A The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. the nurse is assisting in planning care for a client diagnosed with immunodeficiency and should incorporate wh...
NUR 211 Test 3 Questions and Correct
Answers
A
The client with immunodeficiency has inadequate or absence of immune bodies and is
at risk for infection. The priority nursing intervention would be to protect the client from
infection. ✅the nurse is assisting in planning care for a client diagnosed with
immunodeficiency and should incorporate which action as a priority in the plan?
A. Protecting the client for infection
B. Providing emotional support to decrease fear
C. Encouraging discussion about lifestyle changes
D. Identifying factors that decreased the immune function
D
The client with parkinsons disease should be instructed regarding safety measures in
the home. The client should use her or his walker as support to get to the bathroom
becaus e of bradykinesia. The client should sit down to put on pants and shoes to
prevent falling. The client should exercise everyday in the morning when energy levels
are the highest. The client should have all loose rugs in the home removed to prevent
falling. ✅the nurse is instructing a client with parkinsons disease about preventing falls.
Which client statement reflects a need for further teaching?
A. I can sit down to put on my pants and shoes
B. I try to exercise everyday and rest when im tired.
C. My son removed all loose rugs from my bedroom.
D. I dont need to use my walker to get to the bathroom.
C
Although all of these actions fall into the scope of practice for a uap, the uap should help
the client with morning care as needed but the goal is to keep this client as independent
and mobile as possible. The client should be encouraged to perform as much morning
care as possible. Assisting the client in ambulating, reminding them not to look at his
feet to prevent falls, and encouraging the client to feed himself are all appropriate to the
goal of maintaining independence ✅a client with parkinsons disease has a problem
with decreased mobility related to neuromuscular impairment. The nurse observes the
uap performing all of these actions. For which action should the nurse intervene?
A. Helping the client ambulate to the bathroom and back to bed
B. Reminding the client not to look at his feet when he is walking
C. Performing the clients complete bathing and oral care
D. Setting up the clients tray and encouraging the client to feed himself
A
At this time based on the clients statement related to being tired after physical therapy is
the reason behind being unable to perform adls. The other three are related to the
,diagnosis of ms but not related to the topic. ✅a client with ms tells the uap after
physical therapy that she is too tired to take a bath. What is the priority nursing concern
at this time?
A. Fatigue
B. Inability to perform adls
C. Decreased mobility
D. Muscular weakness
A, c, e
Uap education and scope of practice include checking pulse and bp measurements.
The nurse would be sure to instruct the uap to report hr and bp findings. In addition
uaps can reinforce previous teaching or skills taught by the rn or by personnel in other
disciplines like pt or st. Evaluating medication is within the rn scope of practice ✅all if
the following nursing care activities are included in the care plan for a 78 year old man
with parkinsons disease who has been referred to home health agency. Which activities
will the nurse delegate to the uap? Select all that apply
A. Check for orthostatic changes in pulse and bp
B. Assessing for improvement in tremor after levodopa is given
C. Reminding the client to allow adequate time for meals
D. Monitoring for signs of toxic reactions to anti-parkinsons medications
E. Assisting the client with prescribed strengthening exercises
F. Adapting the clients preferred activities to his level of function
B
cdc guidelines indicate that a post exposure prophylaxis is to be used antiretroviral
drug should be started as soon as possible preferably with an hours of exposure. It is
important that staff understand that reporting the possible exposure is a priority so that
the rapid assessment and treatment can be initiated. The other statements are also true
but will not impact the efficacy of any needed treatment ✅when the occupational
health nurse is teaching uap about bloodborne pathogen exposure and hiv risk, which
information is most important to emphasize?
A. Occupational transmission of hiv from patients to health care workers is relatively
rare
B. Occupational exposure to hiv containing fluids should be reported immediately to the
supervisor
C. Treatment for occupational exposure to hiv may include use of antiretroviral
medications
D. Post exposure treatment will include hiv testing at baseline and at several intervals
after the exposure
A
Supplying sterile injections supplies to patients who are at risk for hiv infection can be
done by staff members with uap education. Assessing for high-risk behaviors education
and community assessment are rn level skills ✅the nurse manager in a public health
department is implementing a plan to reduce the incidence of infections with hiv in the
community. Which nursing action will be delegated to uap working for the agency?
