Question 1

The nurse is preparing to administer diphenhydramine (Benadryl) 50 mg intravenously to a patient with severe allergies. Available is diphenhydramine (Benadryl) 25 mg/1 mL. How many mL will the nurse administer? Enter the numeral only.

Accepted Answer

2

Question 2

The nurse has administered prescribed allergen injections twice a week for several weeks to an individual with a bee sting allergy. The patient misses three appointments. What action should the nurse take during the patient's next visit?

Accepted Answer

Consulting the physician is necessary to confirm the appropriate dosage after missed appointments, as adjustments may be needed to ensure safety and efficacy.

Question 3

The nurse is assisting a health care provider with subcutaneous immunotherapy (SCIT). Which is a priority to have readily available?

Accepted Answer

Emergency equipment is essential to have on hand during subcutaneous immunotherapy (SCIT) due to the risk of anaphylaxis or other severe allergic reactions that can occur.

Question 4

While collecting data, the nurse suspects that a patient is experiencing an immune disorder. Which data did the nurse use to come to this conclusion? (Select all that apply.)

Accepted Answer

Rash, fever, joint pain, and swollen glands are common symptoms associated with immune disorders, indicating an abnormal immune response or inflammation. Muscle cramps are less specific and can be related to a variety of conditions, not necessarily immune disorders.

Question 5

The nurse is reviewing laboratory values for a patient and notes an absolute neutrophil count of 300 cells/µL. The nurse knows this result means the patient is experiencing which condition?

Accepted Answer

Neutropenia is defined by an absolute neutrophil count (ANC) less than 1500 cells/µL. An ANC of 300 cells/µL indicates a severe decrease in neutrophils, which is characteristic of neutropenia.

Question 6

The nurse is taking a medication history for a newly admitted patient. The patient states he is allergic to levofloxacin (Levaquin). Which response by the nurse is most appropriate?

Accepted Answer

The nurse should ask the patient what happens when they take the medication to understand the nature and severity of the allergic reaction.

Question 7

The nurse is teaching a class for older adults regarding the importance of vaccinations. Which vaccine should the nurse suggest for this age group?

Accepted Answer

The pneumococcal vaccine is recommended for older adults to protect against pneumococcal diseases, which can be more severe in this age group.

Question 8

The nurse is working in a clinic when a patient presents with shortness of breath, wheezing, and hives. The nurse should plan to implement which order first?

Accepted Answer

Epinephrine is the first-line treatment for anaphylaxis, which the patient's symptoms (shortness of breath, wheezing, hives) suggest. It works rapidly to improve breathing, stimulate the heart, and reduce swelling and hives.

Question 9

The nurse is caring for a patient with a diagnosis of malaria. Which antibody would the nurse expect to see increased?

Accepted Answer

The answer of The nurse is caring for a patient...

Question 10

The nurse is reviewing laboratory results for a group of patients and notes a CD4 count of 120 cells/µL. For which patient would the nurse expect to see this result?

Accepted Answer

A CD4 count of 120 cells/µL is significantly lower than the normal range (500 to 1500 cells/µL) and is indicative of severe immunosuppression, such as that seen in patients with HIV/AIDS.

Question 11

The nurse is caring for a patient being tested for rheumatoid arthritis. In reviewing laboratory values, which should the nurse recognize as being diagnostic of rheumatoid arthritis?

Accepted Answer

C-reactive protein (CRP) is an indicator of inflammation in the body. A level of 12 mg/L is elevated and can be associated with rheumatoid arthritis, although it is not exclusively diagnostic of the condition. It is, however, a significant marker for inflammation that supports the diagnosis in the context of other clinical findings.

Question 12

The nurse is caring for a group of patients. Which patient is at highest risk for developing systemic lupus erythematosus (SLE)?

Accepted Answer

SLE is more prevalent in women than in men and is known to affect African American women more frequently and severely than Caucasian women.

Question 13

The nurse is administering clindamycin (Cleocin) 300 mg in 100 mL of normal saline intravenously to run over 1 hour to a patient with an infection. At what rate will the nurse set the infusion pump? Enter the numeral only.

Accepted Answer

The answer of The nurse is administering clindamycin (Cleocin) 300...

Question 14

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

Accepted Answer

A patient receiving chemotherapy with a temperature of 103°F should be seen first because they are immunocompromised, making a fever potentially life-threatening due to the risk of severe infection.

Question 15

The nurse is caring for a patient with anemia. Which laboratory results should the nurse identify as being consistent with this diagnosis? (Select all that apply.)

Accepted Answer

Anemia is characterized by a decrease in the number of red blood cells (RBCs) or the amount of hemoglobin in the blood. The normal RBC count for a 28-year-old female is 4.2-5.4 * 10¹²/L, for a 19-year-old female is 4.2-5.4 * 10¹²/L, for a 31-year-old male is 4.5-5.9 * 10¹²/L, and for a 43-year-old female is 4.2-5.4 * 10¹²/L. The normal MCV for a 19-year-old female is 80-96/mm³. Therefore, the laboratory results that are consistent with anemia are:- RBC = 4.4 * 10¹²/L in a 31-year-old male- MCV = 72/mm³ in a 19-year-old female- RBC = 5.7 * 10¹²/L in a 43-year-old female

Question 16

The nurse is reinforcing teaching to a person who has tested positive for HIV. Which test should the nurse explain is done to confirm the diagnosis of HIV?

Accepted Answer

The Western blot test is used to confirm the diagnosis of HIV after an initial positive result from a screening test like the ELISA (enzyme-linked immunosorbent assay). It detects antibodies specific to HIV, providing a high level of accuracy for confirmation.

Question 17

The nurse is caring for a group of patients. Which patient is at highest risk for developing a latex allergy?

Accepted Answer

Nurses are at a higher risk for developing a latex allergy due to their frequent exposure to latex products in the healthcare setting, such as gloves and medical devices, which can sensitize the immune system over time.

Question 18

The nurse is taking a health history of a patient who has a weakened immune system. Which does the nurse conclude contributed to weakening the immune system? (Select all that apply.)

Accepted Answer

D) Splenectomy and F) Thymectomy can contribute to a weakened immune system. The spleen plays a significant role in filtering blood and supporting the immune system by producing antibodies and removing bacteria and other pathogens. Its removal can weaken the immune system's ability to fight infections. The thymus is involved in the development of T-lymphocytes (T cells), which are crucial for adaptive immunity. Thymectomy, or removal of the thymus, can impact the production and maturation of these cells, thereby affecting the immune response.

Question 19

The nurse is teaching the family of a child who is allergic to peanuts about important topics regarding the allergy. Which statements made by the parents indicate an understanding of the teaching? (Select all that apply.)

Accepted Answer

The answer of The nurse is teaching the family of...

Question 20

The nurse is caring for a patient who reports enlarged, painful, and moveable preauricular lymph nodes, postauricular lymph nodes, and cervical lymph nodes. Which does the nurse infer from these findings?

Accepted Answer

Enlarged, painful, and moveable lymph nodes are typically indicative of an infection. Painful lymph nodes suggest an inflammatory process, often caused by infection, whereas cancerous lymph nodes are usually hard, fixed, and not tender. Liver failure and thyroid disorders do not directly cause lymph node enlargement in the described manner.

Quiz 18: Immune System Function, Assessment, and Therapeutic Measures