NCLEX - IMMUNE Day1

The clinic nurse performs an admission assessment on a client diagnosed with systemic lupus erythematosus (SLE), Which characteristic cutaneous manifestation of SLE would the nurse most likely assess?

• Butterfly shape rash (87%)
• Petechiae (7%)
• Pruritus (2%)
• Urticaria (2%)
• –

The nurse is caring for a client with immune thrombocytopenia purpura. Which client statements indicate a need for further teaching? Select all that apply.

• I use a soft-bristle toothbrush and mild mouth rinse.
• I enjoy walking and wear nonskid footwear for safety.
• I use a safety razor and gentle shaving cream.
• Sometimes I get constipated, so I have been taking docusate.
• When I have a headache, I take over-the-counter ibuprofen.

A client receiving a first dose of IV cefazolin has developed a diffuse rash, hypotension, and shortness of breath. Which action should the nurse perform first?

• Administer supplemental oxygen (5%)
• Give IM epinephrine (15%)
• Start IV normal saline bolus (3%)
• Stop the infusion and call for help (75%)
• –

The nurse has been made aware of laboratory test results for assigned clients. Which of the following test results would require immediate follow-up? Click the exhibit button for additional client information.

• a WBC count of 13,000/mm3 (13.0 x 109/L) for a client who has cellulitis of the leg (4%)
• a hematocrit of 28% (0.28) and hemoglobin of 9 g/dL (90 g/L) for a client who has chronic kidney disease (17%)
• a 2-hour postprandial serum glucose of 165 mg/dL (9.2 mmol/L) for a client who has type 2 diabetes mellitus (3%)
• a urinalysis showing WBCs and bacteria for a client who had a kidney transplant 1 month ago (73%)
• –

The nurse is reviewing new prescriptions for a client with inflammatory bowel disease and latent pulmonary tuberculosis. The nurse should clarify the prescription for

• prednisone (46%)
• multivitamin (10%)
• lansoprazole (11%)
• metronidazole (32%)
• –

The nurse is assessing a client with scleroderma. Which of the following findings would be a priority to follow up?

• abrupt-onset hypertension and headache (41%)
• color changes on the skin of the fingers (22%)
• dry cough and exertional dyspnea (14%)
• heartburn and difficulty swallowing (21%)
• –

The nurse has been made aware of laboratory test results for a client who is experiencing an acute exacerbation of systemic lupus erythematosus. Which of the following test results would require immediate follow-up? Click the exhibit button for additional information.

• antinuclear antibody titer (25%)
• erythrocyte sedimentation rate (18%)
• hemoglobin level (5%)
• serum creatinine level (50%)
• –

The nurse is planning teaching for a client newly diagnosed with Sjogren's syndrome. Which measures will the nurse include in the teaching plan? Select all that apply.

• Chewing sugar-free gum or using artificial saliva
• Scheduling regular dental examinations
• Showering with lukewarm water and avoiding harsh soaps
• Using over-the-counter decongestants to alleviate nasal symptoms
• Using over-the-counter lubricants to ease vaginal dryness

A clinic nurse is reviewing charts for clients who have appointments later in the day. Which of the following clients should the nurse recognize as appropriate recipients of a prescription for emtricitabine/tenofovir? Select all that apply.

• A client who reports current recreational IV drug use
• A client with a latent tuberculosis infection
• A female client whose spouse has HIV
• A male client who has intercourse with men and women
• A phlebotomist at an outpatient blood bank

Exhibit: A client allergic to bee stings was stung about 20 minutes ago at a picnic. Based on the assessment data, the nurse anticipates which immediate actions? Select all that apply.

• Inhaled albuterol
• Intramuscular epinephrine
• Intravenous methylprednisolone
• Intravenous metoprolol
• Intravenous nitroglycerine