Immune

The well-baby clinic nurse is preparing to administer an immunization when the infant's mother reports that the child has had a fever and has just started taking antibiotics. The nurse takes the child's temperature rectally and notes that it is 101.5° F (38.6° C). Which nursing action is appropriate? 1. Delay the immunization. 2. Administer the immunization. 3. Administer one of the three scheduled immunizations. 4. Administer half of the prescribed dose of each scheduled immunization

1. Delay the immunization.

The nurse preparing to administer an intravenous dose of immune globulin (IGIV) should first ensure the availability of which medication? 1. Epinephrine 2. Acetylcysteine 3. Phytonadione 4. Protamine sulfate

1. Epinephrine

A client who has been prescribed cyclosporine after a renal transplant is receiving medication information from the nurse. Which situation will the nurse identify as being a possible side/adverse effect of this therapy? Select all that apply. 1. Fever 2. Tremors 3. Weight gain 4. Hypertension 5. Swollen gums

1. Fever 2. Tremors 4. Hypertension 5. Swollen gums

Which of the client's parameters should the nurse monitor to determine the effectiveness of prescribed sulfisoxazole therapy? 1. Blood pressure 2. Blood glucose 3. Red blood cell count 4. White blood cell coun

4. White blood cell count

The nurse provides education to a client prescribed quinine. Which statement by the client indicates that teaching has been effective? 1. "This medication is an antimalarial." 2. "This medication is an antimicrobial." 3. "This medication is an antispasmodic." 4. "This medication is an antidysrhythmic."

1. "This medication is an antimalarial."

The nurse assesses the client for the hallmark characteristic of stage I Lyme disease. Which assessment finding should the nurse most likely expect to note? 1. Skin rash 2. Arthralgias 3. Dizziness and headaches 4. Enlarged and inflamed joints

1. Skin rash

What are the specific clinical symptoms of anaphylaxis? Select all that apply. 1. Hives 2. Fever 3. Stridor 4. Dyspnea 5. Urticaria 6. Wheezing

1. Hives 3. Stridor 4. Dyspnea 5. Urticaria 6. Wheezing

The nurse assesses the client diagnosed with acquired immunodeficiency syndrome (AIDS) for early signs of Kaposi's sarcoma. What characteristics would be consistent with that lesion? Select all that apply. 1. Flat 2. Raised 3. Resembling a blister 4. Light blue in color 5. Brownish and scaly in appearance 6. Color varies from pink to dark violet or black

1. Flat 6. Color varies from pink to dark violet or black

The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which should the nurse specifically plan to implement during administration of the medication to minimize the client's risk for injury? Select all that apply. 1. Monitor for hyperthermia. 2. Monitor for an excessive urine output. 3. Administer a concurrent fluid challenge. 4. Assess the intravenous (IV) infusion site. 5. Assess the chest and back for a red, itchy rash. 6. Monitor the client's orientation to time, place, and person.

1. Monitor for hyperthermia. 4. Assess the intravenous (IV) infusion site.

The nurse has given the client with human immunodeficiency virus (HIV) suggestions to minimize dysphagia. The nurse determines that the client has understood the instructions if the client states that she or he should increase intake of which food? 1. Puddings 2. Hot soup 3. Peanut butter 4. Raw vegetables

1. Puddings

A client is prescribed erythromycin. Which laboratory test should the nurse monitor the client for when taking this medication? 1. Renal function studies 2. Complete blood count 3. Hepatic function studies 4. Thyroid function studie

1. Renal function studies

When collecting psychosocial assessment data on a client infected with the human immunodeficiency virus (HIV), what should the nurse focus upon first? 1. The presence of any concerns or fears 2. Identifying factors that delayed treatment 3. Determining if the client's home is a safe environment 4. Assessing whether the client has adequate support at home

1. The presence of any concerns or fears

Moxifloxacin is prescribed for a client with a diagnosis of community-acquired pneumonia. The nurse, after providing instructions, determines that the client understood the information when which statement is made? 1. "I need to limit my daily fluid intake." 2. "I need to wear sunscreen and protective clothing when outdoors." 3. "I need to take the medication with a magnesium-containing antacid." 4. "Joint swellings are expected to occur while I am taking the medication.

2. "I need to wear sunscreen and protective clothing when outdoors."

