Deck 19: Nursing Care of Patients With Immune Disorders

Question 1

The nurse is caring for a patient with serum sickness. Which intervention should the nurse implement?

A)Administer acetaminophen (Tylenol) as ordered.
B)Prepare the patient for a blood transfusion.
C)Teach the patient about immunosuppressive drugs.
D)Restrict the patient's fluid intake.

Answer 1

Administer acetaminophen (Tylenol) as ordered.

Question 2

A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Which action should the nurse take first?

A)Stop the blood infusion.
B)Notify the physician STAT.
C)Start a normal saline infusion.
D)Check vital signs.

Answer 2

Stop the blood infusion.

Question 3

The nurse is teaching a patient with SLE about avoiding triggers. Which statement made by the patient indicates a need for further teaching?

A)"Instead of working in the yard, I got plenty of rest."
B)"I am practicing yoga to help alleviate stress in my life."
C)"If I get plenty of sunlight, it will help reduce symptoms."
D)"I need to check with my doctor before stopping any medication."

Answer 3

"If I get plenty of sunlight, it will help reduce symptoms."

Question 4

The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops?

A)Hives
B)Retinal hemorrhage
C)Jugular vein distention
D)Pallor around the sting sites

Question 5

A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take?

A)Verify the patient's kidney function.
B)Verify the patient's hematocrit level.
C)Verify blood type of the patient and donor.
D)Verify the patient's admitting medical diagnosis.

Question 6

The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms?

A)Installing a hot air heater
B)Covering heating ducts with filters
C)Installing wall-to-wall carpeting
D)Using heavy draperies on sunny windows

Question 7

The nurse is reviewing orders for a patient with systemic lupus erythematosus (SLE). For which medication should the nurse request clarification?

A)Levothyroxine (Synthroid)
B)Phenytoin (Dilantin)
C)Promethazine (Phenergan)
D)Pantoprazole (Protonix)

Question 8

The nurse is teaching a patient about allergic rhinitis. Which statement indicates a need for further teaching?

A)"I will wear a mask when I mow the yard."
B)"I can take my nasal medication any time my allergies bother me."
C)"I will dust my house every day."
D)"I cannot receive immunotherapy since my allergies are not severe."

Question 9

The nurse is caring for a group of patients. Which patient should the nurse see first?

A)A patient with SLE with a butterfly rash
B)A patient with Hashimoto thyroiditis who reports diarrhea and weight loss
C)A patient with allergic rhinitis with copious amounts of clear nasal drainage
D)A patient receiving a blood transfusion who is reporting chills and low back pain

Question 10

A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient?

A)Wear medical alert identification.
B)Stay indoor as much as possible.
C)Wear insect repellent when outdoors.
D)Take corticosteroids before going outdoor.

Question 11

A patient with type O blood is scheduled to undergo open heart surgery. Which blood type would this patient receive?

A)A
B)B
C)AB
D)O

Question 12

The nurse is caring for a patient with SLE. The nurse notes that the patient has foamy, "coke"-colored urine. Which action should the nurse take?

A)Notify the health care provider (HCP).
B)Encourage the patient to increase fluid intake.
C)Prepare the patient for dialysis.
D)Instruct the patient to eat high-protein meals.

Question 13

The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness?

A)A patient who receives IV penicillin for an infection
B)A patient who has a transfusion with packed red blood cells (RBCs)
C)A patient who is given cryoprecipitate and factor IX after an abdominal injury
D)A patient given steroids and immunosuppressant therapy after organ transplantation

Question 14

The nurse is caring for a patient who underwent a liver transplant and is taking cyclosporine (Sandimmune) and azathioprine (Imuran). Which important information should the nurse teach the patient regarding the medication?

A)Take on an empty stomach.
B)Report signs of infection immediately.
C)Monitor for signs of abnormal bleeding.
D)Urine will turn orange.

Question 15

The nurse is teaching a patient about atopic dermatitis (Eczema). Which statement made by the patient indicates an understanding of the teaching?

A)"I will keep my nails long so I can scratch easier."
B)"I should soak in bleach daily."
C)"I will soak in a lukewarm bath at night."
D)"It is better for me to scratch than to rub the itchy area."

Question 16

The nurse is caring for a patient with pernicious anemia. Which deficiency is this patient experiencing?

