A kid is receiving a series of Hep B vaccines and
COMMUNICABLE DISEASES
The nurse provides home care instructions to the
parents of a child hospitalized with pertussis who is
in the convalescent stage and is being prepared for
d/c. What statement made by parent indicates a
NEED for further instruction?
1. We need to encourage our child to drink fluids
2. Coughing spells may be triggered by dust or
smoke
3. Vomiting may occur when our child has
coughing episodes
4. We need to maintain droplet precautions and a
quiet environment for at least 2 weeks
4 the nurse give the parents?
* pertussis is transmitted by direct contact or resp.
droplets from coughing
An infant receives a a DTaP immunization at a well
baby clinic. The parent returns home and calls the
clinic and reports swelling & redness at the
injection site. Which is an appropriate action?
1. Monitor the infant for a fever
2. Bring the infant back to clinic
3. Apply hot pack
4. Apply cold pack
4 A 4 month old comes to clinic for shots. The child
* On occasion tenderness, swelling and redness
appear at the site of a DTaP injection. Cold packs
for the first 24 hrs, followed by cold or warm
compresses if inflammation persist.
A child is scheduled to receive inactivitated Polio
vaccine (IPV) and the nurse preparing the vaccine
reviews the kids chart. The nurse should question
this if what is in the kids chart?
1. Recent recovery from cold
2. A history of frequent respiratory infections
3. A history of an anaphyalactic reaction to
neomycin
4. A local reaction at the site if injection of a
previous IPV
3 4. IM in the anterolateral aspect of the thigh
*This contains neomycin
arrives for a second dose. Before giving the nurse
should ask the kid and parent about a history of a
severe allergic reaction to what?
1. Eggs
2. PCN
3. Sulfonamides
4. A previous dose of HEP B vaccine or component
4
* A contraindication is a previous reaction to a
previous dose of HEP B or a component
( aluminum hydroxide or yeast protein)
A nurse visits a child with Mono and provides care
instructions to the parents. Which instruction should
1. maintain bed rest for 2 weeks
2. maintain Resp. precautions for 1 week
3. Notify HCP if kid develops a fever
4. Notify HCP if child develops ABD pain Left
shoulder pain
4
* Mono is caused by Epstein- Barr virus. Parents
need to report pain in ABD, especially in LUQ or
left shoulder pain ; this may indicate that the spleen
has ruptured.
is up to date. What vaccines should the kid get at
this time?
1. varicella, HEP B
2. DTaP, MMR, IPV
3. MMR, Hib, DTaP
4. DTaP, hib, PCV, RV
4
DTap, hib, PVC and RV are given at 4 months
A nurse prepares to give a MMR to a 5 yr old. What
route should this be given?
1. Sub Q in the gluteal muscle
2. IM in the deltoid
3. subq in the outer aspect of the upper arm
3 B - If an infectious disease is transmitted directly from
MMR is given subq in the outer aspect of the upper
arm
A kid with rubeola (measles) is being admitted to
hosp. The nurse should plan for which precaution
1. enteric
2. airborne
3. protective
4. neutropenic
2
* rubeola is transmitted via airborne particles and
dirsct contact with the infectious drops. People
involved with the kid should wear a mask, private
room, door remains closed,
A nurse is assessing a kid who is scheduled to
receive a live vaccine. What are the general
contraindications associated with receiving a live
virus vaccine? SELECT ALL
1. The kid has symptoms of a cold
2. The child has a previous anaphylactic reaction to
the vaccine
3. mother reports the kid is having intermittent
episodes of diarrhea
4. mother reports that the kid has had no appetite
and has been fussy
5. The kid has a severely deficient immune system
6. Mother reports that the kid has recently been
exposed to infectious disease
2, 5
The contraindications for this are a previous
anaphylactic episode, weakened immune systems,
those with a severe sensitivity to gelatin, or
pregnant women
If an infectious disease can be transmitted directly from
one person to another, it is:
A) A susceptible host
B) A communicable disease
C) A portal of entry to a host
D) A portal of exit from the reservoir
one person to another, it is a communicable disease.
Portals of entry and exit are the mechanisms of disease
transmission. A susceptible host is a person who can
acquire an infection.
In infectious diseases such as hepatitis B and C, a
reservoir for pathogens is:
A) The blood
B) The urinary tract
C) The respiratory tract
D) The reproductive tract
A - The blood is a reservoir for pathogens in hepatitis B
and C. Neither organism can survive in the urinary,
reproductive, or respiratory tract
The most effective way to break the chain of infection is
by:
A) Practicing good hand hygiene
B) Wearing gloves
C) Placing clients in isolation
D) Providing private rooms for clients
A - Good hand hygiene is the most effective way to
break the chain of infection. Wearing gloves can help in
decreasing disease transmission, but clean hands are
required for it to be truly effective. Placing clients in
isolation is costly and often unnecessary, and clients can
be psychologically harmed by isolation. Even providing
private rooms for clients will not be effective if health
care workers do not follow good hand hygiene
practices.
A nurse is assigned to care for a client with a deep
wound infection. Which of the following actions would
result in the contamination of sterile gloves?
A) The nurse grasps a sterile cotton-tipped swab to
clean wound edges.
B) The nurse takes a gauze pad in hand and places it in
the wound.
C) The nurse picks up a gauze pad soaked in sterile
saline to cleanse the wound.
D) The nurse pulls up the sheet over the client's
perineum for better draping.
D - If the nurse touches a sheet (nonsterile) with sterile
gloves, the gloves are contaminated. The other actions
do not contaminate sterile gloves.
A client is isolated because the client has pulmonary
tuberculosis. The nurse notes that the client seems
angry but knows this is a normal response to isolation.
The best intervention is to:
A) Provide a dark, quiet room to calm the client.
B) Explain the isolation procedures and provide
meaningful stimulation.
C) Reduce the level of precautions to keep the client
from becoming angry.
D) Limit family and other caregiver visits to reduce the
risk of spreading the infection
B - When a client is in isolation, the nurse should take
measures to improve the client's stimulation and make
sure to explain the isolation procedures. Darkening the
room can increase the sense of isolation. The nurse
should not change the isolation level but should provide
plenty of emotional support and make time for the
client to prevent a sense of isolation. As long as family
and caregivers follow infection precautions, there is no
reason to limit contact with these individuals.
A gown should be worn when:
A) The client's hygiene is poor.
B) The client has acquired immunodeficiency syndrome
(AIDS) or hepatitis.
C) The nurse is assisting with medication administration.
D) Blood or body fluids may get on the nurse's clothing
from a task the nurse plans to perform.
D - Gowns should be worn when there is a possibility
that blood or body fluids could get on the nurse's
clothes or when the client is on contact isolation status.
The other options are not appropriate uses of gowns.
When a nurse is performing surgical hand hygiene, the
nurse must keep the hands:
A) Above the elbows
B) Below the elbows
C) At a 45-degree angle
D) In a comfortable position
A - When surgical hand hygiene is performed, the hands
should always be kept above the elbows so that the
water runs from the hands to the elbows.
To remove a glove that is contaminated, what should
the nurse do first?
A) Rinse the glove before removing it to minimize
contamination.
B) Pull the glove off the back of the hand until it slides
off the entire hand and discard it.
C) Grasp the outside of the cuff or palm of the glove and
pull it away from the hand without touching the wrist or
fingers.
D) Put the thumb inside the wrist to slide the glove over
the hand with minimal touching of the hand by the
other gloved hand.
C - When the outside of the cuff is grasped with the
contaminated gloved hand, then dirty to dirty
remains intact. Pulling the glove away from the
hand entirely without touching the wrist or fingers
further minimizes the contamination by the gloved
hand. If the nurse puts the gloved thumb inside the
glove, the nurse has contaminated the bare hand
with a contaminated thumb. Pulling the glove off by
holding it at the back sounds good and could
minimize contamination, but it is very difficulty to
remove a glove this way without the risk of tearing
the glove and creating contamination through the
tear. If excessive secretions are present on gloves,
then a towel or the drape could be used to wipe off
excessive secretions before an attempt is made to
remove the gloves.
What is the single most effective method by which the
nurse can break the chain of infection?
A) Give all clients antibiotics.
B) Wear gloves when caring for all clients.
C) Wash hands between procedures and clients.
D) Make sure housekeeping staff are using the right
chemicals.
C - Adequate hand washing will remove bacteria and
wastes or contaminates to minimize cross
contamination between clients. Use of alcohol-based
waterless antiseptics between clients is also effective if
the guidelines for using these cleansers are followed.