A child admitted with nonspecific symptoms of rash, headache, fever, anorexia, and restlessness is diagnosed with Rocky Mountain spotted fever (RMSF). The nurse should anticipate that the child will be prescribed which medication? 1. Thiotepa 2. Thioguanine 3. Doxycycline 4. Ticlopidine hydrochloride

3. Doxycycline

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse include in the plan of care to assist the client in performing activities of daily living? 1. Offer low-microbial food. 2. Provide small, frequent meals. 3. Provide supportive care with hygiene needs. 4. Provide meals and snacks with high nutritional value

3. Provide supportive care with hygiene needs.

After assessment and diagnostic evaluation, it has been determined that the client has a diagnosis of Lyme disease, stage II. The nurse assesses the client for which manifestation that is most indicative of this stage? 1. Lethargy 2. Headache 3. Erythematous rash 4. Cardiac dysrhythmias

4. Cardiac dysrhythmias

4. A client is prescribed amphotericin B intravenously to treat a fungal infection. The nurse monitors and reports the result of which electrolyte study during therapy with this medication? 1. Sodium value of 138 mEq/L (138 mmol/L) 2. Calcium value of 9.0 mg/dL (2.25 mmol/L) 3. Chloride value of 102 mEq/L (102 mmol/L) 4. Potassium value of 3.1 mEq/L (3.1 mmol/L)

4. Potassium value of 3.1 mEq/L (3.1 mmol/L)

A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication? 1. Monitor blood glucose levels for elevation. 2. Administer the medication on an empty stomach only. 3. Apply pressure to venipuncture sites for at least 2 minutes. 4. Provide the client with a soft toothbrush and an electric razor.

4. Provide the client with a soft toothbrush and an electric razor.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) has a T4 count of 150/mm3, and a T4:T8 ratio that is less than 2. How should the nurse interpret these results? 1. The client is malnourished. 2. The client is in stable condition. 3. The client has clinically improved. 4. The client is at risk for opportunistic infection

4. The client is at risk for opportunistic infection

A client diagnosed with human immunodeficiency virus (HIV) has been prescribed saquinavir. When should the nurse instruct the client to take the medication? 1. At bedtime 2. On an empty stomach 3. 30 minutes before breakfast 4. Within 2 hours after a full meal

4. Within 2 hours after a full meal

When administering an oral dose of erythromycin, which liquid should the nurse offer with the medication? 1. Full glass of milk 2. Full glass of water 3. Sip of orange juice 4. Any citrus beverage

2. Full glass of water

Erythromycin has been prescribed for a client diagnosed with a Staphylococcus aureus infection. The nurse should monitor the client for signs/symptoms of which adverse effect of this medication? 1. Urticaria 2. Hepatitis 3. Thrombophlebitis 4. Nausea and vomiting

2. Hepatitis

The sister of a client with human immunodeficiency virus (HIV) asks the nurse what information she needs in order to take care of her sibling. Which instructions are appropriate for the nurse to recommend? Select all that apply. 1. Disinfect surfaces with 100% bleach. 2. Use gloves when handling body fluids. 3. Encourage a minimum of 12 hours sleep per day. 4. Wash soiled clothes in hot water with 1 cup of bleach. 5. Other members of the household should not share a bathroom. 6. Soak cleaning rags, sponges, and mops in 1:10 bleach solution for 5 minutes

2. Use gloves when handling body fluids. 4. Wash soiled clothes in hot water with 1 cup of bleach. 6. Soak cleaning rags, sponges, and mops in 1:10 bleach solution for 5 minutes

The client diagnosed with acquired immunodeficiency syndrome has begun therapy with zidovudine. Which laboratory result should the nurse carefully monitor during treatment with this medication? 1. Blood culture 2. Blood glucose level 3. Complete blood coun 4. Blood urea nitrogen leve

3. Complete blood coun

The nurse is caring for a client who is receiving cyclosporine. Which condition indicates to the nurse that the client is experiencing an adverse effect of the medication? 1. Acne 2. Sweating 3. Joint pain 4. Hyperkalemia

4. Hyperkalemia

Stavudine is prescribed for a client diagnosed with human immunodeficiency virus. The nurse provides medication instructions that stress that it is most important to report which side effect to the health care provider? 1. Headache 2. Constipation 3. Loss of energy 4. Numbness in the hands or feet

4. Numbness in the hands or feet

The nurse is providing medication education to the client prescribed cyclosporine after a renal transplant. The nurse should stress the importance of alerting the primary health care provider of which occurrence? 1. Hair loss 2. Weight loss 3. Hypotension 4. Signs of infection

4. Signs of infectio

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects many body symptoms. Which hematopoietic conditions can occur as a result of SLE? Select all that apply. 1. Anemia 2. Alopecia 3. Pneumonitis 4. Discoid erythema 5. Lymphadenopathy 6. Raynaud's phenomenon

