Chapter 3: Immunologic Problems

Question 1

When scheduling a patient for skin testing for allergies, which information is most important for the allergy clinic nurse to include in patient teaching?

1. Avoid taking antihistamines before the skin testing.
2. Skin testing may be done with an intradermal injection.
3. Swelling and itching may occur at the site of the skin testing.
4. Patient will need to wait in the clinic for 20 minutes after the testing.

Answer 1

Ans: 1

Because antihistamine use before skin testing may prevent a reaction to an allergen, it is important that no antihistamine be taken before arriving for the skin testing, or the testing will have to be rescheduled. The other information may also be included, but it is not as important as avoiding any antihistamine before the skin testing takes place. Focus: Prioritization.

Question 2

Which finding will be most important for the nurse to report to the health care provider about a patient who is taking prednisone chronically after an organ transplant?

1. Multiple arm bruises
2. Sodium level of 146 mEq/dL (146 mmol/L)
3. Blood glucose of 110 mg/dL (6.1 mmol/L)
4. Black-colored stools

Answer 2

Ans: 4

Dark green or black stools may indicate gastrointestinal bleeding, a possible adverse effect of oral steroid use, and further assessment and treatment are needed. Although thinning of the skin, electrolyte disturbances, and changes in glucose metabolism also occur with steroids, bruising and mild changes in sodium or glucose level do not require treatment. Focus: Prioritization.

Question 3

When the occupational health nurse is teaching unlicensed assistive personnel (UAP) about bloodborne pathogen exposure and human immunodeficiency virus (HIV) risk, which information is most important to emphasize?

1. Occupational transmission of HIV from patients to health care workers is relatively rare.
2. Occupational exposure to HIV-containing fluids should be reported immediately to the supervisor.
3. Treatment for occupational exposure to HIV may include use of antiretroviral medications.
4. Postexposure treatment will include HIV testing at baseline and at several intervals after the exposure.

Answer 3

Ans: 2

Centers for Disease Control and Prevention guidelines indicate that if postexposure prophylaxis is to be used, antiretroviral drugs should be started as soon as possible, preferably within hours of the exposure. It is important that staff understand that reporting the possible exposure is a priority so that so that rapid assessment and treatment can be initiated. The other statements are also true but will not impact on the efficacy of any needed treatment. Focus: Prioritization

Question 4

A patient in the allergy clinic who has a rash has received diphenhydramine 50 mg PO. Which patient information is most indicative of a need for action by the nurse?

1. The patient is preparing to drive home.
2. The patient reports itching at the site of the rash.
3. The patient has a history of constipation.
4. The patient states, “My mouth feels so very dry!”

Answer 4

Ans: 1

Sedation is a common effect of the first-generation antihistamines, and patients should be cautioned against driving when taking medications such as diphenhydramine. Itching of the rash is expected with an allergic reaction. The patient should be taught about how to manage common antihistamine side effects such as constipation and oral dryness, but these side effects are not safety concerns. Focus: Prioritization.

Question 5

After change-of-shift report, which newly admitted patient should the nurse assess first?

1. A patient with human immunodeficiency virus (HIV) whose CD4 count is 45 mm3 (45 cells/mcL)
2. A patient with acute kidney transplant rejection who has a scheduled dose of prednisone due
3. A patient with graft-versus-host disease who has frequent liquid stools
4. A patient with hypertension who has angioedema after receiving lisinopril

Answer 5

Ans: 4

Because angioedema may cause airway obstruction, this patient should be assessed for any difficulty breathing, and treatment should be started immediately. The other patients also will need to be assessed as quickly as possible, but the patient with potential airway difficulty will need the most rapid care. Focus: Prioritization.

Question 6

A few minutes after the nurse has given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should the nurse take first?

1. Start oxygen at 6 L/min using a face mask.
2. Obtain IV access with a large-bore IV catheter.
3. Give epinephrine 0.5 mg intramuscularly.
4. Administer albuterol per nebulizer mask.

Answer 6

Ans: 3

World Allergy Organization guidelines indicate that intramuscular epinephrine should be the initial drug for treatment of anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but oxygen delivery will be effective only if airways are open. Albuterol may also be administered to decrease airway narrowing but would not be the first therapy used for anaphylaxis. IV access will take longer to establish and should not be the first intervention. Focus: Prioritization.