,A. Supplying iv drug users with sterile injection equipment such and needles and
syringes
B. Interviewing patients about behaviors that indicate a need for annual hiv testing
C. Teaching high risk community members about the use of condoms in preventing hiv
infection
D. Assessing the community to determine which population groups to target for
education
B
Nystatin should be in contact with the oral and esophageal tissues as long as possible
for maximum effect. The other actions are also inappropriate and should be discussed
with the student but do not require action as quickly. Hiv positive patients do not require
droplet or contact cautions or visitor restrictions to prevent opportunistic infections. Hot
or spicy foods are not usually well tolerated in patients with oral or esophageal fungal
infections ✅the nurse is supervising a student nurse who is caring for a client with hiv.
The patient has severe espohagitis caused by candidia albicans. Which action by the
student nurse requires the most rapid intervention by the nurse?
A. Putting on a mask and gown before entering the room
B. Giving the patient a glass of water after administering the prescribed oral nystatin
suspension
C. Suggesting that the patient should order chile con carne of chicken soup for the next
meal
D. Placing a 'no visitors' sign on the door of the clients room
A
Because tmpsmx can cause steven johnson syndrome a blistering rash indicates a
need to discontinue the medication immediately. 2 l per day of fluid is adequate
supervision crystal urea and renal damage associated with tmpsmx. Tmpsmx can cause
hyperkalemia the nurse report the potassium level to the provider but the leg potassium
level is not caused by the medication. Patient teaching about photosensitivity is needed
but the nurse does not need guidance from the provider to implement this action ✅the
nurse is evaluating a patient with hiv who is receiving trimethoprimsulfamethoxazole as
a treatment for pneumocytis jiroveci pneumonia. Which information is most important to
communicate to the hcp?
A. The patient reports a blistering rash
B. The patients fluid intake is 2l/day
C. The patients potassium is 3.4
D. The patient enjoys spending time outside in the sun
A, b, c, e
Current guidelines indicate that anti-retroviral therapy for hiv should be initiated as soon
as possible after hiv diagnosis. Although ongoing substance abuse is a risk factor for
poor adherence anti-retroviral therapy can be initiated on strategies to improve
adherence are used. Strategies include directly observing patients taking medications
needle exchange programs in referring patients for substance abuse treatment ✅the
nurse is working with a patient woh has a new diagnosis of hiv and who reports current
, use of injectable heroin and methamphetamine. Which actions by the nurse are
appropriate? Select all that apply
A. Refer the patient to a substance abuse treatment program
B. Plan for the patient to participate in a needle exchange program
C. Coordinate the patients schedule for directly observed antiretroviral medications
D. Instruct the patient that ingoing injectable drug use is a contraindication for
antiretroviral therapy
E. Provide patient education about the risk of transmitting hiv to others when haring
needles
A
Cording to the nih guidelines and induration of 5 mm or greater indicates tb infection in
patients with hiv and a chest radiograph will be needed to determine whether the patient
has active or latent tb infection. Teaching about multi drug therapy is needed if the
patient has active tb but latent tb is treated with a single drug only. Positive skin test
results generally persist throughout the patient's lifetime and will not be repeated
although other tests such as follow up chest radiograph and sputumtesting maybe you
to valuate for effective tb treatment ✅a patient with newly diagnosed aids has a 6mm
induration at 48 hours ofter a skin test for tb. Which action will the nurse anticipate
taking next?
A. Arrange for a chest xray to check for active tb
B. Tell the patient the tb test results are negative
C. Teach the patient about multidrug treatment for tb
D. Schedule tb testing again in 12 months
B
The collection of data used to evaluate the therapeutic and adverse effects of
medication is included in the lpn/lvn education and scope of practice. Assistance in
planning and developing teaching programs are more complex skills that require rn
education. Assistance with hygiene and activities of daily living should be delegated to
the uap ✅the nurse is working in a hospice facility for patients with aids. The facility is
staffed with lpn/lvns and uap. Which action will the nurse assign to the lpn?
A. Assessing patients nutritional needs and individualizing diet plans to improve nutrition
B. Collecting data about the patients responses to medications used for pain and
anorexia
C. Developing uap training programs about how to lower the risk for spreading
infections
D. Assisting patients with personal hygiene and other adls as needed
D
Naproxen can cause g.i. bleeding in the stool appearance in the case that blood may be
present in the stool. The healthcare provider should be notified so that action such as
testing a stool specimen for occult blood and administering proton pump inhibitor's can
be prescribed. The other symptoms are common in patients with ra and require further
assessment and intervention but they do not indicate that the patient is experiencing
adverse effects from the medication ✅the nurse is caring for a client with rheumatoid
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