Advanced Concepts Of Medical-Surgical Nursing (NUR 265): NUR265 Test 4 - Exam on AIDS and Infection Management: Questions & Answers| Updated Latest – Galen.

NUR 265 Test 4 - Exam on AIDS and Infection Management: Questions & Answers| Updated Latest – Galen. Question 1 The nurse working in the emergency department (ED) has triaged a client who presented with chest pain, shortness of breath, a productive cough, and reports of night sweats. The client’s health history includes the presence of acquired immune deficiency syndrome (AIDS) and a recent laboratory result that reveals a low CD4+ count. Which of the following actions should the nurse take next? A. Initiate airborne precautions. B. Check the client’s temperature. C. Assess the client for shingles. D. Obtain a throat culture. Question 2 The newly hired nurse is developing a plan of care for a client who has acquired immune deficiency syndrome (AIDS) and was just diagnosed with Pneumocystis jiroveci pneumonia (PJP). Which of the following interventions should the nurse preceptor question? A. Offering the client foods high in calories and protein. B. Instructing the client to drink at least 2 to 3 liters of fluid throughout the day. C. Auscultating the client’s breath sounds for crackles at least once per shift. D. Wearing a surgical mask when standing within 3 feet of the client. Question 3 The nurse is caring for a client who has acquired immune deficiency syndrome (AIDS) and has just been diagnosed with toxoplasmosis encephalitis. Which of the following actions should the nurse take? A. Monitor the client’s level of orientation. B. Initiate airborne precautions for the next 72 hours. C. Ask the client if they ingested undercooked meat. D. Thicken the client’s liquids to honey consistency. Question 4 The nurse working in a community health center has instructed a group of clients who have acquired immune deficiency syndrome (AIDS) about ways to prevent infection. Which of the following statements by a client indicates the need for additional teaching? A. “I will avoid eating uncooked fruits and vegetables.” B. “I will notify my primary health care provider if my temperature is greater than 100° F.” C. “I will wear a surgical mask when I am outside gardening.” D. “I will avoid drinking water that has been standing for longer than 1 hour.” Question 5 The nurse is admitting a client who has acquired immune deficiency syndrome (AIDS) and has developed an infection caused by Toxoplasma gondii. Which of the following client statements is consistent with this diagnosis? A. “I have noticed that my speech has become slurred.” B. “I have developed a persistent dry cough.” C. “I have had severe diarrhea for the past few days.” D. “I have noticed that my food does not taste the same.” Question 6 The nurse is caring for a client who had a heart transplant 10 days ago. Which findings from the box below require follow-up by the nurse? Prolonged prothrombin time (PT). Activity intolerance. Abdominal distention. Shortness of breath. Weight loss of 2 lb. Fatigue. A. 1, 2, 3, 4 B. 2, 3, 4, 6 C. 3, 4, 5, 6 D. 1, 3, 5, 6 Question 7 The nurse has attended a conference about kidney transplantations. Which of the following clients who have end-stage renal disease (ESRD) does the nurse recognize as a transplant candidate? A. 65-year-old who has emphysema and is an active smoker. B. 70-year-old who has an arteriovenous (AV) graft site infection. C. 55-year-old who has been noncompliant with taking prescribed lithium. D. 60-year-old who had a history of colon cancer 10 years ago. Question 8 The nurse is caring for a client who had a liver transplant 48 hours ago. It is a priority for the nurse to notify the surgeon if the client has: A. Scant amounts of serosanguinous drainage from the incision. B. An increasing prothrombin time (PT). C. An increase in blood pressure (BP) from 115/68 to 122/74 mm Hg. D. A urine output that has decreased from 65 to 45 mL/hr since surgery. Question 9 The nurse is caring for a client who had a lung transplant 10 days ago. Which findings from the box below are a priority for the nurse to notify the primary health care provider (PHCP)? Has only used the incentive spirometer (IS) once since last evening. Refused high-frequency chest wall oscillation for the past 24 hours. Developed sputum that is yellow-tinged. A pain rating of 7 on a scale of 0 (no pain) to 10 (severe pain) when taking a deep breath. Elevated body temperature (T) of 100.8° F. A. 1, 3 B. 2, 5 C. 3, 5 D. 3, 4 Question 10 The nurse is caring for a client who had a kidney transplant 2 weeks ago. Which findings from the box below should the nurse correlate to possible organ rejection? Blood pressure (BP) of 182/96 mm Hg. Serum creatinine level of 1.1 mg/dL. Temperature (T) of 101° F. Serum potassium level of 3.5 mEq/L. Blood urea nitrogen (BUN) level of 28 mg/dL. A. 3, 4, 5 B. 1, 3, 5 C. 2, 3, 5 D. 1, 2, 4 Question 11 The nurse working in a primary health care provider’s (PHCP’s) office has just