NCLEX - IMMUNE Day1 (Part 2)

The nurse is caring for a child who has had a tonsillectomy. Which of the following are appropriate nursing interventions? Select all that apply.

• Anticipate ear pain and give acetaminophen as needed
• Educate parents to expect the child to develop bad breath postoperatively
• Encourage the child to drink cold liquids through a straw
• Notify the health care provider about frequent, increased swallowing
• Use an oral suction device regularly to remove secretions from the back of the throat

Answer explanation

Option 1: Anticipate ear pain and give acetaminophen as needed

Option 2: Educate parents to expect the child to develop bad breath postoperatively

Option 3: Encourage the child to drink cold liquids through a straw

Option 4: Notify the health care provider about frequent, increased swallowing

Option 5: Use an oral suction device regularly to remove secretions from the back of the throat

Correct Option: 1,2,4

Explanation: A tonsillectomy may be indicated in some cases of chronic tonsillitis, peritonsillar abscess, or obstructive sleep apnea. Postoperative bleeding is a primary concern after a tonsillectomy because the surgical site is not easily visualized and is vulnerable to irritation and trauma from swallowing and coughing. The nurse should observe for signs of postoperative bleeding (eg, frequent, increased swallowing or clearing of the throat; vomiting bright red blood) and notify the health care provider (Option 4). Expected postoperative findings include ear pain when swallowing (ie, referred pain from the throat) and low-grade fever (<101 F [38.3 C]); analgesics (eg, acetaminophen) may be administered as needed (Option 1). Superficial infection at the surgical site is common and causes white, fluid-filled exudate in the throat with halitosis (ie, bad breath); this is not concerning because it usually resolves spontaneously after 5-10 days (Option 2). (Option 3) Drinking through a straw creates suction that causes localized pressure at the back of the throat and may contribute to bleeding. The client should avoid use of straws or other pointed objects in the mouth. (Option 5) Routine suctioning can cause trauma to the surgical site and induce bleeding. Suction equipment should be available but used only for emergency airway obstruction.

The nurse is teaching a client with newly diagnosed HIV about antiretroviral therapy (ART). Which of the following statements by the client would require follow-up?

• ART consists of several different medications.
• I understand that missing doses of ART can lead to viral resistance.
• ART can be discontinued once my viral load is undetectable.
• I should check for interactions between ART and my current medications.
• -

Answer explanation

Option 1: ART consists of several different medications.

Option 2: I understand that missing doses of ART can lead to viral resistance.

Option 3: ART can be discontinued once my viral load is undetectable.

Option 4: I should check for interactions between ART and my current medications.

Correct Option: 3

Explanation: HIV monitoring parameters & goals of antiretroviral therapy Monitoring parameters Therapy goals Viral load (plasma HIV RNA) Achieve & maintain suppression (ie undetectable viral load) Prevent transmission CD4 count Restore & preserve immunologic function (ie, increase CD4 count) Reduce morbidity (eg, OIs) & mortality. OIs = opportunistic infections. Antiretroviral therapy (ART) (eg, tenofovir, atazanavir) is a multimedication regimen used to manage and prevent the progression of HIV. HIV is a retroviral infection that proliferates within and destroys CD4" T lymphocytes (helper T cells) in the immune system. ART improves immune function and decreases the risk for transmission to others by interfering with viral replication, which decreases viral load and increases the CD4+ T-lymphocyte cell count. Obtaining an undetectable viral load is a goal of ART; clients with an undetectable viral load should not discontinue ART because this would result in an increased viral load and progression of the condition (Option 3). (Option 1) ART consists of a combination of medications with different mechanisms of action to decrease the viral load and prevent progression of the condition. (Option 2) Missed doses of ART can lead to viral resistance, which reduces the efficacy of the medication regimen. In addition, nonadherence may increase the risk for opportunistic infections (eg, tuberculosis) and certain cancers (eg, Kaposi sarcoma). (Option 4) ART interacts with several medications (eg, acyclovir) and may result in severe reactions. Current medications should be reviewed with the health care provider to ensure that no interactions are present.

