Med Surge Immune Function
A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make? "These organs support immunity." "These organs are used in digestion." "These organs regulate electrolyte balance." "These organs assist vitamin absorption."
CORRECT "These organs support immunity." The nurse should inform the client that the function of the thymus, spleen, and lymph nodes is to support immunity and fight infection. Incorrect The thymus, spleen, and lymph nodes are not part of the digestive system. The thymus, spleen, and lymph nodes do not maintain electrolyte balance. The thymus, spleen, and lymph nodes do not work to absorb vitamins.
The nurse is planning to admit several clients to the medical unit. Which of the following clients should the nurse assign to a private room? A client who has a fever of unknown origin A client who had a total hip arthroplasty A client who is HIV positive A client who is neutropenic
CORRECT A client who is neutropenic Clients who have neutropenia (a low count of neutrophils, a type of WBC that helps fight infection) due to immune system compromises, such as clients who have leukemia or major burns or are receiving chemotherapy or allogenic hematopoietic stem cell transplants, require a protective environment to prevent the spread of pathogens to the clients requiring the protective environment. This means a private room with positive airflow. Incorrect The nurse may admit a client with a fever of unknown origin to a semi-private room and continue to use standard precautions. The nurse may admit a client who had a total hip arthroplasty to a semi-private room and continue to use standard precautions. The nurse may admit a client who is HIV-positive to a semi-private room and continue to use standard precautions. Unless the client has AIDS and therefore has a severe immune compromise, the client does not require a private room.
A nurse is caring for a patient who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity (AMI). Which of the following information should the nurse confirm about AMI? AMI is mediated by antibodies produced by B-lymphocytes. Humoral immune response is mediated by T-lymphocytes. AMI involves phagocytic natural killer cells. AMI defends only against viral infections.
CORRECT AMI is mediated by antibodies produced by B-lymphocytes. AMI is mediated by antibodies produced by B-lymphocytes in response to an invading allergen or antigen. Incorrect AMI is not mediated by T-lymphocytes but by B-lymphocytes. However, T-lymphocytes are needed to trigger the formation of antibodies by the B-lymphocytes. AMI does not involve phagocytic natural killer cells but does involve the B-lymphocytes. AMI defends against both viral infections and bacterial infections.
A nurse is reviewing the laboratory results of an adolescent females client and notes a WBC count of 16,000/mm3 with increased immature neutrophils (bands) and normal monocytes. Which of the following is appropriate analysis of the results? An acute infectious process Neutropenia Allergic reaction A resolving inflammatory process
CORRECT An acute infectious process The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information from the elevated WBC count indicating infection or inflammation and the elevated neutrophil count indicating an acute process, the appropriate analysis is that the client has an acute infectious process. Incorrect Neutropenia is a low neutrophil count which places the client at increased risk for infection. A client who is having an allergic reaction will have increased numbers of eosinophils. These cells increase during hypersensitivity reactions and serve to neutralize histamine. The white blood cell (WBC) count is elevated indicating infection. However, when combined with the elevated bands, sometimes referred to as a "shift to the left," this indicates an acute, rather than a resolving, process. In a resolving or chronic process, the nurse would expect to see a greater elevation in the monocytes.
A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicate an allergic transfusion reaction? Generalized urticaria. Blood pressure 184/92 mm Hg. Distended jugular veins. Bilateral flank pain.
CORRECT Generalized urticaria. The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and signs of anaphylaxis with bronchospasm. Incorrect Hypertension may be an indication of circulatory overload rather than an allergic reaction. Distended jugular veins may be an indication of circulatory overload rather than an allergic reaction. Bilateral flank pain may be an indication of a hemolytic transfusion reaction rather than an allergic reaction.
A nurse is completing a physical examination of a patient and notes that laboratory values indicate leukocytosis. The nurse should recognize that which of the following manifestations associated with leukocytosis? Anemia Coagulation disorders Inflammation Renal disorder
CORRECT Inflammation Infection and inflammation are associated with leukocytosis, which is an elevated WBC count. Incorrect Anemia is reflected in an RBC count. Leukocytosis is an elevated WBC count. A coagulation disorder is not indicated by leukocytosis. A renal or hepatic disorder is not indicated by leukocytosis.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include? It is primarily transmitted through casual contact. It is primarily transmitted through accidental puncture wounds. It is primarily transmitted through direct contact with infected body fluids. It is primarily transmitted through mosquitoes.
CORRECT It is primarily transmitted through direct contact with infected body fluids. The nurse should include in the teaching that HIV is transmitted through direct contact with infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk and other body fluids. Incorrect The nurse should include in the teaching that HIV is not transmitted by casual contact, but by infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk, and other body fluids coming into contact with mucous membranes or non-intact skin. The nurse should include in the teaching that HIV is not primarily transmitted by accidental puncture wounds, but by infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk, and other body fluids coming into contact with mucous membranes or non-intact skin. The nurse should include in the teaching that HIV is not transmitted through mosquitoes, but by infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk, and other body fluids coming into contact with mucous membranes or non-intact skin.
