NUR 265 EXAM 4 QUESTIONS AND ANSWERS
The nurse working in the ED is triaging a client who has presented with chest pain, shortness of breath,
a productive cough, and reports nights sweats. That clients health history includes the presence of
acquired immunodeficiency syndrome (AIDS) and the recent laboratory results that reveal a low CD4+
count. Airborne precautions have been initiated. Which of the following actions should the nurse take
next?
ANSWER: Check the client’s temperature
RATIONALE: A fever is a symptom of AIDS exacerbation.
The newly hired nurse is developing a plan of care for a client who has acquired AIDS and was just
diagnosed with pneumocystis jiroveci pneumonia and pain. Which of the following interventions should
the nurse preceptor question?
ANSWER: Placing the client on a pressure-relieving mattress
RATIONALE: That is not an appropriate intervention.
The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis.
Which of the following actions should the nurse take?
ANSWER: Initiate seizure precautions with padded side rails
RATIONALE: Pg.965. Patients may have seizures.
The nurse had provided medication instructions to a client who has human immunodeficiency virus
(HIV) and has been prescribed combination antiretroviral therapy (cART). Which of the following client
statements indicates a correct understanding of the teaching?
ANSWER:“I can avoid developing drug resistance if I take 90% of my drugs on time.”
RATIONALE: Pg. 976. It is important to teach patients to take at least 90% of their meds on time to
prevent drug resistance.
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?
ANSWER: “I will wear a surgical mask when I change my cat’s litter box.”
RATIONALE: Pg. 974. Do not change cat’s litter box. Wear gloves and immediately wash hands.
The nurse is precepting a newly hired nurse who is caring for a client who has AIDS and has developed
Kaposil’s sarcoma. It requires additional teaching by the preceptor if the newly hired nurse
ANSWER: Applies a surgical mask before entering the client’s room.
RATIONALE: Pg.983. This is not an appropriate intervention.
The nurse is caring for a client who had a heart transplant 24 hours ago. Which of the following findings
indicates the clients developing a complication?
ANSWER: Hypotension
RATIONALE: Pg.1842. Hypotension is a symptom of heart transplant rejection.
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, 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
ANSWER: Developed sputum that is yellow tinged
RATIONALE: This is a sign of infection. KEY WORD: “DEVELOPED”
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 PCHP?
ANSWER: 2,4,5,6
RATIONALE: An increase in AST, increase in PT, INR, and bilirubin levels.
PT: 11-13.5
INR: 0.8-1.1
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?
ANSWER:Blood pressure of 172/96
RATIONALE: Pg.3615. Vital signs with special attention to BP.
The nurse working in a primary health care providers office has just administer a routine immunization
to a client. The client is asked to wait in the waiting room for the next 15 mins. 5 mins later the time
client developed swelling of the eyes and reports feeling anxious, SOB, and dizzy. Which of the
following actions should the nurse take first?
ANSWER: Perform a respiratory assessment
RATIONALE: Pg.1009. Immediately assess the respiratory status
The nurse is caring for a client who just received a pneumococcal polysaccharide vaccine. The client
reports feeling anxious, SOB, dizzy, and has an audible wheezing. Which actions from the box below
should the nurse take?
ANSWER:1,2,3,4
RATIONALE: Initiate oxygen via a nonrebreather mask, obtain IV access with a large bore IV,
Administer IM epinephrine 0.3 mL, Have a crash cart available in the client’s room
The newly hired nurse as attended a continuing education conference regarding anaphylaxis work
allergen exposure. Which of the following statements by the newly hired nurse indicates a correct
understanding of assessment findings in the client?
ANSWER: The client will present with widespread hives and hypoxia.
RATIONALE: Table 20-2. Hypoxia and widespread hives
The nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following
findings would the nurse identity as a complication of the disease?
This study source was downloaded by 100000841138256 from CourseHero.com on 06-21-2022 02:33:44 GMT -05:00
https://www.coursehero.com/file/119502905/Literally-Exam-4-NUR265-pdf/
The nurse working in the ED is triaging a client who has presented with chest pain, shortness of breath,
a productive cough, and reports nights sweats. That clients health history includes the presence of
acquired immunodeficiency syndrome (AIDS) and the recent laboratory results that reveal a low CD4+
count. Airborne precautions have been initiated. Which of the following actions should the nurse take
next?
