MSN Exam for Immunologic Problems

EXPLANATION

 

✔Correct answer:

The patient has a non-tender swelling situated above the clavicle. The presence of a non-tender swelling situated above the clavicle in a patient with a history of liver transplant and on immunosuppressive medications like cyclosporine (Sandimmune), prednisone (Deltasone), and mycophenolate (CellCept) is highly concerning. This could be indicative of a lymph node enlargement, potentially suggesting an infection, a malignancy (such as post-transplant lymphoproliferative disorder, PTLD), or another serious condition. Patients on immunosuppressive therapy are at increased risk for infections and certain cancers due to the suppression of their immune system. This finding should be immediately reported to the healthcare provider for further evaluation.

Think of the immune system as a security system of the body. The immunosuppressive medications are like turning down the sensitivity of the security system to avoid false alarms (preventing the body from attacking the transplanted organ). However, this also means that real threats (like infections or cancer) might not be detected early. A swollen lymph node can be like a warning light on a security panel, indicating that there might be a problem that needs immediate investigation.

Lymph nodes are part of the immune system and can become enlarged (lymphadenopathy) when there's an infection, inflammation, or cancer. In the context of a patient on immunosuppressive therapy, the immune system's ability to fight infections and surveil for malignant cells is compromised. The presence of a non-tender, swollen lymph node, especially in a supraclavicular location, is concerning and warrants prompt evaluation to rule out serious conditions like infections or malignancy.

 

✘Incorrect answer options:

The patient's blood glucose level is elevated to 162 mg/dL. While elevated blood glucose levels are a concern and may be associated with the use of prednisone, this finding is not as immediately concerning as a potential lymph node enlargement. Elevated glucose should be managed, but it typically does not require emergency intervention.

The patient has 1+ pitting edema in the feet and ankles. Pitting edema in the feet and ankles can be related to various conditions, including medication side effects or heart, liver, or kidney problems. It is a sign that warrants further assessment but is not as alarming as a non-tender swelling above the clavicle in the context of this patient's history and medication use.

The patient's gums appear notably pink and swollen. Gingival hyperplasia is a known side effect of cyclosporine and, while it requires management and can impact the patient's quality of life, it is not typically an acute, life-threatening condition compared to the potential implications of a swollen lymph node above the clavicle.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Mosby.
• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

Proceed with obtaining a chest x-ray and sputum smear for the patient. A negative TB skin test (Mantoux test) in a patient with AIDS might not reliably indicate the absence of TB due to the patient's compromised immune system. Individuals with AIDS may have a decreased immune response, which can result in a false-negative skin test, even if they are infected with TB. Therefore, Nurse Amelia should proceed with further diagnostic evaluations, such as a chest x-ray and sputum smear/culture, to rule out active tuberculosis more definitively.

Think of a security system designed to sound an alarm when intruders are detected. If the system's batteries are low (akin to an impaired immune system), it might not function properly. Even if no alarm sounds (similar to a negative TB skin test), it doesn't necessarily mean everything is safe. You'd still check the cameras or other security measures (akin to a chest x-ray or sputum smear) to make sure.

The TB skin test relies on an immune response to a substance injected under the skin. In patients with compromised immune systems, like those with AIDS, the body may not mount a sufficient immune response to produce a positive skin test, even if TB bacteria are present. Additional tests like chest x-rays can reveal signs of active pulmonary TB, and sputum smears or cultures can detect the presence of TB bacteria directly.

 

✘Incorrect answer options:

No additional steps are required following the negative skin test. This is incorrect because, in patients with AIDS, a negative TB skin test does not definitively rule out TB due to the possibility of an anergic (non-reactive) immune response.

Educate the patient about the anti-tuberculosis medication, isoniazid (INH). While it's important to educate patients about potential treatments, it's premature to discuss specific medications like INH before confirming the diagnosis with more reliable tests, especially given the patient's immune-compromised status.

Plan to repeat the TB testing in another 6 months. While repeat testing might be part of ongoing surveillance, it should not replace immediate further investigation in a patient with AIDS who has a negative TB skin test, due to the high risk and potential severity of TB in such patients.

 

References

• Jarvis, C. (2019). Physical Examination and Health Assessment. Saunders.
• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

The patient admits to a history of being inconsistent with medication adherence. In the management of HIV with antiretroviral therapy (ART), adherence to medication is paramount. Inconsistent medication adherence can lead to drug resistance, treatment failure, and progression of the disease. When HIV is not effectively suppressed, it can mutate and become resistant to the medications, making future treatment more challenging. Nurse Laura should be most concerned about this admission and work on strategies to improve adherence, such as education on the importance of consistent medication intake, exploring barriers to adherence, and setting up a support system or reminders.

Think of medication adherence like watering a plant. If you're inconsistent with watering, the plant won't grow properly and could wither. Similarly, inconsistent medication intake won't effectively suppress the HIV virus, allowing it to potentially grow stronger and resistant to the medication, just like a plant becoming resistant to poor conditions.

Antiretroviral drugs work by inhibiting the replication of the HIV virus. Inconsistent medication adherence leads to fluctuating drug levels in the body, which may not be sufficient to suppress viral replication effectively. This can lead to the selection of resistant viral strains, as the virus continues to replicate and mutate in the presence of suboptimal drug concentrations.

