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155 16/17/18 nclex
| Question | Answer |
|---|---|
| Which assessment finding on a client with no other health problems does the nurse consider the greatest potential threat to the client’s immune system? | Has poor oral hygiene and numerous dental caries. |
| Which change would the nurse expect to see in the white blood cell differential of a client who has a prolonged, severe intestinal helminth infestation? | Eosinophil count is high. |
| How do macrophages contribute to the neutrophilia that occurs in response to an acute bacterial infection? | At the onset of invasion, macrophages secrete a colony-stimulating factor to induce the bone marrow to increase production and release of neutrophils. |
| Which cells, products, or actions are involved in long-lasting immunity resulting from exposure to a specific antigen? | Memory B-cells, monocyte maturation |
| How do immune system cells differentiate between normal, healthy body cells and non-self cells within the body? | Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as “foreign” by immune system cells. |
| How will the nurse interpret a client’s white blood cell count that has a total count of 9000 cells/mm3 (9 x 109/L) with a lymphocyte count of 4200 cells/mm3 (4.2 × 109/L)? | The client most likely has a viral infection. |
| Which number will the nurse calculate as the absolute neutrophil count (ANC) for a client whose differential includes: total WBCs 5300/mm3 ; segs 2800/mm3; bands 200/mm3; monos 250/mm3; lymphs 2000/mm3; eosins 25/mm3; basos 25? | 3000/mm3 |
| Which differential count will the nurse report to the primary health care provider for a client whose white blood count indicates a total count of 10,000 cells/mm3 (10 × 109/L)? | Monocytes 2000/mm3 (2 × 109/L) |
| What is the nurse’s interpretation of a laboratory result that indicates a client has a high blood concentration of IgG directed against the human papilloma virus? | The client is mounting an appropriate response to a recurrent exposure to the virus. |
| Which client laboratory response indicates to the nurse that granulocyte colony-stimulating factor therapy is successful? | Increased white blood cells |
| Which type of immunity will the nurse initiate by administering an infusion of IV immunoglobulin to a client? | Artificial passive immunity |
| What is the nurse’s best response to a 38-year-old client with a large wound who does not want to receive a tetanus toxoid vaccination because he had a tetanus shot just 1 year ago? | “You may not need this vaccination now, I will check with your health care provider.” |
| What type of health problem will the nurse expect to see in a client who has very few regulator T cells? | Increased severity of allergic and other hypersensitivity reactions |
| What is the most important precaution for the nurse to teach a client who has few natural killer cells and the natural killer cells are not very active? | “You will need to have yearly checkups because your risk for cancer development is greater now.” |
| Which precautions are most important for the nurse to teach as part of health promotion for inflammation and immunity to an 88-year-old client? (Select all that apply.) | Report any temperature elevation to your primary health care provider immediately, Get an influenza vaccination every year, Wear gloves when working in your garden |
| Which client health problems will the nurse identify as an infectious process along with inflammation rather than inflammation alone? (Select all that apply.) | Appendicitis, Cystitis, Sepsis |
| With which client conditions will the nurse expect an inflammatory response without infection? (Select all that apply.) | Poison ivy rash, Welt formation after a bee sting, Blister formation from a burn, Acute myocardial infarction |
| Which types of problems will the nurse expect to find more frequently in a client who does not make adequate amounts of immunoglobulin A (IgA)? (Select all that apply.) | Upper respiratory infections, Cystitis, Diarrhea |
| Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors? | Clipping the newly generated viral proteins into smaller functional pieces |
| Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 X 109/L) to 400 cells/mm3 (0.2 X 109/L) indicates to the nurse that more teaching is needed? | “Although I am still HIV positive, at least I no longer have AIDS.” |
| The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane and he missed all of yesterday’s dosages. What action does the nurse recommend? | Take today’s dosages as normally prescribed and continue to follow your therapy program. |
| What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed this drug? | “Are you allergic to sulfa drugs?” |
| Which activities can the nurse postpone or eliminate for the client who has extreme fatigue today? Select all that apply. | Ambulating in the hall, Providing a complete bed bath, Teaching about nutrition therapy |
| Which dietary change does the nurse suggest for the client who has esophageal candidiasis? | Eat soft, cool food such as pudding and smoothies. |
| Which part of the HIV infection process is disrupted by the antiretroviral drug class of nucleoside reverse transcriptase inhibitors (NRTIs)? | Forming counterfeit bases that prevent DNA synthesis and viral replication |
| Which signs and symptoms does the nurse expect to find in a client diagnosed with Pneumocystis jiroveci infection? | Dyspnea, tachypnea, persistent dry cough, and fever |
| What is the first action a nurse should take after sustaining a needlestick injury after injecting a client who is known to be HIV positive? | Thoroughly scrub and flush the puncture site. |
| The client who wants to use Truvada for preexposure prophylaxis (PreP) asks the nurse why testing is needed for HIV status before starting this drug. How does the nurse respond? | “Although this drug can help prevent HIV infection, it is not enough by itself to control the disease if you are HIV positive.” |
| Which point is most important for the nurse to include when teaching assistive personnel (AP) about protecting themselves from HIV exposure when caring for HIV-positive clients? | “Wear gloves when in contact with clients’ mucous membranes or nonintact skin.” |
| Which concept is the highest priority for the nurse to consider in planning care for the client with HIV-III who has candidial stomatitis? | Comfort |
| Which laboratory test does the nurse analyze to determine the effectiveness of combination antiretroviral drug therapy in an HIV-positive client? | Viral load testing |
| With which antiretroviral drug class will the nurse teach clients to prevent harm by reporting any new onset muscle weakness and muscle pain to the immunity health care provider? | Integrase inhibitors |
