Chapter 21: Care of Clients with HIV Disease and Other Immune Deficiencies Nursing School Test Banks

Chapter 21: Care of Clients with HIV Disease and Other Immune Deficiencies

Test Bank

MULTIPLE CHOICE

1. Which action by the nurse is most effective to prevent becoming exposed to the human immune deficiency virus (HIV)?

a.

Always use Standard Precautions with all clients in the workplace.

b.

Place clients who are HIV positive in Contact Precautions.

c.

Wash hands before and after contact with clients who are HIV positive.

d.

Convert parenteral medications to an oral form for clients who are HIV positive.

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 ControlStandard 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, nausea, and vomiting. What does the nurse do first?

a.

Assess the clients deep tendon reflexes.

b.

Ask the client to place his chin on his chest.

c.

Start an IV line with normal saline.

d.

Assess the clients pupil reaction.

ANS: B

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 meningitis. Which is the best nursing intervention for this client?

a.

Initiate respiratory isolation for the next 72 hours.

b.

Initiate seizure precautions with padded siderails.

c.

Thicken the clients liquids to honey consistency.

d.

Administer IV pentamidine isethionate (Pentam).

ANS: B

Cryptococcosis is a debilitating form of meningitis that can cause seizures, so seizure precautions should be initiated. Respiratory isolation is not indicated. Dysphagia is not seen with cryptococcal meningitis, so thickened liquids are not indicated. Pentam is given for Pneumocystis jiroveci pneumonia (PJP).

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

7. A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 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+ T-cell 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 ControlStandard 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?

a.

Stop taking the medication if you develop a fever.

b.

Rotate the sites where you will be giving the injections.

c.

Take this medication with a snack or a small meal.

d.

Do not drive or operate machinery while taking this drug.

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 TherapiesMedication 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.

The HAART medications are working well right now.

b.

You are not as contagious as you were anymore.

c.

Your HIV infection is becoming resistant to your medications.

d.

You are developing an opportunistic infection.

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 TherapiesExpected 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 teach about the risks of acquiring HIV?

a.

Middle-aged woman with a new sexual partner

b.

Young male who has male sexual partners

c.

All clients who come to the clinic

d.

Young woman having her first gynecologic examination

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 pain, and diarrhea. What orders does the nurse anticipate?

a.

Renal function studies

b.

Liver enzymes

c.

Blood glucose monitoring

d.

Albumin and prealbumin

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 TherapiesAdverse 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 statement by the client indicates that additional teaching is needed?

a.

I can throw the condoms in the trash after I have used them.

b.

I will store my condoms in my wallet so they are always handy.

c.

Water-based lubricants are best to prevent condom breakage.

d.

The condom needs to stay on until I withdraw my penis.

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 student indicates that additional teaching is required?

a.

A woman can still get pregnant if she is HIV positive.

b.

I wont get HIV if I only have oral sex with my partner.

c.

Showering after intercourse will not prevent HIV transmission.

d.

People with HIV are still contagious even if they take HAART drugs.

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 indicates that additional teaching is needed?

a.

I will wash my hands whenever I get home from work.

b.

I will make sure to have my own tube of toothpaste at home.

c.

I will run my toothbrush through the dishwasher every evening.

d.

I will be sure to eat lots of fresh fruits and vegetables every day.

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 immune globulin (IVIG). Which action by the nurse is best?

a.

Start a second IV line for the clients antibiotics.

b.

Call the physician to clarify the order.

c.

Review the clients renal panel before administration.

d.

Obtain baseline vital signs and another set after 15 minutes.

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 TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

18. The nurse is working with a client who has AIDS-related dementia and will soon be 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 TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

20. An HIV-positive client verbalizes concerns about the high cost of antiretroviral medications. What is the nurses best response?

a.

The medications are actually less expensive than they used to be.

b.

These medications are the best course of treatment for you.

c.

You should be glad the medications will help prolong your life.

d.

Lets talk to the social worker about getting financial assistance for you.

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with the Interdisciplinary Team) MSC: Integrated Process: Caring

21. The nurse is caring for a client who is HIV positive. The client has become confused over the 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

Confusion and changes in pupillary assessment in an HIV-positive client indicate increased intracranial pressure (ICP). Increased ICP in these clients is managed with corticosteroids like prednisone. Bactrim is an antibiotic, Pentam is an antiprotozoal, and Nizoral is an antifungal medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis)

22. A client verbalizes a fear of contracting HIV because she has a history of intravenous 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 ControlStandard 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 confirming progression of the clients diagnosis to AIDS?

a.

Generalized lymphadenopathy

b.

HIV-positive status for 8 years

c.

Low-grade fever for the last 10 days

d.

Thick white patches on the clients tongue

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 Pneumocystis jiroveci pneumonia. What is the nurses best response?

a.

This type of pneumonia is an opportunistic infection, so the staff is not at risk.

b.

You should wear a mask and a gown to provide care.

c.

Yes, please institute respiratory isolation because this is very contagious.

d.

You are not at risk for this infection if you have had a vaccination.

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 ControlStandard 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 needs to know. What is the nurses best response?

a.

I just need to make sure that the information you are providing is reliable.

b.

I have to fill in answers to all of the questions on the health history form.

c.

If you are sexually active, we should talk about ways to prevent getting HIV.

d.

I will have to notify your partner if you have a sexually transmitted disease.

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. What is the nurses best opening question?

a.

How long have you been sexually active?

b.

Are you in a monogamous relationship with your spouse?

c.

How do you feel about answering questions about your sexual history?

d.

Have you noticed any problems with your ability to have or enjoy sex?

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 closed-ended 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). Which action by the nurse is most appropriate?

a.

Help the client plan specific meal and dosing times.

b.

Explain that the client will have frequent complete blood counts (CBCs) drawn.

c.

Advise the client to take Videx EC with milk or a small meal.

d.

Tell the client to take Tylenol (acetaminophen) for any abdominal pain.

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 TherapiesAdverse 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 ControlStandard 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 TherapiesMedication 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 TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

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