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The nurse is caring for a client with a suspected diagnosis of HIV. The nurse is preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV?
- A. Advise the client to avoid excess fluid intake.
- B. Advise the client to abstain from having intercourse.
- C. Advise the client to take off any ornaments and metallic objects.
- D. Obtain a written consent from the client.
Correct Answer: D
Rationale: It is important that the nurse obtain written consent from the client before performing an HIV test and keep the results of HIV test confidential. The nurse may not ask the client to avoid excess fluid intake or abstain from intercourse before the tests. The client also need not take off ornaments and metallic objects worn unless they are likely to interfere with the test results.
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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.
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?
- A. Activation of the complement system
- B. Stimulation of colony-stimulating factors
- C. A cell-mediated response
- D. Naturally acquired active immunity
Correct Answer: C
Rationale: A cell-mediated response occurs when T cells survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. An example of a cell-mediated response is one that occurs when an organ is transplanted. The complement system cooperates with antibodies to attract phagocytes and coat antigens to make them more recognizable for phagocytosis and stimulate inflammation and is not related to the surgery. Colony-stimulating factors prompt the bone marrow to produce, mature, and promote the functions of blood cells. Naturally acquired active immunity is a direct result of infection by a specific microorganism.
The nurse has several clients scheduled for annual wellness examinations throughout the day. For which client should the nurse prepare the shingles vaccine?
- A. A 24-year-old client who is pregnant
- B. A 32-year-old client who has never had chickenpox
- C. A 65-year-old client who had chicken pox at the age of 12
- D. A 17-year-old client who will be attending college and living in a dormitory
Correct Answer: C
Rationale: The Centers for Disease Control and Prevention recommends annual seasonal influenza vaccine and pneumococcal polysaccharide vaccine (PPSV23; Pneumovax) for all adults 65 years or older or those who are at high risk, and the shingles vaccine (Zostavax) for all individuals who are over the age of 50. Based on this information, the nurse prepares to administer the shingles vaccine to the client who is 65 years of age. The other clients are not eligible to receive this vaccine until the age of 50 years.
Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and lifestyle during the interview process?
- A. To find out if the client will be compliant with therapeutic treatments
- B. To determine if the client has practices that are risk factors for acquired immunodeficiency syndrome (AIDS)
- C. To determine if the client needs a referral to counseling services
- D. To determine what type of personality the client has
Correct Answer: B
Rationale: The nurse investigates the client's allergy history and asks about practices that put the client at risk for AIDS. The interview will not determine the client's ability to be compliant. The physician would make the determination if a counseling referral should be made. It is irrelevant to determine the personality traits in the initial interview.
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.