Exam 3 Flashcards
Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors?
A. Activating the viral enzyme “integrase” within the infected host’s cells
B. Binding of the virus to the CD4+ receptor and either of the two co-receptors
C. Clipping the newly generated viral proteins into smaller functional pieces
D. Fusing of the newly created viral particle with the infected cell’s membrane
C
Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 × 109/L) to 400 cells/mm3 (0.2 × 109/L) indicates to the nurse that more teaching is needed?
A. “Now my viral load is also probably lower.”
B. “I am so relieved that my drug therapy is working.”
C. “Although I am still HIV positive, at least I no longer have AIDS.”
D. “This change means I am less likely to develop an opportunistic infection.”
c
The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane, so he missed all of yesterday’s dosages. What action does the nurse recommend?
A. “Take today’s dosages as normally prescribed and continue to follow your therapy program.”
B. “Don’t worry. Unless you miss your drugs for 4 days consecutively, there is not a problem.”
C. “Take double doses of the drugs for the next 2 days and do not have sex for at least 4 days.”
D. “Go to the nearest emergency department and have an immediate blood test for assessment of viral load.”
A
What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed this drug?
A. “Do you have glaucoma or any other problem with your eyes?”
B. “Do you take medications for a seizure disorder?”
C. “Are you allergic to sulfa drugs?”
D. “Are you a diabetic?”
C
Which activities can the nurse postpone or eliminate for the client who has extreme fatigue today? Select all that apply.
A. Administering prescribed drug therapy
B. Ambulating in the hall
C. Culturing suspected infectious drainage
D. Performing pulmonary hygiene
E. Performing oral care
F. Providing a complete bed bath
G. Teaching about nutrition therapy
B, F, G
Which dietary change does the nurse suggest for the client who has esophageal candidiasis?
A. “Avoid drinking alcoholic beverages.”
B. “Eat soft, cool food such as pudding and smoothies.”
C. “Limit your intake of fluid to no more than 1 L daily.”
D. “Increase your intake of cooked leafy green vegetables.”
B
Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors?
A. Activating the viral enzyme “integrase” within the infected host’s cells
B. Binding of the virus to the CD4+ receptor and either of the two co-receptors
C. Clipping the newly generated viral proteins into smaller functional pieces
D. Fusing of the newly created viral particle with the infected cell’s membrane
B
Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid?
A. Caffeinated beverages
B. Grapefruit juice
C. Dairy products
D. St. John’s wort
D
A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient’s pregnancy?
A. Abacavir
B. Darunivir
C. Tripanavir
D. Raltegravir
A
Which statement(s) regarding type III hypersensitivity reactions is/are true? Select all that apply.
A. Type III responses are usually directed against self cells and tissues.
B. Susceptibility for developing a type III hypersensitivity response follows an autosomal dominant pattern of inheritance.
C. The hypersensitivity starts as a type II reaction that progresses to a type III reaction.
D. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages.
E. Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity.
F. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.
A, E
Which new-onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm?
A. Increased bruising
B. Increased daily output of slightly foamy urine
C. Failure to see letters in the middle of a word
D. Sensation of nausea within an hour of taking the drug
C
Which statement(s) regarding type I hypersensitivity reactions is/are true? Select all that apply.
A. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine.
B. The response is characterized by the five cardinal symptoms of inflammation.
C. Type I responses are usually directed against non-self but the response is excessive.
D. Susceptibility for developing a type I hypersensitivity response follows an X-linked recessive pattern of inheritance.
E. This type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus.
F. Responses always occur within minutes of exposure to the allergen.
G. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.
B, C, G
Which action will the nurse perform first for a client in anaphylaxis to prevent harm?
A. Applying oxygen by nonrebreather mask
B. Administering IV diphenhydramine
C. Injecting epinephrine
D. Initiating IV access
C
Which client does the oncoming ED nurse see first when assigned to care for four clients?
A. 21-year-old with a skin rash who has been waiting 2 hours to see a provider
B. 30-year-old with influenza who has infusing IV fluids and is resting quietly
C. 47-year-old who fell off of a curb, resulting in a sprained ankle
D. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior
D
What mechanism of injury will the nurse document for a client in a motor vehicle accident whose airbag deployed when the car struck a tree at 40 miles per hour? Select all that apply.
A. Blast
B. Blunt
C. Laceration
D. Penetration
E. Acceleration-deceleration
B, E
On entry to the ED of a client who fell from a roof, what is the nurse’s priority action?
