NCLEX Qs Immunity 1 - 1. The nurse provides home care instructions to...

NCLEX Qs Immunity 1

Immunity Qs and As NCLEX

• The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client

about methods to manage fatigue. Which statement by the client indicates a need for further instruction?

• "I should take hot baths because they are relaxing."
• "I should sit whenever possible to conserve my energy."
• "I should avoid long periods of rest because it causes joint stiffness."
• "I should do some exercises, such as walking, when I am not fatigued."

• The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement

by the client indicates that the client understands the diagnosis?

• "My skin will have tiny red vesicles."
• "The presence of the skin vesicles is caused by a virus."
• "I have an autoimmune disease that causes blistering in the epidermis."
• "The presence of red, raised papules and large plaques covered by silvery scales will be

present on my skin."

• The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should

incorporate which action as a priority in the plan?

• Protecting the client from infection
• Providing emotional support to decrease fear
• Encouraging discussion about lifestyle changes
• Identifying factors that decreased the immune function

• A client calls the nurse in the emergency department and states that he was just stung by a bumblebee

while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take?

• Advise the client to soak the site in hydrogen peroxide.
• Ask the client if he ever sustained a bee sting in the past.
• Tell the client to call an ambulance for transport to the emergency department.
• Tell the client not to worry about the sting unless difficulty with breathing occurs.

Rationale:

In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

• The community health nurse is conducting a research study and is identifying clients in the community at

risk for wormstoilet allergy. Which client population is most at risk for developing this type of allergy?

• Hairdressers
• The homeless
• Children in day care centers
• Individuals living in a group home

• Which interventions apply in the care of a client at high risk for an allergic response to a latex

allergy? Select all that apply.

• Use nonlatex gloves.
• Use medications from glass ampules.

NCLEX Qs Immunity 2

• Place the client in a private room only.

NCLEX Qs Immunity 3

• Keep a latex-safe supply cart available in the client's area.
• Avoid the use of medication vials that have rubber stoppers.
• Use a blood pressure cuff from an electronic device only to measure the blood pressure.

• A client presents at the health care provider's office with complaints of a bulls-eye rash on his upper leg.

Which question should the nurse ask first?

• "Do you have any cats in your home?"
• "Have you been camping in the last month?"
• "Have you or close contacts had any flu-like symptoms within the last few weeks?"
• "Have you been in physical contact with anyone who has the same type of rash?"

Rationale:

The nurse should ask questions to assist in identifying the cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ring-like rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs.

• A client is diagnosed with scleroderma. Which intervention should the nurse anticipate being prescribed?
• Maintain bed rest as much as possible.
• Administer corticosteroids as prescribed for inflammation.
• Advise the client to remain supine for 1 to 2 hours after meals.
• Keep the room temperature warm during the day and cool at night.

• 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 actions are most appropriate? Select all that apply.

• Tell the client that testing is not necessary unless arthralgia develops.
• Tell the client to avoid any woody, grassy areas that may contain ticks.
• Instruct the client to immediately start to take the antibiotics that are prescribed.
• Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the

presence of the disease.

• Tell the client that if this happens again, to never remove the tick but vigorously scrub the

area with an antiseptic.

• The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based

on this diagnosis, the nurse understands that this has been confirmed by which finding?

• Swelling in the genital area
• Swelling in the lower extremities
• Positive punch biopsy of the cutaneous lesions
• Appearance of reddish-blue lesions noted on the skin

• The nurse is conducting allergy skin testing on a client. Which post-procedure interventions are most

appropriate? Select all that apply.

• Record site, date, and time of the test.
• Give the client a list of potential allergens if identified.

NCLEX Qs Immunity 4

• Estimate the size of the wheal and document the finding.
• Tell the client to return to have the site inspected only if there is a reaction.
• Have the client wait in the waiting room for at least 1 to 2 hours after injection.

• The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In

determining the client's risk factors, the nurse should question the client about an allergy to which food item?

• Eggs
• Milk
• Yogurt
• Bananas

Rationale:

Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen.

• A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take

which priority action in caring for this client?

• Monitor for signs of hyperglycemia.
• Administer the medication without food.
• Administer the medication with an antacid.
• Ensure that the client uses an electric razor for shaving

Rationale:

Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach or without food and should not be taken with an antacid.

• The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse

develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection?

• Fever, hypotension, and polyuria
• Hypertension, polyuria, and thirst
• Fever, hypertension, and graft tenderness
• Hypotension, graft tenderness, and hypothermia
• A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The

nurse should monitor the results of which laboratory blood study for adverse effects of therapy?

• Creatinine level
• Potassium concentration
• Complete blood cell (CBC) count
• Blood urea nitrogen (BUN) level