 

✘Incorrect answer options:

The patient continues to engage in sexual activities with multiple partners but insists on using condoms. While multiple sexual partners increase the risk of sexually transmitted infections, the consistent use of condoms significantly reduces this risk and also prevents the spread of HIV to others. This behavior indicates a level of responsibility and understanding of safe sex practices.

The patient has various questions and concerns about the efficacy and safety of the proposed medications. It's natural for patients to have questions and concerns about their medication, especially for a complex and lifelong treatment like ART. This indicates engagement and a desire to understand their treatment, which is a positive sign. Nurse Laura should address these concerns and provide comprehensive information to support the patient's understanding and adherence to the treatment plan.

The patient has been HIV-positive for 8 years and has never undergone any antiretroviral therapy for the condition. While it's concerning that the patient has not received treatment for a long time, the initiation of ART can still significantly improve health outcomes. The key is to start treatment and ensure adherence to the therapy regimen. The lack of prior treatment doesn't pose the same immediate risk of drug resistance as inconsistent medication adherence does.

 

References

• Ricci, S. S., Kyle, T. (2020). Maternity and Pediatric Nursing. Wolters Kluwer Health.
• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

Providing injection drug users with a bleach solution to sterilize needles and syringes. The task of providing injection drug users with a bleach solution to sterilize needles and syringes is a procedural task that does not require extensive medical knowledge, high-level decision-making, or counseling skills. It involves following a specific set of instructions to ensure that the individuals receive the correct information on how to sterilize their equipment, thereby reducing the risk of HIV transmission. This is a task that can be standardized and taught to health assistants, making it an appropriate duty to delegate.

Think of a restaurant kitchen. The chef (nurse manager) is responsible for creating the menu (overall health plan) and ensuring meals are delicious and safe to eat (effective and safe health interventions). However, the chef can delegate the task of washing vegetables (providing bleach for sterilization) to kitchen assistants because it follows a standard procedure and doesn't require the chef's expertise in flavor or meal design.

In the context of HIV prevention, the use of bleach to sterilize needles is based on the principle of infection control. HIV can be transmitted through blood, and sharing needles is a high-risk behavior because it can introduce blood from an infected individual directly into the bloodstream of another. By properly sterilizing needles with bleach, the virus is destroyed, thereby reducing the risk of transmission. This task requires understanding the importance of cleanliness and sterilization but doesn't necessitate advanced medical knowledge, making it suitable for delegation to health assistants.

 

✘Incorrect answer options:

Deciding on the demographic groups that should be the focus of educational initiatives based on a community health assessment. This task involves analyzing data, understanding complex health trends, and making strategic decisions based on this analysis. It requires a high level of understanding of public health principles and is best suited for someone with advanced training and experience, like Nurse Taylor.

Offering pretest and post-test counseling to individuals opting for HIV testing. This task requires a deep understanding of HIV, including transmission, prevention, and the emotional impact of a positive or negative result. It also requires the ability to communicate effectively and sensitively with individuals who may be under significant stress. This level of counseling should be performed by individuals with appropriate training in counseling and a thorough understanding of HIV/AIDS, which might be beyond the scope of health assistants.

Educating members of the community who are at high risk about the importance of using condoms for HIV prevention. While this task might seem straightforward, it involves understanding the nuances of human behavior, cultural sensitivities, and effective communication strategies to change behaviors. It requires more than just procedural knowledge; it requires the ability to engage with individuals or communities, understand their perspectives, and tailor messages in a way that is both respectful and persuasive.

 

References

• Stanhope, M., & Lancaster, J. (2020). Public Health Nursing: Population-Centered Health Care in the Community. Mosby.
• Ricci, S. S., & Kyle, T. (2020). Maternity and Pediatric Nursing. Wolters Kluwer Health.

EXPLANATION

 

✔Correct answer:

Sarah is actively trying to conceive. The most critical piece of information that Nurse Davis should relay to the physician is that Sarah is actively trying to conceive. Methotrexate (Rheumatrex) is a potent medication used to treat rheumatoid arthritis but is teratogenic and can cause severe birth defects or fetal death. It is contraindicated in pregnancy and in women who are actively trying to conceive. This information is crucial for the physician to know so that they can discuss alternative treatment options with Sarah and provide appropriate counseling regarding family planning and the risks associated with methotrexate.

Imagine planting a garden in an area where you know certain fertilizers are harmful to the seeds you want to grow. You wouldn't use those fertilizers because you want your seeds to grow healthily. Similarly, using methotrexate when trying to conceive is like using a harmful fertilizer—it can endanger the developing fetus, so it's important to choose a safer treatment option.

Methotrexate works by inhibiting dihydrofolate reductase, an enzyme involved in DNA synthesis, which makes it effective in treating rheumatoid arthritis by reducing inflammation and slowing joint damage. However, this same mechanism can lead to harmful effects on a developing embryo or fetus, as proper DNA synthesis is critical for fetal development.

 

✘Incorrect answer options:

Sarah mentions that she has previously taken methotrexate. While it's useful for the healthcare provider to know Sarah's treatment history, this information is not as critical as her current pregnancy intentions, especially considering the teratogenic risks of methotrexate.