Question 7

The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will be delegated to unlicensed assistive personnel (UAP) working for the agency?

1. Supplying injection drug users with sterile injection equipment such as needles and syringes
2. Interviewing patients about behaviors that indicate a need for annual HIV testing
3. Teaching high-risk community members about the use of condoms in preventing HIV infection
4. Assessing the community to determine which population groups to target for education

Answer 7

Ans: 1

Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with UAP education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills. Focus: Delegation.

Question 8

The nurse is supervising a student nurse who is caring for a patient with human immunodeficiency virus (HIV). The patient has severe esophagitis caused by Candida albicans. Which action by the student requires the most rapid intervention by the nurse?

1. Putting on a mask and gown before entering the patient’s room
2. Giving the patient a glass of water after administering the prescribed oral nystatin suspension
3. Suggesting that the patient should order chile con carne or chicken soup for the next meal
4. Placing a “No Visitors” sign on the door of the patient’s room

Answer 8

Ans: 2

Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet or contact precautions or visitor restrictions to prevent opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with oral or esophageal fungal infections. Focus: Prioritization.

Question 9

The nurse is evaluating a patient with human immunodeficiency virus (HIV) who is receiving trimethoprim–sulfamethoxazole (TMP-SMX) as a treatment for Pneumocystis jiroveci pneumonia. Which information is most important to communicate to the health care provider?

1. The patient reports a blistering rash.
2. The patient’s fluid intake is 2 L/day.
3. The patient’s potassium is 3.4 mg/dL (3.4 mmol/L).
4. The patient enjoys spending time outside in the sun.

Answer 9

Ans: 1

Because TMP-SMX can cause Stevens-Johnson syndrome (a life- threatening skin condition), a blistering rash indicates a need to discontinue the medication immediately. Two L/day of fluid is adequate to prevent crystalluria and renal damage associated with TMP-SMX. TMP-SMX can cause hyperkalemia; the nurse will report the potassium level to the provider, but the low potassium level is not caused by the medication. Patient teaching about photosensitivity is needed, but the nurse does not need guidance from the provider to implement this action. Focus: Prioritization.

Question 10

The nurse is working with a patient who has a new diagnosis of human immunodeficiency virus (HIV) and who reports current use of injectable heroin and methamphetamine. Which actions by the nurse are appropriate? Select all that apply.

1. Refer the patient to a substance abuse treatment program.
2. Plan for the patient to participate in a needle exchange program.
3. Coordinate the patient’s schedule for directly observed antiretroviral drug treatment.
4. Instruct the patient that ongoing injectable drug use is a contraindication for antiretroviral therapy.
5. Provide patient education about the risk of transmitting HIV to others when sharing needles.

Answer 10

Ans: 1, 2, 3, 5

Current guidelines indicate that antiretroviral therapy for HIV should be initiated as soon as possible after HIV diagnosis. Although ongoing substance abuse is a risk factor for poor adherence, antiretroviral therapy can be initiated when strategies to improve adherence are used. Strategies include directly observing patients taking medications, needle exchange programs, and referring patients for substance abuse treatment. Focus: Prioritization.

Question 11

A patient with newly diagnosed acquired immunodeficiency syndrome (AIDS) has a 6-mm induration at 48 hours after a skin test for tuberculosis (TB). Which action will the nurse anticipate taking next?

1. Arrange for a chest x-ray to check for active TB.
2. Tell the patient that the TB test results are negative.
3. Teach the patient about multidrug treatment for TB.
4. Schedule TB skin testing again in 12 months.

Answer 11

Ans: 1

According to National Institutes of Health guidelines, an induration of 5 mm or greater indicates TB infection in patients with HIV and a chest radiograph will be needed to determine whether the patient has active or latent TB infection. Teaching about multidrug therapy is needed if the patient has active TB, but latent TB is treated with a single drug (usually isoniazid) only. Positive skin test results generally persist throughout the patient’s lifetime and will not be repeated, although other tests such as follow-up chest radiographs and sputum testing may be used to evaluate for effective TB treatment. Focus: Prioritization.

