Question 1

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

Accepted Answer

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

Question 2

A patient with lupus erythematosis is prescribed a corticosteroid.What side effects of this medication should the nurse review with the patient? (Select all that apply.)

Accepted Answer

A)  Tinnitus 
B)  Facial hair 
C)  Moon face 
D)  Mood changes 
E)  Increased weight
F) Rash and pruritus

Question 3

The mother of an infant diagnosed with hypogammaglobulinemia asks the nurse how the disease process occurred.What should the nurse explain to the mother?

Accepted Answer

A)  It rarely occurs in males. 
B)  It occurs after exposure to pesticides. 
C)  It is because the infant was premature. 
D)  There are no known causes for this disorder.

Question 4

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 (1-5)of importance of performance.

Accepted Answer

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 5

A patient is suspected as having a blood transfusion reaction.Which laboratory test should the nurse expect to be done to confirm this diagnosis?

Accepted Answer

A)  Skin testing 
B)  Direct Coombs' test 
C)  White blood cell count 
D)  C-reactive protein level

Question 6

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

Accepted Answer

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 7

A patient is diagnosed with hypogammaglobulinemia.Which of immune cell should the nurse realize is defective in this disorder?

Accepted Answer

A)  T cells 
B)  B cells 
C)  Mast cells 
D)  Plasma cells

Question 8

The nurse notes that a patient has an elevated lactate dehydrogenase,fragmented RBCs seen on microscopic examination,and low RBC count,hematocrit (Hct),and hemoglobin (Hgb)levels.For which health problem should the nurse consider planning care for this patient?

Accepted Answer

A)  Serum sickness 
B)  Pernicious anemia 
C)  Hemolytic transfusion reaction 
D)  Idiopathic autoimmune hemolytic anemia

Question 9

The nurse is caring for a patient with a severe allergic reaction.Which medication should the nurse anticipate being administered to control the itching?

Accepted Answer

A)  Morphine 
B)  Epinephrine 
C)  Diphenhydramine (Benadryl) 
D)  Hydrocortisone sodium succinate (Solu-Cortef)

Question 10

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?

Accepted Answer

A)  Stop the blood infusion. 
B)  Notify the physician STAT. 
C)  Start the new 0.9% normal saline infusion. 
D)  Prepare a new 0.9% normal saline infusion.

Question 11

The nurse is reinforcing teaching on chloroquine side effects for a patient with systemic lupus erythematosus.Which adverse effect should the nurse encourage the patient to report when taking this medication?

Accepted Answer

A)  Tarry stools 
B)  Vision changes 
C)  Any weight gain 
D)  Changes in joint movement

Question 12

The nurse is assisting in an educational seminar on common allergens.What should the nurse include as the most common irritant causing contact dermatitis? (Select all that apply.)

Accepted Answer

A)  Bleach 
B)  Rubber 
C)  Fire ants 
D)  Poison ivy 
E)  Poison oak

Question 13

A patient comes into the emergency department with a fear of developing poison ivy after falling while walking through a wooded area earlier in the day.What should the nurse instruct the patient to do if exposure to poison ivy occurs again?

Accepted Answer

A)  Flood the area with cold water. 
B)  Wrap the area with a thick towel. 
C)  Cover the area with cotton gauze. 
D)  Wash the area with brown soap or any soap.

Question 14

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.)

Accepted Answer

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 15

The nurse is reinforcing teaching provided to a patient with Hashimoto's thyroiditis.What should the nurse explain as occurring initially in this health problem?

Accepted Answer

A)  Thyroid hormone production increases. 
B)  Thyroid hormone production decreases. 
C)  Thyroid-stimulating hormone production increases. 
D)  Thyroid-stimulating hormone production decreases.

Question 16

The nurse is reviewing data collected on several patients.Which patient should the nurse identify as being most likely to exhibit signs and symptoms of systemic lupus erythematosus?

Accepted Answer

A)  A 16-year-old Caucasian man 
B)  A 20-year-old Hispanic woman 
C)  A 45-year-old Caucasian woman 
D)  A 42-year-old Asian American man

Question 17

The nurse is assisting in the planning of care for a patient with chronic serum sickness.Which action should be a priority for this patient?

Accepted Answer

A)  Assessing for a decrease in urine output 
B)  Administration of immunosuppressive medications 
C)  Closely monitoring the patient during the transfusion of blood products 
D)  Discussing with the patient and significant other the need for genetic counseling

Question 18

A patient is experiencing an episode of urticaria.Which intervention should the nurse recommend to include in the teaching plan to assist the patient in controlling the symptoms of urticaria?

Accepted Answer

A)  Avoiding tub baths 
B)  Taking one aspirin daily 
C)  Using relaxation techniques 
D)  Drinking decaffeinated coffee

Question 19

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?

Accepted Answer

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 20

The nurse is caring for a patient at risk for infection.Which immunoglobulin should the nurse consider as being the cause of this patient's infection risk?

Accepted Answer

A)  IgA 
B)  IgE 
C)  IgG 
D)  IgM

Exam 19: Nursing Care of Patients With Immune Disorders