administered a routine immunization to a client. The client is asked to wait in the waiting room for the next 15 minutes. Five minutes later, the client develops swelling of the eyes and reports feeling anxious, short of breath, and dizzy. Which of the following actions should the nurse take first? A. Elevate the client’s feet and legs. B. Perform a respiratory assessment. C. Call the PHCP. D. Prepare to administer epinephrine intramuscular (IM). Question 12 The nurse working in the emergency department (ED) is admitting a client who presents with stridor, dyspnea, and bronchospasm after being stung by a bee. After notifying the ED health care provider, which of the following actions should the nurse take next? A. Initiate oxygen via a nonrebreather mask. B. Reassure the client that interventions have started. C. Call the rapid response team (RRT). D. Remove the bee stinger from the site of the sting. Question 13 The newly hired nurse has attended a continuing education conference regarding anaphylaxis with allergen exposure. Which of the following statements by the newly hired nurse indicates a need for further education? A. “The client may present with widespread hives and hypoxia.” B. “The client may have audible wheezes and cyanosis.” C. “The client may report new-onset abdominal cramping with hyperreflexia.” D. “The client may present with swollen lips and tongue.” Question 14 The nurse is assessing a client who has systemic lupus erythematosus (SLE). Which findings from the box below require follow-up by the nurse? Prolonged capillary refill. Pericardial friction rub. Butterfly rash. Swollen joints. Oliguria. A. 1, 2, 5 B. 2, 3, 5 C. 1, 3, 4 D. 2, 4, 5 Question 15 The nurse is teaching a 32-year-old female client who has systemic lupus erythematosus (SLE) about self-care practices. Which of the following statements by the client indicates the need for additional teaching by the nurse? A. “I should carefully consider whether I should get pregnant again.” B. “I should limit my exposure to direct sunlight to 30 continuous minutes each day.” C. “I should inspect my skin daily for rashes.” D. “I should check my temperature on a regular basis.” Question 16 The nurse working in the emergency department (ED) is caring for a group of assigned clients. Which of the following clients should the nurse see first? A. 35-year-old client who has systemic lupus erythematosus (SLE) and reports a temperature (T) of 100.8° F and increasing fatigue. B. 62-year-old client who has end-stage renal disease (ESRD) and is awaiting a kidney transplant, reports fatigue and redness at the dialysis catheter site. C. 48-year-old client who was diagnosed with Lyme disease 3 weeks ago and reports palpitations and neck stiffness. D. 54-year-old client who has acquired immunodeficiency syndrome (AIDS) and reports new onset of purplish-brown skin lesions. Question 17 The nurse is obtaining a health history on a 40-year-old client who has presented to the primary health care provider’s (PHCP’s) office for a routine physical examination. The client tells the nurse that there is a family history of colon cancer. Which of the following actions should the nurse take next? A. Obtain information about which family members have the history. B. Teach the client about home testing for fecal occult blood. C. Provide the client with instructions regarding dietary changes. D. Inform the PHCP of the client’s family history. Question 18 The nurse is assessing clients for the risk of developing breast cancer. The nurse should recognize that the client at greatest risk for breast cancer is the client who is a: A. 34-year-old Hispanic female who has 2 alcoholic drinks per week and whose maternal grandmother had breast cancer. B. 54-year-old Caucasian female who entered menopause at the age of 43 and uses hormone replacement therapy (HRT). C. 44-year-old African American female who had a bilateral oophorectomy at age 30 and recently quit smoking cigarettes. D. 66-year-old Jewish female who had her first child at age 38 and has a body mass index (BMI) of 33. Question 19 The nurse is assessing clients for the risk of developing cancer. Which of the following clients should the nurse recognize as being at greatest risk for developing the identified cancer? A. The risk for developing prostate cancer in a 65-year-old African American male who has lower urinary tract symptoms and a brother who has bladder cancer. B. The risk for developing uterine cancer in a 32-year-old Latino female who uses an intrauterine device (IUD) and engaged in sexual intercourse at age 16. C. The risk for developing prostate cancer in a 48-year-old Latino male who has a history of renal calculi and had an undescended testicle at birth. D. The risk for developing cervical cancer in a 42-year-old Caucasian female who has a history of uterine polyps and diabetes mellitus. Question 20 The nurse is assessing a client who is suspected of having lung cancer. Which findings from the box below are consistent with