NU 225 Exam Questions With Complete Solutions
_________________________ is a chronic, multisystem,
autoimmune disease characterized by inflammation of the
connective tissue. Correct Answer ANS:
Systemic lupus erythematosus
SLE
SLE varies in severity and is marked by remission and
exacerbations. Although the etiology is unknown, genetic,
hormonal, environmental, and immune response factors are
likely to be responsible.
1. A patient who is receiving an IV antibiotic develops wheezes
and dyspnea. In which order should the nurse implement these
prescribed actions? (Put a comma and a space between each
answer choice [A, B, C, D, E]).
a. Discontinue the antibiotic.
b. Give diphenhydramine IV.
c. Inject epinephrine IM or IV.
d. Prepare an infusion of dopamine.
e. Provide 100% oxygen using a nonrebreather mask. Correct
Answer ANS:
A, E, C, B, D
The nurse should initially discontinue the antibiotic because it is
the likely cause of the allergic reaction. Next, oxygen delivery
should be maximized, followed by treatment of
bronchoconstriction with epinephrine administered IM or IV.
Diphenhydramine will work more slowly than epinephrine, but
will help prevent progression of the reaction. Because the patient
,currently does not have evidence of hypotension, the dopamine
infusion can be prepared last.
DIF: Cognitive Level: Analyze (analysis) REF: 201
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Implementation
MSC: NCLEX: Physiological Integrity
1. The nurse provides discharge instructions to a patient who has
an immune deficiency involving the T lymphocytes. Which
health screening should the nurse include in the teaching plan
for this patient?
a. Screening for allergies
b. Screening for malignancies
c. Screening for antibody deficiencies
d. Screening for autoimmune disorders Correct Answer ANS:
B
Cell-mediated immunity is responsible for the recognition and
destruction of cancer cells. Allergic reactions, autoimmune
disorders, and antibody deficiencies are mediated primarily by B
lymphocytes and humoral immunity.
DIF: Cognitive Level: Apply (application) REF: 196
TOP: Nursing Process: Implementation MSC: NCLEX: Health
Promotion and Maintenance
10. The nurse should assess the patient undergoing
plasmapheresis for which clinical manifestation?
a.
Shortness of breath
c.
,Transfusion reaction
b.
High blood pressure
d.
Extremity numbness Correct Answer ANS: D
Numbness and tingling may occur as the result of the
hypocalcemia caused by the citrate used to prevent coagulation.
The other clinical manifestations are not associated with
plasmapheresis.
DIF: Cognitive Level: Apply (application) REF: 205
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological
Integrity
11. Which statement by a patient would alert the nurse to a risk
for decreased immune function?
a.
"I had a chest x-ray 6 months ago."
b.
"I had my spleen removed after a car accident."
c.
"I take one baby aspirin every day to prevent stroke."
d.
"I usually eat eggs or meat for at least two meals a day."
Correct Answer ANS: B
Splenectomy increases the risk for septicemia from bacterial
infections. The patient's protein intake is good and should
improve immune function. Daily aspirin use does not affect
immune function. A chest x-ray does not have enough radiation
to suppress immune function.
, DIF: Cognitive Level: Apply (application) REF: 206
TOP: Nursing Process: Assessment MSC: NCLEX:
Physiological Integrity
12. Which patient should the nurse assess first?
a.
Patient with urticaria after receiving an IV antibiotic
b.
Patient who is sneezing after subcutaneous immunotherapy
c.
Patient who has graft-versus-host disease and severe diarrhea
d.
Patient with multiple chemical sensitivities who has muscle
stiffness Correct Answer ANS: B
Sneezing after subcutaneous immunotherapy may indicate
impending anaphylaxis and assessment and emergency measures
should be initiated. The other patients also have findings that
need assessment and intervention by the nurse, but do not have
evidence of life-threatening complications.
DIF: Cognitive Level: Analyze (analysis) REF: 203
OBJ: Special Questions: Prioritization | Special Questions:
Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and
Effective Care Environment
13. Ten days after receiving a bone marrow transplant, a patient
develops a skin rash. What would the nurse suspect is the cause
of the rash?
a.
