HIV and Immunity
HIV primarily attacks these immune-system cells, progressively weakening the patient’s ability to fight infection.
CD4 T-helper cells
Anaphylaxis is traditionally classified as this type of hypersensitivity reaction.
Type I hypersensitivity
Smoking, excessive UV exposure, and certain lifestyle exposures belong to this category of cancer risk factors.
Modifiable risk factors
This term refers specifically to an abnormally low amount of oxygen in arterial blood.
Hypoxemia
Because a tracheostomy bypasses the upper airway, patients often require this to keep secretions from becoming thick and difficult to clear.
Humidification
This medication strategy is used before a potential HIV exposure to reduce the risk of acquiring HIV.
PrEP (pre-exposure prophylaxis)
A patient develops an itchy rash several days after skin exposure to an allergen. This delayed response is associated with this hypersensitivity classification.
Type IV hypersensitivity
A patient receiving chemotherapy develops painful inflammation and ulceration of the oral mucosa. This complication is known as this.
Mucositis / stomatitis
Restlessness, confusion, increasing respiratory rate, and falling oxygen saturation should make the nurse concerned about worsening this problem.
Impaired oxygenation / hypoxia
Tracheostomy suctioning is performed based on this — not simply because a certain number of hours has passed.
Clinical signs that suctioning is needed
A nurse experiences a needlestick while caring for a patient with HIV. This HIV-prevention strategy should be considered promptly after the exposure.
PEP (post-exposure prophylaxis)
Minutes after receiving an IV medication, a patient develops wheezing, facial swelling, hypotension, and generalized hives. This medication is the priority treatment.
Epinephrine
A patient receiving cancer treatment has severe neutropenia. Which finding should be reported immediately?
A. Mild fatigue
B. Fever
C. Hair loss
D. Decreased appetite
B — Fever
ABG: pH 7.30, PaCO₂ 52 mmHg. What primary acid-base disturbance is suggested?
Respiratory acidosis
This technique is used when inserting the suction catheter into a tracheostomy in acute care.
Sterile technique
A patient with HIV says, “I feel fine now, so I don’t think I need to take my medications every day.” Give the most important teaching point
Take antiretroviral therapy consistently as prescribed.
Fifteen minutes after a blood transfusion begins, the patient develops chills, fever, low-back pain, and shortness of breath. What is the nurse’s FIRST action?
Stop the blood transfusion
A patient with thrombocytopenia needs additional teaching after making which statement?
A. “I’ll use an electric razor.”
B. “I’ll report unusual bruising.”
C. “I’ll use a soft toothbrush.”
D. “I’ll take aspirin if I get a headache.”
D — “I’ll take aspirin if I get a headache.”
A patient on home oxygen says, “My nose gets dry, so I put petroleum jelly inside my nostrils.” What teaching is needed?
Avoid petroleum-based products while using oxygen
During tracheostomy suctioning, the patient’s oxygen saturation falls rapidly and the patient becomes distressed. What should the nurse do FIRST?
Stop suctioning and allow the patient to reoxygenate
Which patient with HIV should the nurse assess FIRST?
A. Requests PrEP information for a partner
B. Reports fatigue for one week
C. Has a new fever, worsening cough, and shortness of breath
D. Asks when the next HIV labs are due
C — the patient with fever, worsening cough, and shortness of breath
A patient being discharged after treatment for anaphylaxis says, “I carry my epinephrine injector in my car so I always know where it is.” What does this statement indicate?
A need for additional teaching
Soon after treatment for a cancer with a high tumor burden, a patient develops major metabolic abnormalities and declining renal function from rapid destruction of malignant cells. Name the oncologic emergency.
Tumor lysis syndrome
Which patient should the nurse assess FIRST?
A. A patient receiving 2 L/min by nasal cannula who reports increasing dyspnea with ambulation and has an SpO₂ of 91% after returning to bed
B. A patient receiving 4 L/min by nasal cannula whose SpO₂ decreased from 94% to 88% and is now restless and mildly confused
C. A patient receiving 6 L/min by simple face mask who reports new pleuritic chest pain rated 7/10 but has an SpO₂ of 94%
D. A patient receiving home oxygen who reports a worsening productive cough and an SpO₂ of 90%, compared with a usual baseline of 92%
Patient B demonstrates an acute decline in oxygenation plus a change in mental status
A patient with a tracheostomy has coarse breath sounds, visible secretions, and an ineffective cough. The nurse determines suctioning is needed.
Explain the correct sequence for suctioning the tracheostomy, including the key safety steps.
1. Assess the patient and explain the procedure.
2. Perform hand hygiene and prepare sterile suction equipment.
3. Increase oxygenation/preoxygenate as appropriate. (100% Oxygen)
4. Don sterile gloves and maintain sterile technique.
6. Insert the suction catheter without applying suction. Apply suction only while withdrawing the catheter.
8. Use a rotating motion while withdrawing.
9. Limit each suction pass to about 10–15 seconds.
10. Reoxygenate and allow the patient to recover between passes.
11. Reassess breath sounds, respiratory status, oxygen saturation, and patient tolerance.
12. Document the procedure and characteristics of the secretions.