Professional Documents
Culture Documents
Test Bank
MULTIPLE CHOICE
1. Which action by the nurse is most effective to prevent becoming exposed to the human
a.
b.
c.
d.
ANS: A
The best prevention for health care providers is the consistent use of Standard Precautions
with all clients, as recommended by the Centers for Disease Control and Prevention (CDC).
Contact Precautions are not indicated unless the client has an infection such as Clostridium
difficile or MRSA (methicillin-resistant Staphylococcus aureus).
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is caring for a young client who has acquired immune deficiency syndrome (AIDS)
and a very low CD4+ cell count. The nurse is teaching the client how to avoid infection at
home. Which statement by the client indicates that additional teaching is needed?
a. I will let my sister clean my pet iguanas cage from now on.
b. My brother will change the kitty litter box from now on.
c. It will seem funny but Ill run my toothbrush through the dishwasher.
d. I will not drink juice that has been sitting out for longer than an hour.
ANS: A
Immune compromised clients should avoid having reptiles or turtles as pets and should avoid
changing cat litter to help prevent opportunistic infections. Drinking juice that has been at
room temperature for longer than 1 hour can lead to opportunistic infection and should be
avoided. Clients should clean their toothbrushes daily by running them in the dishwasher or
rinsing them in liquid laundry bleach.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
3. The nurse is working with a client at a public health clinic. The client says to the nurse, The
doctor said that my CD4+ count is 450. Is that good? What is the nurses best response?
a. Your count is high so you can cut back on your medication.
b. Your count is normal because your medications are working well.
c. Your count is a bit low and you are susceptible to infection.
d. Your count is very low and you actually now have AIDS.
ANS: C
A CD4+ T-cell count of 450 cells/mm3 of blood is low, and the client is at increased risk for
developing an infection. Normal CD4+ counts range from 800 to 1000 cells/mm3. To be
diagnosed with AIDS, a client must have a CD4+ T-cell count of <200 cells/mm3 (or a CD4+
T-cell percentage of <4%) and/or an opportunistic infection.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 360
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory
Values)
MSC: Integrated Process: Teaching/Learning
4. The nurse is caring for a young woman at the primary health care clinic. Which assessment
finding leads the nurse to question the client about risk factors for HIV?
a. Six vaginal yeast infections in the last 12 months
b. Unable to become pregnant for the last 2 years
c. Severe cramping and irregular periods
d. Very heavy periods and breakthrough bleeding
ANS: A
Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women.
Decreased immune function allows overgrowth of this fungus. Infertility, heavy periods, and
cramping are not generally indicative of HIV.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 361
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
5. A client who is positive for HIV presents with confusion, fever, headache, blurred vision,
The clients symptoms are associated with cryptococcal meningitis, so the nurse should first
ask the client to place the chin on his or her chest. The presence of nuchal rigidity (pain when
flexing the chin to the chest) helps confirm the diagnosis. An IV line may be started after the
neurologic assessment is completed.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal
a.
b.
c.
d.
ANS: B
2 weeks. The clients purified protein derivative (PPD) test, placed 3 days ago in the clinic, is
negative. Which action by the nurse is most appropriate?
a. Place the client in Airborne Precautions.
b. Facilitate the clients chest x-ray.
c. Initiate a 3-day calorie count.
d. Start an IV of normal saline.
ANS: A
The clients symptoms are indicative of tuberculosis (TB). With AIDS, the clients CD4+ Tcell count is so low that the client cannot mount an immune response to the PPD; thus it
appears negative. The client needs to be placed in Airborne Precautions until other diagnostic
tests rule out TB. The other interventions are appropriate, but they do not take priority over
infection control principles.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Analysis)
8. The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide
(Fuzeon). Which precaution is important for the nurse to communicate to this client?
Stop taking the medication if you develop a fever.
Rotate the sites where you will be giving the injections.
Take this medication with a snack or a small meal.
Do not drive or operate machinery while taking this drug.
a.
b.
c.
d.
ANS: B
Fuzeon is available only as a subcutaneous injection and can cause injection site reactions and
nodules. The client should be taught the subcutaneous technique, including rotation of sites.