Giving all clients antibiotics is impractical and is a source
of new superinfections when persons who do not need
antibiotics are given them and then the bacteria mutate
to become resistant to older drugs. It would be both
unethical and costly to try to control infections by
treating everyone in the facility. Although wearing
gloves to perform procedures that carry the risk of
direct contact with contaminated material is a correct
method of bacterial control, wearing gloves at all times
is impractical, expensive, and unrealistic. Housekeeping
staff are trained to use the correct agents for
decontamination and disinfection of all surfaces that
place clients at risk.
Which of the following statements reflects the current
trend in the directives from the Centers for Disease
Control and Prevention (CDC) for minimizing risks of
infection?
A) Discard all dressings into red bags.
B) Do not recap bottles of solutions to minimize risk of
contamination.
C) Recap syringes or break needles off before discarding
into sharps containers.
D) Keep all drainage tubing below the level of the waist
and/or site of insertion.
D - Keeping the solution in drainage tubes draining away
from the drainage site on the body reduces the risk for
bacteria growth. Running any solution backward in the
tubing puts the client at risk by bringing any bacteria
that may be present lower in the system back to the
body, and cross contamination will occur. As in surgical
areas, anything below the waist should be considered at
potential risk for infection. Needles are not to be
recapped or cut because of the increased risk of
experiencing puncture wounds while doing so. Not all
dressings need to be placed in red bags; only dressings
with moisture require placement in a red bag. Bottles of
solution that are sitting in the client's room should be
closed to prevent airborne contaminants from entering
and creating an unsterile situation.
The nurse has just admitted a client to rule out active
hepatitis B. The client is confused, spitting and
scratching everyone who enters the room. The nurse
should:
A) Wait an hour until the client calms down and then
use gloves when touching the client.
B) Use gloves, mask, face shield, and gown when
entering the room to perform the initial assessment.
C) Administer a sedative and then perform the
assessment after the client is asleep; no precautions
would be needed.
D) Realize that isolation equipment might further
confuse the client and avoid using a face mask and
shield but use gown and gloves.
B - Hepatitis virus is a blood-borne virus, but the client is
increasing the risk of cross contamination by spitting
(saliva can be a source of bacterial contamination) and
scratching others, which can break the skin and become
a source of risk. All of the barriers listed would minimize
cross contamination from the client to the nurse. Even
though gloves may be all that is needed because of
limited contact with the client, after an hour the client
will remain confused and may not understand. The
client may become aggressive again and spit or scratch,
and other barriers are needed to stop that source of
possible risks. A sedative may be given if needed, but
trying to perform an assessment when the client is
asleep is not appropriate and will prevent the nurse
from successfully establishing rapport with the client.
Although masks and shields might be frightening to
some confused clients, if the client is spitting and body
fluids could be exchanged, a barrier should still be used.
For which airborne disease(s) would the nurse be
required to use gloves, respiratory devices, and gown
when in close contact with the client?
A) Herpes simplex, scabies
B) Viral pneumonia, atelectasis
C) Chickenpox, pulmonary tuberculosis
D) Multidrug-resistant respiratory syncytial virus
C - Airborne precautions are required for chickenpox
and tuberculosis, because in these diseases small
particles float in the air and a barrier is required to
prevent contamination of the nurse. A respiratory
protection device is form-fitted to the face to prevent
the escape of air around the seal. Gloves and gown are
also worn to prevent contamination and transport of
infective particles to other clients. For viral pneumonia
a regular mask is used as a barrier because the particles
do not float in the air and are more likely to be found on
surfaces unless coughing or spitting is occurring.
Atelectasis is the collapse of alveoli, and airborne
precautions are not needed. Herpes and scabies are
spread by contact, and gloves and gown would be
necessary; masks would not be needed. For multidrug-
resistant respiratory syncytial virus the protection of the
client would be as important as preventing the spread
of these disorders. Therefore, gown, gloves, and mask
would be used as in reverse isolation to prevent cross
contamination of the client.
Before the nurse washes the hands when leaving an
isolation room, what is the last thing that is removed?
A) Mask
B) Gown
C) Goggles
D) Head cover
A - Remove goggles by touching only the ear pieces.
Next remove the gown and the nurse should untie the
neck ties and allow the gown to fall from shoulders and
only touch the inside of the gown. The mask is removed
last by removing the elastic from the ears or untying the
bottom mask string followed by the top mask string. In
both cases the nurse's hands only touch the ties of the
mask. Head covers are usually not worn in isolation
rooms as a barrier.
The nurse is setting up a sterile field for the physician.
Which of the following statements concerning a sterile
field is correct?
A) The sides of the drape over the table are still sterile
until they are touched.
B) Reaching over the field is not a source of
contamination if the nurse has on a clean gown and
gloves.
C) One inch around the border should be considered to
be the barrier between the sterile field and under the
table.
D) A liquid spill onto the sterile field is a source of
contamination from the table below the drape, even if
the barrier is waterproof.
C - A 1-inch margin is considered unsterile and is the
barrier spacing between the sterile field in the center of
the drape and the edge of the drape. Liquids spilled on
a waterproof drape will not absorb from or be
contaminated from the surface beneath. Although such
a situation could be messy, bacteria would not cross
from the unsterile to the sterile side. The edge of the
table and the 1-inch border create the edge of the
sterile field. Anything below the edge, including the side
of the drape, becomes unsterile. Reaching over a sterile
field is always a source of contamination and should not
be done.
When transferring a sterile item to a sterile field, the
nurse should:
A) Open the outer package and let the sterile assistant
take the item from the nurse to put on the edge of the
drape.
B) Use a sterile lifting tool (forceps) to pick up the inner
package and transfer it to the middle of the field.
C) Open the outer package and use a sterile glove to
pick up the item and drop it on the sterile field in the
middle of the drape.
D) Open the package by peeling back the cover without
touching the inner package and drop the item within
the sterile field without touching the 1-inch border.
D - The rule is "sterile to sterile" to prevent
contamination. The outer cover is considered unsterile.
As long as the inner packet is not touched, the packet is
considered sterile. The 1-inch border or barrier between
the edge of the drape and the field is the dividing line
for sterile versus nonsterile. Using a sterile glove to
remove the inner packet is all right, but dropping it into
the middle of the field will contaminate other items. A
sterile assistant can take the item from the nurse, but
placing it on the edge of the drape will contaminate the
item because it is not inside the 1-inch border/barrier.
Using sterile forceps to remove the inner packet is
acceptable, but putting the item into the middle of the
field will again risk potential contamination from
reaching over the sterile field.
Which statement comparing a surgical scrub with a
regular hand-washing session is correct?
A) Water and soap are turned on with the leg or foot
pedal in both cases.
B) A surgical scrub lasts the same length of time as a
hand washing between clients.
C) The hands are held in the same position after the
scrub as after regular hand washing to prevent
contamination from other sources of contact.
D) The fingers are held down to rinse in routine hand-
washing but are held upright when performing a
surgical scrub.
D - In hand washing, rinsing is from clean to dirty; the
arms are considered cleaner than the fingers and
therefore rinsing is away from the cleaner part of the
arm. In the surgical scrub the arm is considered more
contaminated because the hands and nails are more
thoroughly scrubbed; therefore, in a surgical scrub the
hands are held above the elbows. In hand washing the
fingers are held downward to rinse and are dried in the
same manner. Keeping hands in sight is important in
both cases, but no special position is needed after hand
washing. Although a foot or knee pedal is a preferred
method of soap and water delivery, using a faucet can
be just as safe if a paper towel is used to turn off the
water after the hands have been washed.
What part of a sterile glove is considered contaminated
once the glove is applied by the open gloving method?
A) The inner cuff of each glove
B) The back of the gloved hands
C) Any surface that the powder from the gloves touches
D) The outer part of the glove that touched the inner
wrapper
A - The cuff is folded and touched to apply the glove;
thus, it becomes contaminated during application of the
glove. Usually the cuff will fall down over the wrist, but
if it does not, then it is considered unsterile and should
not be touched during the procedure. All of the outer
part of the glove is sterile unless it has been
contaminated. The inner wrapper that held the sterile
glove is not contaminated unless one touches it.
Therefore, the outer part of the glove can touch it
without contamination. The powder is sterile and will
not contaminate anything it touches.