A. Place nasal cannula to administer oxygen.
B. Apply pressure to small bleeding wounds.
C. Assess airway and stabilize cervical spine.
D. Initiate large-bore IV to infuse normal saline.
C
What is the nurse’s priority action for the unconscious patient who is breathing who has been brought to the ED?
A. Assess breath sounds and respiratory efforts
B. Establish vascular access with a large-bore catheter
C. Remove clothing to perform a complete physical assessment
D. Evaluate level of consciousness (LOC) using the Glasgow Coma Sale (GCS)
A
. After assessing four clients, which will the triage nurse identify to be seen first in the ED?
A. Client with fever of 101.2°F
B. Client who reports slurred speech
C. Client who reports bilateral ear pain
D. Client with urinary burning and frequency
A
What teaching will the nurse provide to an older adult who has a history of heat exhaustion? Select all that apply.
A. Take frequent rest breaks when doing activities
B. Drink caffeinated beverages before going in the sun
C. Wear dark clothing to protect the skin from burning
D. Stay indoors in an air-conditioned room when possible
E. Take warm baths or showers to regulate the body temperature
A,D,E
When caring for four clients, which does the nurse identify as at the highest risk for frostbite?
A. 19-year old who takes antihistamines
B. 28-year old who is a vegetarian
C. 41-year old who is being treated for hypothyroidism
D. 57-year old who drinks 4-5 beers per day
D
In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake?
A. Apply ice to the site of the wound
B. Extract venom by sucking the wound
C. Apply a tourniquet to the affected arm
D. Immobilize the extremity at the level of the heart
D
When caring for a client who become ill while mountain climbing, which assessment finding requires immediate nursing intervention? Select all that apply.
A. Blue nail beds
B. Lung crackles
C. Tachypnea at rest
D. Pink, frothy sputum
E. Persistent dry cough
F. Pulmonary infiltrates per x-ray
G. Increased pulmonary artery pressure
All
What is the priority nursing action when a nurse observes an adult drowning in a lake?
A. Stabilize the spine with a board
B. Consider personal swimming abilities
C. Safely remove person from the water
D. Initiate airway clearance and deliver rescue breaths
b
In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake?
A. Apply ice to the site of the wound
B. Extract venom by sucking the wound
C. Apply a tourniquet to the affected arm
D. Immobilize the extremity at the level of the heart
d
After a mass casualty event, which client will the nurse triage with a yellow tag?
A. 29-year old with third-degree burns over 80% of the body
B. 36-year old with closed fractures of both legs
C. 48-year old with wheezing and difficulty breathing
D. 52-year old with multiple abrasions and contusions
b
Which assignment will the ED charge nurse make when nurses from within the hospital are floated to the ED to care for clients affected by an earthquake? Select all that apply.
A. GI laboratory nurse assigned to clients needing sedation
B. Psychiatric nurse assigned to care for clients with lacerations
C. Orthopedic nurse assigned to accompany clients to radiology
D. Nurse administrator assigned to sit with loved ones in the waiting room
E. Medical-surgical nurse assigned to health care worker who is feeling overwhelmed
A, C, D
When creating a personal emergency preparedness plan, which does the nurse include? Select all that apply.
A. Assembling a go bag
B. Arranging for child care
C. Determining who will care for pets
D. Noting who will be called when the plan is activated
E. Identifying how long the emergency is expected to last
F. Noting where a nurse is expected to report if the emergency plan is activated
G. Collecting names, addresses, and telephone numbers to be used if a crisis occurs
A, B, C, D, F, G
What is the appropriate nursing action when assessing that a client scored 40 on the IES-R?
A. Triage with a black tag
B. Prepare for discharge to home
C. Administer oxygen and assess saturation
D. Refer to a psychiatrist or mental health counselor
D
What is the appropriate nursing response when asked to report to work to assist with a mass casualty event?
A. Report to work when asked by a supervisor
B. Refrain from working to care for family members
C. Refer to the ANA Code of Ethics for Nurses for direction
D. Agree to work for several hours until other nurses arrive to assist
C
A client with obesity tells the nurse, “My genes are the only thing that have made me obese.” What is the appropriate nursing response? Select all that apply.
A. “Genes can contribute to obesity.”
B. “Tell me about your family history.”
C. “Let’s talk about your nutrition intake.”
D. “Have you considered bariatric surgery?”
E. “How do you feel about physical activity?”
F. “What lifestyle modifications have you tried?”
A, B, C, E, F