Question 12

The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs/LVNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN/LVN?

1. Assessing patients’ nutritional needs and individualizing diet plans to improve nutrition
2. Collecting data about the patients’ responses to medications used for pain and anorexia
3. Developing UAP training programs about how to lower the risk for spreading infections
4. Assisting patients with personal hygiene and other activities of daily living as needed

Answer 12

Ans: 2

The collection of data used to evaluate the therapeutic and adverse effects of medications is included in LPN/LVN education and scope of practice. Assessment, planning, and developing teaching programs are more complex skills that require RN education. Assistance with hygiene and activities of daily living should be delegated to the UAP. Focus: Assignment, Delegation.

Question 13

A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine and methylprednisolone. Which staff member is best to assign to care for this patient?

1. RN who floated to the medical unit from the coronary care unit for the day
2. RN with 3 years of experience in the operating room who is orienting to the medical unit
3. RN who has worked on the medical unit for 5 years and is working a double shift today
4. Newly graduated RN who needs experience with IV medication administration

Answer 13

Ans: 3

To be most effective, cyclosporine must be mixed and administered in accordance with the manufacturer’s instructions, so the RN who is likely to have the most experience with the medication should care for this patient or monitor the new graduate carefully during medication preparation and administration. The coronary care unit float nurse and the nurse who is new to the unit would not have experience with this medication. Focus: Assignment.

Question 14

The nurse is caring for a patient with rheumatoid arthritis who is taking naproxen twice a day to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider?

1. Joint pain worse in the morning
2. Dry eyes bilaterally
3. Round and moveable nodules under the skin
4. Dark-colored stools

Answer 14

Ans: 4

Naproxen, a nonsteroidal anti-inflammatory drug, can cause gastrointestinal bleeding, and the stool appearance indicates that blood may be present in the stool. The health care provider should be notified so that actions such as testing a stool specimen for occult blood and administering proton pump inhibitors can be prescribed. The other symptoms are common in patients with rheumatoid arthritis and require further assessment or intervention, but they do not indicate that the patient is experiencing adverse effects from the medications. Focus: Prioritization.

Question 15

Which of these patients cared for by the nurse in the clinic presents the highest risk for infection with human immunodeficiency virus (HIV) during sexual intercourse?

1. Uninfected man who reports performing oral intercourse with an HIV- infected woman
2. Uninfected man who is the receiver during anal intercourse with an HIV- infected man
3. Uninfected woman who has had vaginal intercourse with an HIV-infected man
4. Uninfected woman who has performed oral intercourse with an HIV- infected woman

Answer 15

Ans: 2

Because anal intercourse allows contact of the infected semen with mucous membrane and causes tearing of mucous membrane, there is a high risk of transmission of HIV. HIV can be transmitted through oral or vaginal intercourse as well but not as easily. Focus: Prioritization.

Question 16

A patient with a history of liver transplantation is receiving cyclosporine, prednisone, and mycophenolate. Which finding is of most concern?

1. Gums that appear very pink and swollen
2. Blood glucose level of 162 mg/dL (9 mmol/L)
3. Nontender lump above the clavicle
4. Grade 1 + pitting edema in the feet and ankles

Answer 16

Ans: 3

Patients taking immunosuppressive medications are at increased risk for development of cancer. A nontender swelling or lump may signify that the patient has lymphoma. The other data indicate that the patient is experiencing common side effects of the immunosuppressive medications. Focus: Prioritization.

Question 17

A patient with human immunodeficiency virus (HIV) who has been started on antiretroviral therapy is seen in the clinic for follow-up. Which test will be best to monitor when determining the response to therapy?

1. CD4 level
2. Complete blood count
3. Total lymphocyte percent
4. Viral load

Answer 17

Ans: 4

Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the antiretroviral therapy is effective. The CD4 level, total lymphocytes, and complete blood count will also be used to assess the impact of HIV on immune function but will not directly measure the effectiveness of antiretroviral therapy. Focus: Prioritization.

Question 18

A hospitalized patient with acquired immunodeficiency syndrome (AIDS) has wasting syndrome. Which nursing action is appropriate to assign to an LPN/LVN who is providing care to this patient?

