1) A patient with SLE has come to the clinic for a routine check-up. When auscultating the
patient's apical heart rate, the nurse notes the presence of a distinct “scratching” sound.
What is the nurse's most appropriate action?
a) Assess for any presence of peripheral pitting edema.
b) Document the presence of S3 and monitor the patient closely.
c) Inform the health care provider that a friction rub may be present.
d) Ask if patient has history of heart valve replacement recently.
2) A 70-year-old patient obtained 35% burn over the body. What gerontologic considerations should
the nurse include while implementing collaborative plan of care for this patient? Select all that apply.
a) Delayed wound healing is associated with higher mortality.
b) Increased cardiovascular compensatory response increases risk for complication.
c) Medication dosing is affected by kidney and hepatic function.
d) Older adult have profound alterations in metabolism.
e) Older adult patients have increased risk for multiple organ failure.
3) To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the
nurse review?
a) Nucleic Acid testing
b) Viral load testing
c) Rapid HIV antibody testing
d) Western Blot antibody testing
4) Which findings are AIDS-defining characteristics? Select all that apply
a) CD4+ cell count less than 200/mm3
b) Infection with pulmonary tuberculosis
c) Positive viral load testing
d) Presence of HIV wasting syndrome
e) Taking antiretroviral medications
5) A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection,
the nurse should prioritize assessment of what skin surfaces?
a) Perianal region and oral mucosa
b) Sacral region and lower abdomen
c) Scalp and skin over the scapulae
d) Axillae and upper thorax
6) The nurse is caring for a client who has been admitted for the treatment of AIDS. In the morning,
the client tells the nurse that he experienced night sweats and recently “coughed up some
blood.” What is the nurse's most appropriate action?
a) Discuss the proper usage of incentive spirometry.
b) Review the client's most recent viral load and CD4+ count.
c) Place the client on respiratory isolation and inform the physician.
d) Perform oral suctioning to reduce the client's risk for aspiration.
7) A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome leading to
nutritional deficit. Which intervention should the nurse implement related to nutrition? Select all that
apply.
a) Administer opiod and viscous lidocaine for oral lesions
b) Assess oral intake and may require enteral feeding
c) Provide oral hygiene before and after meals
d) Monitor hematocrit, hemoglobin, and ferritin levels
e) Encourage to turn, cough, and deep breath especially when activity is decreased.
, 8) A patient who has AIDS is being treated in the hospital and admits to having periods of extreme
anxiety. What would be the most appropriate nursing intervention?
a) Teach the patient guided imagery.
b) Give the patient more control of her antiretroviral regimen.
c) Increase the patient's activity level.
d) Collaborate with the patient's physician to obtain an order for hydromorphone.
9) A patient was admitted in the unit who has been diagnosed with AIDS complicated by chronic
diarrhea. What priority intervention should be included in the plan of care after assessing this patient?
Select all that apply.
a) Discourage smoking if indicated.
b) Maintain fluid intake of at least 1liter per day.
c) Encourage bananas, fried foods, nuts and raw vegetables.
d) Obtain a stool culture to identify possible pathogens.
e) Administer opioids and anticholinergic medication as prescribed.
10) While assessing the patient with systemic lupus eryhtematosus, which finding denotes possible
progression of the disease and takes a priority to report to the health care provider?
a) ph of 5.0 in the urinalysis report
b) blood pressure reading of 165/89 mm Hg
c) serum creatinine of 1.0 mg/dL
d) urine output of 250 ml in 8 hour shift
11) A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula.
The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of
administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
Round to the whole number.
a) 350 mL/hour
b) 523 mL/hour
c) 938 mL/hour
d) 1250 mL/hour
12) A patient is admitted to the burn unit after being transported from a facility 60 miles away. The
patient has burns to the groin area and circumferential burns to both upper thighs. While assessing the
patient's legs distal to the wound site, the nurse noted signs of ischemia. Which intervention should
the nurse implement related to the findings? Select all that apply.
a) report loss of pulse or presence of pain
b) elevate burned extremities
c) prepare to assist with possible escharotomies
d) apply sequential compression device to the affected leg
e) assess for urine output, increased BUN and creatinine
13) The nurse is caring for a client with systemic lupus erythematosus (SLE). Which interventions
would be beneficial for this client? Select all that apply.
a) Teach stress reduction techniques.
b) Teach ways to avoid exposure to sunlight.
c) Encourage balancing rest and activity.
d) Apply infection prevention measures.
e) Report signs of swelling on extremities and weight gain
14) An employee spills industrial acids on both arms and legs at work. What is the priority action that
the occupational health nurse at the facility should take?
a) Remove non-adherent clothing and jewelry.
b) Apply an alkaline solution to the affected area.
c) Place cool compresses on the area of exposure.
d) Cover the affected area with dry, sterile dressings.
patient's apical heart rate, the nurse notes the presence of a distinct “scratching” sound.