this diagnosis? Weight loss. Barrel chest. Rust-colored sputum. Recurrent pleural effusions. Petechiae on the anterior chest wall. A. 2, 3, 4 B. 1, 3, 4 C. 1, 2, 3 D. 2, 3, 5 Question 21 The nurse is caring for a client who is receiving a chemotherapeutic agent that has the potential to cause alopecia. Which of the following actions should the nurse take to support the client’s self-esteem? A. Provide the client with brochures on alopecia. B. Inform the client that hair usually grows back once chemotherapy is complete. C. Teach the client to wash the hair gently with mild shampoo to minimize hair loss. D. Encourage the client to purchase a wig or hat to wear. Question 22 The nurse has instructed a client who is scheduled to begin teletherapy (external) radiation therapy of the chest. Which of the following client statements indicates the need for further teaching? A. “I will place a heating pad over my site for comfort.” B. “I will cleanse my irradiated areas with mild soap and water.” C. “I will wear soft clothing over my skin at the irradiated site.” D. “I will avoid rubbing my skin with a cotton towel after I bathe.” Question 23 The nurse working on the oncology unit has been made aware of the following client situations. The nurse should initially assess the client who has: A. Reports of back pain with painful urination and is receiving intravenous (IV) chemotherapy. B. A platelet count of 100,000/mm³ and is requesting an enema to relieve constipation. C. Tumor lysis syndrome (TLS) and a potassium level of 4.6 mEq/dL. D. Gastric cancer and is preparing to eat pickled foods brought in by a family member. Question 24 The nurse is reviewing the following laboratory results of a client who is receiving chemotherapy: Hematocrit (Hct): 30% Hemoglobin (Hgb): 9 g/dL White blood cell (WBC) count: 4,000/mm³ Platelets: 30,000/mm³ Which of the following client assessment findings is a priority for follow-up? A. Petechiae on the anterior abdomen. B. Bruising on the arms and legs. C. Reports of increased nausea and vomiting. D. Reports of activity intolerance and fatigue. Question 25 The nurse working on the oncology unit has received the hand-off report on the following clients. Which client should the nurse assess first? A. 24-year-old client who is receiving neck radiation and is reporting xerostomia. B. 42-year-old client who is sobbing after receiving a new diagnosis of ovarian cancer. C. 35-year-old client who is reporting burning with urination and is receiving abdominal radiation. D. 56-year-old client who is receiving chest radiation and has developed changes in taste. Question 26 The nurse working in the oncology unit has received hand-off reports on the clients listed below. Place the clients in the correct order based on priority for assessment by the nurse. Client receiving radiation therapy who has a white blood cell (WBC) count of 4,500/mm³. Client receiving chemotherapy who has a platelet count of 50,000/mm³. Client who is crying because they just learned their cancer has metastasized. Client who has questions about upcoming chemotherapy. A. 4, 1, 2, 3 B. 3, 4, 2, 1 C. 2, 3, 1, 4 D. 2, 1, 4, 3 Question 27 The charge nurse is observing a newly hired nurse care for a client who has laryngeal cancer and had a total laryngectomy 12 hours ago. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse? A. Applying humidified oxygen to the client’s tracheostomy. B. Providing preprinted flashcards for communication. C. Keeping the head of bed (HOB) elevated to enhance comfort. D. Monitoring tissue flap integrity via Doppler every 2 hours. Question 28 The nurse is caring for a client who is receiving radiation therapy and chemotherapy and has developed tumor lysis syndrome (TLS). Which of the following actions should the nurse take? A. Initiate a high-potassium diet. B. Encourage the client to maintain bedrest. C. Encourage the client to increase daily fluid intake. D. Instruct the client to cough and deep breathe every hour. Question 29 The nurse is caring for a client who has cancer, has developed a spinal cord compression, and is receiving high-dose corticosteroid therapy. Which of the following additional treatment options should the nurse anticipate will be prescribed to alleviate the client’s symptoms? A. A fentanyl transdermal patch. B. Buck’s traction. C. High-dose radiation therapy. D. Lumbar puncture. Question 30 The nurse is caring for a client who is receiving chemotherapy. Which of the following findings alerts the nurse to the possibility that the client is developing disseminated intravascular coagulation (DIC)? A. The development of ecchymosis where the blood pressure was taken. B. The development of engorged blood vessels of the upper body. C. A white blood cell (WBC) count that has decreased to 2,500/mm³. D. A platelet count of 150,000/mm³. Question 31 The nurse is caring for a client who has bone metastasis and has developed hypercalcemia. Which medications from the box below should the nurse be prepared