1. Administering oxandrolone 5 mg/day
2. Assessing the patient for other nutritional risk factors
3. Developing a plan of care to improve the patient’s appetite
4. Providing instructions about a high-calorie, high-protein diet

Answer 18

Ans: 1

Administration of oral medication is included in LPN/LVN education and scope of practice. Assessment, planning of care, and teaching are more complex RN-level interventions. Focus: Assignment.

Question 19

The nurse assesses a 24-year-old patient with rheumatoid arthritis who is considering using methotrexate for treatment. Which patient information is most important to communicate to the health care provider?

1. The patient has many concerns about the safety of the drug.
2. The patient has been trying to get pregnant.
3. The patient takes a daily multivitamin tablet.
4. The patient says that she has taken methotrexate in the past.

Answer 19

Ans: 2

Methotrexate is teratogenic and should not be used by patients who are pregnant. The health care provider will need to discuss the use of contraception during the time the patient is taking methotrexate. The other patient information may require further patient assessment or teaching but does not indicate that methotrexate may be contraindicated for the patient. Focus: Prioritization.

Question 20

An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone 20 mg/day for 4 days. Which action prescribed by the health care provider is most important for the nurse to question?

1. Discontinue prednisone after today’s dose.
2. Give a “catch-up” dose of varicella vaccine.
3. Check the patient’s C-reactive protein level.
4. Administer ibuprofen 800 mg PO TID.

Answer 20

Ans: 2

The varicella (chickenpox) vaccine is a live-virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone. The other medical actions may need some further clarification by the nurse. Prednisone doses should be tapered gradually when patients have received long-term steroid therapy, but tapering is not usually necessary for short-term prednisone use. Measurement of C-reactive protein level is not the most specific test for monitoring treatment, but the test is inexpensive and frequently used. High doses of nonsteroidal anti-inflammatory drugs such as ibuprofen are more likely to cause side effects such as gastrointestinal bleeding but are useful in treating the joint pain associated with exacerbations of SLE. Focus: Prioritization; Test Taking Tip: Because even an attenuated virus may lead to serious infection in patients with inadequate immune function, think about the patient’s immune status whenever administering an attenuated live-virus vaccine such as measles, mumps, and rubella; varicella; or rotavirus.

Question 21

A patient with wheezing and coughing caused by an allergic reaction is admitted to the emergency department. Which medication will the nurse anticipate administering first?

1. Methylprednisolone 100 mg IV
2. Cromolyn 20 mg via nebulizer
3. Albuterol 3 mL via nebulizer
4. Aminophylline 500 mg IV

Answer 21

Ans: 3

Albuterol is the most rapidly acting of the medications listed. Corticosteroids are helpful in preventing and treating allergic reactions but are not rapidly acting. Cromolyn is used as a prophylactic medication to prevent asthma attacks but not to treat acute attacks. Aminophylline is not a first-line treatment for bronchospasm. Focus: Prioritization.

Question 22

A patient with systemic lupus erythematosus (SLE) is admitted to the hospital with acute joint inflammation. Which information obtained in the laboratory testing will be of highest concern to the nurse?

1. Elevated blood urea nitrogen level
2. Increased C-reactive protein level
3. Positive antinuclear antibody test result
4. Positive lupus erythematosus cell preparation

Answer 22

Ans: 1

A high number of patients with SLE develop nephropathy, so an increase in blood urea nitrogen level may indicate a need for a change in therapy or for further diagnostic testing such as a creatinine clearance test or renal biopsy. The other laboratory results are expected in patients with SLE. Focus: Prioritization; Test Taking Tip: When prioritizing which information to discuss with a provider, consider which patient signs and symptoms are typical of the patient’s disease and which findings may indicate complications. New findings that may indicate disease complications should be reported, but symptoms that are frequently seen as a part of the disease process are not usually a priority to report unless further treatment is necessary.

Question 23

The nurse obtains this information when assessing a patient with human immunodeficiency virus (HIV) who is taking antiretroviral therapy. Which finding is most important to report to the health care provider?

1. The blood glucose level is 144 mg/dL (8 mmol/L).
2. The hemoglobin level is 10.9 g/dL (109 g/L).
3. The patient reports frequent nausea.
4. The patient’s viral load has increased.