Sarah takes a daily multivitamin supplement. This is generally good information for overall health assessment and to check for potential interactions, but it's not as immediately critical as the need to avoid teratogenic drugs during preconception.

Sarah expresses numerous concerns about the safety of the medication. While it's important to address Sarah's concerns and provide her with thorough information about the safety and potential side effects of methotrexate, the immediate clinical concern is the potential teratogenic effect of methotrexate if Sarah is trying to conceive.

 

References

• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
• Karch, A. M. (2020). Focus on Nursing Pharmacology. Wolters Kluwer Health.

EXPLANATION

 

✔Correct answer:

Gather information on how the patient is responding to medications prescribed for pain and anorexia. Gathering information on how patients are responding to medications prescribed for pain and anorexia is within the scope of practice for an LPN (Licensed Practical Nurse). LPNs are trained to monitor patients' responses to medications and report any concerns or changes in the patients' conditions. This task involves observing, recording, and reporting, which are key components of an LPN's role.

Think of a garden where the gardener (RN) is responsible for planning and overseeing the entire garden's health. The gardener's assistant (LPN) helps by monitoring the plants (patients) and reporting back on their condition, like how they are responding to sunlight or water (medications). The assistant doesn't decide what the plants need, but they play a crucial role in observing and reporting.

Monitoring a patient's response to medication is critical, especially in patients with AIDS, due to their compromised immune systems and the potential for multiple medication interactions. Pain management and nutritional support, like managing anorexia, are essential for improving quality of life. An LPN is well-equipped to observe and report changes in pain levels or appetite, which are subjective and require consistent monitoring for effective management.

 

✘Incorrect answer options:

Help patients with personal hygiene and other activities of daily living as needed. This task is more appropriately delegated to nursing assistants or aides. They are trained to assist with the basic care needs of patients, including personal hygiene and activities of daily living (ADLs).

Educate the nursing assistants on infection control measures to minimize the risk of transmission. Educational and training responsibilities, especially on critical topics like infection control, typically fall within the RN's scope of practice. RNs have the education and expertise to provide detailed instructions and ensure that protocols are followed correctly.

Evaluate patients' nutritional requirements and tailor diet plans to enhance their nutritional status. This task is complex and typically requires the expertise of an RN or a registered dietitian, especially in a specialized care setting like an AIDS hospice. Tailoring diet plans involves a thorough understanding of nutrition, the interactions between different medications and foods, and the specific needs of patients with advanced illness.

 

References

• Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2020). Fundamentals of Nursing. Mosby.
• Ignatavicius, D.D., Workman, M.L., Rebar, C.R., & Heimgartner, N.M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Administer 0.3 mL of epinephrine (Adrenalin) subcutaneously. Mark is exhibiting signs of anaphylaxis, a severe, potentially life-threatening allergic reaction. Symptoms like anxiety, shortness of breath, dizziness, and reddened blotches on the skin are consistent with this condition. Immediate treatment is critical. The first-line treatment for anaphylaxis is epinephrine, which acts quickly to improve breathing, stimulate the heart, reverse hives, and reduce swelling of the face, lips, and throat.

Epinephrine is administered subcutaneously or intramuscularly (preferably intramuscularly in the outer thigh for fastest absorption) at a dose of 0.3 mL (for adults). It's crucial for Nurse Sarah to administer epinephrine promptly to counteract the severe allergic reaction Mark is experiencing.

Think of Mark's allergic reaction like a fire alarm going off, indicating a serious problem. Epinephrine is like the fire extinguisher – it's the first thing you reach for to control the situation before it escalates. Just as a fire extinguisher acts quickly to douse flames, epinephrine works fast to counteract the life-threatening symptoms of anaphylaxis.

 

✘Incorrect answer options:

Establish IV access using a large-bore IV catheter. While establishing IV access is important in managing anaphylaxis, it is not the first intervention. Epinephrine is the priority. IV access can be established after initial epinephrine administration for ongoing treatment and to administer additional medications if needed.

Initiate oxygen therapy at 4 L/min via a nasal cannula. Oxygen therapy may be a supportive measure in the treatment of anaphylaxis, especially if the patient is experiencing respiratory distress. However, it is not the first-line treatment and should not take precedence over administering epinephrine.

Provide albuterol (Proventil) via a nebulizer. Albuterol, a bronchodilator, may be used to relieve respiratory symptoms like wheezing in anaphylaxis. However, it is not a substitute for epinephrine, which is the most critical medication for reversing the overall severe allergic reaction.

 

References

• Simons, F. E. R., Ardusso, L. R., Bilò, M. B., El-Gamal, Y. M., Ledford, D. K., Ring, J., ... & World Allergy Organization. (2011). World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organization Journal, 4(2), 13-37.
• Campbell, R. L., Bellolio, M. F., Knutson, B. D., Bellamkonda, V. R., Fedko, M. G., Nestler, D. M., ... & Hess, E. P. (2015). Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. Journal of Allergy and Clinical Immunology: In Practice, 3(1), 76-80.

