NCLEX Immunity Questions and Correct
Answers(With Rationale)
-The nurse provides home care instructions to a client with systemic lupus
erythematosus and tells the client about methods to manage fatigue. Which statement
by the client indicates a need for further instruction?
1."I should take hot baths because they are relaxing."
2."I should sit whenever possible to conserve my energy."
3."I should avoid long periods of rest because it causes joint stiffness."
4."I should do some exercises, such as walking, when I am not fatigued.
" ((Answer))1.
"I should take hot baths because they are relaxing."
Rationale:
To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should
instruct the client to sit whenever possible, avoid hot baths (because they exacerbate
fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a
balanced diet. The client is instructed to avoid long periods of rest because it promotes
joint stiffness)
-The nurse is conducting a teaching session with a client on their diagnosis of
pemphigus. Which statement by the client indicates that the client understands the
diagnosis?
1.
"My skin will have tiny red vesicles."
2.
"The presence of the skin vesicles is caused by a virus."
3.
"I have an autoimmune disease that causes blistering in the epidermis."
4.
,"The presence of red, raised papules and large plaques covered by silvery scales will
be present on my skin
." ((Answer))3.
"I have an autoimmune disease that causes blistering in the epidermis."
Rationale:
Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client
has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a
thin covering of skin and break easily, leaving large denuded areas of skin. On initial
examination, clients may have crusting areas instead of intact blisters. Option 1
describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis.)
-The nurse is assisting in planning care for a client with a diagnosis of
immunodeficiency and should incorporate which action as a priority in the plan?
1.
Protecting the client from infection
2.
Providing emotional support to decrease fear
3.
Encouraging discussion about lifestyle changes
4.
Identifying factors that decreased the immune function
((Answer))1.
Protecting the client from infection
Rationale:
The client with immunodeficiency has inadequate or absence of immune bodies and is
at risk for infection. The priority nursing intervention would be to protect the client from
infection. Options 2, 3, and 4 may be components of care but are not the priority.)
-A client calls the nurse in the emergency department and states that he was just stung
by a bumblebee while gardening. The client is afraid of a severe reaction because the
client's neighbor experienced such a reaction just 1 week ago. Which action should the
nurse take?
1.
Advise the client to soak the site in hydrogen peroxide.
2.
Ask the client if he ever sustained a bee sting in the past.
3.
,Tell the client to call an ambulance for transport to the emergency department.
4.
Tell the client not to worry about the sting unless difficulty with breathing occurs.
((Answer))2.
Ask the client if he ever sustained a bee sting in the past.
Rationale:
In some types of allergies, a reaction occurs only on second and subsequent contacts
with the allergen. The appropriate action, therefore, would be to ask the client if he ever
experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is
unnecessary. The client should not be told "not to worry.")
-The community health nurse is conducting a research study and is identifying clients in
the community at risk for latex allergy. Which client population is most at risk for
developing this type of allergy?
1.
Hairdressers
2.
The homeless
3.
Children in day care centers
4.
Individuals living in a group home
((Answer))1.
Hairdressers
Rationale:
Individuals most at risk for developing a latex allergy include health care workers;
individuals who work in the rubber industry; or those who have had multiple surgeries,
have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto
mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts, or water chestnuts.)
-Which interventions apply in the care of a client at high risk for an allergic response to a
latex allergy? Select all that apply.
1.
Use nonlatex gloves.
2.
Use medications from glass ampules.
, 3.
Place the client in a private room only.
4.
Keep a latex-safe supply cart available in the client's area.
5.
Avoid the use of medication vials that have rubber stoppers.
6.
Use a blood pressure cuff from an electronic device only to measure the blood
pressure.
((Answer))1.
Use nonlatex gloves.
2.
Use medications from glass ampules.
4.
Keep a latex-safe supply cart available in the client's area.
5.
Avoid the use of medication vials that have rubber stoppers.
Rationale:
If a client is allergic to latex and is at high risk for an allergic response, the nurse would
use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart
available in the client's area. Any supplies or materials that contain latex would be
avoided. These include blood pressure cuffs and medication vials with rubber stoppers
that require puncture with a needle. It is not necessary to place the client in a private
room.)
-A client presents at the health care provider's office with complaints of a bulls-eye rash
on his upper leg. Which question should the nurse ask first?
1.
"Do you have any cats in your home?"
2.
"Have you been camping in the last month?"
3.
"Have you or close contacts had any flu-like symptoms within the last few weeks?"