The interval when a client manifests signs and
symptoms specific to a type of infection is the:
1. Illness Stage
2. Convalescence
3. Prodromal Stage
4. Incubation Period
1. Illness Stage
After coming in contact with infected clients, and after
handling contaminated equipment or organic material,
visitors are encouraged to:
1. Wear gloves before eating or handling food
2. Use a private room to talk with family members
3. Leave the facility to prevent contamination of others
4. Perform hand hygiene before eating or handling food
4. Perform hand hygiene before eating or handling food
The nurse has redressed a client's wound and now plans A. A diagnosis of AIDS and cytomegalovirus
to administer a medication to the client. It is important B. A positive PPD with an abnormal chest x-
to: ray
C. A tentative diagnosis of viral pneumonia
D. Advanced carcinoma of the lung
1. Leave the gloves on to administer the medication
2. Remove gloves and perform hand hygiene before
4. Which of the following is the FIRST priority in
leaving the room preventing infections when providing care for a
3. Remove gloves and perform hand hygiene before client?
administering the medication
4. Leave the medication on the bedside table to avoid A. Handwashing
having to remove gloves before leaving the client's B. Wearing gloves
room C. Using a barrier between client’s furniture
and nurse’s bag
Remove gloves and perform hand hygiene before D. Wearing gowns and goggles
administering the medication
5. An adult woman is admitted to an isolation unit
To sterilize surgical instruments, parenteral solutions, in the hospital after tuberculosis was detected
and surgical dressings: during a pre-employment physical. Although
frightened about her diagnosis, she is anxious to
1. An autoclave is used
cooperate with the therapeutic regimen. The
teaching plan includes information regarding the
2. Soap and water is used
most common means of transmitting the tubercle
3. Ethylene oxide gas is used bacillus from one individual to another. Which
4. Chemicals are used for disinfection contamination is usually responsible?
An autoclave is used
A. Hands.
B. Droplet nuclei.
1. A child is admitted to the pediatric unit with a C. Milk products.
diagnosis of suspected meningococcal meningitis. D. Eating utensils.
Which of the following nursing measures should the
nurse do FIRST? 6. A 2 year old is to be admitted in the pediatric
unit. He is diagnosed with febrile seizures. In
A. Institute seizure precautions preparing for his admission, which of the following
B. Assess neurologic status is the most important nursing action?
C. Place in respiratory isolation
D. Assess vital signs A. Order a stat admission CBC.
B. Place a urine collection bag and specimen
2. A client is diagnosed with methicillin resistant cup at the bedside.
staphylococcus aureus pneumonia. What type of C. Place a cooling mattress on his bed.
isolation is MOST appropriate for this client? D. Pad the side rails of his bed.

A. Reverse isolation 7. A young adult is being treated for second and

B. Respiratory isolation third degree burns over 25% of his body and is now
C. Standard precautions ready for discharge. The nurse evaluates his
D. Contact isolation understanding of discharge instructions relating to
wound care and is satisfied that he is prepared for
3. Several clients are admitted to an adult medical home care when he makes which statement?
unit. The nurse would ensure airborne precautions
for a client with which of the following medical A. “I will need to take sponge baths at home to
conditions? avoid exposing the wounds to unsterile bath
water.”
 B. “If any healed areas break open I should first
cover them with a sterile dressing and then
report it.”
C. “I must wear my Jobst elastic garment all
day and can only remove it when I’m going
to bed.”
D. “I can expect occasional periods of low-
grade fever and can take Tylenol every 4
hours.”
8. An eighty five year old man was admitted for
surgery for benign prostatic hypertrophy.
Preoperatively he was alert, oriented, cooperative,
and knowledgeable about his surgery. Several hours
after surgery, the evening nurse found him acutely
confused, agitated, and trying to climb over the
protective side rails on his bed. The most
appropriate nursing intervention that will calm an
agitated client is
A. limit visits by staff.
B. encourage family phone calls.
C. position in a bright, busy area.
D. speak soothingly and provide quiet music.
9. Ms. Smith is admitted for internal radiation for
cancer of the cervix. The nurse knows the client
understands the procedure when she makes which
of the following remarks the night before the
procedure?
A. She says to her husband, “Please bring me a
hamburger and french fries tomorrow when
you come. I hate hospital food.”
B. “I told my daughter who is pregnant to
either come to see me tonight or wait until I
go home from the hospital.”
C. “I understand it will be several weeks before
all the radiation leaves my body.”
D. “I brought several craft projects to do while
the radium is inserted.”
10. The nurse in charge is evaluating the infection
control procedures on the unit. Which finding
indicates a break in technique and the need for
education of staff?
A. The nurse aide is not wearing gloves when
feeding an elderly client.
B. A client with active tuberculosis is asked to
wear a mask when he leaves his room to go
to another department for testing.
C. A nurse with open, weeping lesions of the
hands puts on gloves before giving direct
client care.
D. The nurse puts on a mask, a gown, and
gloves before entering the room of a client
on strict isolation.
11. The charge nurse observes a new staff nurse
who is changing a dressing on a surgical wound.
After carefully washing her hands the nurse dons
sterile gloves to remove the old dressing. After
removing the dirty dressing, the nurse removes the
gloves and dons a new pair of sterile gloves in
preparation for cleaning and redressing the wound.
The most appropriate action for the charge nurse is
to:
A. interrupt the procedure to inform the staff
nurse that sterile gloves are not needed to
remove the old dressing.
B. congratulate the nurse on the use of good
technique.
C. discuss dressing change technique with the
nurse at a later date.
D. interrupt the procedure to inform the nurse
of the need to wash her hands after removal
of the dirty dressing and gloves.
12. Nurse Jane is visiting a client at home and is
assessing him for risk of a fall. The most important
factor to consider in this assessment is:
A. Correct illumination of the environment.
B. amount of regular exercise.
C. the resting pulse rate.
D. status of salt intake.
13. Mrs. Jones will have to change the dressing on
her injured right leg twice a day. The dressing will
be a sterile dressing, using 4 X 4s, normal saline
irrigant, and abdominal pads. Which statement best
indicates that Mrs. Jones understands the
importance of maintaining asepsis?
A. “If I drop the 4 X 4s on the floor, I can use
them as long as they are not soiled.”
B. “If I drop the 4 X 4s on the floor, I can use
them if I rinse them with sterile normal
saline.”
C. “If I question the sterility of any dressing
material, I should not use it.”
 D. “I should put on my sterile gloves, then open
the bottle of saline to soak the 4 X 4s.”
14. A client has been placed in blood and body fluid
isolation. The nurse is instructing auxiliary
personnel in the correct procedures. Which
statement by the nursing assistant indicates the best
understanding of the correct protocol for blood and
body fluid isolation?
A. Masks should be worn with all client
contact.
B. Gloves should be worn for contact with
nonintact skin, mucous membranes, or
soiled items.
C. Isolation gowns are not needed.
D. A private room is always indicated.
15. A client has been placed in blood and body fluid
isolation. The nurse is instructing auxiliary
personnel in the correct procedures. Which
statement by the nursing assistant indicates the best
understanding of the correct protocol for blood and
body fluid isolation?
A. Masks should be worn with all client
contact.
B. Gloves should be worn for contact with
nonintact skin, mucous membranes, or
soiled items.
C. Isolation gowns are not needed.
D. A private room is always indicated.
16. The nurse is evaluating whether nonprofessional
staff understand how to prevent transmission of
HIV. Which of the following behaviors indicates
correct application of universal precautions?
A. A lab technician rests his hand on the desk
to steady it while recapping the needle after
drawing blood.
B. An aide wears gloves to feed a helpless
client.
C. An assistant puts on a mask and protective
eye wear before assisting the nurse to
suction a tracheostomy.
D. A pregnant worker refuses to care for a
client known to have AIDS.
17. Jayson, 1 year old child has a staph skin
infection. Her brother has also developed the same
infection. Which behavior by the children is most
likely to have caused the transmission of the
organism?
A. Bathing together.
B. Coughing on each other.
C. Sharing pacifiers.
D. Eating off the same plate.
18. Jessie, a young man with newly diagnosed
acquired immune deficiency syndrome (AIDS) is
being discharged from the hospital. The nurse
knows that teaching regarding prevention of AIDS
transmission has been effective when the client:
A. verbalizes the role of sexual activity in
spread of the disorder.
B. states he will make arrangements to drop his
college classes.
C. acknowledges the need to avoid all contact
sports.
D. says he will avoid close contact with his
three-year-old niece.
19. Which question is least useful in the assessment
of a client with AIDS?
A. Are you a drug user?
B. Do you have many sex partners?
C. What is your method of birth control?
D. How old were you when you became
sexually active?
20. Mrs. Parker, a 70-year-old woman with severe
macular degeneration, is admitted to the hospital the
day before scheduled surgery. The nurse’s
preoperative goals for Mrs. M. would include:
A. independently ambulating around the unit.
B. reading the routine preoperative education
materials.