The nurse has taught the parents of a 6-year-old client with chronic allergic rhinitis that is triggered by dust and pollen. Which of the following statements by the parents would indicate a correct understanding of the teaching? Select all that apply.

• We are planning to purchase an air purifier with a high-efficiency particulate air filter.
• We will keep the windows open during warm weather to air out our house.
• We should use hypoallergenic covers on our child's mattress and pillow.
• We will clean our wood floors with a damp mop at least once a week.
• We are planning to remove the carpet from our child's bedroom.

Answer explanation

Option 1: We are planning to purchase an air purifier with a high-efficiency particulate air filter.

Option 2: We will keep the windows open during warm weather to air out our house.

Option 3: We should use hypoallergenic covers on our child's mattress and pillow.

Option 4: We will clean our wood floors with a damp mop at least once a week.

Option 5: We are planning to remove the carpet from our child's bedroom.

Correct Option: 1,3,4,5

Explanation: Chronic allergic rhinitis is a hypersensitivity response to specific allergen triggers (eg, dust, mold, pollen, animal dander). Symptoms include sneezing, nasal drainage and congestion, sore throat, and itching of the eyes and/or nose. Clients and their families can minimize symptoms by identifying the client's individualized allergen triggers and implementing strategies to reduce or avoid exposure to them. Interventions to reduce exposure to household and environmental allergens include: Installing high-efficiency air purifiers and air conditioners with particulate air (HEPA) filters (Option 1). Applying hypoallergenic pillow and mattress covers to prevent exposure to dust mites (Option 3). Mopping hard floors and damp-dusting furniture at least once a week (Option 4). Reducing or removing carpet and area rugs (Option 5). (Option 2) Windows should be kept closed, particularly during times of heavy pollen. Opening windows allows environmental allergens, such as pollen, to enter the home.

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response?

• Depression is common with fibromyalgia, but a low dose of this drug can prevent it.
• It can relieve your chronic pain and help you sleep better at night.
• It helps to relieve the adverse effects of your other prescribed drugs.
• You have the right to refuse. I will notify your health care provider (HCP).

Answer explanation

Option 1: Depression is common with fibromyalgia, but a low dose of this drug can prevent it.

Option 2: It can relieve your chronic pain and help you sleep better at night.

Option 3: It helps to relieve the adverse effects of your other prescribed drugs.

Option 4: You have the right to refuse. I will notify your health care provider (HCP).

Correct Option: 2

Explanation: Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well (Option 2). Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug. (Option 1) Although depression often accompanies chronic pain, duloxetine can be prescribed specifically to treat the chronic pain associated with FM. (Option 3) Duloxetine is prescribed for major depressive disorder and to relieve pain associated with diabetic neuropathy and FM. It is not given to relieve the adverse effects of other drugs. (Option 4) A client has the right to refuse any drug. However, the nurse should first explain the purpose of the drug to the client before notifying the HCP.

Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination?

• Haemophilus influenzae type b vaccine for client allergic to penicillin
• Hepatitis A vaccine for a client with a "cold" and temperature of 99.0 F (37.2 C)
• Pneumococcal vaccine for client with local swelling after last immunization
• Varicella-zoster vaccine for client recently diagnosed with leukemia

Answer explanation

Option 1: Haemophilus influenzae type b vaccine for client allergic to penicillin

Option 2: Hepatitis A vaccine for a client with a "cold" and temperature of 99.0 F (37.2 C)

Option 3: Pneumococcal vaccine for client with local swelling after last immunization

Option 4: Varicella-zoster vaccine for client recently diagnosed with leukemia

Correct Option: 4

Explanation: Vaccines should be administered at specific ages and intervals as passive placental immunity decreases and the child's immune system develops enough to produce antibodies in response to the vaccine. The nurse should always assess for allergies to vaccine components (eg, neomycin, gelatin, yeast) and screen for an allergy to latex (eg, lips swelling from contact with bananas, kiwis, or latex balloons). Severely immunocompromised children (eg, corticosteroid therapy, chemotherapy, AIDS) generally should not receive live vaccines (eg, varicella-zoster vaccine, measles-mumps-rubella, rotavirus, yellow fever) (Option 4). Passive immunization may be the only option for children with severe immunosuppression or those unable to mount an antibody immune response. Common misperceptions of contraindications to immunization: Penicillin allergy (Option 1). Mild illness (with or without an elevated temperature) (Option 2). Mild site reactions (eg, swelling, erythema, soreness) (Option 3). Recent infection exposure. Current course of antibiotics.