4.
Answers(With Rationale)
-The nurse provides home care instructions to a client with systemic lupus
erythematosus and tells the client about methods to manage fatigue. Which statement
by the client indicates a need for further instruction?
1."I should take hot baths because they are relaxing."
2."I should sit whenever possible to conserve my energy."
3."I should avoid long periods of rest because it causes joint stiffness."
4."I should do some exercises, such as walking, when I am not fatigued.
" ((Answer))1.
"I should take hot baths because they are relaxing."
Rationale:
To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should
instruct the client to sit whenever possible, avoid hot baths (because they exacerbate
fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a
balanced diet. The client is instructed to avoid long periods of rest because it promotes
joint stiffness)
-The nurse is conducting a teaching session with a client on their diagnosis of
pemphigus. Which statement by the client indicates that the client understands the
diagnosis?
1.
"My skin will have tiny red vesicles."
2.
"The presence of the skin vesicles is caused by a virus."
3.
"I have an autoimmune disease that causes blistering in the epidermis."
4.
,"The presence of red, raised papules and large plaques covered by silvery scales will
be present on my skin
." ((Answer))3.
"I have an autoimmune disease that causes blistering in the epidermis."
Rationale:
Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client
has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a
thin covering of skin and break easily, leaving large denuded areas of skin. On initial
examination, clients may have crusting areas instead of intact blisters. Option 1
describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis.)
-The nurse is assisting in planning care for a client with a diagnosis of
immunodeficiency and should incorporate which action as a priority in the plan?
1.
Protecting the client from infection
2.
Providing emotional support to decrease fear
3.
Encouraging discussion about lifestyle changes
4.
Identifying factors that decreased the immune function
((Answer))1.
Protecting the client from infection
Rationale:
The client with immunodeficiency has inadequate or absence of immune bodies and is
at risk for infection. The priority nursing intervention would be to protect the client from
infection. Options 2, 3, and 4 may be components of care but are not the priority.)
-A client calls the nurse in the emergency department and states that he was just stung
by a bumblebee while gardening. The client is afraid of a severe reaction because the
client's neighbor experienced such a reaction just 1 week ago. Which action should the
nurse take?
1.
Advise the client to soak the site in hydrogen peroxide.
2.
Ask the client if he ever sustained a bee sting in the past.
3.
,Tell the client to call an ambulance for transport to the emergency department.
4.
Tell the client not to worry about the sting unless difficulty with breathing occurs.
((Answer))2.
Ask the client if he ever sustained a bee sting in the past.
Rationale:
In some types of allergies, a reaction occurs only on second and subsequent contacts
with the allergen. The appropriate action, therefore, would be to ask the client if he ever
experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is
unnecessary. The client should not be told "not to worry.")
-The community health nurse is conducting a research study and is identifying clients in
the community at risk for latex allergy. Which client population is most at risk for
developing this type of allergy?
1.
Hairdressers
2.
The homeless
3.
Children in day care centers
4.
Individuals living in a group home
((Answer))1.
Hairdressers
Rationale:
Individuals most at risk for developing a latex allergy include health care workers;
individuals who work in the rubber industry; or those who have had multiple surgeries,
have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto
mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts, or water chestnuts.)
-Which interventions apply in the care of a client at high risk for an allergic response to a
latex allergy? Select all that apply.
1.
Use nonlatex gloves.
2.
Use medications from glass ampules.
, 3.
Place the client in a private room only.
4.
Keep a latex-safe supply cart available in the client's area.
5.
Avoid the use of medication vials that have rubber stoppers.
6.
Use a blood pressure cuff from an electronic device only to measure the blood
pressure.
((Answer))1.
Use nonlatex gloves.
2.
Use medications from glass ampules.
4.
Keep a latex-safe supply cart available in the client's area.
5.
Avoid the use of medication vials that have rubber stoppers.
Rationale:
If a client is allergic to latex and is at high risk for an allergic response, the nurse would
use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart
available in the client's area. Any supplies or materials that contain latex would be
avoided. These include blood pressure cuffs and medication vials with rubber stoppers
that require puncture with a needle. It is not necessary to place the client in a private
room.)
-A client presents at the health care provider's office with complaints of a bulls-eye rash
on his upper leg. Which question should the nurse ask first?
1.
"Do you have any cats in your home?"
2.
"Have you been camping in the last month?"
3.
"Have you or close contacts had any flu-like symptoms within the last few weeks?"
4.