The client should not stop taking this medication for fever, it can be given without regard to
food, and the drug will not make the client sleepy or drowsy, so caution with driving or
operating machinery is not needed.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Medication Administration) MSC:
Integrated Process: Teaching/Learning
9. A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, The
doctor said that my viral load is reduced. What does this mean? What is the nurses best
response?
a.
b.
c.
d.
ANS: A
The fact that the amount of virus is reduced means that the HAART regimen is working well
to suppress viral replication. The risk of becoming infected by an HIV-positive person is
always present. The reduced viral load is not related to an opportunistic infection or to
resistance to medication.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 370
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes)
MSC: Integrated Process: Communication and Documentation
10. The nurse is seeing clients at a drop-in primary health clinic. Which client does the nurse
a.
b.
c.
d.
ANS: C
All sexually active people should know their HIV status, and all people need to have
education on their risk of acquiring HIV infection. Anyone who engages in sexual activity has
some risk.
DIF: Cognitive Level: Knowledge/Remembering
REF: p. 362
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems)
MSC: Integrated Process: Teaching/Learning
11. An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal
a.
b.
c.
d.
ANS: B
Kaletra can cause liver complications, and clients taking it should have liver function studies.
The clients symptoms could indicate a liver problem. Renal function and blood glucose are
not affected by Kaletra. The client may have an albumin and a prealbumin drawn if he or she
has lost a great deal of weight and malnutrition is suspected, but the more common diagnostic
test for a client taking Kaletra would be liver function studies.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
12. The nurse has been exposed to HIV through splashing of urine from a client who is HIV
positive with a low viral load. The urine came into contact with the nurses face. Which drug
regimen does the nurse prepare to initiate?
a. Retrovir (zidovudine) for 14 days
b. Retrovir (zidovudine) for 28 days
c. Retrovir (zidovudine) and Epivir (lamivudine) for14 days
d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days
ANS: D
The Centers for Disease Control and Prevention have developed guidelines for postexposure
prophylaxis (PEP). This nurses exposure requires basic PEP with two drugs for 28 days.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Planning)
13. The nurse is teaching a client how to prevent transmitting HIV to his sexual partner. Which
a.
b.
c.
d.
ANS: B
Condoms should be stored in a cool, dry place. Wallets are not recommended because body
heat can weaken the latex in the condom. The condom should stay on the penis until it is
completely withdrawn. Condoms should be used only once and then discarded. Oil-based
lubricants can weaken latex, possibly causing tearing or leakage, so only water-based
lubricants are recommended.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Teaching/Learning
14. The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a
a.
b.
c.
d.
ANS: B
HIV may be transmitted via oral sex when mucous membranes or nonintact skin comes in
contact with infected body fluids (semen or vaginal secretions) or blood. Women who are HIV
positive may get pregnant, and showering after intercourse will not reduce the risk of HIV
transmission. HAART will lower viral loads, but the client will still be able to transmit the
HIV virus to others.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Teaching/Learning
15. The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement
a.
b.
c.
d.
ANS: D
The client should avoid eating raw fruits, vegetables, and salads because of the risk of
infection. Hands should be washed whenever returning home, and immune compromised
clients should not share toothbrushes or toothpaste. Toothbrushes should be run through the
dishwasher nightly.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
16. The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The
client states, Im an old woman! I cannot possibly get HIV. What is the nurses best
response?
a. Your vaginal walls become thicker after menopause, which increases your risk.
b. Women in your age-group are the fastest growing population of AIDS clients
today.
c. Hormonal fluctuations after menopause make it harder to fight off infection.
d. You might be right. How often do you engage in sexual activities?
ANS: B
Women are the fastest growing group with HIV infection and AIDS. Infection with HIV can
occur at any age, and postmenopausal women experience thinning of vaginal tissue along with
an age-related (not hormonal) decline in immune function. This places the older woman at
higher risk of acquiring HIV infection. The frequency of sexual activity is not as relevant as
the sexual activities the person practices.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 361
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Teaching/Learning
17. A client has selective immune globulin A (IgA) deficiency. The provider orders an infusion of
a.
b.
c.
d.
