary output a toxic medication that can produce symptoms during administration such as chills, fever, headache, vomiting, and impaired renal function.
Dapsone is prescribed for the client diagnosed with acquired immunodeficiency syndrome for the treatment of toxoplasmosis. The nurse should reinforce medication instructions and determine that the client understands the instructions if the client makes which statement?
Report a sore throat to the primary health care provider. The medication suppresses bone marrow activity, and the complete blood count is monitored closely.
A client diagnosed with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine therapy. The clinic nurse would reinforce which instruction to this client?
Come to the health care clinic to be seen by the primary health care provider. Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. The client should be seen by the primary health care provider and be monitored for indications of developing pancreatitis.
Mycophenolate mofetil is prescribed for the client as prophylaxis for organ rejection following an allogeneic renal transplant. Which instruction would the nurse most reinforce regarding administration of this medication?
Contact the primary health care provider (PHCP) if a sore throat occurs.
The home care nurse is selecting dressing supplies for a client who has an allergy to latex. The nurse would ask the medical supply personnel to deliver which items?
Cotton pads and silk tape they are latex-free products
Ribavirin is prescribed for the hospitalized child with respiratory syncytial virus (RSV). The nurse prepares to administer this medication via which route?
Via face mask Administration is via hood, face mask, or oxygen tent. The medication is most effective if administered within the first 3 days of the infection.
A client who is diagnosed with human immunodeficiency virus (HIV) seropositive has been taking stavudine. The nurse would monitor which parameter closely while the client is taking this medication?
Gait The medication can cause peripheral neuropathy
Amikacin is prescribed for a client with a diagnosed bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs?
Hearing loss Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity.
A client prescribed infliximab via intravenous (IV) injection is complaining of difficulty swallowing. Which would be the initial nursing action?
Notify the registered nurse (RN). Allergic reactions and anaphylaxis can occur from this medication and can be fatal. This complaint could be the first sign of an anaphylactic reaction. The RN must be notified, and it is imperative that the infusion be shut off as soon as possible.
The nurse should interpret that the client prescribed zalcitabine is experiencing an adverse effect of this medication when which event is reported by the client?
Numbness in the legs Rationale:Peripheral neuropathy is an adverse effect
The nurse should interpret that the client prescribed zalcitabine is experiencing an adverse effect of this medication when which event is reported by the client?
Numbness in the legs Rationale:Peripheral neuropathy is an adverse effect
Lamivudine is prescribed for a client diagnosed with human immunodeficiency virus (HIV) who is prescribed zidovudine. Which would the nurse reinforce in the medication instructions to the client?
To report vomiting or abdominal pain to the primary health care provider Pancreatitis, evidenced by nausea, vomiting, and abdominal pain, is also an adverse effect of the medication and requires primary health care provider notification.
A client prescribed zidovudine has been diagnosed with severe neutropenia. The nurse anticipates which intervention would be implemented?
The medication will be temporarily discontinued. Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery.
Cyclosporine is prescribed for a client following an allogenic kidney transplant. The nurse would reinforce which instructions to the client regarding this medication?
Blood levels of the medication will need to be measured periodically. an immunosuppressant. To avoid toxicity from high drug levels and to avoid organ rejection from low drug levels, blood levels of cyclosporine should be measured periodically. In the organ transplant client, an immunosuppressant will need to be taken for life. Oral administration is the route of choice; intravenous administration is reserved for clients who cannot take the medication orally. The most serious adverse effects are nephrotoxicity and infection.
The nurse is collecting data on a client complaining of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse would further check for which manifestation that is also indicative of the presence of SLE?
Butterfly rash on the cheeks and bridge of the nose
A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a low T4 count. The nurse initiates prophylactic treatment as prescribed with aerosolized pentamidine isethionate and would monitor for which expected outcome?
The client has a respiratory rate and depth within normal limits for the activity level. Rationale:Aerosolized pentamidine is given prophylactically to clients with a T4 count below 200 to prevent Pneumocystis jiroveci pneumonia, which is the most common opportunistic infection that occurs in clients with AIDS. A respiratory rate and depth within normal limits for activity level would indicate that the client was not experiencing the respiratory difficulty that is associated with pneumonia. Standard precautions are always maintained on all clients.
The client with a diagnosis of acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which procedure will be done to confirm whether these lesions are due to Kaposi's sarcoma?
Skin biopsy
A client diagnosed with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a client problem of impaired gas exchange written in the plan of care. Which indicates that the expected outcome of care has not yet been achieved?
The client limits fluid intake. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.
The client diagnosed with acquired immunodeficiency syndrome (AIDS) has begun therapy with zidovudine. The nurse would monitor which laboratory result during treatment with this medication?
Complete blood count (A common side/adverse effect of therapy with zidovudine is leukopenia and anemia.)
