NUR 265 – EXAM 4
1. The nurse working in the ED is triaging a client who has presented with chest pain, shortness of breath,
a productive cough, and reports night sweats. The client’s health history includes the presence of
acquired immune deficiency syndrome (AIDS) and a recent lab result that reveals a low CD4+ count.
Airborne precautions have been initiated. Which of the following actions should the nurse take next?
o Assess the client for shingles
o Obtain a throat culture
o Check the client’s temperature
o Prepare the client for insertion of a chest tube
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) and pain. Which
of the following interventions should the nurse preceptor question?
o Instruct the client to drink at least two to three liters of fluid throughout the dayp354
o Telling the client to keep the door to the room closed at all times??????
o Offering the client foods high in calories and protein p354
o Placing the client on a pressure-relieving mattress p353
3. The nurse is caring for a client with acquired immune deficiency syndrome (AIDS) who has just been
diagnosed with cryptococcal meningitis. Which of the following actions should the nurse take?
o Administer IV pentamidine isethionate
o Thicken the client’s liquids to honey consistency
o Initiate seizure precautions with padded siderails
o Initiate airborne precautions for the next 72 hours
4. The nurse has provided medication instructions to a client who has HIV and has been prescribed
combination antiretroviral therapy (cART). Which of the following client statements indicates a correct
understanding of the teaching?
o I am less likely to develop opportunistic infections once I begin taking my prescribed
medications
o I can avoid developing drug resistance if I take 90% of my drugs on time
o I should discontinue my medication if I develop severe diarrhea
o I understand that this combination of drugs will kill the virus
5. 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, if made by a client, would indicate the need for additional teaching?
o I will eat plenty of fresh fruits and raw vegetables
o I will wear gloves and then wash my hands immediately if I need to change my cats litter box
o I will make sure no one uses my deodorant or toothpaste
o I will avoid planting vegetables and flowers in our garden
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, NUR 265 – EXAM 4
6. The nurse is precepting a newly hired nurse who is caring for a client who has acquired immune
deficiency syndrome (AIDS) and has developed Kaposi’s sarcoma (KS). It requires additional teaching
by the preceptor if the newly hired nurse
o Inspects the clients mouth at least once every 8 hours
o Keeps open, weeping lesions clean and covered with prescribed dressing
o Applies a surgical mask before entering the client’s room
o Instructs the client that make-up can be applied to lesions that are not open
7. The nurse is caring for a client who had a heart transplant 24 hours ago. Which of the following findings
indicated the client is developing a complication?
o Facial flushing
o Abdominal distention
o Hypertension
o Prothrombin time (PT) of 11 seconds
8. The nurse is caring for a client who had a lung transplant 10 days ago. It would be a priority for the
nurse to notify the PHCP if the client has
o A pain rating of “7” when taking a deep breath
o Only used the inventive spirometer once since last evening
o Refused to get out of bed for the past 24 hours
o Developed sputum that is yellow-tinged
9. The nurse is caring for a client who had a liver transplant 48 hours ago. Which findings from the box
below is a priority for the nurse to report to the PHCP?
1. A decrease in urine output from 50 to 30 ml/hr since surgery
2. An increase in aspartate aminotransferase (AST) from 28 to 32 units/L in the past
24 hrs
3. A pulse rate that has decreased from 88 to 72 over the last 8 hours
4. A prothrombin time (PT) of 20 seconds
5. An international normalized ration (INR) of 2.5 seconds
6. An increase in serum bilirubin levels over the last 12 hours
7. A decrease in alkaline phosphate levels
o 2, 3, 5
o 2, 4, 5, 6
o 1, 4, 6, 7
o 1, 3, 7
10. The nurse is caring for a client who had a kidney transplant two weeks ago. Which of the following
findings should the nurse correlate to possible organ rejection?
o Urinalysis is positive for ketones
o BP of 172/96 mm Hg
o BUN level of 15mg/dL
o Serum creatine level of 0.9 mg/dL
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1. The nurse working in the ED is triaging a client who has presented with chest pain, shortness of breath,
a productive cough, and reports night sweats. The client’s health history includes the presence of
acquired immune deficiency syndrome (AIDS) and a recent lab result that reveals a low CD4+ count.
