MSN Exam for Immunologic Problems

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1. You give an intradermal injection of allergen to a patient who is undergoing skin testing for allergies. A few minutes later, the patient complains about feeling  anxious, short of breath, and dizzy. You notice that the patient has reddened blotches on the face and arms. All of these therapies are available on your emergency cart. Which action should you take first?

  1. Start oxygen at 4 L/min using a nasal cannula.
  2. Obtain IV access with a large-bore IV catheter.
  3. Administer epinephrine (Adrenalin) 0.3 mL subcutaneously
  4. Give albuterol (Proventil) with a nebulizer

2. As the nurse manager in a public health department, you are responsible for  developing a plan to reduce the incidence of infection with the human immunodeficiency virus (HIV) in the community. Which nursing action is best delegated to health assistants working for the agency?

  1. Supply injection drug users with bleach solution for cleaning needles and syringes
  2. Provide pretest and post-test counseling to those patients who are seeking HIV testing
  3. Educate high-risk community members about the use of condoms in HIV prevention
  4. Determine which population groups to target for educational based on community assessment

3. You are working with a student nurses who is assigned to care for an HIV-positive patient with severe esophagitis caused by Candida albicans. Which action by the student indicates that you need to intervene most quickly?

  1. The student puts on a mask and gown before entering the patient room.
  2. The student gives the patient a glass of water after the oral nystatin (Mycostatin) suspension.
  3. The student offers the patient a choice of chicken soup or chile con carne for lunch.
  4. The student places a “No Visitors” sign on the door of the patient’s room

4. You are evaluating an HIV-positive patient who is receiving IV pentamidine (Pentam) as a treatment for Pneumocystis carinii pneumonia. Which information is most important to communicate to the physician?

  1. The blood pressure decreased to 104/76 during administration.
  2. The patient is complaining of pain at the site of the infusion.
  3. The patient is not taking in an adequate amount of oral fluids.
  4. Blood glucose is 55 mg/dL after the medication administration.

5. You are completing an assessment and health history for an HIV-positive patient who is considering starting antiretroviral therapy with several medications. Which patient information concerns you the most?

  1. Patient has been HIV positive for 8 years and has never been on any drug therapy for the HIV infection.
  2. Patient tells you that he never has been very consistent about taking medications in the past.
  3. Patient continues to be sexually active with multiple partners and says that he is careful to use condoms.
  4. Patient has many questions and concerns regarding how effective and safe the medications are.

6. You have suffered a needle stick injury after giving a patient an IM injection, but you have no information about the patient’s HIV status. What is the most appropriate method for obtaining this information about the patient?

  1. You should ask the patient to authorize HIV testing as soon as possible.
  2. The nurse manager for the unit is responsible for obtaining the information.
  3. The occupational health nurse should discuss HIV status with the patient.
  4. HIV testing should be done the next time blood is drawn for other tests.

7. A patient with acquired immunodeficiency syndrome (AIDS) has a negative tuberculosis (TB) skin test. Which nursing action is indicated next?

  1. Obtain a chest x-ray and sputum smear.
  2. No further action is needed after the negative skin test.
  3. Teach about the anti-tuberculosis drug isoniazid (INH)
  4. Schedule TB testing again in 6 months

8. You are working in an AIDS hospice facility that is also staffed with LPNs and nursing assistants. Which of these nursing actions is best to delegate to an LPN you are supervising?

  1. Assess patients’ nutritional needs and individualize diet plans to improve nutrition.
  2. Collect data about the patient’s response to medications used for pain and anorexia.
  3. Teach the nursing assistants about how to lower the risk for spreading infections.
  4. Assist patients with personal hygiene and other activities of daily living as needed.

9. A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine (Sandimmune) and methylprednisolone (Solu-Medrol). Which staff member is best to assign to care for this patient?

  1. An RN who floated to the medical unit from the coronary care unit for the day.
  2. An RN with 3 years of experience in the operating room who is orienting top the medical unit.
  3. An RN who has worked on the medical unit for 5 years and is working a double shift today.
  4. A new graduate RN who needs experience with IV medication administration.

10.Your patient with rheumatoid arthritis (RA) is taking prednisone (Deltasone) and naprozen (Alleve) to reduce inflammation and joint paint. Which of these symptoms is the strongest indicator that a change in therapy may be necessary?

  1. The patient states that the RA symptoms are worst in the morning
  2. The patient complains about having dry eyes.
  3. The patient has round and moveable nodules just under the skin.
  4. The patient has stools that are very dark in color.

11.A patient with chronic hepatitis C has been receiving interferon alfa-2a (Roferon-A) injections for the last month. Which information gathered during a visit in the home to conduct an interview and physical assessment is most important to communicate to the physician?

  1. The patient has chronic nausea and vomiting
  2. The patient is giving the medication by the IM route to her lateral thigh.
  3. The patient has a temperature of 99.7o F orally.
  4. The patient complains of chronic fatigue, muscle aches, and anorexia.