1. Anemia 5. Lymphadenopathy

The nurse is reviewing the medical record of a young adult client who is suspected of having systemic lupus erythematosus (SLE). Which assessment finding should the nurse expect to document that is related to this diagnosis? 1. Recurrent emboli 2. Ascites noted in the abdomen 3. Butterfly rash on cheeks and bridge of the nose 4. Presence of 2 hemoglobin S genes in the blood cell report

3. Butterfly rash on cheeks and bridge of the nose

Which clinical manifestation should the nurse expect to note in a client experiencing stage III Lyme disease? 1. A generalized skin rash 2. A cardiac dysrhythmia 3. Complaints of joint pain c4. Paralysis in the extremity bitten by the tick

3. Complaints of joint pain

A client diagnosed with acquired immunodeficiency syndrome (AIDS) has a problem with nutrition resulting in a weight loss. The nurse has instructed the client regarding methods of increasing weight for health maintenance. The nurse determines that there is a need for further instruction if the client states the need to implement which measure? 1. Eat low-calorie snacks between meals. 2. Eat small, frequent meals throughout the day. 3. Consume nutrient-dense foods and beverages. 4. Keep easy-to-prepare foods available in the home.

1. Eat low-calorie snacks between meals.

The nurse has provided dietary instructions to a client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse determines that there is a need for further instructions about methods to maintain and increase weight when the client makes which statement? 1. "I need to eat low-calorie snacks between meals." 2. "I need to eat small, frequent meals throughout the day." 3. "I need to consume nutrient-dense foods and beverages." 4. "I need to keep easy-to-prepare foods available in the home."

1. "I need to eat low-calorie snacks between meals."

Which statement by the client indicates the need for further teaching by the nurse regarding cyclosporine therapy? 1. "I need to obtain a yearly influenza vaccine." 2. "I need to monitor my blood pressure at home." 3. "I need to have dental checkups every 3 months." 4. "I need to call my doctor if my urine becomes cloudy.

1. "I need to obtain a yearly influenza vaccine."

The nurse is orienting a new RN in the care for a client diagnosed with an immunodeficiency condition. Which statement by the new RN indicates that teaching has been effective? 1. "The client has an absence of immune bodies." 2. "The disorder is the result of a congenital source." 3. "The client will likely have a difficult time developing coping skills." 4. "Interventions should be planned for a nursing diagnosis of risk for self-harm."

1. "The client has an absence of immune bodies."

A client diagnosed with acquired immunodeficiency syndrome (AIDS) will be receiving aerosolized pentamidine isethionate prophylactically once every 4 weeks. The home health nurse visits and instructs the client about the medication. Which statement by the client indicates a need for further teaching? 1. "There are no known side effects of this therapy." 2. "I may experience some nausea with the inhalation therapy." 3. "If I have any visual disturbances, I need to let the health care provider know." 4. "I'll report if I develop a cough or shortness of breath after I begin this therapy."

1. "There are no known side effects of this therapy."

The nurse provides instructions to the client prescribed the hepatitis A vaccine. Which statement, when made by the client, indicates a need for further teaching? 1. "This vaccine will also protect me against hepatitis B." 2. "This vaccine will be given by the intramuscular route." 3. "This vaccine contains the inactive virus of hepatitis A." 4. "A booster dose is recommended 6 to 12 months after the initial injection.

1. "This vaccine will also protect me against hepatitis B."

An adult calls the emergency department seeking advice on managing the pain caused by a bee sting to the arm. The client states that previous bee stings did not result in any allergic reactions. What should the nurse tell the client to do first? 1. Apply ice and elevate the arm. 2. Place a heating pad to the sting site. 3. Place the arm in a dependent position. 4. Cleanse the sting site with warm soapy water.

1. Apply ice and elevate the arm.

Efavirenz, an antiviral medication, is prescribed for a client diagnosed with human immunodeficiency virus (HIV) infection. The nurse should educate the client that it is best to take the medication at which time? 1. At bedtime 2. With lunch 3. With dinner 4. Just before breakfast

1. At bedtime

A client has a prescription for ketoconazole. Which instruction should the nurse teach the client to follow while taking this medication? 1. Avoid exposure to sunlight. 2. Limit alcohol to 2 ounces per day. 3. Take the medication with an antacid. 4. Take the medication on an empty stomach

1. Avoid exposure to sunlight.

The nurse is planning to teach a client diagnosed with multiple allergies about measures to reduce allergens in the home. Which measures should the nurse include in the teaching plan? Select all that apply. 1. Avoid having pets with hair. 2. Use a humidifier year round. 3. Use a damp cloth for dusting. 4. Clean air conditioners periodically. 5. Maintain a dedicated smoking area outside

1. Avoid having pets with hair. 3. Use a damp cloth for dusting. 4. Clean air conditioners periodically.

A client diagnosed with late-stage human immunodeficiency virus (HIV) is extremely upset about the diagnosis. What should be the priority psychosocial nursing intervention for the client and family? 1. Encourage the client and family to discuss their feelings about the disease. 2. Encourage the client to seek out a support group that is focused on families. 3. Advise the client to choose a family member to serve as a medical surrogate. 4. Help the client write a list of relevant questions to be discussed with the doctor.

