NUR 265 – EXAM 4 | QUESTIONS AND
ANSWERS | 2025 UPDATE | 100%
CORRECT – GALEN
Question 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?
A) Assess the client for shingles
B) Obtain a throat culture
C) Check the client’s temperature
D) Prepare the client for insertion of a chest tube
Correct Answer---C) Check the client’s temperature
Rationale: The client is on airborne precautions (suspected TB). Assessing
temperature helps evaluate for fever, a key sign of infection. The priority after
initiating precautions is ongoing assessment.
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) and pain. Which of the following
interventions should the nurse preceptor question?
A) Instruct the client to drink at least two to three liters of fluid throughout the day
B) Telling the client to keep the door to the room closed at all times
,C) Offering the client foods high in calories and protein
D) Placing the client on a pressure-relieving mattress
Correct Answer---B) Telling the client to keep the door to the room closed at
all times
Rationale: PJP requires droplet precautions, not airborne. The door does not need
to be closed unless airborne precautions are required (e.g., TB). Closed door may
impede observation.
Question 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?
A) Administer IV pentamidine isethionate
B) Thicken the client’s liquids to honey consistency
C) Initiate seizure precautions with padded siderails
D) Initiate airborne precautions for the next 72 hours
Correct Answer---C) Initiate seizure precautions with padded siderails
Rationale: Cryptococcal meningitis can cause seizures. Seizure precautions protect
the client. Pentamidine is for PJP, not cryptococcus.
Question 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?
A) I am less likely to develop opportunistic infections once I begin taking my
prescribed medications
B) I can avoid developing drug resistance if I take 90% of my drugs on time
C) I should discontinue my medication if I develop severe diarrhea
D) I understand that this combination of drugs will kill the virus
,Correct Answer---A) I am less likely to develop opportunistic infections once I
begin taking my prescribed medications
Rationale: cART reduces viral load and raises CD4 count, reducing risk of OIs. It
does not kill the virus (it suppresses). Adherence must be near 100% to avoid
resistance.
Question 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?
A) I will eat plenty of fresh fruits and raw vegetables
B) I will wear gloves and then wash my hands immediately if I need to change my
cat’s litter box
C) I will make sure no one uses my deodorant or toothpaste
D) I will avoid planting vegetables and flowers in our garden
Correct Answer---A) I will eat plenty of fresh fruits and raw vegetables
Rationale: Raw fruits and vegetables may carry pathogens (e.g., Toxoplasma,
bacteria). Immunocompromised clients should wash or cook produce thoroughly.
Question 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:
A) Inspects the client’s mouth at least once every 8 hours
B) Keeps open, weeping lesions clean and covered with prescribed dressing
C) Applies a surgical mask before entering the client’s room
D) Instructs the client that make-up can be applied to lesions that are not open
, Correct Answer---C) Applies a surgical mask before entering the client’s room
Rationale: KS is not airborne; no mask is needed for standard precautions. A mask
may be worn if the nurse has a respiratory infection, but it is not required for KS.
Question 7: The nurse is caring for a client who had a heart transplant 24 hours
ago. Which of the following findings indicates the client is developing a
complication?
A) Facial flushing
B) Abdominal distention
C) Hypertension
D) Prothrombin time (PT) of 11 seconds
Correct Answer---B) Abdominal distention
Rationale: Abdominal distention may indicate postoperative ileus, bleeding, or
organ rejection (e.g., fluid accumulation). Hypertension is common
post-transplant; PT 11 sec is normal.
Question 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:
A) A pain rating of “7” when taking a deep breath
B) Only used the incentive spirometer once since last evening
C) Refused to get out of bed for the past 24 hours
D) Developed sputum that is yellow-tinged
Correct Answer---D) Developed sputum that is yellow-tinged
Rationale: Yellow sputum suggests infection (pneumonia or bronchiolitis
obliterans), a serious complication after lung transplant. Pain and inactivity are
important but less urgent.