| Which statement made to the nurse by an assistive personnel (AP) assigned to care for an HIV-positive client indicates a breach of confidentiality and requires further education by the nurse? | “The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client.” |
| Which statement made by the nurse during an admission assessment for a client who is HIV positive demonstrates a nonjudgmental approach in discussing sexual practices and behaviors? | “Have you had sex with men or women or both?” |
| Which statements about the transmission of HIV are true? (Select all that apply.) | Clients with HIV-III and no drug therapy are very infectious, Newly infected clients with a high viral load are very infectious, HIV-positive clients who have an undetectable viral load appear to not transmit the disease |
| Which practices are generally recommended to prevent sexual transmission of HIV? (Select all that apply.) | Latex gloves for finger or hand contact with the vagina or rectum, Latex dental dam genital and anal intercourse, Water-based lubricant with a latex condom, Latex or polyurethane condoms for genital and anal intercourse |
| Which laboratory results does the nurse expect to decrease in a client who has untreated HIV-III (AIDS)? (Select all that apply.) | Total white blood cell count, CD4+ T-cell, Lymphocytes |
| Which conditions or factors will the nurse teach at a community seminar as probable transmission routes for HIV? (Select all that apply.) | Using injection drugs, Having unprotected intercourse with multiple partners, Breast-feeding |
| Which statement(s) regarding type III hypersensitivity reactions is/are true? Select all that apply. | Type III responses are usually directed against self cells and tissues, Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity. |
| A client who is six feet two inches tall and weighs 205 lb is having an anaphylactic reaction. Which dose of epinephrine will the nurse prepare for this client? | 0.5 mL of a 1:1000 solution |
| Which new onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm? | Failure to see letters in the middle of a word |
| What is the nurse’s best response to a client who had a severe allergic reaction to shrimp states, “I have had shrimp once before and did not have a reaction. Why is this happening now?” | “The first time your body recognized the shrimp as an allergen, and the second time it reacted to it.” |
| Which type of hypersensitivity reaction will the nurse suspect in a client who develops as circular rash on the skin underneath a new necklace worn for 3 days? | Type IV |
| For which hypersensitivity situation will the nurse prepare a client for management with plasmapheresis? | A 35 year old with drug-induced hemolytic anemia |
| Which action is the priority for the alert 58-year-old client who is admitted to the emergency department with wheezing, dyspnea, angioedema, blood pressure of 70/52 mm Hg, and an irregular apical pulse of 122 beats/min? | Applying oxygen via a high-flow nonrebreather mask at 90% to 100% |
| What is the most important action to prevent harm for the nurse to perform after a client’s oral and facial swelling from an angiotensin-converting enzyme inhibitor (ACEI) have resolved? | Monitoring the client for return of symptoms for at least the next 2 to 4 hours |
| Which client statement about the use and care of an epinephrine autoinjector for a peanut allergy indicates to the nurse that more teaching is needed? | “If I keep the injector in the refrigerator, the drug will not expire as quickly.” |
| Which client with persistent joint and muscle pain will the nurse consider as most likely to have a systemic lupus erythematosus (SLE) diagnosis? | A 33-year-old African-American woman whose mother has psoriasis. |
| What precaution is most important for the nurse to teach the client with systemic lupus erythematosus (SLE) prescribed to take 45 mg of a corticosteroid daily for 2 weeks to manage an SLE flare? | Do not suddenly stop taking the drug when your flare is over. |
| What is the nurse’s best response to a client newly diagnosed with systemic lupus erythematosus (SLE) who asks why nicotine use, especially cigarette smoking or vaping, should be avoided? | “Nicotine reduces blood flow to your organs and increases the risk for permanent damage.” |
| Which precaution is a priority to prevent harm for the nurse to teach a client with systemic lupus erythematosus (SLE) who is newly prescribed to take hydroxychloroquine for disease management? | See your ophthalmologist for visual field testing every 6 months. |
| Which statement by a client who has systemic lupus erythematosus (SLE) indicates to the nurse that more education about the disorder and its management is needed? | “At the first sign of a flare, I will begin taking my medication again.” |
| What response by the nurse would be most therapeutic when a client who has systemic lupus erythematosus (SLE) says, “My face has changed so much. I feel really ugly”? | “I bet that was hard to say. Thank you for trusting me with your feelings.” |
| What is the pathophysiologic basis for Lyme disease progression to stage III? | Changing the organism’s surface antigens leading to chronic inflammation and elevated cytokine levels |
| Which type of drug therapy will the nurse prepare a client in the early disseminated stage of Lyme disease to take for control or cure of this disease? | Antibiotics |
| Which statement(s) regarding type IV hypersensitivity reactions is/are true? (Select all that apply.) | major mechanism = release of mediators, IV = non-self but the response is excessive, Rashes and blister formation, Mediated by IgE rather than histamine |
| After a client is hospitalized for an anaphylactic reaction to a bee sting, a nurse is teaching the client about the use of an epinephrine autoinjector. Which instruction/ instructions should be included in client education? (Select all that apply.) | Keep the device with you at all times; After administering the device, hospital monitoring is necessary; Use the device before calling 911; If the drug becomes discolored, order a replacement device |
| Which assessment findings will the nurse expect to see in a client who is suspected to have systemic lupus erythematosus (SLE)? (Select all that apply.) | Anemia, Joint pain and swelling, Hair loss, Fever, Fatigue, Facial redness |
| Which of the drugs or supplements taken daily taken by a client who is newly diagnosed with drug-induced systemic lupus erythematosus (SLE) does the nurse suspect is most likely to have caused this problem? | Hydralazine |
Created by:
mpvought
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