1. Encourage the client and family to discuss their feelings about the disease.

What should the nurse administering immunizations to a child ensure is available as the priority item during the administration of a vaccine? 1. Epinephrine 2. ⅞-inch needle 3. Pediatric syringes 4. Diphenhydramine

1. Epinephrine

The nurse is performing an assessment on a client with a diagnosis of systemic lupus erythematosus (SLE). Which finding should the nurse expect to note? Select all that apply. 1. Fever 2. Bradycardia 3. Lymphadenopathy 4. Butterfly rash on the face 5. Muscular aches and pains

1. Fever 3. Lymphadenopathy 4. Butterfly rash on the face 5. Muscular aches and pains

The nurse is monitoring the client prescribed amphotericin B for adverse effects of this medication. Which indicates the presence of an adverse effect? Select all that apply. 1. Fever 2. Chills 3. Tremors 4. Hypertension 5. Abdominal pain 6. Rapid heartbeat

1. Fever 2. Chills 3. Tremors 5. Abdominal pain

The nurse is assigned to care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving amphotericin B for a fungal respiratory infection. Which would indicate an adverse effect of the medication? 1. Hypokalemia 2. Hypernatremia 3. Hypochloremia 4. Hypercalcemia

1. Hypokalemia

client has been prescribed amphotericin B for a fungal respiratory infection. Which laboratory finding is an indication of an adverse effect of the medication? 1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypercalcemia

1. Hypokalemia

The nurse providing discharge instructions to the client prescribed doxycycline should instruct the client to monitor for which adverse effect? 1. Infection 2. Urticaria 3. Dysphagia 4. Photosensitivity

1. Infection

Which symptoms are frequently seen in clients with stage 4 human immunodeficiency virus (HIV) infection according to the World Health Organization (WHO)? Select all that apply. 1. Lymphoma 2. Kaposi's sarcoma 3. Asymptomatic infection 4. Candidiasis of the esophagus 5. Recurrent upper respiratory infection 6. Unintentional weight loss less than 10% of body weight

1. Lymphoma 2. Kaposi's sarcoma 4. Candidiasis of the esophagus

An oral powder form of nelfinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse should tell the client to mix the powder with which food item? 1. Milk 2. Applesauce 3. Orange juice 4. Grapefruit juic

1. Milk

When a diagnosis of stage I Lyme disease is confirmed, the nurse discusses the recommended treatment for the disease with the client. Which form of treatment should the nurse tell the client will most likely be prescribed? 1. Oral antibiotic therapy 2. Ultraviolet light therapy 3. Treatment with intravenous (IV) penicillin G 4. Treatment that focuses on the client's specific symptomology

1. Oral antibiotic therapy

The nurse preparing to give a client a first dose of cyclosporine should plan to have what emergency items available? Select all that apply. 1. Oxygen 2. Code cart 3. Epinephrine 4. Cardiac monitor 5. Oxygen saturation monitor

1. Oxygen 2. Code cart 3. Epinephrine

A client who was tested for human immunodeficiency virus (HIV) after a recent exposure had a negative test result. What information should the nurse include in post-test counseling? 1. The test should be repeated in 6 months. 2. The client probably has immunity to HIV. 3. The client's sexual partners were obviously not infected. 4. This ensures that the client is not infected with the HIV virus

1. The test should be repeated in 6 months.

The nurse is preparing to administer childhood vaccinations to a 15-month-old child. Which vaccine should be added to the child's routine immunizations at this time? 1. Varicella 2. Hepatitis B 3. Hepatitis A 4. Pneumococcal vaccine (PVC)

1. Varicella

A client being tested for human immunodeficiency virus (HIV) has had 2 positive enzyme-linked immunosorbent assay (ELISA) tests. The nurse anticipates that which diagnostic test will be prescribed next? 1. Western blot 2. CD4 cell count 3. Bone marrow biopsy 4. T-helper lymphocyte count