ANSWERS | 2025 UPDATE | 100%
CORRECT – GALEN
Question 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?
A) Assess the client for shingles
B) Obtain a throat culture
C) Check the client’s temperature
D) Prepare the client for insertion of a chest tube
Correct Answer---C) Check the client’s temperature
Rationale: The client is on airborne precautions (suspected TB). Assessing
temperature helps evaluate for fever, a key sign of infection. The priority after
initiating precautions is ongoing assessment.
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) and pain. Which of the following
interventions should the nurse preceptor question?
A) Instruct the client to drink at least two to three liters of fluid throughout the day
B) Telling the client to keep the door to the room closed at all times
,C) Offering the client foods high in calories and protein
D) Placing the client on a pressure-relieving mattress
Correct Answer---B) Telling the client to keep the door to the room closed at
all times
Rationale: PJP requires droplet precautions, not airborne. The door does not need
to be closed unless airborne precautions are required (e.g., TB). Closed door may
impede observation.
Question 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?
A) Administer IV pentamidine isethionate
B) Thicken the client’s liquids to honey consistency
C) Initiate seizure precautions with padded siderails
D) Initiate airborne precautions for the next 72 hours
Correct Answer---C) Initiate seizure precautions with padded siderails
Rationale: Cryptococcal meningitis can cause seizures. Seizure precautions protect
the client. Pentamidine is for PJP, not cryptococcus.
Question 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?
A) I am less likely to develop opportunistic infections once I begin taking my
prescribed medications
B) I can avoid developing drug resistance if I take 90% of my drugs on time
C) I should discontinue my medication if I develop severe diarrhea
D) I understand that this combination of drugs will kill the virus
,Correct Answer---A) I am less likely to develop opportunistic infections once I
begin taking my prescribed medications
Rationale: cART reduces viral load and raises CD4 count, reducing risk of OIs. It
does not kill the virus (it suppresses). Adherence must be near 100% to avoid
resistance.
Question 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?
A) I will eat plenty of fresh fruits and raw vegetables
B) I will wear gloves and then wash my hands immediately if I need to change my
cat’s litter box
C) I will make sure no one uses my deodorant or toothpaste
D) I will avoid planting vegetables and flowers in our garden
Correct Answer---A) I will eat plenty of fresh fruits and raw vegetables
Rationale: Raw fruits and vegetables may carry pathogens (e.g., Toxoplasma,
bacteria). Immunocompromised clients should wash or cook produce thoroughly.
Question 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:
A) Inspects the client’s mouth at least once every 8 hours
B) Keeps open, weeping lesions clean and covered with prescribed dressing
C) Applies a surgical mask before entering the client’s room
D) Instructs the client that make-up can be applied to lesions that are not open
, Correct Answer---C) Applies a surgical mask before entering the client’s room
Rationale: KS is not airborne; no mask is needed for standard precautions. A mask
may be worn if the nurse has a respiratory infection, but it is not required for KS.
Question 7: The nurse is caring for a client who had a heart transplant 24 hours
ago. Which of the following findings indicates the client is developing a
complication?
A) Facial flushing
B) Abdominal distention
C) Hypertension
D) Prothrombin time (PT) of 11 seconds
Correct Answer---B) Abdominal distention
Rationale: Abdominal distention may indicate postoperative ileus, bleeding, or
organ rejection (e.g., fluid accumulation). Hypertension is common
post-transplant; PT 11 sec is normal.
Question 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:
A) A pain rating of “7” when taking a deep breath
B) Only used the incentive spirometer once since last evening
C) Refused to get out of bed for the past 24 hours
D) Developed sputum that is yellow-tinged
Correct Answer---D) Developed sputum that is yellow-tinged
Rationale: Yellow sputum suggests infection (pneumonia or bronchiolitis
obliterans), a serious complication after lung transplant. Pain and inactivity are
important but less urgent.