A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the pain? Take the client's rectal temperature each day. Increase raw produce in the client's diet. Limit visitors to healthy adults. Instruct the client to floss his teeth daily.
CORRECT Limit visitors to healthy adults. The expected reference range of absolute neutrophil count is 2500 to 8000/mm3. This client has a reduced absolute neutrophil count (neutropenia) and is immunosuppressed. A client who has neutropenia is at an increased risk for infection. The nurse should restrict visitors for a client who has neutropenia to healthy adults to reduce the risk for infection. Incorrect The nurse should not take a rectal temperature from a client who has a low ANC to reduce the risk of causing bacteremia by introducing the bacterial flora from the client's rectum into his blood. The client who has a low ANC should follow a low-bacteria diet. Foods such as raw fruits and vegetables, undercooked meat, fish, or eggs, and pepper are eliminated from the diet because they contain organisms that pose a risk for introduction of bacteria into the gastrointestinal system. The client who has a low ANC should not floss his teeth to reduce the risk of causing bacteremia by introducing the bacterial flora in the client's mouth into his blood.
A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy? Quantitative RNA assay Platelet count Enzyme immunoassay (EIA) test Western blot
CORRECT Quantitative RNA assay A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness. Incorrect Platelet counts can indicate a client's overall health but do not assess HIV disease progression or treatment effectiveness. An EIA test is performed to determine the presence of HIV in a client. It does not measure disease progression. Western blot is performed to confirm a diagnosis when the results of an EAI test are positive. It does not measure disease progression.
A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? Encourage fluid intake of 1500 mL/day. Position head of bed at 10 degrees. Cough and deep breathe every 8 hr. Obtain a sputum culture.
CORRECT The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia. Incorrect The nurse should encourage a fluid intake of 3000 mL/day, not 1500 mL/day, to loosen sputum. The nurse should position the head of the bed at 30 to 45 degrees, not 10 degrees, to assist in deep breathing exercises. The nurse should implement cough and deep breathing every 2 to 4 hr, not every 8 hr, for pulmonary hygiene.
A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations? Bronchospasm Serum sickness Tissue damage at the site Excessive mucus secretion
CORRECT Tissue damage at the site The nurse should expect the manifestations of edema, induration, ischemia, and tissue damage at the site occurring hours to days after exposure. A positive purified protein derivative test for tuberculosis is an example of a type IV hypersensitivity reaction. Incorrect Bronchospasm is a finding consistent with anaphylaxis, a type I immediate hypersensitivity reaction, such as allergic rhinitis. Serum sickness is a finding consistent with a type III immune complex hypersensitivity reaction. Excessive mucus secretion is a finding consistent with a type I immediate hypersensitivity reaction, such as allergic rhinitis.
A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells? Bacterial phagocytosis Hay fever allergy Transplant rejection Anaphylaxis
CORRECT Transplant rejection is affected by the cellular response, or cell-mediated immunity, of the T-cells. Incorrect Bacterial phagocytosis is affected by the humoral response, or antibody-mediated immunity, of the B-cells. Hay fever allergy is affected by the humoral response, or antibody-mediated immunity, of the B-cells. Anaphylaxis is affected by the humoral response, or antibody-mediated immunity, of the B-cells.
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis? CD4+ T-cell count Western blot analysis Quantitative RNA assay Viral load test
CORRECT Western blot analysis The Western blot analysis is used to confirm seropositivity when the ELISA test has a positive result. ELISA is inexpensive and accurate with few false-positives. Western blot is expensive, so is done only for confirmation. Incorrect After confirmation of HIV infection, the CD4+ T-cell count helps providers decide when to initiate antiretroviral medication therapy. A low CD4+T-cell count is associated with more disease manifestations. After confirmation of HIV infection, quantitative RNA assays (a type of viral load test) use gene amplification to determine the amount of HIV- RNA in the client's serum. After confirmation of HIV infection, a viral load test helps determine the amount of viral genetic material (DNA or RNA) in the client's blood, rather than the body's response to HIV infection.
A nurse in a community health clinic is administering the seasonal inactive influenza vaccine. Shellfish Eggs Gelatin Yeast
CORRECT Eggs The nurse should assess the client for allergies to eggs. The seasonal influenza vaccine contains small amounts of egg protein and can induce a severe allergic reaction in clients who are hypersensitive. Incorrect The seasonal influenza vaccine does not contain shellfish derivatives. The seasonal influenza vaccine does not contain gelatin derivatives. The seasonal influenza vaccine does not contain yeast derivatives.
A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicate a positive result? Immunoglobulin G (IgG) Immunoglobulin A (IgA) Immunoglobulin E (IgE) Immunoglobulin M (IgM)
Immunoglobulin E (IgE) RAST involves measuring the quantity of IgE present in the serum after exposure to specific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST. Incorrect IgG assumes a major role in bloodborne and tissue infections. IgA protects against respiratory, gastrointestinal, and genitourinary infections IgM is the first immunoglobulin produced in response to bacterial and viral infections.