ANS: B
Clients with selective IgA deficiency are not treated with IVIG because it contains very little
IgA, and because the risk of allergic reactions is high. The nurse should contact the provider
to clarify what medications the client will be taking.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
discharged to the care of family members. What teaching topic is best for the nurse to include
in the discharge plan?
a. Feed the client when he will not do it by himself.
b. Make sure that a clock and a calendar are easily visible.
c. Remove locks from bathroom and bedroom doors.
d. Do not allow the client to smoke when he is alone.
ANS: B
Having a clock and a calendar easily visible will help the client keep track of the date and time
and will assist with reorientation. Banning smoking, removing locks, and feeding the client
will not facilitate reorientation when the client is confused.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Behavioral Interventions)
MSC: Integrated Process: Teaching/Learning
19. A client with HIV who is taking highly active antiretroviral therapy (HAART) medications is
in radiology waiting for a chest x-ray when medications are due. What action by the nurse is
best?
a. Call radiology to see when the client will be brought back to the nursing unit.
b. Send the nursing assistant to radiology to bring the client back to the nursing unit.
c. Take the clients medications to radiology and administer them there if possible.
d. Stagger the next dose of the medication if the current dose is given late.
ANS: C
HAART medications must be given on time and in the correct dose when an HIV client is in
the hospital. Missing or delaying even a few doses can lead to drug resistance. The best option
would be for the nurse to administer the medications in radiology as the client continues to
wait for the x-ray. Calling the radiology department might give the nurse information but does
not ensure that the client receives the medication on time. Bringing the client back to the
nursing unit might delay the x-ray.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Medication Administration)
MSC: Integrated Process: Nursing Process (Implementation)
20. An HIV-positive client verbalizes concerns about the high cost of antiretroviral medications.
a.
b.
c.
d.
ANS: D
This response demonstrates the nurses role as client advocate by identifying resources to help
meet the clients needs. The nurse should not belittle the clients concerns by telling the client
to be glad the medications are working, or that they are less expensive than previously.
course of the shift, and the clients pupils are no longer reacting to light equally. The nurse
anticipates an order for which medication?
a. Prednisone (Deltazone)
b. Trimethoprim/sulfamethoxazole (Bactrim)
c. Pentamidine isethionate (Pentam)
d. Ketoconazole (Nizoral)
ANS: A
substance abuse. What instructions does the nurse provide to the client to help minimize this
risk?
a. Boil all needles and syringes for at least 20 minutes before using them again and
be sure not to share them.
b. Rinse used needles and syringes with water followed by laundry bleach after using
them.
c. Rinse used needles and syringes with rubbing alcohol before and after using
them.
d. Run all needles and syringes through the dishwasher with an extra rinse cycle
before using them again.
ANS: B
To minimize the risk for HIV transmission, needles should be cleaned with laundry bleach
after use. Boiling needles and syringes and rinsing with alcohol are not recommended.
Running needles and syringes through the dishwasher will not sanitize them sufficiently. The
client should be encouraged not to share needles and syringes.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 362
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Teaching/Learning
23. The nursing supervisor is working with an HIV-positive nurse who has open weeping blisters
on her arms after being exposed to poison ivy. Which instructions should the nursing
supervisor provide to the nurse before she starts her shift?
a. You should reassure your clients that you are not contagious.
b. You should work phone triage at the desk today rather than taking clients.
c. You should wear a long-sleeved scrub jacket today while working with clients.
d. You should not care for clients who are immune compromised or in isolation.
ANS: B
HIV-positive health care workers should not perform direct client care when they have open
sores.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Planning)
24. The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in
a.
b.
c.
d.
ANS: D
Candidiasis, which presents with thick white patches on the tongue and oral mucosa, is
associated with the development of AIDS after HIV infection. The fact that the client has been
positive for 8 years or has a low-grade fever is not significant.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
25. A nursing assistant asks the nurse if respiratory isolation is needed for a client with
a.
b.
c.
d.
ANS: A
Pneumocystis jiroveci pneumonia is an opportunistic infection that will not cause disease in
staff with healthy immune systems. Standard Precautions should be used for this client.