12.You obtain these assessment data while completing as admission for a patient with a history of a liver transplant who is receiving cyclosporine (Sandimmune), prednisone (Deltasone), and mycophenolate (CellCept) to suppress immune function. Which one will be of most concern?

  1. The patient’s gums appear very pink and swollen.
  2. The patient’s blood glucose is increased to 162 mg/dL
  3. The patient has a non-tender swelling above the clavicle.
  4. The patient has 1+ pitting edema in the feet and ankles.

13.While caring for an HIV-positive patient who is hospitalized with Pneumocystis carinii pneumonia, you note that all of these drug therapies are scheduled for 10:00 AM. Which nursing action is most essential to accomplish at the scheduled time?

  1. Administer the protease inhibitor indinavir (Crixivan) 800 mg PO.
  2. Infuse pentamidine (Pentam-300) 300 mg IV over 60 minutes.
  3. Have the patient “swish and swallow” nystatin (Mycostatin) 5 mL.
  4. Apply acyclovir (Zovirax) cream to oral herpes simplex lesions.

14. An HIV-positive patient who has been started on antiretroviral therapy (ART) is seen in the clinic for follow-up. Which test will be most helpful in determining the response to therapy?

  1. Lymphocyte count
  2. ELISA testing
  3. Western blot analysis
  4. Viral load testing

15. You have developed a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements for a hospitalized patient with AIDS who has anorexia and nausea. Which of these nursing actions is most appropriate to delegate to an LPN who is providing care for this patient?

  1. Administer oxandrolone (Oxanddrin) 5 mg daily in morning.
  2. Provide oral care with a soft toothbrush every 8 hours.
  3. Instruct the patient about a high-calorie, high-protein diet.
  4. Assess the patient for other nutrition risk factors.

16.You assess a 24-year-old with RA who is considering using methotrexate (Rheumatrex) for treatment. Which information is most important to communicate with the physician?

  1. The patient has many concerns about the safety of the drug.
  2. The patient has been trying to get pregnant.
  3. The patient takes a daily multivitamin tablet.
  4. The patient says that she has taken methotrexate in the past.

17.An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone (Deltasone) 20 mg daily for 4  hours. Which of these medical orders should you question?

  1. Discontinue prednisone after today’s dose.
  2. Administer first dose of varicella vaccine.
  3. Check patient’s C-reactive protein (CRP).
  4. Give Ibuprofen (Advil) 800 mg every 6 hours.

18.A patient with wheezing and coughing caused by an allergic reaction to penicillin is admitted to the emergency department (ED). Which of these medications do you anticipate administering first?

  1. Methylprednisolone (Solu-Medrol) 100 mg IV
  2. Cromolyn sodium (Intal) 20 mg per nebulizer
  3. Albuterol (Proventil) 0.5 mL per nebulizer
  4. Aminophylline 500 mg IV over 20 minutes

19.A patient with systemic lupus erythematosus (SLE) is admitted to the hospital for evaluation and management of acute joint inflammation. Which information obtained in the admission laboratory testing concerns you most?

  1. The blood urea nitrogen (BUN) level is elevated.
  2. The C-reactive protein (CRP) level is increased.
  3. The anti-nuclear antibody (ANA) test is positive.
  4. The lupus erythematosus (LE) cell prep is positive.

20. As the hospital employee health nurse, you are completing a health history for a newly hired nursing assistant. Which information given by the new employee most indicates the need for further nursing action prior to orienting the nursing assistant to patient care?