1. Western blot

The nurse is evaluating the client's response to amoxicillin/clavulanate. The nurse notes that the client has developed a rash and is reporting diarrhea. Which nursing intervention is most appropriate at this time? 1. Withhold the medication. 2. Continue to monitor the client. 3. Document that a side effect has occurred. 4. Check the client's most recent laboratory repor

1. Withhold the medication.

The nurse is providing discharge instructions regarding side effects to the client who has been prescribed raltegravir. Which statement, when made by the client, indicates a need for further instruction? 1. "Nausea is a side effect of this medication." 2. "I might develop a rash, but this is expected." 3. "Headache is a side effect of this medication." 4. "I might have some diarrhea after starting this medication.

2. "I might develop a rash, but this is expected."

Which individual is least likely to be at risk for the development of Kaposi's sarcoma? 1. A kidney transplant client 2. A client receiving antineoplastic medications 3. An individual working with asbestos products 4. A male with a history of same-gender sexual partners

2. A client receiving antineoplastic medications

The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention should the nurse include in the plan of care to manage this symptom? 1. Administer a sedative at bedtime. 2. Administer an antipyretic at bedtime. 3. Cover the client with only a light blanket. 4. Provide a back rub and comfort measures before bedtime.

2. Administer an antipyretic at bedtime.

Which instructions should the nurse provide to the client about the prevention and early detection of Lyme disease? Select all that apply. 1. Wear dark clothing when walking in wooded areas. 2. Avoid heavily wooded areas and areas with thick underbrush. 3. Wear long-sleeved tops and long pants with closed shoes and a hat or cap. 4. Bathe after being in an infested area, and inspect the body carefully for ticks. 5. Avoid the use of insect repellent on the skin and clothing because of its toxicity. 6. If a tick is found, report to the health care provider immediately for a blood test to detect the presence of Lyme disease.

2. Avoid heavily wooded areas and areas with thick underbrush. 3. Wear long-sleeved tops and long pants with closed shoes and a hat or cap. 4. Bathe after being in an infested area, and inspect the body carefully for ticks.

A community health nurse providing an educational session regarding Lyme disease should include which instruction during the session? 1. Avoid emptying cat litter boxes. 2. Check skin for ticks after camping. 3. Avoid contact with infected individuals. 4. Wear a mask when doing yard work around trees.

2. Check skin for ticks after camping.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) shares with the nurse feelings of social isolation. Which strategy should the nurse suggest as the most useful way to decrease the client's stated loneliness? 1. Reinstituting contact with the client's family, who live in a distant city 2. Contacting a support group for clients with AIDS that is available in the local region 3. Using the Internet or the computer to facilitate communication while maintaining isolation 4. Using the television and newspapers to maintain a feeling of being "in touch" with the world

2. Contacting a support group for clients with AIDS that is available in the local region

The nurse suggests which strategy as the most useful way to decrease the stated feelings of isolation reported by a client diagnosed with acquired immunodeficiency syndrome (AIDS)? 1. Using the Internet to facilitate communication 2. Contacting local support groups for clients with AIDS 3. Reinstituting contact with the client's family, who live in a distant city 4. Using television and newspapers to maintain a feeling of being socially "in touch"

2. Contacting local support groups for clients with AIDS

The nurse caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS) is monitoring for signs of associated complications. What is the earliest assessment finding that would indicate the presence of Pneumocystis jiroveci? 1. Fever 2. Cough 3. Dyspnea at rest 4. Dyspnea when ambulating

2. Cough

Which assessment question should the nurse ask the mother before administering an inactivated poliovirus vaccine (IPV) to a child? 1. Is the child currently experiencing diarrhea? 2. Does the child have an allergy to neomycin? 3. Has the child had any ear infections recently? 4. Does the child have a known allergy to eggs?

2. Does the child have an allergy to neomycin?

The nurse is preparing to administer a first dose of prescribed pentamidine isethionate intravenously to a client. Before administering the dose, which safety measure should the nurse consider for this client? 1. Assign to a private room. 2. Establish a supine position. 3. Place on respiratory precautions. 4. Assist to a semi-Fowler's position.