C. maneuvering safely after orientation to the
room.
D. using a bedpan for elimination needs.
37. A 4-month-old with meningococcal meningitis
has just been admitted to the pediatric unit. Which
nursing intervention has the highest priority?
A. Instituting droplet precautions
B. Administering acetaminophen (Tylenol)
C. Obtaining history information from the
parents
D. Orienting the parents to the pediatric unit
42. A tuberculosis intradermal skin test to detect
tuberculosis infection is given to a high-risk
adolescent. How long after the test is administered
should the result be evaluated?
A. Immediately
B. Within 24 hours
C. In 48 to 72 hours
D. After 5 days
HIV/AIDS
A patient who has vague symptoms of fatigue,
headaches, and a positive test for human
immunodeficiency virus (HIV) antibodies using an
enzyme immunoassay (EIA) test. What instructions
should the nurse give to this patient?
a. "The EIA test will need to be repeated to verify
the results."
b. "A viral culture will be done to determine the
progression of the disease."
c. "It will probably be 10 or more years before you
develop acquired immunodeficiency syndrome
(AIDS)."
d. "The Western blot test will be done to determine
whether acquired immunodeficiency syndrome
(AIDS) has developed."
a d. "Can you tell me more about the kind of thoughts
A patient who has a positive test for human
immunodeficiency virus (HIV) antibodies is
admitted to the hospital with Pneumocystis jiroveci
pneumonia (PCP) and a CD4+ T-cell count of less
than 200 cells/uL. Based on diagnostic criteria
established by the Centers for Disease Control and
Prevention (CDC), which statement by the nurse is
correct?
a. "The patient meets the criteria for a diagnosis of
an acute HIV infection."
b. "The patient will be diagnosed with
asymptomatic chronic HIV infection."
c. "The patient has developed acquired
immunodeficiency syndrome (AIDS)."
d. "The patient will develop symptomatic chronic
HIV infection in less than a year."
c
A patient with a positive rapid antibody test result
for human immunodeficiency virus (HIV) is
anxious and does not appear to hear what the nurse
is saying. What action by the nurse is most
important at this time?
a. Teach the patient about the medications available
for treatment.
b. Inform the patient how to protect sexual and
needle-sharing partners.
c. Remind the patient about the need to return for
retesting to verify the results.
d. Ask the patient to notify individuals who have
had risky contact with the patient.
c
A patient who is diagnosed with acquired
immunodeficiency syndrome (AIDS) tells the nurse,
"I feel obsessed with thoughts about dying. Do you
think I am just being morbid?" Which response by
the nurse is best?
a. "Thinking about dying will not improve the
course of AIDS."
b. "It is important to focus on the good things about
your life now."
c. "Do you think that taking an antidepressant might
be helpful to you?"
that you are having?"
d
A pregnant woman with a history of asymptomatic
chronic human immunodeficiency virus (HIV)
infection is seen at the clinic. The patient states, "I
am very nervous about making my baby sick."
Which information will the nurse include when
teaching the patient?
a. The antiretroviral medications used to treat HIV
infection are teratogenic.
b. Most infants born to HIV-positive mothers are
not infected with the virus.
c. Because she is at an early stage of HIV infection,
the infant will not contract HIV.
d. It is likely that her newborn will become infected
with HIV unless she uses antiretroviral therapy
(ART).
b a. Patient who is currently HIV negative but has
Which patient exposure by the nurse is most likely
to require postexposure prophylaxis when the
patient's human immunodeficiency virus (HIV)
status is unknown?
a. Needle stick with a needle and syringe used to
draw blood
b. Splash into the eyes when emptying a bedpan
containing stool
c. Contamination of open skin lesions with patient
vaginal secretions
d. Needle stick injury with a suture needle during a
surgical procedure
a
A young adult female patient who is human
immunodeficiency virus (HIV)-positive has a new
prescription for efavirenz (Sustiva). Which
information is most important to include in the
medication teaching plan?
a. Driving is allowed when starting this medication.
b. Report any bizarre dreams to the health care
provider.
c. Continue to use contraception while on this
medication.
d. Take this medication in the morning on an empty
stomach.
c c. Patient symptoms
A patient who is human immunodeficiency virus
(HIV)-infected has a CD4+ cell count of 400/µL.
Which factor is most important for the nurse to
determine before the initiation of antiretroviral
therapy (ART) for this patient?
a. HIV genotype and phenotype
b. Patient's social support system
c. Potential medication side effects
d. Patient's ability to comply with ART schedule
d
The nurse will most likely prepare a medication
teaching plan about antiretroviral therapy (ART) for
which patient?
unprotected sex with multiple partners
b. Patient who was infected with HIV 15 years ago
and now has a CD4+ count of 840/µL
c. HIV-positive patient with a CD4+ count of
160/µL who drinks a fifth of whiskey daily
d. Patient who tested positive for HIV 2 years ago
and now has cytomegalovirus (CMV) retinitis
d
The nurse palpates enlarged cervical lymph nodes
on a patient diagnosed with acute human
immunodeficiency virus (HIV) infection. Which
action would be most appropriate for the nurse to
take?
a. Instruct the patient to apply ice to the neck.
b. Advise the patient that this is probably the flu.
c. Explain to the patient that this is an expected
finding.
d. Request that an antibiotic be prescribed for the
patient.
c
Which information would be most important to help
the nurse determine if the patient needs human
immunodeficiency virus (HIV) testing?
a. Patient age
b. Patient lifestyle
d. Patient sexual orientation
a
A patient who uses injectable illegal drugs asks the
nurse about preventing acquired immunodeficiency
syndrome (AIDS). Which response by the nurse is
best?
a. "Avoid sexual intercourse when using injectable
drugs."
b. "It is important to participate in a needle-
exchange program."
c. "You should ask those who share equipment to be
tested for HIV."
d. "I recommend cleaning drug injection equipment
before each use."
b d. Aerosolized pentamidine (NebuPent)
Which nursing action will be most useful in
assisting a college student to adhere to a newly
prescribed antiretroviral therapy (ART) regimen?
a. Give the patient detailed information about
possible medication side effects.
b. Remind the patient of the importance of taking
the medications as scheduled.
c. Encourage the patient to join a support group for
students who are HIV positive.
d. Check the patient's class schedule to help decide
when the drugs should be taken.
d The nurse cares for a patient who is human
A patient with human immunodeficiency virus
(HIV) infection has developed Mycobacterium
avium complex infection. Which outcome would be
appropriate for the nurse to include in the plan of
care?
a. The patient will be free from injury.
b. The patient will receive immunizations.
c. The patient will have adequate oxygenation.
d. The patient will maintain intact perineal skin.
d
A patient treated for human immunodeficiency
virus (HIV) infection for 6 years has developed fat
redistribution to the trunk, with wasting of the arms,
legs, and face. What instructions will the nurse give
to the patient?
a. Review foods that are higher in protein.
b. Teach about the benefits of daily exercise.
c. Discuss a change in antiretroviral therapy.
d. Talk about treatment with antifungal agents.
c
The nurse prepares to administer the following
medications to a hospitalized patient with human
immunodeficiency (HIV). Which medication is
most important to administer at the right time?
a. Oral acyclovir (Zovirax)
b. Oral saquinavir (Invirase)
c. Nystatin (Mycostatin) tablet
b
To evaluate the effectiveness of antiretroviral
therapy (ART), which laboratory test result will the
nurse review?
a. Viral load testing
b. Enzyme immunoassay
c. Rapid HIV antibody testing
d. Immunofluorescence assay
a
immunodeficiency virus (HIV) positive and taking
antiretroviral therapy (ART). Which information is
most important for the nurse to address when
planning care?
a. The patient's blood glucose level is 142 mg/dL.
b. The patient complains of feeling "constantly
tired."
c. The patient is unable to state the side effects of
the medications.
d. The patient states, "Sometimes I miss a dose of
zidovudine (AZT)."
d
Eight years after seroconversion, a human
immunodeficiency virus (HIV)-infected patient has
a CD4+ cell count of 800/µL and an undetectable
viral load. What is the priority nursing intervention
at this time?
a. Teach about the effects of antiretroviral agents.
b. Encourage adequate nutrition, exercise, and
sleep.
c. Discuss likelihood of increased opportunistic
infections.
d. Monitor for symptoms of acquired
immunodeficiency syndrome (AIDS).
b a. Methods to prevent perinatal HIV transmission
Which of these patients being seen at the human
immunodeficiency virus (HIV) clinic should the
nurse assess first?
