PRACTICE QUESTIONS FOR 265 EXAM
2 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS (GRADED A+)
Question: A nurse working in the emergency department has just completed the
triage of a patient presenting with acute chest discomfort, shortness of breath, a
productive cough, and a history of intense night sweats. The patient’s medical
background includes an AIDS diagnosis, and recent laboratory results indicate a
severely low CD4+ T-cell count. Which action must the nurse implement
immediately?
Initiate airborne precautions
Check the client's temp
Assess the client for shingles
Obtain a throat culture
Answer: ✔✔ Initiate airborne precautions
(Rationale: In a patient with advanced HIV/AIDS, symptoms like a productive
cough, night sweats, and chest pain are highly suspicious for active pulmonary
Tuberculosis. The nurse must place the patient in an isolation room with negative
pressure ventilation and initiate airborne precautions right away before
performing further diagnostic tests.)
Question: A newly hired nurse is creating an individualized plan of care for a
patient with advanced AIDS who has just been diagnosed with Pneumocystis
jirovecii pneumonia (PJP). Which intervention, if included in the plan, requires the
nurse preceptor to step in and question its appropriateness?
Offering the client foods high in calories and protein
Instructing the client to drink at least 2-3L of fluid throughout the day
Wearing a surgical mask when standing within 3 ft of the client
Auscultating the client's breath sounds for crackles at least once per shift
Answer: ✔✔ Wearing a surgical mask when standing within 3 ft of the client.
,(Rationale: PJP is an opportunistic fungal infection that is acquired via
environmental exposure, not transmitted from person to person. Standard
precautions are entirely sufficient; droplet precautions—such as a surgical mask—
are clinically unnecessary unless the patient has a co-infection that requires it.)
the RN has provided d/c teaching to a pt who developed a pulmonary embolism
(PE) following a surgical procedure. the pt will be taking newly prescribed
Warfarin at home. which of the following pt statements indicates a correct
understanding of the teaching?
"i should avoid anything rectally, such as enemas or suppositories"
- no enemas, take stool softners, benefiber
the RN is caring for a pt who appears to have developed a pulmonary embolism
(PE). which of the following arterial blood gas results would the RN expect the pt
to initially have?
pH=7.50, PaO2=79mmHg, PaCO2=32mmHg, HCO3=23mEq/L, SaO2=88%
- respiratory alkalosis
the RN is caring for a pt who has a chest tube. which assessment finding from the
box below requires the RN to immed notify the PHCP?
- tracheal deviation (closes off the aorta, lose pedal pulses)
- 100 ml of drainage within an hour (over 70!!!!)
- visibility of the eyelets of the chest tube
, the RN is assessing a pt who has a chest tube places 36 hours ago for the tx of a
pneumothorax. the RN observes continuous bubbling in the water seal chamber.
which of the following actions should the RN take?
inform the PHCP that there is a leak in the system
the RN is assessing patients for the risk of developing ARDS. the RN should
identify at greatest risk is the pt who...?
had a stroke and is having difficulty swallowing
the RN has been made aware of the following pt situations. the RN should initially
follow up with the pt who is receiving...?
mechanical ventilation for the tx of ARDS and has an absence of breath sounds in
the LL lobe
- sx of PNEUMOTHORAX
the RN is caring for a pt who developed ARDS and has been placed on mechanical
ventilation. which of the following is a priority action for the RN to take?
initiate prescribed TPN
the RN has attended a continuing education program on interdisciplinary care. it
would indicate a correct understanding of the program if the RN identifies that an
interdisciplinary conference would be the most important for the pt who is...?
either / or
2 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS (GRADED A+)
Question: A nurse working in the emergency department has just completed the
triage of a patient presenting with acute chest discomfort, shortness of breath, a
productive cough, and a history of intense night sweats. The patient’s medical
background includes an AIDS diagnosis, and recent laboratory results indicate a
severely low CD4+ T-cell count. Which action must the nurse implement
immediately?
Initiate airborne precautions
Check the client's temp
Assess the client for shingles
Obtain a throat culture
Answer: ✔✔ Initiate airborne precautions
(Rationale: In a patient with advanced HIV/AIDS, symptoms like a productive
cough, night sweats, and chest pain are highly suspicious for active pulmonary
Tuberculosis. The nurse must place the patient in an isolation room with negative
pressure ventilation and initiate airborne precautions right away before
performing further diagnostic tests.)
Question: A newly hired nurse is creating an individualized plan of care for a
patient with advanced AIDS who has just been diagnosed with Pneumocystis
jirovecii pneumonia (PJP). Which intervention, if included in the plan, requires the
nurse preceptor to step in and question its appropriateness?
Offering the client foods high in calories and protein
Instructing the client to drink at least 2-3L of fluid throughout the day
Wearing a surgical mask when standing within 3 ft of the client
Auscultating the client's breath sounds for crackles at least once per shift
Answer: ✔✔ Wearing a surgical mask when standing within 3 ft of the client.
,(Rationale: PJP is an opportunistic fungal infection that is acquired via
environmental exposure, not transmitted from person to person. Standard
precautions are entirely sufficient; droplet precautions—such as a surgical mask—
are clinically unnecessary unless the patient has a co-infection that requires it.)
the RN has provided d/c teaching to a pt who developed a pulmonary embolism
(PE) following a surgical procedure. the pt will be taking newly prescribed
Warfarin at home. which of the following pt statements indicates a correct
understanding of the teaching?
"i should avoid anything rectally, such as enemas or suppositories"
- no enemas, take stool softners, benefiber
the RN is caring for a pt who appears to have developed a pulmonary embolism
(PE). which of the following arterial blood gas results would the RN expect the pt
to initially have?
pH=7.50, PaO2=79mmHg, PaCO2=32mmHg, HCO3=23mEq/L, SaO2=88%
- respiratory alkalosis
the RN is caring for a pt who has a chest tube. which assessment finding from the
box below requires the RN to immed notify the PHCP?
- tracheal deviation (closes off the aorta, lose pedal pulses)
- 100 ml of drainage within an hour (over 70!!!!)
- visibility of the eyelets of the chest tube
, the RN is assessing a pt who has a chest tube places 36 hours ago for the tx of a
pneumothorax. the RN observes continuous bubbling in the water seal chamber.
which of the following actions should the RN take?
inform the PHCP that there is a leak in the system
the RN is assessing patients for the risk of developing ARDS. the RN should
identify at greatest risk is the pt who...?
had a stroke and is having difficulty swallowing
the RN has been made aware of the following pt situations. the RN should initially
follow up with the pt who is receiving...?
mechanical ventilation for the tx of ARDS and has an absence of breath sounds in
the LL lobe
- sx of PNEUMOTHORAX
the RN is caring for a pt who developed ARDS and has been placed on mechanical
ventilation. which of the following is a priority action for the RN to take?
initiate prescribed TPN
the RN has attended a continuing education program on interdisciplinary care. it
would indicate a correct understanding of the program if the RN identifies that an
interdisciplinary conference would be the most important for the pt who is...?
either / or