EXPLANATION

 

✔Correct answer:

Offering the patient a glass of water right after administering oral nystatin (Mycostatin) suspension. Nystatin (Mycostatin) suspension is a topical antifungal medication used to treat infections like Candida esophagitis. For maximum effectiveness, the medication needs to coat the mouth and throat. Drinking water immediately after taking the medication would rinse the medication away, thereby reducing its effectiveness in treating the infection. The student nurse should be instructed to advise the patient to avoid eating or drinking anything for at least 30 minutes after taking the medication to ensure that the medication has enough time to exert its effect.

Think of applying a lawn treatment to kill weeds. If you water the lawn immediately after applying the treatment, it will wash away the chemicals before they have had a chance to act on the weeds. Similarly, drinking water right after taking nystatin would wash the medication away before it has a chance to act on the infection.

Candida albicans is a common fungal pathogen that causes infections in immunocompromised individuals, such as those with HIV. In the case of esophagitis, the fungus infects the esophageal lining, leading to pain and difficulty swallowing. Nystatin works by binding to sterols in the fungal cell membrane, weakening the membrane, and causing the contents of the fungal cell to leak out, thereby killing the fungus. For nystatin to work effectively, it needs to be in direct contact with the infected area for a sufficient period.

 

✘Incorrect answer options:

Posting a "No Visitors" sign on the entrance of the patient's room. While HIV is not spread by casual contact, this action might be based on specific orders related to the patient's overall health status or other infections that warrant isolation. Therefore, without additional context, this action doesn't necessarily require immediate intervention.

Providing the patient with lunch options that include either chicken soup or chile con carne. While spicy foods like chile con carne might be uncomfortable for a patient with esophagitis to eat, offering a choice of foods, including a mild option like chicken soup, is appropriate. The patient can choose what they feel they can tolerate.

Donning a mask and gown before entering the patient's room. This action might be part of standard precautions or based on specific orders related to the patient's condition (e.g., if the patient has another infection that requires droplet or contact isolation). It's a protective measure and, without further context indicating otherwise, is not inappropriate.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Mosby.
• Yarnell, K. (2019). Pathophysiology for Nurses at a Glance. Wiley-Blackwell.

EXPLANATION

 

✔Correct answer:

Nurse Olivia should directly request the patient to consent for an immediate HIV test. After a needlestick injury, especially when the source patient's HIV status is unknown, it is crucial to determine the status as soon as possible. This information is vital for Nurse Olivia to receive appropriate post-exposure prophylaxis (PEP) if needed. The most direct and respectful approach is for Nurse Olivia (or another healthcare provider involved in the care of the patient) to explain the situation to the patient and request consent for an immediate HIV test. This approach ensures timely testing and respects the patient's autonomy and right to consent to the test.

Imagine you're a chef who accidentally cuts your finger while preparing a meal and you're not sure if the knife was clean. To ensure your safety and take the right steps (like getting a tetanus shot if the knife was rusty), you'd want to find out as quickly as possible. Similarly, after a needlestick injury, Nurse Olivia needs to know the patient's HIV status promptly to decide the next steps for her health.

After a needlestick injury, the risk of infection transmission depends on factors such as the type of needle, depth of injury, and the source patient's viral load if they are HIV-positive. Early identification of the source patient's HIV status allows for an immediate decision regarding the need for PEP, which is most effective when started within hours of exposure. PEP involves taking antiretroviral medications for a certain period to prevent seroconversion (developing detectable HIV antibodies in the blood).

 

✘Incorrect answer options:

HIV testing should be performed the next time the patient has blood drawn for other tests. This approach is not proactive and may lead to delays in testing. Immediate action is necessary in such situations to determine the need for PEP.

The nurse specialized in occupational health should inquire about the patient's HIV status. While occupational health services are indeed involved in managing needlestick injuries, relying solely on this nurse to inquire about the patient's HIV status may introduce unnecessary delays. Immediate action is required, and the direct care nurse or team is in the best position to request consent for HIV testing promptly.

The nurse manager overseeing the unit should be responsible for obtaining this information. While the nurse manager is a key figure in managing staff and unit operations, the immediate concern after a needlestick injury is the potential health impact on the staff member involved. Direct and prompt action by the healthcare provider involved in the incident or their immediate team is crucial, rather than waiting for administrative processes.

 

References

• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
• Perry, A.G., Potter, P.A., Ostendorf, W. (2020). Clinical Nursing Skills and Techniques. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

The patient has notably dark-colored stools. The presence of notably dark-colored stools (melena) can indicate gastrointestinal (GI) bleeding, a known complication of nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen (Alleve). Long-term use of NSAIDs can lead to GI ulceration, which may result in bleeding. Additionally, corticosteroids like prednisone (Deltasone) can also increase the risk of GI bleeding, especially when used in combination with NSAIDs. This symptom is a significant concern and warrants an immediate reevaluation of the patient's current therapy.

Think of the gastrointestinal tract as a protective tube lined with a special layer, much like the inner tube of a tire. Medications like naproxen and prednisone can cause wear and tear on this lining, similar to how rough roads can damage a tire. Just as you might see air leaking from a damaged tire, dark-colored stools can be a sign of the protective lining in the GI tract leaking blood.

