A client who has no history of immunosupressive
disease and is at low risk for tuberculosis has a
Mantoux test.
The results indicate an area of induration that is 8
mm in size.
The nurse interprets that the client :
1 Has active tuberculosis
2 Has a history of tuberculosis
3 Has been exposed to tuberculosis
4 Has a negative response
A client with active tuberculosis is to be admitted
to a medical-surgical unit.
When planning a bed assignment,the nurse
1 plans to transfer the client to the intensive
care unit
2 Assigns the client to a double room because
intravenous antibiotics will be administered
3 Assigns the client to a double room and places
a "strict handwashing" sign outside the door
4 Places the client in a private, well-ventilated
room
A nurse is developing a plan of care for a client
with acquired immunodeficiency syndrome (AIDS).
The nurse documents which appropriate goal in the
plan of care ?
1 The client does not experience respiratory distress.
2 The client has no increased platelet aggregation.
3 The client has no evidence of dissecting aortic aneurysm.
4 The client has a urinary output of 50 ml per hour.
A client is suspected of having pulmonary tuberculosis.
The nurse assesses the client for which signs and
symptoms of tuberculosis ?
1 Weight gain, insomnia, and night sweats
2 Low-grade fever, fatigue, and productive cough
3 High fever and chest pain
4 Increased appetite, dyspnea, and chills
A nurse is caring for a human immunodeficiency
virus (HIV) positive pregnant client.
To help the transmission of HIV from the woman
to her fetus during the intrapartum period, the
nurse plans to initiate measures to avoid :
1 Cesarean birth
2 External fetal monitoring
3 Epidural anesthesia
4 Direct (internal) fetal heart rate monitoring
A male client being seen in the ambulatory
care clinic has a history of being treated for
syphilis infection.
The nurse interprets that the client has been
reinfected if which characteristic is noted in
a penile lesion ?
1 Multiple vesicles, with some that have ruptured
2 Papular areas and erythema
3 Cauliflower-like appearance
4 Induration and absence of pain
A nurse is called to a client's room by
another nurse.
When the nurse arrives at the room,
she discovers that a fire has occurred
in the client's waste basket.
The first nurse had removed the client
from the room.
What is the second nurse's next action ?
1 Evacuate the unit
2 Extinguish the fire
3 Confine the fire
4 Activate the fire alarm
A nurse is preparing to suction a client through
a tracheostomy tube. Which protective items
would the nurse wear to perform this procedure?
1 Gown,mask, and sterile gloves
2 Goggles,mask, and sterile gloves
3 Mask,gown,and a cap
4 Mask,sterile gloves,and a cap
A client who works as a security guard at night
in an industrial building is brought to the emergency
room with suspected carbon monoxide poisoning.
list in order of priority the actions that the nurse
takes on arrival of the client.
( ) Notifies the local health department and requests
an inspection at the industrial building
( ) Draws blood for carboxyhemoglobin levels
( ) Assesses the client
( ) Administers 100% oxygen
A nurse is admitting a client with a diagnosis
of acquired immunodeficiency syndrome(AIDS)
to the medical-surgical unit.
The nurse most importantly assesses for which
of the following ?
1 Jaundiced skin
2 White patches in the oral cavity
3 Bradypnea
4 Urine specific gravity of 1.010