to administer to lower the client’s calcium level? Vitamin D. Calcitonin. Furosemide. Normal saline. Magnesium sulfate. Hydrochlorothiazide. A. 1, 2, 3 B. 3, 5, 6 C. 1, 4, 5 D. 2, 3, 4 Question 32 The nurse is assessing a client who is suspected of having superior vena cava syndrome (SVCS). Which of the following findings is consistent with this diagnosis? A. Engorged blood vessels noted on the upper chest and arms. B. Swelling around the client’s ankles upon awakening. C. The presence of enlarged lymph nodes in the client’s axilla. D. A blood pressure that is higher in one arm when compared to the other. Question 33 The nurse is caring for a client who is diagnosed with advanced colon cancer. The client reports having trouble sleeping and eating, difficulty concentrating at work, and no longer experiencing any pleasure from painting, but wants to continue. The nurse concludes the client may be experiencing: A. Acceptance. B. Normal grief. C. Delayed grief. D. Disenfranchised grief. Question 34 The nurse is caring for a client who has been diagnosed with metastatic breast cancer. The client reports feeling overwhelmed and asks the nurse, “What does this diagnosis mean for the years to come?” Which of the following responses by the nurse is most appropriate? A. “Metastatic breast cancer is a serious condition, but with new treatment options, many people live for many years.” B. “Metastatic breast cancer means the cancer has spread, but there are ways to manage it and improve your quality of life.” C. “This means we will need to schedule a series of tests to determine the best course of treatment.” D. “I understand this is a lot to process. Let’s talk about your fears and concerns.” Question 35 The nurse is providing postmortem care for a client. Which of the following interventions is appropriate prior to allowing the family to visit? A. Contact the funeral home to schedule the transport of the deceased. B. Prepare and position the body comfortably and in a natural position. C. Cleanse the body thoroughly and ensure all personal belongings are removed. D. Call the physician to verify the time of death before moving the body. Question 36 A nurse in the emergency department (ED) has attended an in-service on maintaining client safety in the ED. Which of the following statements by the nurse indicates a correct understanding of the in-service? A. “Protection from skin injuries or breakdown is not necessary in the ED since clients are only here for a short period of time.” B. “It is necessary to anticipate hostile or violent behavior by clients, family members, or visitors.” C. “I should ask a client’s family member to leave if the client appears confused.” D. “When searching through the belongings of a client who is confused, someone from the security department should perform the search.” Question 37 The nurse working in the emergency department (ED) has attended a continuing education conference on cultural considerations. Which of the following statements indicates the need for additional teaching? A. “A client who is Muslim may have specific beliefs about having their body exposed in the health care setting.” B. “A client who is deaf should be provided with a pen and paper to write down any questions or concerns.” C. “A client who is a Jehovah’s Witness may not believe in taking medications that contain blood components.” D. “A client who is non-English speaking should be offered a telephone language line or dedicated interpreter to ensure informed consent.” Question 38 The nurse working in the emergency department (ED) is triaging clients. Which of the following clients should the nurse see first? A. 81-year-old who has a temperature (T) of 101° F and respirations (R) of 20. B. 18-year-old who had a repair of tetralogy of Fallot (TOF) as an infant and is reporting nonspecific symptoms of fatigue. C. 45-year-old who has acquired immune deficiency syndrome (AIDS) and is reporting the development of a cough with yellow sputum. D. 30-year-old who was in a bicycle accident, has bruising on the left flank, and has a blood pressure (BP) of 80/55 mm Hg. Question 39 The nurse working in the emergency department (ED) is triaging the following clients who were involved in an industrial accident. The nurse should categorize a client as emergent if the client has: A. An open fracture of the left lower leg and a diminished left pedal pulse. B. Lower extremity injuries and is oriented to person but not date or time. C. Singed eyebrows, hoarse voice, and audible wheezing. D. A partial thickness burn of the left arm and is reporting pain rated as 8/10. Question 40 The charge nurse is observing a newly hired nurse tag clients during a mass casualty event using the disaster triage tag system. It requires the charge nurse to intervene if the newly hired nurse is observed tagging: A. A client who has a Glasgow coma score (GCS) of 3 as expectant (black). B. A client who has a penetrating object in the thigh as urgent (yellow). C. A client