A nurse is caring for a client with a diagnosis of fibromyalgia. During care, the client reports having suicidal thoughts. What currently prescribed medication should the nurse question in regard to this new finding?

• Amitriptyline
• Celecoxib
• Cyclobenzaprine
• Hydrocodone

Answer explanation

Option 1: Amitriptyline

Option 2: Celecoxib

Option 3: Cyclobenzaprine

Option 4: Hydrocodone

Correct Option: 1

Explanation: Fibromyalgia is a chronic, nonspecific pain disorder. Common sequelae include fatigue, sleep disturbances, emotional distress (eg, anxiety, depression), and even mild cognitive impairments (eg, forgetfulness, difficulty concentrating). Treatment is focused on symptom management and often includes: Muscle relaxers (eg, cyclobenzaprine). Narcotic analgesics (eg, tramadol, hydrocodone). Nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen, celecoxib). Neuropathic pain relievers (eg, pregabalin, gabapentin). Antidepressants such as selective serotonin reuptake inhibitors (eg, fluoxetine, duloxetine) and tricyclic antidepressants (eg, amitriptyline). Antidepressants can cause suicidal ideation and behaviors, especially during the initial few weeks of therapy. This risk is even higher for young adults (age 18-24). The nurse must assess for this adverse effect and alert the provider (Option 1). (Options 2, 3, and 4) Celecoxib, cyclobenzaprine, and hydrocodone are not known to cause suicidal ideation.

The nurse is talking with a client with rheumatoid arthritis who has a new prescription for adalimumab. Which of the following statements by the client would require follow-up?

• I usually take naproxen for pain twice a week.
• I received my annual influenza vaccine injection 3 weeks ago.
• I received a negative test result for my tuberculin skin test one week ago.
• I started a course of antibiotic therapy to treat a urinary tract infection 2 days ago.

Answer explanation

Option 1: I usually take naproxen for pain twice a week.

Option 2: I received my annual influenza vaccine injection 3 weeks ago.

Option 3: I received a negative test result for my tuberculin skin test one week ago.

Option 4: I started a course of antibiotic therapy to treat a urinary tract infection 2 days ago.

Correct Option: 4

Explanation: Tumor necrosis factor (TNF) inhibitor medications (eg, adalimumab) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These medications reduce the manifestations of autoimmune disorders (eg, rheumatoid arthritis) by inhibiting the inflammatory response. TNF inhibitors also cause immunosuppression and increase susceptibility to infection and malignancies. Because of this, a client with a current (eg, urinary tract infection), recent, or chronic infection should not take a TNF inhibitor (Option 4). (Option 1) In clients with rheumatoid arthritis, NSAIDs (eg, naproxen) can be used in combination with TNF inhibitors to effectively treat pain and minimize inflammation. (Option 2) Due to the increased risk for immunosuppression, clients taking TNF inhibitors should receive an annual inactivated (ie, injectable) influenza vaccine to reduce the risk of contracting the virus. (Option 3) Latent tuberculosis can be activated by the immunosuppressive action of TNF inhibitors. Because of this, a tuberculin skin test should be administered prior to beginning TNF inhibitor therapy.

A client with ulcerative colitis is prescribed the drug sulfasalazine. Which information should the nurse discuss with the client concerning this drug? Select all that apply.