Answer 23

Ans: 4

The increase in viral load indicates ineffective therapy, which will require further evaluation and treatment. The patient may not be adhering to the prescribed regimen, or resistance to the antiviral medications may have developed. Nausea, anemia, and hyperglycemia are common adverse effects with antiretroviral therapy and may require further evaluation, but the most concerning finding is the lack of effectiveness of the medications. Focus: Prioritization.

Question 24

Initiation of subcutaneous etanercept for a patient with rheumatoid arthritis is being considered. Which patient information is most important for the nurse to communicate with the health care provider?

1. The patient is currently taking methotrexate.
2. The patient has a positive tuberculin skin test result.
3. The patient has had type 2 diabetes for 5 years.
4. The patient is anxious about having to self-inject.

Answer 24

Ans: 2

Tumor necrosis factor antagonists such as etanercept suppress immune function and increase the risk for reactivation of latent tuberculosis (TB). Further assessment for and possible treatment of TB will be needed before starting etanercept therapy. The other data will be communicated and may require patient monitoring or teaching but are not contraindications to starting etanercept. Focus: Prioritization.

Question 25

The hospital employee health nurse is completing a health history for a newly hired staff member. Which information given by the new employee most indicates the need for further nursing action before the new employee begins orientation to patient care?

1. The employee takes enalapril for hypertension.
2. The employee has allergies to bananas, avocados, and papayas.
3. The employee received a tetanus vaccination 3 years ago.
4. The employee’s tuberculin skin test has a 5-mm induration at 48 hours.

Answer 25

Ans: 2

A high incidence of latex allergy in seen in individuals with allergic reactions to these fruits. More information or testing is needed to determine whether the new employee has a latex allergy, which might affect the ability to provide direct patient care. The other findings are important to include in documenting the employee’s health history but do not affect the ability to provide patient care. Focus: Prioritization.

Question 26

A patient who has human immunodeficiency virus (HIV) and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider?

1. The patient exclaims, “I’m afraid I’m going to die right here!”
2. The prescribed patient medications include midazolam 2 mg IV immediately.
3. The patient is diaphoretic and tremulous and reports dizziness.
4. The symptoms occurred suddenly while the patient was driving to work.

Answer 26

Ans: 2

Because protease inhibitors decrease the metabolism of many drugs, including midazolam, serious toxicity can develop when protease inhibitors are given with other medications. Midazolam should not be given to this patient. The other patient data are consistent with the patient’s diagnosis of panic attack and do not indicate an urgent need to communicate with the provider. Focus: Prioritization; Test Taking Tip: Because the antiretroviral drug combinations used to treat HIV infection affect the metabolism of many other medications, investigate for possible drug interactions before administration of any new medications in patients who are taking antiretrovirals.

Question 27

A patient seen in the sexually transmitted disease clinic has just tested positive for human immunodeficiency virus (HIV) with a rapid HIV test. Which action will the nurse take next?

1. Ask about patient risk factors for HIV infection.
2. Send a blood specimen for Western blot testing.
3. Provide information about antiretroviral therapy.
4. Discuss the positive test results with the patient.

Answer 27

Ans: 4 A major purpose of HIV testing for asymptomatic patients is to ensure that HIV-positive individuals are aware of their HIV status, take actions to prevent HIV transmission, and effectively treat the HIV infection. According to current national guidelines, the other actions are also appropriate, but the initial action will be to communicate the test results to the patient. Rapid HIV testing must be confirmed by another test, usually the Western blot test. Antiretroviral therapy is recommended for all HIV-positive patients. Risk factor information will be used in tracking patient contacts and in teaching the patient how to reduce the risk for transmission to others. Focus: Prioritization.

Question 28

Methylprednisolone 60 mg IV is prescribed for a patient who is experiencing a systemic lupus erythematosus (SLE) exacerbation. Based on the label for the medication below, the nurse will administer _________________________ mL.

Answer 28

Ans: 0.96 mL

When administering endocrine medications such as steroids through parenteral routes, the nurse should avoid rounding the medication. 125 mg in 2 mL equals 60 mg in 0.96 mL. Focus: Prioritization.