NSAIDs inhibit cyclooxygenase (COX) enzymes, which are involved in the production of prostaglandins. While this reduces inflammation and pain (the intended effect for treating RA), it also decreases the production of protective prostaglandins in the stomach lining. This reduction can lead to increased gastric acid secretion and diminished mucosal defenses, making the stomach lining more susceptible to ulcers and bleeding. Corticosteroids like prednisone further increase the risk by inhibiting the repair of the gastric mucosa and also promoting peptic ulcer formation.

 

✘Incorrect answer options:

The patient has palpable, round, and mobile subcutaneous nodules. Subcutaneous nodules are common in patients with rheumatoid arthritis and are typically associated with more severe disease. While they indicate the disease's activity and severity, they are not directly related to the adverse effects of the medications (prednisone and naproxen).

The patient reports that RA symptoms are most severe during the morning. Morning stiffness and increased symptoms in the morning are characteristic of RA due to prolonged immobility during sleep, leading to stiffness and pain. This is a typical symptom of the disease rather than a side effect of the medications.

The patient complains about experiencing dry eyes. Dry eyes can be a symptom of Sjögren's syndrome, which is an autoimmune disorder commonly associated with RA. While it is an important symptom to address, it does not directly suggest a complication of the therapy like GI bleeding does.

 

References

• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
• Goodman & Gilman's The Pharmacological Basis of Therapeutics, 13th Edition. Brunton, L., Hilal-Dandan, R., & Knollmann, B.C. (2018).

EXPLANATION

 

✔Correct answer:

Begin the varicella vaccine series with the first dose. Nurse Emma should question the order to begin the varicella vaccine series with the first dose for Lisa, who is experiencing an exacerbation of systemic lupus erythematosus (SLE) and is on prednisone (Deltasone). Prednisone is a corticosteroid that suppresses the immune system, and live vaccines, such as the varicella vaccine, are generally contraindicated in immunocompromised patients due to the potential for causing vaccine-induced disease. Administering a live vaccine to a patient on significant immunosuppression could lead to severe complications.

Imagine you have a protective fence (immune system) that's temporarily weakened. Inviting a playful but unpredictable dog (live vaccine) into your yard might usually be fine, but when the fence is down, it could lead to unwanted situations. Similarly, introducing a live vaccine into a body with a weakened immune system might cause more harm than good.

The varicella vaccine is a live attenuated vaccine, meaning it contains a live but weakened version of the virus. It relies on the recipient's immune system to respond to the vaccine, build immunity, and not get the disease. In a person whose immune system is compromised by medications like prednisone, the weakened virus in the vaccine could potentially cause the disease it's meant to prevent.

 

✘Incorrect answer options:

Administer Ibuprofen (Advil) 800 mg every 6 hours. While combining ibuprofen (a nonsteroidal anti-inflammatory drug) with prednisone increases the risk of gastrointestinal ulcers and bleeding, this combination can be clinically justified in certain situations with appropriate monitoring for side effects. It's not as immediately concerning as administering a live vaccine to an immunocompromised patient.

Cease prednisone administration after today's dose. Prednisone is typically tapered off rather than stopped abruptly to avoid adrenal insufficiency. However, if Lisa is being switched to another form of treatment or there is another clinical justification for stopping prednisone, this order might be appropriate. The nurse should clarify the plan with the healthcare provider but doesn't necessarily need to question it immediately.

Measure the patient's C-reactive protein (CRP) levels. CRP is a marker of inflammation and is often measured in patients with inflammatory conditions like SLE to assess disease activity and response to treatment. This is a standard and appropriate order for a patient with an exacerbation of SLE.

 

References

• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
• Plotkin, S. A., Orenstein, W. A., Offit, P. A., & Edwards, K. M. (2018). Plotkin's Vaccines. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Viral load testing. Viral load testing is the most informative diagnostic test for assessing a patient's response to antiretroviral therapy (ART). This test measures the amount of HIV RNA in the blood, providing a direct assessment of the virus's activity and replication rate. A decreasing viral load indicates that the ART regimen is effective in suppressing the virus, which is the primary goal of HIV treatment.

Think of the viral load as a crowd of people in a room (the virus in the patient's body) and ART as the security team trying to clear the room. Viral load testing is like counting the number of people left in the room after the security team (ART) has started working. A smaller crowd means the security team (ART) is effectively clearing the room (suppressing the virus).

HIV targets and destroys CD4+ T cells, a type of lymphocyte important in maintaining the immune system. ART works by interfering with various stages of the HIV life cycle, reducing the virus's ability to replicate and infect new cells. Monitoring the viral load helps assess how well ART is containing the virus. An effective ART regimen should decrease the viral load, ideally to undetectable levels, thereby preserving the immune function and reducing the risk of HIV-related complications and transmission.

 

✘Incorrect answer options:

Western blot analysis. While the Western blot test is used to confirm HIV infection after a positive screening test (like ELISA), it is not useful for monitoring the effectiveness of ART. It detects antibodies to HIV, which remain present even when the virus is well-controlled by ART.

Enzyme-linked immunosorbent assay (ELISA) testing. ELISA is a screening test for detecting antibodies to HIV. Like the Western blot, it is not used to monitor the response to ART, as it does not measure the actual amount of virus in the blood.

Counting the number of lymphocytes. While the CD4+ T cell count (a type of lymphocyte) is an important indicator of immune function in HIV-positive patients and is monitored over time, it does not provide direct information about the activity or replication of the virus like viral load testing does. It's more of an indirect measure of the impact of HIV on the immune system.