• Drinking 8 glasses of water daily
• Stopping the medicine if blood is present in stool
• Stopping the medicine if urine turns an orange-yellow color
• Taking folic acid supplements
• Wearing sunscreen when outdoors

Answer explanation

Option 1: Drinking 8 glasses of water daily

Option 2: Stopping the medicine if blood is present in stool

Option 3: Stopping the medicine if urine turns an orange-yellow color

Option 4: Taking folic acid supplements

Option 5: Wearing sunscreen when outdoors

Correct Option: 1,4,5

Explanation: Sulfasalazine (Azulfidine) is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic disease-modifying antirheumatic drug (DMARD) used for mild to moderate chronic inflammatory rheumatoid arthritis (RA) and inflammatory bowel disease (eg, ulcerative colitis). It inhibits the production of prostaglandin, a mediator in the body's inflammatory response. Most "sulfa" medications (eg, trimethoprim, sulfamethoxazole) share common side effects, including: 1. Crystalluria causing kidney injury — client should drink 8 glasses of water daily to maintain adequate urine output (eg, 1200-1500 mL/day). 2. Photosensitivity and risk for sunburn — client should avoid sun exposure and apply sunscreen. 3. Folic acid deficiency (megaloblastic anemia and stomatitis) — client should eat folate-rich foods and take 1 mg/day folic acid supplement. 4. Rarely life-threatening agranulocytosis (leukopenia) — client should be monitored for complete blood count at the start of therapy and report fever or sore throat immediately. 5. Stevens-Johnson syndrome — client should stop the medicine if rash develops. (Option 2) Ulcerative colitis is characterized by bloody diarrhea, and the medication is taken to reduce this effect. (Option 3) Urine and skin can turn an orange-yellow color but will return to normal when the drug is discontinued. This is an expected finding.

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan?

• Have an ophthalmologic examination every 6 months
• Take the medication on an empty stomach
• Take vitamin D and calcium supplements
• Wear a MedicAlert bracelet

Answer explanation

Option 1: Have an ophthalmologic examination every 6 months

Option 2: Take the medication on an empty stomach

Option 3: Take vitamin D and calcium supplements

Option 4: Wear a MedicAlert bracelet

Correct Option: 1

Explanation: Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months (Option 1). (Option 2) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (common side effect). (Option 3) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation is not required. (Option 4) There are no effects of hydroxychloroquine that would require wearing a MedicAlert bracelet.

The nurse has provided education about proper use of an epinephrine auto-injector to a client with a history of a severe hypersensitivity reaction to bee stings. Which of the following client statements indicate that teaching has been effective? Select all that apply.

• I may have a rapid heartbeat and palpitations after injecting the medication.
• I must call an ambulance or go to the nearest hospital following an injection.
• I should avoid storing my device in extremely hot or cold temperatures.
• The area to be injected should be cleansed with alcohol or soap and water.
• The medication is injected at a 90-degree angle into the outer thigh.

Answer explanation

Option 1: I may have a rapid heartbeat and palpitations after injecting the medication.

Option 2: I must call an ambulance or go to the nearest hospital following an injection.

Option 3: I should avoid storing my device in extremely hot or cold temperatures.

Option 4: The area to be injected should be cleansed with alcohol or soap and water.

Option 5: The medication is injected at a 90-degree angle into the outer thigh.

Correct Option: 1,2,3,5

Explanation: Epinephrine auto-injectors (EAIs) are devices used as an emergency treatment for anaphylactic reactions to allergens (eg, insect bites, foods, chemicals). Clients with a history of anaphylaxis must be properly educated on EAI use because delaying or failing to administer epinephrine is a frequent cause of death. Nurses educating clients on EAI use should include the following information: • Administer injection at a 90-degree angle into the outer thigh at the first sign of an allergic reaction (Option 5). • Hold the auto-injector in place for 10 seconds to ensure delivery of the entire dose. • Seek immediate medical care after an injection because anaphylactic reactions may resume when the effects of the epinephrine subside (ie, 10-20 minutes) (Option 2). • Expect to experience tachycardia, palpitations, and/or dizziness after administration (Option 1). • Store EAIs at room temperature in a dark place to prevent inactivation by heat or light, or device failure from cold (Option 3). (Option 4) Clients should be instructed to administer EAIs as quickly as possible if symptoms of anaphylaxis develop. Skin preparation is not necessary, and delaying administration to cleanse the injection site increases the risk of death from anaphylactic shock.