a. Patient whose latest CD4+ count is 250/µL
b. Patient whose rapid HIV-antibody test is positive
c. Patient who has had 10 liquid stools in the last 24
hours
d. Patient who has nausea from prescribed
antiretroviral drugs
c infection. Which prophylactic measures will the
An older adult who takes medications for coronary
artery disease has just been diagnosed with
asymptomatic chronic human immunodeficiency
virus (HIV) infection. Which information will the
nurse include in patient teaching?
a. Many medications have interactions with
antiretroviral drugs.
b. Less frequent CD4+ level monitoring is needed
in older adults.
c. Hospice care is available for patients with
terminal HIV infection.
d. Progression of HIV infection occurs more rapidly
in older patients.
a
The registered nurse (RN) caring for an HIV-
positive patient admitted with tuberculosis can
delegate which action to unlicensed assistive
personnel (UAP)?
a. Teach the patient about how to use tissues to
dispose of respiratory secretions.
b. Stock the patient's room with all the necessary
personal protective equipment.
c. Interview the patient to obtain the names of
family members and close contacts.
d. Tell the patient's family members the reason for
the use of airborne precautions.
b
The nurse designs a program to decrease the
incidence of human immunodeficiency virus (HIV)
infection in the adolescent and young adult
populations. Which information should the nurse
assign as the highest priority?
b. Ways to sterilize needles used by injectable drug
users
c. Prevention of HIV transmission between sexual
partners
d. Means to prevent transmission through blood
transfusions
c
The nurse cares for a patient infected with human
immunodeficiency virus (HIV) who has just been
diagnosed with asymptomatic chronic HIV
nurse include in the plan of care (select all that
apply)?
a. Hepatitis B vaccine
b. Pneumococcal vaccine
c. Influenza virus vaccine
d. Trimethoprim-sulfamethoxazole
e. Varicella zoster immune globulin
a,b,c
According to the Center for Disease Control (CDC)
guidelines, which personal protective equipment
will the nurse put on when assessing a patient who
is on contact precautions for diarrhea caused by
Clostridium difficile (select all that apply)?
a. Mask
b. Gown
c. Gloves
d. Shoe covers
e. Eye protection
b,c
The nurse plans a presentation for community
members about how to decrease the risk for
antibiotic-resistant infections. Which information
will the nurse include in the teaching plan (select all
that apply)?
a. Continue taking antibiotics until all the
medication is gone.
b. Antibiotics may sometimes be prescribed to
prevent infection.
c. Unused antibiotics that are more than a year old
should be discarded.
d. Antibiotics are effective in treating influenza
associated with high fevers.
e. Hand washing is effective in preventing many
viral and bacterial infections.
a,b,e
A patient who has tested positive for the human
immunodeficiency virus (HIV) arrives at the clinic
with a report of fever, nonproductive cough, and
fatigue. The patient's CD4 count is 184 cells/mcL.
How should the healthcare provider interpret these
findings?
Please choose from one of the following options.
A. The patient is diagnosed with acquired
immunodeficiency syndrome (AIDS).
B.The patient is now in the latent stages of HIV
infection
C.These findings provide evidence that the patient
has seroconverted.
D. This is an expected finding because the patient
has tested positive for HIV.
The patient is diagnosed with acquired
immunodeficiency syndrome (AIDS).
Which member of the health care team
demonstrates reducing the risk for infection for the
client with acquired immunodeficiency syndrome
(AIDS)?
A) The dietary worker hands the disposable meal
trays to the LPN assigned to the client.
B) The social worker encourages the client to
verbalize about stressors at home.
C) Housekeeping thoroughly cleans and disinfects
the hallways near the client's room.
D) Health care provider orders vital signs including
temperature every 8 hours.
(A)
A) The dietary worker hands the disposable meal
trays to the LPN assigned to the client.
Rationale: This limits the number of health care
personnel entering the room.
The nurse is instructing an unlicensed health care
worker on the care of the client with HIV who also
has active genital herpes. Which statement by the
health care worker indicates effective teaching of
standard precautions?
A) ''I need to know my HIV status, so I must get
tested before caring for any clients."
B) ''Putting on a gown and gloves will cover up the
itchy sores on my elbows.''
C) ''Washing my hands and putting on a gown and
gloves is what I must do before starting care.''
D) ''I will wash my hands before going into the
room, and then put on gown and gloves only for
direct contact with the client's genitals."
(C)
C) ''Washing my hands and putting on a gown and
gloves is what I must do before starting care.''
Rationale: Standard precautions include whatever
personal protective equipment (PPE) is necessary
for the prevention of transmission of HIV and
genital herpes.
Which statement made to the nurse by a health care
worker assigned to care for the client with HIV
indicates a breach of confidentiality and requires
further education by the nurse?
A) ''I told the family members they needed to wash
their hands when they enter and leave the room.''
B) ''The other health care worker and I were out in
the hallway discussing how we were concerned
about getting HIV from our client, so no one could
hear us in the client's room.''
C) ''Yes, I understand the reasons why I have to
wear gloves when I bathe my client.''
D) ''The client's spouse told me she got HIV from a
blood transfusion.
(B)
B) ''The other health care worker and I were out in
the hallway discussing how we were concerned
about getting HIV from our client, so no one could
hear us in the client's room.''
Rationale: Discussing this client's illness outside the
client's room is a breach of confidentiality.
When preparing the newly diagnosed client with
HIV and significant other for discharge, which
explanation by the nurse accurately describes proper
condom use?
A) ''Condoms should be used when lesions on the
penis are present.''
B) ''Always position the condom with a space at the
tip of an erect penis.''
C) ''Make sure it fits loosely to allow for penile
erection.''
D) ''Use adequate lubrication such as petroleum
jelly.''
B)
B) ''Always position the condom with a space at the
tip of an erect penis.''
Rationale: This allows for the collection of semen at
the tip of the condom.
The nurse presents a seminar on HIV testing to a
group of seniors and their caregivers in an assisted
living facility. Which responses fit the Centers for
Disease Control and Prevention's (CDC's)
recommendations for HIV testing? (Select all that
apply.)
A) ''I am 78 years old and I was treated and cured of
syphilis many years ago.''
B) ''In 1986, I received a transfusion of platelets.''
C) ''Seven years ago, I was released from a
penitentiary.''
D) ''I used to smoke marijuana 30 years ago, but I
have not done any drugs since.''
E) ''I had sex with a man with a disreputable past
from New York back in the late 1960s, but I have
been happily married since 1971.''
F) ''At 68, I am going to get married for the fourth
time.''
G) ''Downtown was where I picked up the best
hookers back in the 1950s.'
-(A, C, F)
A) ''I am 78 years old and I was treated and cured of
syphilis many years ago.''
Rationale: People who have had sexually
transmitted diseases should be tested for HIV.
C) ''Seven years ago, I was released from a
penitentiary.''
Rationale: HIV testing is recommended for people
who are or have been in jails or prisons.
F) ''At 68, I am going to get married for the fourth
time.''
Rationale: People who are planning to get married
should be tested for HIV.
Which interventions does the home health nurse
teach to family members to reduce confusion in the
client diagnosed with AIDS dementia? (Select all
that apply.)
A) Report any behavior changes.
B) Use the Glasgow Coma Scale on a daily basis.
C) Change the decorations in the home according to
the season.
D) Put the bed close to the window.
E) Write out all instructions and have the client read
them over before performing a task.
F) Ask the client when he or she wants to shower or
bathe.
G) Mark off the days of the calendar, leaving open
the current date.
H) For continuity, the primary caregiver should be
the only person reorienting the client.
-(C, D, F, G)
C) Change the decorations in the home according to
the season.
Rationale: Seasonal decorations in the home helps
with maintaining orientation.
D) Put the bed close to the window.
Rationale: This allows the client to visualize
seasonal and weather changes and assists in
orientation.
F) Ask the client when he or she wants to shower or
bathe.
Rationale: Involving the client in planning the daily
schedule helps with orientation.
G) Mark off the days of the calendar, leaving open
the current date.
Rationale: Using calendars and crossing off past
dates helps with orientation.
The home health nurse is making an initial home
visit to the client currently living with family
members after being hospitalized with pneumonia
and newly diagnosed with AIDS. Which statement
by the nurse best acknowledges the client's fear of
discovery by his family?
A) ''Do you think that I could post a sign on your
bedroom door for everyone about the need to wash
their hands?''
B) ''Is there somewhere private in the home we can
go and talk?''
C) ''I hope that all of your family members know
about your disease and how you need to be
protected, since you have been so sick.''