 

References

• Bartlett, J. G., & Gallant, J. E. (2020). Medical Management of HIV Infection. Johns Hopkins Medicine Health Publishing.
• Mandell, G. L., Bennett, J. E., & Dolin, R. (2020). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

A tuberculin skin test showing 5-mm induration after 48 hours. The tuberculin skin test (TST) or Mantoux test is used to detect latent tuberculosis infection. The test involves injecting a small amount of tuberculin into the skin and then measuring the induration (not redness) after 48-72 hours. The interpretation of the test depends on the individual's risk factors and the size of the induration.

For most individuals, including healthcare workers like Mr. Roberts, an induration of 5 mm is considered significant and may indicate latent tuberculosis infection. Given that Mr. Roberts is a healthcare worker who will be in contact with patients, this finding is concerning and requires further evaluation. It may necessitate additional testing, such as a chest x-ray and possibly treatment, to ensure he does not have active tuberculosis and does not pose a risk to patients or other healthcare workers.

Think of the tuberculin skin test as a smoke detector in your home. Just like a smoke detector beeps loudly when it detects smoke, signaling a potential fire, a positive TST result acts as an alert. In this case, the 'beep' (or the 5-mm induration) is signaling that Mr. Roberts might have been exposed to the bacteria that cause TB. Just as you would immediately investigate and address the cause of the smoke detected by the smoke detector, Nurse Michelle should also take immediate action upon seeing a positive TST result to confirm whether Mr. Roberts has TB and to take appropriate steps to treat it and prevent its spread.

 

✘Incorrect answer options:

Having received a tetanus vaccination 3 years prior. Receiving a tetanus vaccination 3 years ago is generally not a concern. Tetanus vaccinations are recommended to be updated every 10 years for adults, so Mr. Roberts is within the safe range.

Reported allergies to bananas, avocados, and papayas. While it's important to document allergies, allergies to bananas, avocados, and papayas typically do not impact Mr. Roberts' ability to perform his duties as a nursing assistant, unless his role specifically involves handling or being in contact with these foods.

Currently on enalapril (Vasotec) for managing hypertension. Being on enalapril for hypertension is also not typically a concern in the context of initial employment health assessments unless it is poorly controlled or there are other related health issues. Hypertension, when managed properly, usually doesn't interfere with one's ability to work in a healthcare setting.

 

References

• American Thoracic Society. (2000). Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR Recomm Rep, 49(RR-6), 1-51.
• Centers for Disease Control and Prevention. (2015). Tuberculosis (TB). Testing & Diagnosis. https://www.cdc.gov/tb/topic/testing/default.htm

EXPLANATION

 

✔Correct answer:

The patient experiences persistent nausea and vomiting. Persistent nausea and vomiting in a patient undergoing treatment with interferon alfa-2a (Roferon-A) for chronic hepatitis C is a significant concern. These symptoms can indicate severe side effects of the medication and may lead to dehydration, electrolyte imbalances, and inadequate nutrition, which can further compromise the patient's health and the effectiveness of the treatment. It is crucial for Nurse Riley to relay this information to the physician for potential management strategies or treatment adjustments.

Imagine your car's oil light is on (persistent nausea and vomiting), indicating there might be a serious issue under the hood. You wouldn't keep driving without checking it out because it might cause more significant damage to the car. Similarly, persistent nausea and vomiting are signs that there might be a serious issue with the patient's treatment, and it needs immediate attention.

Interferon alfa-2a is an immunomodulatory agent used to treat chronic hepatitis C, but it can have significant side effects, including flu-like symptoms, gastrointestinal disturbances, and hematological changes. Persistent nausea and vomiting are particularly concerning because they can lead to dehydration, weight loss, and malnutrition, impacting the patient's overall health and ability to tolerate and respond to the treatment.

 

✘Incorrect answer options:

The patient administers the medication via the intramuscular route into her lateral thigh. While the subcutaneous route is generally preferred for the administration of interferon alfa-2a, intramuscular administration is not necessarily incorrect and does not pose an immediate concern compared to persistent nausea and vomiting.

The patient reports ongoing fatigue, muscle aches, and loss of appetite. These are common side effects of interferon alfa-2a treatment and are generally expected. While they should be monitored and managed, they do not usually require urgent intervention unless they are severe or worsening.

The patient's oral temperature is 99.7°F. A slightly elevated temperature is not uncommon during interferon treatment and is not immediately concerning unless it indicates an infection or is significantly higher. The persistent nausea and vomiting are more directly related to the treatment's side effects and have more immediate implications for the patient's well-being.

 

References

• Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition, Hinkle J.L., & Cheever K.H.
• Goodman & Gilman's The Pharmacological Basis of Therapeutics, 13th Edition, Brunton L., Hilal-Dandan R., & Knollmann B.C.

EXPLANATION

 

✔Correct answer:

An increased blood urea nitrogen (BUN) level. An increased blood urea nitrogen (BUN) level in Ms. Davis, who has systemic lupus erythematosus (SLE), is most concerning and should be closely monitored by Nurse Olivia. SLE can affect multiple organ systems, including the kidneys. Elevated BUN levels may indicate renal involvement or lupus nephritis, a serious complication of SLE. Kidney function is critical, and impaired renal function can lead to a range of severe complications.