2. Establish a supine position.

A client calls the health care clinic and asks the nurse to describe the first signs of Lyme disease. The nurse informs the client to watch for which signs/symptoms of stage I Lyme disease? 1. Painful joints 2. Flulike symptoms 3. Tremors and weakness 4. Headaches and blurred vision

2. Flulike symptoms

The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). Which condition-associated finding should be immediately reported to the health care provider? Select all that apply. 1. Anorexia 2. Hematuria 3. Abdominal pain 4. Red facial rash 5. Increased weight 6. Decreased urine outpu

2. Hematuria 5. Increased weight 6. Decreased urine outpu

Which information should cause postponement or cancellation of the administration of an immunization? Select all that apply. 1. Over 60 years of age 2. History of allergic response 3. Immune deficiency disease 4. Insulin-dependent diabetes mellitus 5. Axillary temperature of 98.8° F (37.1° C) 6. Negative tuberculin skin test at 48 hours

2. History of allergic response 3. Immune deficiency disease

The nurse educator is teaching a group of nurses about toxoplasmosis. Which information is appropriate to include in the teaching? Select all that apply. 1. It is caused by an amoeba. 2. It is treated with sulfadiazine. 3. The organism is found in rare pork. 4. It may cause a severe inflammatory response. 5. The spores live up to 2 weeks in the environment. 6. Pregnant individuals should not empty litter boxes

2. It is treated with sulfadiazine. 3. The organism is found in rare pork. 4. It may cause a severe inflammatory response. 6. Pregnant individuals should not empty litter boxes

The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who asks for a snack. Which food would be the appropriate choice for this client to meet nutritional needs? 1. Apple 2. Poached pears 3. Fresh fruit salad 4. Homemade yogurt

2. Poached pears

The nurse is orienting a new RN in the care of a client with acquired immunodeficiency syndrome (AIDS). Which statement by the new RN indicates that the teaching has been effective? 1. "The client should be assessed frequently for bradypnea." 2. "Jaundiced skin is often seen a late sign in clients with AIDS." 3. "An assessment should always include a thorough exam of their oral cavity." 4. "I should monitor for a low-specific-gravity urine, which indicates dehydration."

3. "An assessment should always include a thorough exam of their oral cavity."

The student nurse is listening to a lecture on the different types of allergic reactions. Which statement by the student nurse indicates that teaching has been effective? 1. "Atopic allergic reactions are the most life threatening." 2. "Hemolytic allergic reactions are the most life threatening." 3. "Anaphylaxis is the most life-threatening allergic reaction." 4. "Hypersensitivity is the most life-threatening allergic reaction."

3. "Anaphylaxis is the most life-threatening allergic reaction."

The nurse provides medication instructions to the client prescribed azathioprine after a renal transplant. Which statement by the client indicates the need for further instructions? 1. "I need to watch for signs of infection." 2. "I need to call my doctor if I miss more than one dose." 3. "I need to discontinue the medication after 14 days of use." 4. "I will take the medication with meals to prevent any nausea."

3. "I need to discontinue the medication after 14 days of use.

The community health nurse has provided a teaching session to parents and children regarding methods to prevent Lyme disease. Which statement by a child should indicate the need for additional teaching? 1. "We need to wear hats when we go on our hiking trip." 2. "Wearing long-sleeved tops and long pants is important." 3. "We shouldn't use insect repellents because they will attract the ticks." 4. "We need to wear long socks that can be pulled up over our pant legs."

3. "We shouldn't use insect repellents because they will attract the ticks."

The nurse is caring for a client who is receiving tobramycin sulfate intravenously every 8 hours. Which result should indicate to the nurse that the client is experiencing an adverse effect of the medication? 1. A total bilirubin of 0.5 mg/dL (8.5 mcmol/L) 2. An erythrocyte sedimentation rate of 15 mm/hour 3. A blood urea nitrogen (BUN) of 30 mg/dL (10.8 mmol/L) 4. A white blood cell count (WBC) of 6000 mm3 (6 × 109/L)

3. A blood urea nitrogen (BUN) of 30 mg/dL (10.8 mmol/L)

The home care nurse is making a follow-up visit to a client after receiving a renal transplant. Which assessment data support the possible existence of acute graft rejection? Select all that apply. 1. Pale skin color 2. Urine output of 45 mL/hour 3. Blood pressure of 164/98 mm Hg 4. Temperature of 102.4° F (39.1° C) 5. Client reporting "feeling so very tired" 6. Client reporting that graft site is tender when touched

3. Blood pressure of 164/98 mm Hg 4. Temperature of 102.4° F (39.1° C) 5. Client reporting "feeling so very tired" 6. Client reporting that graft site is tender when touched

A client is diagnosed with idiopathic autoimmune hemolytic anemia. The nurse expects the health care provider to write prescriptions for which first-line therapy to treat this disorder? 1. Radiation therapy 2. Platelet transfusion 3. Corticosteroid medication 4. Immunosuppressive agents