D) ''It is your duty to protect your family members
from getting AIDS.''
(B)
B) ''Is there somewhere private in the home we can
go and talk?''
Rationale: A nonthreatening approach initially to
find out whether the client has informed family
members or desires privacy is very important.
A client with acquired immunodeficiency syndrome
(AIDS) has a nursing diagnosis of Imbalanced
nutrition: less than body requirements. The nurse
plans which of the following goals with this client?
a) consume foods and beverages that are high in
glucose
b) plan large menus and cook meals in advance
c) eat low-calorie snacks between meals
d) eat small, frequent meals throughout the day
D immunodeficiency virus (HIV), and the client and family
- The client should eat small, frequent meals
throughout the day. The client also should take in
nutrient-dense and high-calorie meals and snacks
rather than those that are high in glucose only. The
client is encouraged to eat favorite foods to keep
intake up and plan meals that are easy to prepare.
The client can also avoid taking fluids with meals to
increase food intake before satiety sets in.
A client with acquired immunodeficiency syndrome
(AIDS) is experiencing shortness of breath related
to Pneumocystis jiroveci pneumonia. Which
measure should the nurse include in the plan of care
to assist the client in performing activities of daily
living?
a) provide supportive care with hygiene needs
b) provide meals and snacks with high-protein, high
calorie, and high-nutritional value
c) provide small, frequent meals
A
- Providing supportive care with hygiene needs as
needed reduces the client's physical and emotional
energy demands and conserves energy resources for
other functions such as breathing. Options B, C, and
D are important interventions for the client with
AIDS but do not address the subject of activities of
daily living.
A client who was tested for human immunodeficiency
virus (HIV) after a recent exposure had a negative result.
During the post-test counseling session, the nurse tells
the client which of the following?
a) the test should be repeated in 6 months
b) this ensures that the client is not infected with the
HIV virus
c) the client no longer needs to protect himself from
sexual partners
d) the client probably has immunity to the acquired
immunodeficiency virus
A
- A negative test result indicates that no HIV
antibodies were detected in the blood sample. A
repeated test in 6 months is recommended because
false-negative test results have occurred early in the
infection.
A client is diagnosed with late stage human
are extremely upset about the diagnosis. The priority
psychosocial nursing intervention for the client and
family is to:
a) tell the client and family to stop smoking because
it will predispose the client to respiratory infections
b) tell the client and family that raw or improperly
washed foods can produce microbes
c) encourage the client and family to discuss their
feelings about the disease
d) advise the client to avoid becoming pregnant
because of the risk of transmission of the infection
C
- The priority psychosocial nursing intervention for
the client and family is to encourage the client and
family to discuss their feelings about the disease.
Options A, B, and D identify physiological not
psychosocial concerns.
A client is diagnosed with human
immunodeficiency virus (HIV) infection. The nurse
prepares a care plan for the client, knowing that
HIV is primarily a condition in which:
a) immunosuppression occurs and is indicated by a
T4 lymphocyte count of less than 200/mm3
b) bacterial infection occurs, causing weakness
c) fungal infection occurs, causing a rash and
pruritus
d) protozoan infection occurs, causing a fever and
nonproductive cough
A treatment. ELISA test results indicate exposure to or
- HIV infection causes immunosuppression and is
indicated by a T4 lymphocyte count of less than
200/mm3. Although bacterial, fungal, and protozoal
infection can occur, these occur as opportunistic
infections as a result of the immunosuppression.
Which intervention should the nurse implement
when caring for a client diagnosed with
Pneumocystis carinii pneumonia related to acquired
immunodeficiency syndrome who is crying over the
loss of friends and family members because they
will not talk to him anymore?
A. Advising the client not to worry, and telling him
everything will be alright
B. Asking the health care provider for a psychiatric
consult to assess the client's mental functioning
C. Sitting down and listening to the client's
concerns and frustrations
D. Telling the client that the friends probably were
not true friends anyway
C Immediately on noticing the client's sign and
rying is evidence that the client is beginning to
express concerns to the nurse. In response, active,
nonjudgmental listening would most appropriate
because is aids in the development of a trusting
relationship. Advising the client not to worry or
saying that everything will be alright provides false
reassurance, which does not help the client cope.
Further assessment is needed to determine whether
a psychiatric consult should be considered. Telling
the client that the friends were not true friends
discounts the client's feeling and hinders the
development of a therapeutic relationship.
Nurse Vince sustained a dirty needle stick injury.
Which diagnostic test would be ordered on a client?
A. Enzyme-linked immunosorbent assay (ELISA)
B. SUDS screening test
C. Antibody titers
D. Skin biopsy for Kaposi's sarcoma
B
SUDS screening test results are available in 30 to
60 minutes. The test is performed on a client to
determine if the health care worker with a dirty
needle stick injury should begin antiretroviral
infection with human immunodeficiency virus
(HIV), but the test does not diagnose acquired
immunodeficiency syndrome (AIDS). Antibody
titers would not be appropriate to determine
whether the health care worker has been exposed to
HIV or hepatitis. Kaposi's sarcoma is usually
associated with AIDS but not immediately after a
needle stick.
After the first injection of an immunotherapy
program, the nurse notices a large, red wheal on the
client's arm, coughing, and expiratory wheezing.
Which intervention should the nurse implement
first?
A. Notifying the health care provider immediately
B. Administering I.M. epinephrine per protocol
C. Beginning oxygen by way of nasal cannula
D. Starting an I.V. line for medication
administration
B
symptoms, the nurse would determine that the client
is experiencing anaphylaxis to the injection. The
first action is to give 0.2 to 0.5 ml of 1:1,000
epinephrine I.M. Notifying the health care provider,
beginning oxygen administration, and starting an
I.V. line follow after the initial injection of
epinephrine is administered.
During the past 6 months, a client diagnosed with
acquired immunodeficiency syndrome has had
chronic diarrhea and has lost 18 pounds. Additional
assessment findings include tented skin turgor, dry
mucous membranes, and listleness. Which nursing
diagnosis focuses attention on the client's most
immediate problem?

A. Deficient fluid volume related to diarrhea and
abnormal fluid loss
B. Imbalanced nutrition: less than body
requirements related to nausea and vomiting
C. Disturbed thought processes related to central
nervous system effects of disease
D. Diarrhea related to the disease process and acute
infection
A
Based on the client's assessment findings, the most
immediate problem is dehydration because of
chronic diarrhea. The nursing diagnosis of deficient
fluid volume is the priority, and interventions are
geared to improving the client's fluid status.
Although imbalanced nutrition, disturbed thought
processes, and diarrhea are involved, they assume a
lower priority at this time.
For a male client who has acquired
immunodeficiency syndrome with chronic diarrhea,
anorexia, a history of oral candidiasis, and weight
loss, which dietary instruction would be included in
the teaching plan?
A. "Follow a low-protein, high-carbohydrate diet."
B. "Eat three large meals per day."
C. "Include unpasteurized dairy products in the
diet."
D. "Follow a high-protein, high-calorie diet.
D
Dietary instructions should include the need for a
high-protein, high-calorie diet. The patient should
be taught to eat small, frequent meals and include
low-microbial foods, such as pasteurized dairy
products, washed and peeled fruits and vegetables,
and well-cooked meats.
A client with acquired immunodeficiency syndrome
has a respiratory infection from Pneumocystis
jiroveci and a nursing diagnosis of Impaired Gas
Exchange written in the plan of care. Which of the
following indicates that the expected outcome of
care has not yet been achieved?
A. Client has clear breath sounds
B. Client now limits his fluid intake
C. Client expectorates secretions easily
D. Client is free of complaints of shortness of breath
B
The status of the client with a diagnosis of Impaired
gas exchange would be evaluated against the
standard outcome criteria for this nursing diagnosis.
These would include the client stating that breathing
is easier and is coughing up secretions effectively,
and has clear breath sounds. The client should not
limit fluid intake because fluids are needed to
decrease the viscosity of secretions for
expectoration.
Human Papilloma Virus in AIDS patients is
manifested as:
A. Cough, evening fever, night sweats, weight loss
and anemia
B. Persistent fever, tachypnoea, hypoxia, cyanosis
and tachycardia.
C. Genital warts, flat warts, skin warts, neoplasm of
cervix, vagina and penis
D. Watery diarrhea, abdominal pain, nausea and
vomiting
C
Dermatologic human papillomavirus (HPV)
infection in HIV patients manifests as both
anogenital and nongenital skin disease. Cutaneous
HPV-related disease in nongenital skin is also
increased in HIV-positive patients, in the form of
benign common warts, epidermodysplasia
verruciformis-like skin lesions, and nonmelanoma
skin cancers.