The donor T cells are attacking the patient's skin cells.
_________________________ is a chronic, multisystem,
autoimmune disease characterized by inflammation of the
connective tissue. Correct Answer ANS:
Systemic lupus erythematosus
SLE
SLE varies in severity and is marked by remission and
exacerbations. Although the etiology is unknown, genetic,
hormonal, environmental, and immune response factors are
likely to be responsible.
1. A patient who is receiving an IV antibiotic develops wheezes
and dyspnea. In which order should the nurse implement these
prescribed actions? (Put a comma and a space between each
answer choice [A, B, C, D, E]).
a. Discontinue the antibiotic.
b. Give diphenhydramine IV.
c. Inject epinephrine IM or IV.
d. Prepare an infusion of dopamine.
e. Provide 100% oxygen using a nonrebreather mask. Correct
Answer ANS:
A, E, C, B, D
The nurse should initially discontinue the antibiotic because it is
the likely cause of the allergic reaction. Next, oxygen delivery
should be maximized, followed by treatment of
bronchoconstriction with epinephrine administered IM or IV.
Diphenhydramine will work more slowly than epinephrine, but
will help prevent progression of the reaction. Because the patient
,currently does not have evidence of hypotension, the dopamine
infusion can be prepared last.
DIF: Cognitive Level: Analyze (analysis) REF: 201
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Implementation
MSC: NCLEX: Physiological Integrity
1. The nurse provides discharge instructions to a patient who has
an immune deficiency involving the T lymphocytes. Which
health screening should the nurse include in the teaching plan
for this patient?
a. Screening for allergies
b. Screening for malignancies
c. Screening for antibody deficiencies
d. Screening for autoimmune disorders Correct Answer ANS:
B
Cell-mediated immunity is responsible for the recognition and
destruction of cancer cells. Allergic reactions, autoimmune
disorders, and antibody deficiencies are mediated primarily by B
lymphocytes and humoral immunity.
DIF: Cognitive Level: Apply (application) REF: 196
TOP: Nursing Process: Implementation MSC: NCLEX: Health
Promotion and Maintenance
10. The nurse should assess the patient undergoing
plasmapheresis for which clinical manifestation?
a.
Shortness of breath
c.
,Transfusion reaction
b.
High blood pressure
d.
Extremity numbness Correct Answer ANS: D
Numbness and tingling may occur as the result of the
hypocalcemia caused by the citrate used to prevent coagulation.
The other clinical manifestations are not associated with
plasmapheresis.
DIF: Cognitive Level: Apply (application) REF: 205
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological
Integrity
11. Which statement by a patient would alert the nurse to a risk
for decreased immune function?
a.
"I had a chest x-ray 6 months ago."
b.
"I had my spleen removed after a car accident."
c.
"I take one baby aspirin every day to prevent stroke."
d.
"I usually eat eggs or meat for at least two meals a day."
Correct Answer ANS: B
Splenectomy increases the risk for septicemia from bacterial
infections. The patient's protein intake is good and should
improve immune function. Daily aspirin use does not affect
immune function. A chest x-ray does not have enough radiation
to suppress immune function.
, DIF: Cognitive Level: Apply (application) REF: 206
TOP: Nursing Process: Assessment MSC: NCLEX:
Physiological Integrity
12. Which patient should the nurse assess first?
a.
Patient with urticaria after receiving an IV antibiotic
b.
Patient who is sneezing after subcutaneous immunotherapy
c.
Patient who has graft-versus-host disease and severe diarrhea
d.
Patient with multiple chemical sensitivities who has muscle
stiffness Correct Answer ANS: B
Sneezing after subcutaneous immunotherapy may indicate
impending anaphylaxis and assessment and emergency measures
should be initiated. The other patients also have findings that
need assessment and intervention by the nurse, but do not have
evidence of life-threatening complications.
DIF: Cognitive Level: Analyze (analysis) REF: 203
OBJ: Special Questions: Prioritization | Special Questions:
Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and
Effective Care Environment
13. Ten days after receiving a bone marrow transplant, a patient
develops a skin rash. What would the nurse suspect is the cause
of the rash?
a.
The donor T cells are attacking the patient's skin cells.