3. Corticosteroid medication

When a pregnant client asks the nurse why tetracycline hydrochloride cannot be prescribed for her acne, the nurse's response is based upon which fact about the medication's possible adverse effects on an unborn fetus? 1. May cause preterm labor 2. May cause deafness in the fetus 3. May darken the teeth in the fetus 4. May increase allergic reactions in the fetus

3. May darken the teeth in the fetus

The nurse is caring for a client with a diagnosis of pemphigus vulgaris. On assessment of the client, the nurse should look for which sign characteristic of this condition? 1. Turner's sign 2. Chvostek's sign 3. Nikolsky's sign 4. Trousseau's sign

3. Nikolsky's sig

The nurse has a prescription to administer foscarnet sodium intravenously to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Before administering this medication, which measure should the nurse implement? 1. Obtain a sputum culture. 2. Obtain folic acid as an antidote. 3. Place the solution on a controlled infusion pump. 4. Ensure that liver enzyme levels have been drawn as a baseline.

3. Place the solution on a controlled infusion pump.

The nurse providing discharge teaching to the client who has been prescribed gemifloxacin should include what information in the teaching session? 1. Take concurrently with iron supplements. 2. Limit fluid intake while on this medication. 3. Take with 8 ounces of water without regard to food. 4. Discontinue the medications when symptoms resolve

3. Take with 8 ounces of water without regard to food.

Which statement by the client will assist the nurse in determining that the client needs further teaching about the influenza vaccine? 1. "Fall is the traditional flu season." 2. "I should get a flu vaccine even though I'm healthy." 3. "I shouldn't get the vaccine because I'm allergic to eggs." 4. "I don't need the vaccine this year because I had one last year.

4. "I don't need the vaccine this year because I had one last year.

The nurse instructs a client diagnosed with oral candidiasis (thrush) about caring for the disorder. Which statement by the client indicates a need for additional teaching? 1. "I can eat foods that are liquid or pureed." 2. "I should eliminate spicy foods from my diet." 3. "It's best if I don't drink citrus juices or hot liquids." 4. "I need to rinse my mouth four times daily with commercial mouthwash."

4. "I need to rinse my mouth four times daily with commercial mouthwash."

A newborn infant receives the first dose of hepatitis B vaccine within 12 hours of birth. The nurse instructs the parent regarding the immunization schedule for this vaccine and should tell the parent that the second vaccine is administered at which time periods? 1. 3 years of age and then during the adolescent years 2. 8 months of age and then 1 year after the initial dose 3. 6 months of age and then 8 months after the initial dose 4. 1 to 2 months of age and then 6 months after the initial dose

4. 1 to 2 months of age and then 6 months after the initial dose

A client has a positive sputum culture for Mycobacterium tuberculosis and is prescribed streptomycin as part of the treatment. The nurse determines that the client is experiencing a toxic effect of the medication when which test result is abnormal? 1. Vision testing 2. Hepatic enzymes 3. Hemoglobin and hematocrit 4. Blood urea nitrogen (BUN) and creatinine

4. Blood urea nitrogen (BUN) and creatinine

After assessment and diagnostic evaluation, it has been determined that a client has stage II Lyme disease. The nurse expects to note which assessment finding that is indicative of this stage? 1. Arthralgias 2. Erythematous rash 3. Enlargement of joints 4. Cardiac conduction defect

4. Cardiac conduction defect

The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication? 1. Hypotension 2. Photophobia 3. Profuse sweating 4. Decrease in urine output

4. Decrease in urine output

Two weeks after being diagnosed positive for human immunodeficiency virus (HIV), a client is referred for a mental health assessment. In assessing the client, the nurse understands that which response is most typical? 1. The shock and disbelief would be resolved by anger, self-pity, and malingering. 2. Anxiety is the prevailing affective response experienced continuously once the diagnosis is known. 3. Extreme anxiety and hypervigilance behaviors beginning approximately 2 weeks after the diagnosis is delivered 4. Demonstration of symptomatology similar to post-traumatic stress disorder (PTSD) during the first few weeks after receiving the diagnosis

4. Demonstration of symptomatology similar to post-traumatic stress disorder (PTSD) during the first few weeks after receiving the diagnosis

On assessment of the client diagnosed with stage III Lyme disease, which clinical manifestation should the nurse expect to note? 1. Palpitations 2. A cardiac dysrhythmia 3. A generalized skin rash 4. Enlarged and inflamed joints

4. Enlarged and inflamed joints

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is admitted to the hospital with an additional diagnosis of histoplasmosis. The nurse should assess the client for which finding associated with disease progression? 1. Abdominal distention 2. Complaints of a headache 3. An elevated blood pressure 4. Enlargement of the lymph nodes

4. Enlargement of the lymph nodes

The school nurse sends information regarding the hepatitis B vaccine to parents seeking permission to administer the vaccine series to any unvaccinated child. Which assessment question should the nurse ask the parents to identify contraindications to receiving the vaccine? 1. Is your child allergic to aspirin? 2. Has your child had any recent sore throats? 3. Has your child had any gastrointestinal distress? 4. Has your child ever had an allergic reaction to baker's yeast?