Think of the kidneys as a filtration system in a fish tank, keeping the water clean and free of waste. If the filter starts to fail (elevated BUN indicating potential kidney issues), the water becomes toxic for the fish (toxins build up in the body, harming the patient). This situation requires immediate attention to prevent further harm.

The kidneys filter waste products from the blood, which are then excreted in the urine. BUN is a waste product formed from the breakdown of protein. Elevated levels can indicate that the kidneys are not functioning properly. In the context of SLE, this could be due to inflammation of the kidneys, known as lupus nephritis, which can lead to decreased kidney function and ultimately kidney failure if not managed properly.

 

✘Incorrect answer options:

A positive anti-nuclear antibody (ANA) test. A positive ANA test is common in patients with SLE and is often used as part of the diagnostic criteria. While it supports the diagnosis of SLE, it is not typically used to gauge disease severity or acute exacerbations.

Elevated levels of C-reactive protein (CRP). CRP is a marker of inflammation and can be elevated in many conditions, including SLE. While it indicates inflammation, it is nonspecific and does not directly suggest organ involvement or imminent risk of complications like elevated BUN does.

A positive lupus erythematosus (LE) cell prep test. The LE cell prep test is an older test that was used in the past to help diagnose SLE. A positive test indicates the presence of LE cells, a type of white blood cell seen in SLE and other autoimmune diseases. However, this test is less commonly used now and is not as critical for immediate clinical management as monitoring BUN levels for kidney function.

 

References

• Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer.
• McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The Biologic Basis for Disease in Adults and Children (8th ed.). Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Offer oral care using a soft-bristled toothbrush every 8 hours. Offering oral care using a soft-bristled toothbrush every 8 hours is a suitable nursing intervention for an LPN (Licensed Practical Nurse) caring for a patient with AIDS who is experiencing anorexia and nausea. Good oral hygiene can help improve the patient's appetite and willingness to eat by keeping the mouth clean and fresh, making this intervention appropriate and within the scope of practice for an LPN.

Consider a scenario where you're preparing to enjoy a meal, but you have an unpleasant taste in your mouth. You'd likely want to brush your teeth or use mouthwash to freshen your mouth first. Similarly, for patients experiencing anorexia and nausea, maintaining oral hygiene can make the idea of eating more appealing, much like how cleaning your mouth can make food more appetizing.

Patients with AIDS often experience symptoms like anorexia and nausea, which can lead to inadequate nutritional intake. Maintaining good oral hygiene can help alleviate discomfort in the mouth, remove any unpleasant tastes that may be contributing to anorexia, and potentially stimulate appetite. Regular oral care is particularly important for patients who may have compromised immune systems, as it also reduces the risk of infections.

 

✘Incorrect answer options:

Administer oxandrolone (Oxandrin) 5 mg every morning. Administering medications, especially those that require monitoring for therapeutic effects and potential side effects, is typically within the RN's scope of practice, not the LPN's. Oxandrolone is an anabolic steroid that may be used to promote weight gain, but its administration should be closely monitored by an RN or a healthcare provider.

Evaluate the patient for additional risk factors affecting nutrition. Evaluating the patient for additional risk factors affecting nutrition involves a comprehensive assessment and is generally more complex, typically falling within the RN's scope of practice. This process requires a thorough understanding of the patient's overall health status, potential interactions between different conditions, and the ability to make complex clinical judgments.

Educate the patient about incorporating a high-calorie, high-protein diet. While LPNs play a role in reinforcing education provided by the RN or a registered dietitian, the initial education about significant dietary changes, especially for a patient with a complex condition like AIDS, should be provided by an RN or a dietitian. This ensures that the dietary advice is tailored to the patient's specific health needs and takes into account the interactions between the patient's condition, nutrition, and treatments.

 

References

• Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2020). Fundamentals of Nursing. Mosby.
• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

Administer trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis carinii pneumonia. Pneumocystis carinii pneumonia (PCP) is a potentially life-threatening infection commonly seen in immunocompromised patients, such as those with HIV. Trimethoprim-sulfamethoxazole (TMP-SMX) is the first-line treatment for PCP and is crucial in managing the infection effectively. Timely administration of TMP-SMX is essential to ensure optimal blood levels of the medication for fighting the infection. Hence, Nurse Morgan should prioritize administering TMP-SMX at the scheduled time to maximize its efficacy in treating PCP.

Think of a house on fire (PCP infection) in a neighborhood. While it's important to maintain the garden (manage HIV with antiretrovirals), repaint the house (manage mild discomfort with pain medication), or check the security system (manage blood pressure with antihypertensives), the most urgent task is to extinguish the fire. Similarly, addressing the immediate threat of PCP with TMP-SMX takes priority over the other medications.

Pneumocystis carinii pneumonia is caused by the fungus Pneumocystis jirovecii and is characterized by inflammation and fluid accumulation in the lungs, impairing gas exchange. TMP-SMX works by inhibiting sequential steps in bacterial folate synthesis, making it an effective combination for treating PCP. The timely administration is crucial to maintain therapeutic drug levels and to prevent the progression of the infection, which can be rapid and severe in immunocompromised patients.