A nurse is an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? Assess the client's level of consciousness. Administer epinephrine. Auscultate for wheezing. Monitor for hypotension.
CORRECT Auscultate for wheezing. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest. Incorrect The nurse should assess and monitor the client's level of consciousness as anaphylaxis causes widespread vasodilation and anaphylactic shock may develop. However, this is not the priority intervention action when taking the airway, breathing, circulation (ABC) approach to client care. The nurseshould administer epinephrine as this medication causes vasoconstriction, bronchodilation, and improves cardiac output. However, this is not the priority action when taking the airway, breathing, circulation (ABC) approach to client care. The nurse should monitor for hypotension because the anaphylactic reaction causes systemic vasodilation placing the client at risk for hypovolemic shock. However, another action is the priority when taking the airway, breathing, circulation (ABC) approach to client care.
A nurse is assigned to care for a client with autoimmune or idiopathic thrombocytopenia purpura (ITP). When reviewing the clients plan of care prior to caring for client, the nurse should recognize that the priority concern for caring for the client is to monitor for? side effects of immunosuppressants. constipation. fatigue. bleeding.
CORRECT Bleeding Thrombocytopenia refers to a decreased platelet count, which puts the client at risk for bleeding. In ITP, the immune system destroys healthy platelets, thinking they are foreign bodies. Using the airway, breathing, circulation (ABC) priority-setting framework is the priority concern for the nurse when providing care for this client. Incorrect The client who has ITP develops fatigue that is not associated with the administration of immunosuppressant therapy. While the nurse should monitor the client for fatigue, another assessment is the priority. The client who has ITP is at increased risk for bleeding and should be discouraged from straining when constipated or when passing stool. While the nurse should monitor the client for constipation, another assessment is the priority. Idiopathic thrombocytopenic purpura is an autoimmune disorder in which the platelets are destroyed by antibodies the client has developed. Treatment of this condition involves the administration of medications to suppress the client's immune function. While the nurse should monitor the client for side effects related to immunosuppressants, another assessment is the priority.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? Positive Western blot test CD4-T-cell count 180 cells/mm3 Platelets 150,000/mm3 WBC 5,000/mm3
CORRECT CD4-T-cell count 180 cells/mm3 A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider. Incorrect The client's platelet count is within the expected reference range. Therefore, another value is the priority. The client's WBC count is within the expected reference range. Therefore, another value is the priority. The client is already identified as HIV positive. Therefore, another value is the priority.
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as a personal protective equipment when taking which of the following actions? Talking to the client at the bedside Administering an intermittent IV bolus medication Completing a dressing change Administering an IM injection
CORRECT Completing a dressing change Standard precautions require personal protective equipment when there is a risk of contact with body fluids. A dressing change does present a risk for coming into contact with body fluids. Incorrect Standard precautions do not require the nurse to wear personal protective equipment while at the bedside of a client who is HIV positive and postoperative unless there is a risk of contact with body fluids. Standard precautions require personal protective equipment when there is a risk of contact with body fluids. Administering an intermittent IV bolus does not present a risk of contact with body fluids. Standard precautions require personal protective equipment when there is a risk of contact with body fluids. The nurse should wear gloves when administering an IM injection to this client.
A nurse is reviewing the laboratory results of a client who acute radiation syndrome and notes the client has leukopenia. Which of the following assessment findings should the nurse identify as being consistent with leukocytosis? Fever Bruising Pallor Petechiae
CORRECT Fever Acute radiation syndrome results in a decrease in many of the blood cell types including lymphocytes, leukocytes, thrombocytes, and red blood cells. A fever would be an expected finding of a decreased number of white blood cells (leukopenia). Incorrect Acute radiation syndrome results in a decrease in many of the blood cells including lymphocytes, leukocytes, thrombocytes, and red blood cells. Bruising would be an expected finding of the decreased number of platelets (thrombocytopenia) Acute radiation syndrome results in a decrease in many of the blood cell types including lymphocytes, leukocytes, thrombocytes, and red blood cells. Pallor would be an expected finding of the decreased number of red blood cells (anemia). Acute radiation syndrome results in a decrease in many of the blood cell types including lymphocytes, leukocytes, thrombocytes, and red blood cells. This is a manifestation caused due to a decreased number of platelets.
A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor the client for which of the following conditions? Dehydration Fungal infection Compartment syndrome Pleural effusion
CORRECT Fungal Infections The nurse should monitor the client for fungal infections due to the impairment of the phagocytic cells. Fungal and bacterial infections are the primary results of the dysfunction. Incorrect The nurse does not need to monitor the client for dehydration. The nurse does not need to monitor the client for compartment syndrome. The nurse does not need to monitor the client for pleural effusion.