4. Has your child ever had an allergic reaction to baker's yeast?

A client is diagnosed with human immunodeficiency virus (HIV) infection. The nurse creates a plan of care for the client, knowing what about HIV? 1. Urine is not a medium by which HIV is transferred. 2. Bacterial infections are not likely to occur with this diagnosis. 3. When protozoan infection occurs, the client is generally asymptomatic. 4. Immunosuppression occurs when the T4 lymphocyte count of less than 200/mm3

4. Immunosuppression occurs when the T4 lymphocyte count of less than 200/mm3

When indinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV), what information should the nurse include when providing medication instructions to the client? 1. Expect the urine to turn red. 2. Take the medication with a large meal. 3. Expect a significant amount of weight loss. 4. Increase fluid intake to at least 1.5 liters per day

4. Increase fluid intake to at least 1.5 liters per day

A 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 is appropriate? 1. Refer the client for a blood test immediately. 2. Ask the client about the size and color of the tick. 3. Inform the client that the tick is needed to perform a test. 4. Inform the client that she will need to return in 6 weeks to be tested

4. Inform the client that she will need to return in 6 weeks to be tested

A client diagnosed with acquired immunodeficiency syndrome (AIDS) reports dyspnea on exertion, tachypnea, and a dry cough. On auscultation of the lungs, the nurse notes crackles. The nurse reports the findings to the primary health care provider, knowing that these signs/symptoms are most likely the result of which complication associated with AIDS? 1. Toxoplasmosis 2. Cryptosporidiosis 3. Malignant lymphoma 4. Pneumocystis jiroveci pneumonia

4. Pneumocystis jiroveci pneumonia

When lamivudine is prescribed for a client who is presently taking zidovudine, the nurse provides medication information to the client that includes which instruction? 1. The medication must be taken with food. 2. Numbness of the hands and feet is expected. 3. Discontinue the zidovudine while taking lamivudine. 4. Report the occurrence of vomiting or abdominal pain immediately.

4. Report the occurrence of vomiting or abdominal pain immediately

The nurse is teaching a client who is taking cyclosporine after renal transplant about medication information. The nurse should tell the client to be especially alert for which problem? 1. Hair loss 2. Weight loss 3. Hypotension 4. Signs of infection

4. Signs of infection

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is now diagnosed with Pneumocystis jiroveci pneumonia. Which findings should the nurse expect to note during the assessment? 1. Temperature 98.6° F, pulse 80 beats per minute, respiration 32 breaths per minute 2. Temperature 98.6° F, pulse 80 beats per minute, respiration 18 breaths per minute 3. Temperature 101.5° F, pulse 80 beats per minute, respiration 18 breaths per minute 4. Temperature 101.5° F, pulse 120 beats per minute, respiration 32 breaths per minute

4. Temperature 101.5° F, pulse 120 beats per minute, respiration 32 breaths per minute

The nurse is caring for a client diagnosed with a genitourinary tract infection who is receiving amoxicillin 500 mg every 8 hours. Which sign or symptom should indicate to the nurse that the client is experiencing an adverse effect related to the medication? 1. Nausea 2. Headache 3. Hypertension 4. Watery diarrhea

4. Watery diarrhea

The nurse evaluates that the client prescribed tobramycin is responding well to the medication therapy when which laboratory result is noted? 1. Sodium of 145 mEq/L (145 mmol/L) and chloride of 106 mEq/L (106 mmol/L) 2. Sodium of 140 mEq/L (140 mmol/L) and potassium of 3.9 mEq/L (3.9 mmol/L) 3. WBC count of 15,000 mm3 (15 × 109/L) and a blood urea nitrogen (BUN) of 38 mg/dL (13.68 mmol/L) 4. White blood cell (WBC) count of 8000 mm3 (8 × 109/L) and creatinine level of 0.9 mg/dL (79.5 mcmol/L)

4. White blood cell (WBC) count of 8000 mm3 (8 × 109/L) and creatinine level of 0.9 mg/dL (79.5 mcmol/L)