  1. The new employee takes enalapril (Vasotec) for hypertension.
  2. The new employee is allergic to bananas, avocados, and papayas.
  3. The new employee received a tetanus vaccination 3 years ago.
  4. The new employee’s TB skin test has a 5-mm induration at 48 hours.
Answers and Rationales
  1. ANSWER C – Epinephrine given rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but generally is administered using a non-rebreather mask at 90%-100% Fio2 Albuterol may also be used to decrease airway narrowing, but would not be the first therapy used for anaphylaxis. An IV access will take longer to establish and should not be the first intervention.
  2. ANSWER A – Supplying bleach solution to patients who are at risk for HIV infection can be done by staff members with health assistant education. Pre-operative/post-operative test counseling may be done by non-RN personnel with specialized training; however, an RN would be better prepared to answer questions that are likely to be asked by at-risk individuals. Education and community assessment are RN-level skills.
  3. ANSWER B – Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet/contact precautions or visitor restrictions for opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with oral or esophageal fungal infections.
  4. ANSWER D – Pentamidine can cause fatal hypoglycemia, so the low blood glucose level indicates a need for a change in therapy. The low blood pressure suggests that the IV infusion rate may need to be slowed. The other responses indicated need for independent nursing actions (such as obtaining a new IV site and encouraging oral intake) but are not associated with pentamidine infusion.
  5. ANSWER B – Drug therapy for HIV infection requires taking multiple medications on a very consistent schedule. Failure to take the medications consistently can lead to mutations and the emergence of more virulent forms of the virus. Although the other data indicate the need for further assessments or interventions, they will not affect the decision to initiate antiretroviral therapy for this patient.
  6. ANSWER C – The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and obtaining a patient’s HIV status and/or patient HIV testing is the occupational health nurse. Doing unauthorized HIV testing or asking the patient yourself would be unethical. The nurse manager is not responsible for obtaining this information (unless the manager is also in charge of occupational health).
  7. ANSWER A – Patients with severe immunodeficiency may be unable to produce an immune response, so a negative TB skin test does not completely rule out a TB diagnosis for this patient. The next steps in diagnosis are a chest x-ray and sputum culture. Teaching about INH and follow-up TB testing may be required, depending on the x-ray and sputum culture results.
  8. ANSWER B – Collecting data used to evaluate the therapeutic and adverse effects of medications is included in LPN/LVN education and scope of practice. Assessment, planning, and teaching are more complex skills that will require RN education. Assistance with hygiene and activities of daily living should be delegated to the nursing assistants.
  9. ANSWER C – To be most effective, cyclosporine must be mixed and administered following the manufacturer’s instructions, so the RN who is likely to have the most experience with the medication should care for this patient or monitor the new graduate carefully during medication preparation and administration. The coronary care unit (CCU) float nurse and new orientee would not have experience with this medication
  10. ANSWER D – Both naproxen (an NSAID) and prednisone (a corticosteroid) can cause gastrointestinal bleeding and the stool appearance indicated that there may be blood present in the stool. A stool specimen should be checked for occult blood. Also, it is likely that patient needs to start taking aproton-pump inhibitor such as pantopraxole (Protonix) to reduce gastric acid secretion. The other symptoms are common in patients with RA and will require assessments and interventions, but do not indicated that therapy needs to be altered.
  11. ANSWER A – Nausea and vomiting are common adverse effects of interferon alfa-2a, but continued vomiting should be reported to the physician because dehydration may occur. The medication may be given by either the subcutaneous or intramuscular route. Flu-like symptoms such as a mild temperature elevation, headache, muscle aches, and anorexia are common after initiating therapy but tend to decrease over time.
  12. ANSWER C – Patients taking immunosuppressive medications are at increased risk for development of cancer. A non-tender swelling or lump may indicate the patient has lymphoma. The other data indicate that the patient is experiencing common side effects of the immunosuppressive medications.
  13. ANSWER A – Taking antiretroviral medications such as indinavir on a rigid time schedule is essential for effective treatment of HIV infection and to avoid development of drug resistant-strains of the virus. The other medications should also be given within the time frame indicated in the hospital policy (usually within 30 minutes of the scheduled time).
  14. ANSWER D – Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the ART is effective. The lymphocyte count is used to assess the impact of HIV on immune function but will not directly measure the effectiveness of antiretroviral therapy. The ELISA and Western blot tests monitor for the presence of antibodies to HIB, so these will be positive after the patient is infected with HIV  even if drug therapy is effective.
  15. ANSWER A – Administration of oral medication is appropriate for LPN education and scope of practice. Oral care should be delegated to a nursing assistant. Teaching and assessment are more complex RN-level interventions.
  16. ANSWER B – Methotrexate is teratogenic and should not be used in patients who are pregnant. The physician will need to discuss use of contraception during the time the patient is taking methotrexate. The other patient information may require further patient assessment or teaching but does not indicate that methotrexate may be contraindicated for the patient.
  17. ANSWER B – The varicella (chickenpox) vaccine is a live-virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone. The other medical orders are appropriate. Prednisone dose should be tapered gradually when patients have been on long-term steroid therapy, but tapering is not necessary for short-term prednisone use. CRP levels are not the most specific test for monitoring treatment but are inexpensive and frequently used. High does of NSAIDs such as ibuprofen are more likely to cause side effects such as gastrointestinal bleeding but are
    useful in treating the joing pain associated with SLE exacerbations.
  18. ANSWER C – Albuterol is the most rapid acting of the medications listed. Corticosteroids are helpful in prevention of allergic reactions, but are not as rapid acting. Cromolyn is used as a prophylactic medication to prevent
  19. ANSWER A – A high number of patients with SLE develop nephropathy, so an increase in BUN may indicate a need for a change in therapy or for further diagnostic testing such as creatinine clearance test or renal biopsy. The other laboratory results are not unusual in  patients with SLE.
  20. ANSWER B – Individuals with allergic reactions to these fruits have a high incidence of latex allergy. More information and/or testing is needed to determine whether the new employee has a latex allergy, which might affect ability to provide direct patient care. The other findings would be important to include in documenting the employee’s health history, but would not affect ability to provide patient care. Focus: Prioritization