A client is diagnosed with oral candidiasis. Nurse
Tina knows that this condition in AIDS is treated
with:
A. Trimethoprim + sulfamethoxazole
B. Fluconazole
C. Acyclovir
D. Zidovudine
B
Oral candidiasis usually responds to topical
treatments such as clotrimazole troches and nystatin
suspension (nystatin "swish and swallow").
Systemic antifungal medication such as fluconazole
or itraconazole may be necessary for oropharyngeal
infections that do not respond to these treatments.
The decision to begin antiretroviral therapy is based
on:
A. The CD4 cell count
B. The plasma viral load
C. The intensity of the patient's clinical symptoms
D. All of the above
D C. Toxoplasmosis
A person's CD4 count is an important factor in the
decision to start ART. A low or falling CD4 count
indicates that HIV is advancing and damaging the
immune system. A rapidly decreasing CD4 count
increases the urgency to start ART. Regardless of
CD4 count, there is greater urgency to start ART
when a person has a high viral load or any of the
following conditions: pregnancy, AIDS, and certain
HIV-related illnesses and co infections.
Which client problem relating to altered nutrition is
a consequence of AIDS?
A. Increased appetite
B. Decreased protein absorption
C. Increased secretions of digestive juices
D. Decreased gastrointestinal absorption
B b. Infection with Tuberculosis, HIV and
Often the complications of the acquired
immunodeficiency syndrome (AIDS) have a
negative impact on nutritional status. Weight loss
and protein depletion are commonly seen among the
AIDS population.
As a knowledgeable nurse, you know that the
primary goals of antiretroviral therapy (ART)
include all, EXCEPT:
A. Reduce HIV-associated morbidity and prolong
the duration and quality of survival
B. Restore and preserve immunologic function
C. Maximally and durably suppress plasma HIV
viral load
D. Elimination of HIV entirely from the body
D c. Feces and saliva
Eradication of HIV infection cannot be achieved
with available antiretroviral (ARV) regimens even
when new, potent drugs are added to a regimen that
is already suppressing plasma viral load below the
limits of detection of commercially available
assays.
Which is the most common HIV-related
neurological complication?
A. Tuberculosis
B. Kaposi's sarcoma
D. Lymphoma
C
Toxoplasmosis is the most common central nervous
system infection in patients with the acquired
immunodeficiency syndrome (AIDS) who are not
receiving appropriate prophylaxis. This infection
has a worldwide distribution and is caused by the
intracellular protozoan parasite, Toxoplasma gondii.
Ms. X is diagnosed with acquired
immunodeficiency syndrome (AIDS). The nurse
caring for this patient is aware that for a patient to
be diagnosed with HIV she should have which
condition?
a. Infection of HIV, have a CD4+ T-cell count of
500 cells/microliter, history of acute HIV infection
cytomegalovirus
c. Infection of HIV, have a CD4+ T-cell count of
>200 cells/microliter, history of acute HIV infection
d. Infection with HIV, history of HIV infection and
T-cell count below 200 cells/microliter
Answer C. The three criteria for a client to be
diagnosed with AIDS are the following:
• HIV positive
• CD4+ T-cell count below 200 cells/microliter
• Have one or more specific conditions that include
acute infection of HIV
The nurse observes precaution in caring for Mr. X
as HIV is most easily transmitted in:
a. Vaginal secretions and urine
b. Breast milk and tears
d. Blood and semen
Answer D. Keyword: MOST EASILY. Rationale:
HIV is MOST EASILY transmitted in blood, semen
and vaginal secretions. However, it has been noted
to be found in fecal materials, urine, saliva, tears
and breast milk.
Nurse Jaja is giving an injection to Ms. X. After
giving an injection, the nurse accidentally stuck her
finger with the needle when the client became very
agitated. To determine if the nurse became infected
with HIV when is the best time to test her for HIV
antibodies?
a. Immediately and repeat the test after 12 weeks
b. Immediately and repeat the test after 4 weeks
c. After a week and repeat the test in 4 months
d. After a weeks and repeat the test in 6 months
Answer A. Keyword: BEST TIME. Rationale: To
determine if a preexisting infection is present a test
should be done immediately and is repeated again in
3 months time (12 weeks) to detect seroconversion
as a result of the needle stick.
The blood test first used to identify a response to
HIV infection is:
a. Western blot
b. ELISA test
c. CD4+ T-cell count
d. CBC
Answer B. Keyword: FIRST. Rationale: The ELISA
test is the first screening test for HIV. A Western
blot test confirms a positive ELISA test. Other
blood tests that support the diagnosis of HIV
include CD4+ and CD8 + counts, CBC,
immunoglobulin levels, p24 antigen assay, and
quantitative ribonucleic acid assays.
What is the main reason why it is difficult to
develop a vaccine against HIV?
a. HIV is still unknown to human
b. HIV mutates easily
c. HIV spreads rapidly throughout the body
d. HIV matures easily
Answer B. Keyword: MAIN REASON. Rationale:
HIV was identified in 1983, thus, A is incorrect. By
1988 two strains of HIV existed, HIV-1 and HIV-2.
Viruses spread rapidly and mature easily but these
factors don't affect the potential for development
against HIV. Mutating too easily makes it hard to
create a vaccine against it.
Human Immunodeficiency virus belongs to which
classifications?
a. Rhabdovirus
b. Rhinovirus
c. Retrovirus
d. Rotavirus
Answer C. Rationale: HIV is a retrovirus that has a
ribonucleic acid dependent reverse transcriptase.
When teaching a patient infected with HIV
regarding transmission of the virus to others, which
statement made by the patient would indicate a need
for further teaching?
A. "I will need to isolate any tissues I use so as not
to infect my family."
B. "I will notify all of my sexual partners so they
can get tested for HIV."
C. "Unprotected sexual contact is the most common
mode of transmission."
D. "I do not need to worry about spreading this
virus to others by sweating at the gym."
A. "I will need to isolate any tissues I use so as not
to infect my family."
HIV is not spread casually. The virus cannot be
transmitted through hugging, dry kissing, shaking
hands, sharing eating utensils, using toilet seats, or
attending school with an HIV-infected person. It is
not transmitted through tears, saliva, urine, emesis,
sputum, feces, or sweat.
The nurse is providing care for a patient who has
been living with HIV for several years. Which
assessment finding most clearly indicates an acute
exacerbation of the disease?
A. A new onset of polycythemia
B. Presence of mononucleosis-like symptoms
C. A sharp decrease in the patient's CD4+ count
D. A sudden increase in the patient's WBC count
C. A sharp decrease in the patient's CD4+ count
A decrease in CD4+ count signals an exacerbation
of the severity of HIV. Polycythemia is not
characteristic of the course of HIV. A patient's
WBC count is very unlikely to suddenly increase,
with decreases being typical. Mononucleosis-like
symptoms such as malaise, headache, and fatigue
are typical of early HIV infection and
seroconversion.
A pregnant woman who was tested and diagnosed
with HIV infection is very upset. What should the
nurse teach this patient about her baby's risk of
being born with HIV infection?
A. "The baby will probably be infected with HIV."
B. "Only an abortion will keep your baby from
having HIV."
C. "Treatment with antiretroviral therapy will
decrease the baby's chance of HIV infection."
D. "The duration and frequency of contact with the
organism will determine if the baby gets HIV
infection."
C. "Treatment with antiretroviral therapy will
decrease the baby's chance of HIV infection."
On average, 25% of infants born to women with
untreated HIV will be born with HIV. The risk of
transmission is reduced to less than 2% if the
infected pregnant woman is treated with
antiretroviral therapy. Duration and frequency of
contact with the HIV organism is one variable that
influences whether transmission of HIV occurs.
Volume, virulence, and concentration of the
organism as well as host immune status are
variables related to transmission via blood, semen,
vaginal secretions, or breast milk.
A 25-year-old male patient has been diagnosed with
HIV. The patient does not want to take more than
one antiretroviral drug. What reasons can the nurse
tell the patient about for taking more than one drug?
A. Together they will cure HIV.
B. Viral replication will be inhibited.
C. They will decrease CD4+ T cell counts.
D. It will prevent interaction with other drugs
B. Viral replication will be inhibited.
The major advantage of using several classes of
antiretroviral drugs is that viral replication can be
inhibited in several ways, making it more difficult
for the virus to recover and decreasing the
likelihood of drug resistance that is a major problem
with monotherapy. Combination therapy also delays
disease progression and decreases HIV symptoms
and opportunistic diseases. HIV cannot be cured.