A)Vitamin A
B)Vitamin B12
C)Vitamin C
D)Vitamin D

Question 17

The nurse is preparing to administer levofloxacin (Levaquin) to a patient with pneumonia. Which is most important for the nurse to ask prior to administering the medication?

A)"Have you experienced nausea or vomiting from antibiotics?"
B)"Are you allergic to any medication?"
C)"Do you know why you are receiving this medication?"
D)"Do you have an allergy to latex?"

Question 18

The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease?

A)Gardening outdoors on dry, windy days
B)Wearing a mask when mowing the lawn
C)Driving the car with the windows open during high pollen counts
D)Taking frequent walks outside in spring when the weather is warm

Question 19

The nurse is caring for a patient with angioedema. Which nursing action should have the highest priority?

A)Monitor for restlessness.
B)Identify cause of the angioedema.
C)Identify the presence of skin lesions.
D)Teach the patient about immunotherapy.

Question 20

The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient?

A)Assist with ambulation
B)Teach good hand hygiene.
C)Avoid intramuscular injections.
D)Obtain manual blood pressures.

Question 21

The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patient's collaborative plan of care? (Select all that apply.)

A)Physical therapy daily
B)Sitz baths three times daily
C)Tylenol #3 every 4 hours prn for pain
D)Administering Remicade as prescribed
E)Activity as tolerated; up with assistance

Question 22

The nurse is administering methylprednisolone (Solu-Medrol) 40 mg IM to a patient with SLE. The available dose is 80 mg/mL. How many mL will the nurse administer? Enter the numeral only.

Question 23

The nurse is assessing a patient with pernicious anemia. Which clinical manifestations can the nurse expect to document? (Select all that apply.)

A)Pallor
B)Wheals on the skin
C)Butterfly rash
D)Weakness
E)Glossitis
F)Peripheral neuropathy

Question 24

The nurse is contributing to the teaching plan for a patient diagnosed with Hashimoto thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions should the nurse recommend? (Select all that apply.)

A)Eat a soft diet.
B)Increase activity slowly.
C)Eat more foods high in iodine.
D)Keep home at a cool temperature.
E)Eat a high-carbohydrate, high-protein diet.
F)During low-energy periods, use anti-embolism stockings.

Question 25

The nurse is caring for a patient who develops a hemolytic reaction during a blood transfusion. The nurse should expect to implement which order from the HCP first?

A)Call the blood bank to send up a different unit of blood.
B)Administer diphenhydramine (Benadryl) 50 mg IV.
C)Place the patient in Trendelenburg's position.
D)Administer acetaminophen (Tylenol).

Question 26

A patient with SLE is prescribed Prednisone, 60 mg PO, in three equal doses. If using 5-mg tablets, how many tablets should the nurse provide for each dose?

Question 27

The nurse is contributing to the plan of care for a patient with SLE. Which interventions should the nurse recommend for this patient? (Select all that apply.)

A)Eat a balanced diet.
B)Report "foamy urine" to physician.
C)Take cool showers or baths to relieve joint stiffness.
D)Avoid naps and obtain a minimum of 6 hours of sleep.
E)Exercise when pain and inflammation in joints are increased.
F)Use a daily personal schedule to plan activities to reduce fatigue.

Question 28

A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Place the actions in order, from 1 to 5, of importance of performance.

A) ___ Stop the blood infusion.
B) ___ Notify the physician STAT.
C) ___ Obtain vital signs and assess patient.
D) ___ Start the new 0.9% normal saline infusion.
E) ___ Prepare a new 0.9% normal saline infusion.

Question 29

The nurse applies clean, white, cotton socks over the hands of a patient with contact dermatitis. What should the nurse explain to the patient about the purposes of this intervention? (Select all that apply.)

A)Cotton allows air movement.
B)White cotton has no dye in the material.
C)White cotton prevents the wounds from spreading.
D)The cotton will absorb the drainage from the wounds.
E)Scratching is less during sleep when the area is covered.

Question 30

The nurse is caring for a group of patients. Which patient should the nurse see first?

A)A patient with serum sickness experiencing fever and malaise
B)A patient with atopic dermatitis with red, weeping lesions
C)A patient with ankylosing spondylitis reporting level 4 back pain
D)A patient stung by an insect experiencing angioedema