who has an open fracture of the femur as nonurgent (green). D. A client who has a spinal cord injury (SCI) at the level of C2 as expectant (black). Question 41 The nurse working in the emergency department (ED) is admitting a client who was involved in a motor vehicle crash and is currently unresponsive. Which of the following actions should the nurse take first? A. Document the time the client arrived in the ED. B. Perform a head-to-toe assessment. C. Initiate cardiac monitoring. D. Assess the client for Battle’s sign. Question 42 The charge nurse is observing nursing personnel provide client care during an external disaster in the community. Which of the following actions by a nurse requires the charge nurse to intervene? A. Inserting an oropharyngeal airway in a conscious client. B. Splinting an injured client’s extremity in the position it is found. C. Performing a jaw-thrust maneuver on a client who has a suspected cervical spine injury. D. Leaving a penetrating object in a client in place. Question 43 The nurse in the emergency department (ED) has admitted a client who presents with a temperature (T) of 104.1° F, skin that is hot and dry, and who appears confused. After ensuring that the client has a patent airway, effective breathing, adequate circulation, and IV access, which of the following actions is the priority? A. Assess the client’s blood glucose level. B. Determine what medications the client takes on a regular basis. C. Obtain the client’s arterial blood gases (ABGs). D. Remove the client’s clothing. Question 44 The nurse is caring for an adult female client who presents to the emergency department (ED) with injuries consistent with domestic violence. While taking the client’s history, the nurse suspects the client may be hesitant to disclose the cause of their injuries. Which of the following actions should the nurse take first? A. Document the client’s injuries in detail and focus on medical care only. B. Minimize the situation and say, “These injuries look like they could have happened accidentally.” C. Assure the client that law enforcement will be involved immediately. D. Express concern to the client about the injuries and offer support. Question 45 The nurse has attended a continuing education program about resuscitation interventions in the emergency department (ED). Which of the following statements by the nurse indicates the need for additional teaching? A. “IV access can be effectively achieved by using a 16-gauge peripheral IV in the antecubital area.” B. “Permission must be obtained to cut away the clothing of a client who is unresponsive and requires resuscitation.” C. “A client who has the presence of a radial pulse has a systolic blood pressure of at least 80 mm Hg.” D. “A jaw-thrust maneuver should be used to establish the airway of a client with a suspected cervical spinal injury.” Question 46 The nurse is caring for a client who has been diagnosed with high-altitude illness. Which of the following commonly prescribed medications should the nurse be prepared to administer to the client? A. Albuterol. B. Acetazolamide. C. Nifedipine. D. Furosemide. Question 47 The nurse working in the emergency department (ED) is admitting a client who has a temperature (T) of 82° F. Which of the following findings does the nurse expect to observe in a client who has severe hypothermia? A. Bradycardia. B. Decreased muscle coordination. C. Slurred speech. D. Shivering. Question 48 The nurse working on the medical-surgical unit must recommend a client for discharge to make a bed available due to a mass casualty. Which of the following clients is most appropriate for the nurse to recommend for discharge? A. An 18-year-old who had a minor concussion and has been symptom-free for 24 hours and is awaiting observation for another 12 hours as a precaution. B. A 52-year-old who has lung cancer and is receiving their last dose of chemotherapy. C. A 22-year-old client who has a sickle cell crisis and is receiving IV fluids and pain medication. D. A 71-year-old who had a left hip arthroplasty and is scheduled to go to rehab in the morning. Question 49 The triage nurse in the emergency department (ED) suspects a potential bioterrorism incident in the community. Which of the following supports the nurse’s suspicion? A. Several school-age children present with itchy, blister-like rashes on the skin. B. A group of clients from a long-term care (LTC) facility present with symptoms of influenza. C. Several adult clients present with fever and raised pustules on the skin. D. A group of clients present with nausea and vomiting after attending a wedding. Question 50 The nurse in the emergency department (ED) is assessing a client who was involved in a motor vehicle crash and sustained a penetrating abdominal trauma. Which of the following actions should the nurse take first? A. Insert a nasogastric (NG) tube. B. Auscultate the client’s bowel sounds. C. Measure the client’s abdominal girth. D. Prepare the client for surgery.