Contact, Airborne, or Droplet Precautions are not indicated for this client. Health care staff do
not get vaccinated for this infection.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
26. When obtaining a sexual history from a client in a clinic setting, the nurse notes that the client
appears very uncomfortable and pauses for long periods before answering the nurses
questions. What is the nurses best response?
a. I am sorry that my questions are making you very uncomfortable.
b. Dont worry. Well be done with these questions in no time at all.
c. Take your time. I realize that this is a very private topic to talk about.
d. These questions are making you uncomfortable, so well finish next time.
ANS: C
The client should be given time to collect his or her thoughts and composure before answering
questions. The nurse should not apologize for asking pertinent questions about the clients
health history. The sexual history should not be deferred until the next appointment.
Recognizing the difficulty the client may be experiencing is helpful in establishing a
therapeutic relationship.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)
MSC: Integrated Process: Caring
27. The nurse asks a young adult client if she is sexually active. The client asks why the nurse
a.
b.
c.
d.
ANS: C
The nurse should assess whether the client is sexually active to determine whether it is
appropriate to teach about safer sex practices. The nurse would not notify the clients sexual
partners if a sexually transmitted disease were diagnosed.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
MSC: Integrated Process: Caring
28. The nurse is completing a health history for a client and begins to obtain a sexual history.
a.
b.
c.
d.
ANS: C
The nurse should begin with an assessment of the clients comfort level with the topic. The
nurse should not assume that the client is sexually active or start with questions about the
clients spouse. The nurse also should not use words like monogamous, which frequently
are misunderstood by the public. The question about sexual ability and enjoyment is a closedended question, and if the client answers no, it will be awkward for the nurse to continue
discussing this topic.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)
MSC: Integrated Process: Caring
29. The nurse is caring for a client with HIV who has been prescribed didanosine (Videx EC).
ANS: A
Videx EC must be taken on an empty stomach 30 minutes before or 2 hours after a meal. The
nurse should assist the client in planning a daily schedule that includes meals and drug doses.
Videx does not affect bone marrow, so frequent CBCs are not needed. A client on this drug
who reports abdominal pain should be assessed for pancreatitis, a common adverse effect.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
MULTIPLE RESPONSE
1. The nurse is caring for a hospitalized client who has AIDS and is severely immune
compromised. Which interventions are used to help prevent infection in this client? (Select all
that apply.)
a. Use sterile gloves and gowns whenever the nursing staff is in contact with the
client.
b. Provide an incentive spirometer to encourage coughing and deep breathing by the
client.
c. Keep a blood pressure cuff, thermometer, and stethoscope in the clients room for
his or her use only.
d. Use N95 respirators (all nursing staff) when in the clients room.
e. Request that the family take home the fresh flowers that are at the clients bedside.
f. Assist the client with meticulous oral care after meals and at bedtime.
ANS: B, C, E, F
The nursing staff should encourage coughing and deep breathing to prevent pneumonia, and
incentive spirometry will be helpful. Assessment equipment such as thermometers and blood
pressure cuffs should be kept in the room only for the use of this client, rather than being used
by other clients on the unit as well. Fresh flowers can harbor microorganisms and should be
removed from the room. Meticulous oral care will help to prevent infection by Candida.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
SHORT ANSWER
1. The nurse is to give a client ganciclovir (Cytovene) for cytomegalovirus (CMV) retinitis. The
dosage is 5 mg/kg IV every 12 hours. The client weighs 185 pounds. How many milligrams of
ganciclovir does the client receive per dose?
mg/dose
ANS:
420
185 lb 1 kg/2.2 lb 5 mg/kg = 420 mg/dose
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Medication Administration)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is to give a client rifampin (Rifadin) for tuberculosis. The dosage is 10 mg/kg/day.
The client weighs 198 lb, and the medication is available in 150-mg capsules. How many
capsules of rifampin does the client receive daily? __________ capsules/day
ANS:
6
198 lb 1 kg/2.2 10 mg/kg = 900 mg 1 capsule/150 mg = 6 capsules/day
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Medication Administration)
MSC: Integrated Process: Nursing Process (Implementation)