Airborne precautions have been initiated. Which of the following actions should the nurse take next?
o Assess the client for shingles
o Obtain a throat culture
o Check the client’s temperature
o Prepare the client for insertion of a chest tube
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) and pain. Which
of the following interventions should the nurse preceptor question?
o Instruct the client to drink at least two to three liters of fluid throughout the dayp354
o Telling the client to keep the door to the room closed at all times??????
o Offering the client foods high in calories and protein p354
o Placing the client on a pressure-relieving mattress p353
3. The nurse is caring for a client with acquired immune deficiency syndrome (AIDS) who has just been
diagnosed with cryptococcal meningitis. Which of the following actions should the nurse take?
o Administer IV pentamidine isethionate
o Thicken the client’s liquids to honey consistency
o Initiate seizure precautions with padded siderails
o Initiate airborne precautions for the next 72 hours
4. The nurse has provided medication instructions to a client who has HIV and has been prescribed
combination antiretroviral therapy (cART). Which of the following client statements indicates a correct
understanding of the teaching?
o I am less likely to develop opportunistic infections once I begin taking my prescribed
medications
o I can avoid developing drug resistance if I take 90% of my drugs on time
o I should discontinue my medication if I develop severe diarrhea
o I understand that this combination of drugs will kill the virus
5. 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, if made by a client, would indicate the need for additional teaching?
o I will eat plenty of fresh fruits and raw vegetables
o I will wear gloves and then wash my hands immediately if I need to change my cats litter box
o I will make sure no one uses my deodorant or toothpaste
o I will avoid planting vegetables and flowers in our garden
mailto:https://www.stuvia.com/user/Wisdoms
, NUR 265 – EXAM 4
6. The nurse is precepting a newly hired nurse who is caring for a client who has acquired immune
deficiency syndrome (AIDS) and has developed Kaposi’s sarcoma (KS). It requires additional teaching
by the preceptor if the newly hired nurse
o Inspects the clients mouth at least once every 8 hours
o Keeps open, weeping lesions clean and covered with prescribed dressing
o Applies a surgical mask before entering the client’s room
o Instructs the client that make-up can be applied to lesions that are not open
7. The nurse is caring for a client who had a heart transplant 24 hours ago. Which of the following findings
indicated the client is developing a complication?
o Facial flushing
o Abdominal distention
o Hypertension
o Prothrombin time (PT) of 11 seconds
8. The nurse is caring for a client who had a lung transplant 10 days ago. It would be a priority for the
nurse to notify the PHCP if the client has
o A pain rating of “7” when taking a deep breath
o Only used the inventive spirometer once since last evening
o Refused to get out of bed for the past 24 hours
o Developed sputum that is yellow-tinged
9. The nurse is caring for a client who had a liver transplant 48 hours ago. Which findings from the box
below is a priority for the nurse to report to the PHCP?
1. A decrease in urine output from 50 to 30 ml/hr since surgery
2. An increase in aspartate aminotransferase (AST) from 28 to 32 units/L in the past
24 hrs
3. A pulse rate that has decreased from 88 to 72 over the last 8 hours
4. A prothrombin time (PT) of 20 seconds
5. An international normalized ration (INR) of 2.5 seconds
6. An increase in serum bilirubin levels over the last 12 hours
7. A decrease in alkaline phosphate levels
o 2, 3, 5
o 2, 4, 5, 6
o 1, 4, 6, 7
o 1, 3, 7
10. The nurse is caring for a client who had a kidney transplant two weeks ago. Which of the following
findings should the nurse correlate to possible organ rejection?
o Urinalysis is positive for ketones
o BP of 172/96 mm Hg
o BUN level of 15mg/dL
o Serum creatine level of 0.9 mg/dL
mailto:https://www.stuvia.com/user/Wisdoms