 

✘Incorrect answer options:

Administer antiretroviral medication. While antiretroviral medications are critical for managing HIV, the immediate life-threatening condition is PCP. The administration of antiretrovirals, although important, can be slightly delayed while addressing the acute infection.

Administer a pain medication for mild discomfort. Managing pain is important for patient comfort and recovery. However, mild discomfort does not take precedence over a potentially life-threatening infection like PCP.

Administer an antihypertensive medication. Controlling blood pressure is essential for overall health and preventing complications. However, in the context of prioritization, the immediate treatment of a life-threatening infection like PCP is more critical than the routine administration of an antihypertensive, unless the patient is experiencing a hypertensive crisis.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Mosby.
• Mandell, G. L., Bennett, J. E., & Dolin, R. (2020). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

The patient's blood glucose level has dropped to 55 mg/dL post-medication administration. Pentamidine (Pentam) is an antimicrobial medication used to treat Pneumocystis carinii (also known as Pneumocystis jirovecii) pneumonia, a common opportunistic infection in HIV-positive patients. While it's effective against this infection, pentamidine is also known to cause several side effects, including hypoglycemia (low blood glucose levels). A blood glucose level of 55 mg/dL is considered hypoglycemic and can be dangerous, leading to symptoms like shaking, confusion, dizziness, or even loss of consciousness and seizures if not promptly addressed. This is a critical piece of information that Nurse Ashley should urgently communicate to the attending physician to manage the patient's hypoglycemia and adjust the treatment plan if necessary.

Think of the patient's body as a car and glucose as the fuel. If the fuel level drops too low (hypoglycemia), the car won't run properly and might even stop running altogether, potentially leading to an accident or breakdown. Just as you would urgently need to refuel the car, you need to address the patient's low glucose level urgently to prevent health complications.

Glucose is a primary energy source for the body's cells. Pentamidine can interfere with the secretion of insulin, the hormone that regulates blood glucose levels, leading to either hypoglycemia or hyperglycemia. Hypoglycemia occurs when the blood glucose level falls below the normal range, which can impair brain function and lead to neurological symptoms, as the brain relies heavily on glucose for energy. Severe hypoglycemia is a medical emergency that requires immediate intervention.

 

✘Incorrect answer options:

The patient reports discomfort at the site where the IV infusion is administered. While discomfort at the IV site might indicate issues like infiltration or phlebitis and needs to be addressed, it is generally not as urgent as a significant drop in blood glucose levels.

The patient's oral fluid intake appears to be insufficient. Insufficient fluid intake is a concern, especially in patients with pneumonia, as hydration is crucial for optimal recovery and overall health. However, it is not as immediately life-threatening as hypoglycemia and can be managed with interventions to encourage fluid intake or IV hydration.

The patient's blood pressure has fallen to 104/76 mm Hg during the drug administration. While it's important to monitor blood pressure during medication administration, a blood pressure of 104/76 mm Hg is within normal limits for most adults and is not typically considered urgent unless it represents a significant drop from the patient's baseline or the patient is symptomatic.

 

References

• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
• Thomas, C.C., Casiano, E.R. (2020). Manual of IV Therapeutics: Evidence-Based Practice for Infusion Therapy. F.A. Davis Company.

EXPLANATION

 

✔Correct answer:

An RN with five years of experience on the medical unit, presently working a double shift. The patient with signs of acute kidney transplant rejection and on IV cyclosporine and methylprednisolone requires careful monitoring and management. An RN with five years of experience on the medical unit would be the most suitable choice despite working a double shift. This RN would have the necessary experience and familiarity with the medical unit's protocols and procedures, including managing patients with complex conditions and administering medications like IV cyclosporine and methylprednisolone.

Consider a situation where you need someone to manage a sophisticated piece of machinery urgently. Would you prefer someone very familiar with similar machinery but currently managing multiple tasks, or someone inexperienced who might not fully understand the complexities? Naturally, you'd lean towards the person with relevant experience because they have a better chance of handling the situation effectively, despite being busy.

Acute rejection is a serious condition that can occur after a kidney transplant, where the recipient's immune system attacks the new kidney. IV cyclosporine and methylprednisolone are used to suppress the immune system and reduce inflammation, respectively. These medications require precise dosing and monitoring for side effects, making experienced nursing care crucial.

 

✘Incorrect answer options:

An RN with three years of operating room experience who is currently orienting to the medical unit. While this RN has valuable experience, operating room nursing is quite different from medical unit nursing. The RN is also currently orienting to the unit, indicating they might not be fully accustomed to the routines and protocols specific to this unit.

An RN from the coronary care unit who is floating to the medical unit for the day. This RN likely has critical care experience but might not be familiar with the specific protocols and management strategies of the medical unit or the care of post-transplant patients, which can compromise the patient's care.

A newly graduated RN who requires experience in administering IV medications. A newly graduated RN might not yet have the experience or confidence to manage complex patients with acute conditions and administer high-risk medications like cyclosporine and methylprednisolone, which require careful monitoring for side effects and interactions.

 

References

• Ignatavicius, D.D., Workman, M.L., Rebar, C.R., & Heimgartner, N.M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.
• Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.