ANSWER: Check the client’s temperature
RATIONALE: A fever is a symptom of AIDS exacerbation.
The newly hired nurse is developing a plan of care for a client who has acquired AIDS and was just
diagnosed with pneumocystis jiroveci pneumonia and pain. Which of the following interventions should
the nurse preceptor question?
ANSWER: Placing the client on a pressure-relieving mattress
RATIONALE: That is not an appropriate intervention.
The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis.
Which of the following actions should the nurse take?
ANSWER: Initiate seizure precautions with padded side rails
RATIONALE: Pg.965. Patients may have seizures.
The nurse had provided medication instructions to a client who has human immunodeficiency virus
(HIV) and has been prescribed combination antiretroviral therapy (cART). Which of the following client
statements indicates a correct understanding of the teaching?
ANSWER:“I can avoid developing drug resistance if I take 90% of my drugs on time.”
RATIONALE: Pg. 976. It is important to teach patients to take at least 90% of their meds on time to
prevent drug resistance.
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?
ANSWER: “I will wear a surgical mask when I change my cat’s litter box.”
RATIONALE: Pg. 974. Do not change cat’s litter box. Wear gloves and immediately wash hands.
The nurse is precepting a newly hired nurse who is caring for a client who has AIDS and has developed
Kaposil’s sarcoma. It requires additional teaching by the preceptor if the newly hired nurse
ANSWER: Applies a surgical mask before entering the client’s room.
RATIONALE: Pg.983. This is not an appropriate intervention.
The nurse is caring for a client who had a heart transplant 24 hours ago. Which of the following findings
indicates the clients developing a complication?
ANSWER: Hypotension
RATIONALE: Pg.1842. Hypotension is a symptom of heart transplant rejection.
This study source was downloaded by 100000841138256 from CourseHero.com on 06-21-2022 02:33:44 GMT -05:00
https://www.coursehero.com/file/119502905/Literally-Exam-4-NUR265-pdf/
, 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
ANSWER: Developed sputum that is yellow tinged
RATIONALE: This is a sign of infection. KEY WORD: “DEVELOPED”
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 PCHP?
ANSWER: 2,4,5,6
RATIONALE: An increase in AST, increase in PT, INR, and bilirubin levels.
PT: 11-13.5
INR: 0.8-1.1
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?
ANSWER:Blood pressure of 172/96
RATIONALE: Pg.3615. Vital signs with special attention to BP.
The nurse working in a primary health care providers office has just administer a routine immunization
to a client. The client is asked to wait in the waiting room for the next 15 mins. 5 mins later the time
client developed swelling of the eyes and reports feeling anxious, SOB, and dizzy. Which of the
following actions should the nurse take first?
ANSWER: Perform a respiratory assessment
RATIONALE: Pg.1009. Immediately assess the respiratory status
The nurse is caring for a client who just received a pneumococcal polysaccharide vaccine. The client
reports feeling anxious, SOB, dizzy, and has an audible wheezing. Which actions from the box below
should the nurse take?
ANSWER:1,2,3,4
RATIONALE: Initiate oxygen via a nonrebreather mask, obtain IV access with a large bore IV,
Administer IM epinephrine 0.3 mL, Have a crash cart available in the client’s room
The newly hired nurse as attended a continuing education conference regarding anaphylaxis work
allergen exposure. Which of the following statements by the newly hired nurse indicates a correct
understanding of assessment findings in the client?
ANSWER: The client will present with widespread hives and hypoxia.
RATIONALE: Table 20-2. Hypoxia and widespread hives
The nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following
findings would the nurse identity as a complication of the disease?
This study source was downloaded by 100000841138256 from CourseHero.com on 06-21-2022 02:33:44 GMT -05:00
https://www.coursehero.com/file/119502905/Literally-Exam-4-NUR265-pdf/
