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A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse of having several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?
- A. Administer the medications that the physician ordered.
- B. Call the pharmacy and let them know the client has several drug allergies.
- C. Consult drug references to make sure the medicines do not contain substances to which the client is hypersensitive.
- D. Give the client one medicine at a time and observe for allergic reactions.
Correct Answer: C
Rationale: Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy but still maintains responsibility for the medications administered.
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The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?
- A. Stem cells
- B. Cytokines
- C. Lymphoid tissues
- D. Red blood cells
Correct Answer: C
Rationale: The immune system actually is a collection of specialized white blood cells and lymphoid tissues that cooperate to protect a person from external invaders and the body's own altered cells. The function of these structures is assisted and supported by the activities of natural killer cells, antibodies, and nonantibody proteins such as cytokines and the complement system. Red blood cells and stem cells are not part of the immune system.
The nurse is beginning the physical examination of a client who has reported fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
- A. The client appears mildly ill, listless, and disheveled.
- B. The client has a blood pressure of 120/72 mm Hg.
- C. The client is alert and oriented to all spheres.
- D. The client has palpable peripheral pulses in the upper extremities.
Correct Answer: A
Rationale: The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then perform a more comprehensive examination.
The nurse is caring for a client on tube feedings. The physician has ordered Osmolite HN as the feeding formula for the client. The family asks why the physician has ordered Osmolite HN instead of another formula to feed their family member. What is an important reason that tube-feeding formulas, such as Impact, Immun-Aid, or Perative, be recommended to clients?
- A. To suppress immune system function
- B. To block tumor necrosis factor
- C. To enhance the production of T-cell lymphocytes and NK cells
- D. To stimulate the immune system to attack tumor cells
Correct Answer: C
Rationale: Immune-enhancing tube-feeding formulas enhance the production of lymphocytes and NK cells, resulting in increased cell-mediated immunity. Drugs such as azathioprine, cyclosporine, and muromonab-CD3 suppress immune system function, whereas infliximab and etanercept minimize inflammation by blocking tumor necrosis factor. Aldesleukin is used as biologic therapy for clients who do not respond to conventional cancer treatment. Aldesleukin stimulates the immune system's ability to attack tumor cells.
A client asks the nurse about the importance of taking supplements to maximize immune function. The client is healthy and does not have any medical problems. What is the best information to give to the client?
- A. Instead of taking supplements, eat a lot of fruits and vegetables to maximize immune function.
- B. Adopt a vegetarian diet and omit all meats, and you will maximize immune function.
- C. You should take a variety of vitamin and mineral supplements to maximize immune function.
- D. Eating a moderate diet that is balanced and varied will maximize immune function.
Correct Answer: D
Rationale: Until more is known about nutrient interactions, the best dietary advice to maximize immune function in healthy people is to eat a moderate diet that is balanced and varied. Eating fruits and vegetables and a vegetarian lifestyle may be healthy choices but do not maximize immune function as a balanced diet will.
A client who is a teenager has been brought to the clinic by the parent and is suspected of having an immune system disorder. What tests would the nurse expect to be ordered for this young client?
- A. Cerebral spinal fluids aspiration
- B. Sedimentary rate
- C. Complete blood count with differential
- D. Complete chemistry panel
Correct Answer: C
Rationale: Laboratory tests are used to identify immune system disorders. They usually include a complete blood count with differential. Protein electrophoresis screens for diseases associated with a deficiency or excess of immunoglobulins. T-cell and B-cell assays (or counts) and the enzyme-linked immunosorbent assay may be performed. The other options are not diagnostic of immune disorders.