What is the nurse's most appropriate action?
a) Assess for any presence of peripheral pitting edema.
b) Document the presence of S3 and monitor the patient closely.
c) Inform the health care provider that a friction rub may be present.
d) Ask if patient has history of heart valve replacement recently.
2) A 70-year-old patient obtained 35% burn over the body. What gerontologic considerations should
the nurse include while implementing collaborative plan of care for this patient? Select all that apply.
a) Delayed wound healing is associated with higher mortality.
b) Increased cardiovascular compensatory response increases risk for complication.
c) Medication dosing is affected by kidney and hepatic function.
d) Older adult have profound alterations in metabolism.
e) Older adult patients have increased risk for multiple organ failure.
3) To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the
nurse review?
a) Nucleic Acid testing
b) Viral load testing
c) Rapid HIV antibody testing
d) Western Blot antibody testing
4) Which findings are AIDS-defining characteristics? Select all that apply
a) CD4+ cell count less than 200/mm3
b) Infection with pulmonary tuberculosis
c) Positive viral load testing
d) Presence of HIV wasting syndrome
e) Taking antiretroviral medications
5) A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection,
the nurse should prioritize assessment of what skin surfaces?
a) Perianal region and oral mucosa
b) Sacral region and lower abdomen
c) Scalp and skin over the scapulae
d) Axillae and upper thorax
6) The nurse is caring for a client who has been admitted for the treatment of AIDS. In the morning,
the client tells the nurse that he experienced night sweats and recently “coughed up some
blood.” What is the nurse's most appropriate action?
a) Discuss the proper usage of incentive spirometry.
b) Review the client's most recent viral load and CD4+ count.
c) Place the client on respiratory isolation and inform the physician.
d) Perform oral suctioning to reduce the client's risk for aspiration.
7) A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome leading to
nutritional deficit. Which intervention should the nurse implement related to nutrition? Select all that
apply.
a) Administer opiod and viscous lidocaine for oral lesions
b) Assess oral intake and may require enteral feeding
c) Provide oral hygiene before and after meals
d) Monitor hematocrit, hemoglobin, and ferritin levels
e) Encourage to turn, cough, and deep breath especially when activity is decreased.
, 8) A patient who has AIDS is being treated in the hospital and admits to having periods of extreme
anxiety. What would be the most appropriate nursing intervention?
a) Teach the patient guided imagery.
b) Give the patient more control of her antiretroviral regimen.
c) Increase the patient's activity level.
d) Collaborate with the patient's physician to obtain an order for hydromorphone.
9) A patient was admitted in the unit who has been diagnosed with AIDS complicated by chronic
diarrhea. What priority intervention should be included in the plan of care after assessing this patient?
Select all that apply.
a) Discourage smoking if indicated.
b) Maintain fluid intake of at least 1liter per day.
c) Encourage bananas, fried foods, nuts and raw vegetables.
d) Obtain a stool culture to identify possible pathogens.
e) Administer opioids and anticholinergic medication as prescribed.
10) While assessing the patient with systemic lupus eryhtematosus, which finding denotes possible
progression of the disease and takes a priority to report to the health care provider?
a) ph of 5.0 in the urinalysis report
b) blood pressure reading of 165/89 mm Hg
c) serum creatinine of 1.0 mg/dL
d) urine output of 250 ml in 8 hour shift
11) A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula.
The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of
administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
Round to the whole number.
a) 350 mL/hour
b) 523 mL/hour
c) 938 mL/hour
d) 1250 mL/hour
12) A patient is admitted to the burn unit after being transported from a facility 60 miles away. The
patient has burns to the groin area and circumferential burns to both upper thighs. While assessing the
patient's legs distal to the wound site, the nurse noted signs of ischemia. Which intervention should
the nurse implement related to the findings? Select all that apply.
a) report loss of pulse or presence of pain
b) elevate burned extremities
c) prepare to assist with possible escharotomies
d) apply sequential compression device to the affected leg
e) assess for urine output, increased BUN and creatinine
13) The nurse is caring for a client with systemic lupus erythematosus (SLE). Which interventions
would be beneficial for this client? Select all that apply.
a) Teach stress reduction techniques.
b) Teach ways to avoid exposure to sunlight.
c) Encourage balancing rest and activity.
d) Apply infection prevention measures.
e) Report signs of swelling on extremities and weight gain
14) An employee spills industrial acids on both arms and legs at work. What is the priority action that
the occupational health nurse at the facility should take?
a) Remove non-adherent clothing and jewelry.
b) Apply an alkaline solution to the affected area.
c) Place cool compresses on the area of exposure.
d) Cover the affected area with dry, sterile dressings.
