NR 545 EXAM 3 COMPREHENSIVE
QUESTIONS WITH VERIFIED PRACTICE
SOLUTIONS
●● 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
●● The client with acquired immunodeficiency syndrome is diagnosed
with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse
understands that this has been confirmed by which finding?
1. Swelling in the genital area
,2. Swelling in the lower extremities
3. Positive punch biopsy of the cutaneous lesions
4. Appearance of reddish-blue lesions noted on the skin
Answer: 3. Positive punch biopsy of the cutaneous lesions
Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on
the lower legs that change into plaques. These large plaques ulcerate or
open and drain. The lesions spread by metastasis through the upper body
and then to the face and oral mucosa. They can move to the lymphatic
system, lungs, and gastrointestinal tract. Late disease results in swelling
and pain in the lower extremities, penis, scrotum, or face. Diagnosis is
made by punch biopsy of cutaneous lesions and biopsy of pulmonary
and gastrointestinal lesions.
●● The home care nurse is preparing to visit a client who has undergone
renal transplantation. The nurse develops a plan of care that includes
monitoring the client for signs of acute graft rejection. The nurse
documents in the plan to assess the client for which signs of acute graft
rejection?
1. Fever, hypotension, and polyuria
2. Hypertension, polyuria, and thirst
,3. Fever, hypertension, and graft tenderness
4. Hypotension, graft tenderness, and hypothermia
Answer: 3. Fever, hypertension, and graft tenderness
●● A client with acquired immunodeficiency syndrome (AIDS) has been
started on therapy with zidovudine. The nurse should monitor the results
of which laboratory blood study for adverse effects of therapy?
1. Creatinine level
2. Potassium concentration
3. Complete blood cell (CBC) count
4. Blood urea nitrogen (BUN) level
Answer: 3. Complete blood cell (CBC) count
Acquired immunodeficiency syndrome is a viral disease caused by the
human immunodeficiency virus (HIV), which destroys T cells, thereby
increasing susceptibility to infection and malignancy. Common adverse
effects of zidovudine are agranulocytopenia and anemia. The nurse
, should monitor the CBC count for these changes. Creatinine, potassium,
and BUN are unrelated to this medication.
●● The nurse is performing an assessment on a female client who
complains of fatigue, weakness, muscle and joint pain, anorexia, and
photosensitivity. Systemic lupus erythematosus (SLE) is suspected.
What should the nurse further assess for that also is indicative of SLE?
1. Ascites
2. Emboli
3. Facial rash
4. Two hemoglobin S genes
Answer: 3. Facial rash
Systemic lupus erythematosus is a chronic, progressive, inflammatory
connective tissue disorder that can cause major body organs and systems
to fail. A butterfly rash on the cheeks and bridge of the nose is an
essential sign of SLE. Ascites and emboli are found in many conditions
but are not associated with SLE. Two hemoglobin S genes are found in
sickle cell anemia.
QUESTIONS WITH VERIFIED PRACTICE
SOLUTIONS
●● 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
●● The client with acquired immunodeficiency syndrome is diagnosed
with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse
understands that this has been confirmed by which finding?
1. Swelling in the genital area
,2. Swelling in the lower extremities
3. Positive punch biopsy of the cutaneous lesions
4. Appearance of reddish-blue lesions noted on the skin
Answer: 3. Positive punch biopsy of the cutaneous lesions
Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on
the lower legs that change into plaques. These large plaques ulcerate or
open and drain. The lesions spread by metastasis through the upper body
and then to the face and oral mucosa. They can move to the lymphatic
system, lungs, and gastrointestinal tract. Late disease results in swelling
and pain in the lower extremities, penis, scrotum, or face. Diagnosis is
made by punch biopsy of cutaneous lesions and biopsy of pulmonary
and gastrointestinal lesions.
●● The home care nurse is preparing to visit a client who has undergone
renal transplantation. The nurse develops a plan of care that includes
monitoring the client for signs of acute graft rejection. The nurse
documents in the plan to assess the client for which signs of acute graft
rejection?
1. Fever, hypotension, and polyuria
2. Hypertension, polyuria, and thirst
,3. Fever, hypertension, and graft tenderness
4. Hypotension, graft tenderness, and hypothermia
Answer: 3. Fever, hypertension, and graft tenderness
●● A client with acquired immunodeficiency syndrome (AIDS) has been
started on therapy with zidovudine. The nurse should monitor the results
of which laboratory blood study for adverse effects of therapy?
1. Creatinine level
2. Potassium concentration
3. Complete blood cell (CBC) count
4. Blood urea nitrogen (BUN) level
Answer: 3. Complete blood cell (CBC) count
Acquired immunodeficiency syndrome is a viral disease caused by the
human immunodeficiency virus (HIV), which destroys T cells, thereby
increasing susceptibility to infection and malignancy. Common adverse
effects of zidovudine are agranulocytopenia and anemia. The nurse
, should monitor the CBC count for these changes. Creatinine, potassium,
and BUN are unrelated to this medication.
●● The nurse is performing an assessment on a female client who
complains of fatigue, weakness, muscle and joint pain, anorexia, and
photosensitivity. Systemic lupus erythematosus (SLE) is suspected.
What should the nurse further assess for that also is indicative of SLE?
1. Ascites
2. Emboli
3. Facial rash
4. Two hemoglobin S genes
Answer: 3. Facial rash
Systemic lupus erythematosus is a chronic, progressive, inflammatory
connective tissue disorder that can cause major body organs and systems
to fail. A butterfly rash on the cheeks and bridge of the nose is an
essential sign of SLE. Ascites and emboli are found in many conditions
but are not associated with SLE. Two hemoglobin S genes are found in
sickle cell anemia.
