NR 464 – EXAM 3 (SAUNDERS) | 2025 ADVANCED NURSING 120
QUESTIONS WITH CORRECT ANSWERS FOR IMMUNE DISORDERS &
COMPLEX CARE WITH MOST TESTED QUESTIONS INCLUDED
NR 464 EXAM 3 (SAUNDERS) COVERS HIGH-PRIORITY NURSING CONCEPTS RELATED TO
IMMUNODEFICIENCIES, AUTOIMMUNE CONDITIONS, AND OPPORTUNISTIC INFECTIONS. THIS 2025-
READY RESOURCE PREPARES NURSING STUDENTS TO MAKE SAFE, INFORMED CLINICAL DECISIONS,
INTERPRET DIAGNOSTICS, AND IMPLEMENT TARGETED INTERVENTIONS FOR COMPLEX IMMUNE
COMPROMISED PATIENTS IN ACUTE AND COMMUNITY CARE SETTINGS
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." - CORRECT ANSWER-1. "I
should take hot baths because they are relaxing."
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 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 - CORRECT ANSWER-1. Protecting the
client from infection
The client with immunodeficiency has inadequate or an 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.
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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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.
A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The
client asks what will be done next because the result of the enzyme-linked immunosorbent assay
(ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to
the client?
1. No further diagnostic studies are needed.
2. A Western blot will be done to confirm these findings.
3. The client probably will have a bone marrow biopsy done.
4. A CD4+ cell count will be done to measure T helper lymphocytes. - CORRECT ANSWER-2. A
Western blot will be done to confirm these findings.
The nurse is caring for a client with acquired immunodeficiency syndrome and detects early
infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation?
1. Fever
2. Cough
3. Dyspnea at rest
4. Dyspnea on exertion - CORRECT ANSWER-2. Cough
Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic
infection. The client with P. jiroveci infection usually has a cough as the first sign. The cough begins
as nonproductive and then progresses to productive. Later signs and symptoms include fever,
dyspnea on exertion, and finally dyspnea at rest.
A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of
histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes.
How should the nurse interpret this assessment finding?
1. The histoplasmosis is resolving.
2. The client has disseminated histoplasmosis infection.
3. This is a side effect of the medications given to treat AIDS.
, 4. The client probably has another infection that is developing. - CORRECT ANSWER-2. The client has
disseminated histoplasmosis infection.
Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory infection in
the client with AIDS and then becomes a disseminated infection, with enlargement of lymph nodes,
spleen, and liver. The client experiences dyspnea, fever, cough, and weight loss. The remaining
options are incorrect.
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing
night fever and night sweats. Which nursing interventions would be helpful in managing this
symptom? Select all that apply.
1. Keep liquids at the bedside.
2. Place a towel over the pillowcase.
3. Make sure the pillow has a plastic cover.
4. Keep a change of bed linens nearby in case they are needed.
5. Administer an antipyretic after the client has a spike in temperature. - CORRECT ANSWER-1. Keep
liquids at the bedside.
2. Place a towel over the pillowcase.
3. Make sure the pillow has a plastic cover.
4. Keep a change of bed linens nearby in case they are needed.
For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an
antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a
temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The
pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is
profuse. The client should have liquids at the bedside to drink.
A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The
nurse should include which measure in the dietary plan?
1. Provide large, nutritious meals.
2. Serve foods while they are hot.
3. Add spices to food for added flavor.
4. Remove dairy products and red meat from the meal. - CORRECT ANSWER-4. Remove dairy
products and red meat from the meal.
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. The
client with AIDS who has nausea and vomiting should avoid fatty products such as dairy products
and red meat. Meals should be small and frequent to lessen the chance of vomiting. The client
QUESTIONS WITH CORRECT ANSWERS FOR IMMUNE DISORDERS &
COMPLEX CARE WITH MOST TESTED QUESTIONS INCLUDED
NR 464 EXAM 3 (SAUNDERS) COVERS HIGH-PRIORITY NURSING CONCEPTS RELATED TO
IMMUNODEFICIENCIES, AUTOIMMUNE CONDITIONS, AND OPPORTUNISTIC INFECTIONS. THIS 2025-
READY RESOURCE PREPARES NURSING STUDENTS TO MAKE SAFE, INFORMED CLINICAL DECISIONS,
INTERPRET DIAGNOSTICS, AND IMPLEMENT TARGETED INTERVENTIONS FOR COMPLEX IMMUNE
COMPROMISED PATIENTS IN ACUTE AND COMMUNITY CARE SETTINGS
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." - CORRECT ANSWER-1. "I
should take hot baths because they are relaxing."
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 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 - CORRECT ANSWER-1. Protecting the
client from infection
The client with immunodeficiency has inadequate or an 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.
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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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.
A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The
client asks what will be done next because the result of the enzyme-linked immunosorbent assay
(ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to
the client?
1. No further diagnostic studies are needed.
2. A Western blot will be done to confirm these findings.
3. The client probably will have a bone marrow biopsy done.
4. A CD4+ cell count will be done to measure T helper lymphocytes. - CORRECT ANSWER-2. A
Western blot will be done to confirm these findings.
The nurse is caring for a client with acquired immunodeficiency syndrome and detects early
infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation?
1. Fever
2. Cough
3. Dyspnea at rest
4. Dyspnea on exertion - CORRECT ANSWER-2. Cough
Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic
infection. The client with P. jiroveci infection usually has a cough as the first sign. The cough begins
as nonproductive and then progresses to productive. Later signs and symptoms include fever,
dyspnea on exertion, and finally dyspnea at rest.
A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of
histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes.
How should the nurse interpret this assessment finding?
1. The histoplasmosis is resolving.
2. The client has disseminated histoplasmosis infection.
3. This is a side effect of the medications given to treat AIDS.
, 4. The client probably has another infection that is developing. - CORRECT ANSWER-2. The client has
disseminated histoplasmosis infection.
Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory infection in
the client with AIDS and then becomes a disseminated infection, with enlargement of lymph nodes,
spleen, and liver. The client experiences dyspnea, fever, cough, and weight loss. The remaining
options are incorrect.
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing
night fever and night sweats. Which nursing interventions would be helpful in managing this
symptom? Select all that apply.
1. Keep liquids at the bedside.
2. Place a towel over the pillowcase.
3. Make sure the pillow has a plastic cover.
4. Keep a change of bed linens nearby in case they are needed.
5. Administer an antipyretic after the client has a spike in temperature. - CORRECT ANSWER-1. Keep
liquids at the bedside.
2. Place a towel over the pillowcase.
3. Make sure the pillow has a plastic cover.
4. Keep a change of bed linens nearby in case they are needed.
For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an
antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a
temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The
pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is
profuse. The client should have liquids at the bedside to drink.
A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The
nurse should include which measure in the dietary plan?
1. Provide large, nutritious meals.
2. Serve foods while they are hot.
3. Add spices to food for added flavor.
4. Remove dairy products and red meat from the meal. - CORRECT ANSWER-4. Remove dairy
products and red meat from the meal.
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. The
client with AIDS who has nausea and vomiting should avoid fatty products such as dairy products
and red meat. Meals should be small and frequent to lessen the chance of vomiting. The client