CD4+ T cell counts increase with therapy. There are
dangerous interactions with many antiretroviral
drugs and other commonly used drugs.
The woman is afraid she may get HIV from her
bisexual husband. What should the nurse include
when teaching her about preexposure prophylaxis
(select all that apply)?
A. Take fluconazole (Diflucan).
B. Take amphotericin B (Fungizone).
C. Use condoms for risk-reducing sexual relations.
D. Take emtricitabine and tenofovir (Truvada)
regularly.
E. Have regular HIV testing for herself and her
husband.
C. Use condoms for risk-reducing sexual relations.
D. Take emtricitabine and tenofovir (Truvada)
regularly.
E. Have regular HIV testing for herself and her
husband.
Using male or female condoms, having monthly
HIV testing for the patient and her husband, and the
woman taking emtricitabine and tenofovir regularly
has shown to decrease the infection of heterosexual
women having sex with a partner who participates
in high-risk behavior. Fluconazole and amphotericin
B are taken for Candida albicans, Coccidioides
immitis, and Cryptococcosus neoformans, which
are all opportunistic diseases associate with HIV
infection
The nurse was accidently stuck with a needle used
on an HIV-positive patient. After reporting this,
what care should this nurse first receive?
A. Personal protective equipment
B. Combination antiretroviral therapy
C. Counseling to report blood exposures
D. A negative evaluation by the manage
B. Combination antiretroviral therapy
Postexposure prophylaxis with combination
antiretroviral therapy can significantly decrease the
risk of infection. Personal protective equipment
should be available although it may not have
stopped this needle stick. The needle stick has been
reported. The negative evaluation may or may not
be needed but would not occur first.
The HIV-infected patient is taught health promotion
activities including good nutrition; avoiding
alcohol, tobacco, drug use, and exposure to
infectious agents; keeping up to date with vaccines;
getting adequate rest; and stress management. What
is the rationale behind these interventions that the
nurse knows?
A. Delaying disease progression
B. Preventing disease transmission
C. Helping to cure the HIV infection
D. Enabling an increase in self-care activities
A. Delaying disease progression
These health promotion activities along with mental
health counseling, support groups, and a therapeutic
relationship with health care providers will promote
a healthy immune system, which may delay disease
progression. These measures will not cure HIV
infection, prevent disease transmission, or increase
self-care activities
The patient is admitted to the ED with fever,
swollen lymph glands, sore throat, headache,
malaise, joint pain, and diarrhea. What nursing
measures will help identify the need for further
assessment of the cause of this patient's
manifestations (select all that apply)?
A. Assessment of lung sounds
B. Assessment of sexual behavior
C. Assessment of living conditions
D. Assessment of drug and syringe use
E. Assessment of exposure to an ill person
B. Assessment of sexual behavior
D. Assessment of drug and syringe use
With these symptoms, assessing this patient's sexual
behavior and possible exposure to shared drug
equipment will identify if further assessment for the
HIV virus should be made or the manifestations are
from some other illness (e.g., lung sounds and
living conditions may indicate further testing for
TB).
Transmission of HIV from an infected individual to
another most commonly occurs as a result of
a. unprotected anal or vaginal sexual intercourse.
b. low levels of virus in the blood and high levels of
CD4+ T cells.
c. transmission from mother to infant during labor
and delivery and breastfeeding.
d. sharing of drug-using equipment, including
needles, syringes, pipes, and straws
Correct answer: a
Rationale: Unprotected sexual contact (semen,
vaginal secretions, or blood) with a partner
During HIV infection
a. the virus replicates mainly in B-cells before
spreading to CD4+ T cells.
b. infection of monocytes may occur, but antibodies
quickly destroy these cells.
c. the immune system is impaired predominantly by
the eventual widespread destruction of CD4+ T
cells.
d. a long period of dormancy develops during which
HIV cannot be found in the blood and there is little
viral replication
Correct answer: c
Rationale: Immune dysfunction in HIV disease is
caused predominantly by damage to and destruction
of CD4+ T cells (i.e., T helper cells or CD4+ T
lymphocytes)
Which statements accurately describe HIV infection
(select all that apply)?
a. Untreated HIV infection has a predictable pattern
of progression.
b. Late chronic HIV infection is called acquired
immunodeficiency syndrome (AIDS).
c. Untreated HIV infection can remain in the early
chronic stage for a decade or more.
d. Untreated HIV infection usually remains in the
early chronic stage for 1 year or less.
e. Opportunistic diseases occur more often when the
CD4+ T cell count is high and the viral load is low
Correct answers: a, b, c
Rationale: The typical course of untreated HIV
infection follows a predictable pattern. However,
treatment can significantly alter this pattern, and
disease progression is highly individualized. Late
chronic infection is another term for acquired
immunodeficiency syndrome (AIDS). The median
interval between untreated HIV infection and a
diagnosis of AIDS is about 11 years.
A diagnosis of AIDS is made when an HIV-infected
patient has
a. a CD4+ T cell count below 200/µL.
b. a high level of HIV in the blood and saliva.
c. lipodystrophy with metabolic abnormalities.
d. oral hairy leukoplakia, an infection caused by
Epstein-Barr virus.
Correct answer: a
Rationale: AIDS is diagnosed when an individual
with HIV infection meets one of several criteria;
one criterion is a CD4+ T cell count below 200
cells/L. Other criteria are listed in Table 15-9.
Screening for HIV infection generally involves
a. laboratory analysis of blood to detect HIV
antigen.
b. electrophoretic analysis for HIV antigen in
plasma.
c. laboratory analysis of blood to detect HIV
antibodies.
d. analysis of lymph tissues for the presence of HIV
RNA.
Correct answer: c
Rationale: The most useful screening tests for HIV
detect HIV-specific antibodies
Antiretroviral drugs are used to
a. cure acute HIV infection.
b. decrease viral RNA levels.
c. treat opportunistic diseases.
d. decrease pain and symptoms in terminal disease.
Correct answer: b
Rationale: The goals of drug therapy in HIV
infection are to (1) decrease the viral load, (2)
maintain or raise CD4+ T cell counts, and (3) delay
onset of HIV infection-related symptoms and
opportunistic diseases.
Opportunistic diseases in HIV infection
a. are usually benign.
b. are generally slow to develop and progress.
c. occur in the presence of immunosuppression.
d. are curable with appropriate drug interventions.
Correct answer: c
Rationale: Management of HIV infection is
complicated by the many opportunistic diseases that
can develop as the immune system deteriorates (see
Table 15-10).
Which statement about metabolic side effects of
ART is true (select all that apply)?
a. These are annoying symptoms that are ultimately
harmless.
b. ART-related body changes include central fat
accumulation and peripheral wasting.
c. Lipid abnormalities include increases in
triglycerides and decreases in high-density
cholesterol.
d. Insulin resistance and hyperlipidemia can be
treated with drugs to control glucose and
cholesterol.
e. Compared to uninfected people, insulin resistance
and hyperlipidemia are more difficult
Correct answers: b, c, d
Rationale: Some HIV-infected patients, especially
those who have been infected and have received
ART for a long time, develop a set of metabolic
disorders that include changes in body shape (e.g.,
fat deposits in the abdomen, upper back, and breasts
along with fat loss in the arms, legs, and face) as a
result of lipodystrophy, hyperlipidemia (i.e.,
elevated triglyceride levels and decreases in high-
density lipoprotein levels), insulin resistance and
hyperglycemia, bone disease (e.g., osteoporosis,
osteopenia, avascular necrosis), lactic acidosis, and
cardiovascular disease.
Which strategy can the nurse teach the patient to
eliminate the risk of HIV transmission?
a. Using sterile equipment to inject drugs
b. Cleaning equipment used to inject drugs
c. Taking zidovudine (AZT, ZDV, Retrovir) during
pregnancy
d. Using latex or polyurethane barriers to cover
genitalia during sexual contact
Correct answer: a
Rationale: Access to sterile equipment is an
important risk-elimination tactic. Some
communities have needle and syringe exchange
programs (NSEPs) that provide sterile equipment to
users in exchange for used equipment. Cleaning
equipment before use is a risk-reducing activity. It
decreases the risk when equipment is shared, but it
takes time, and a person in drug withdrawal may
have difficulty cleaning equipment.
What is the most appropriate nursing intervention to
help an HIV-infected patient adhere to a treatment
regimen?
a. "Set up" a drug pillbox for the patient every
week.
b. Give the patient a video and a brochure to view
and read at home.
c. Tell the patient that the side effects of the drugs
are bad but that they go away after a while.
d. Assess the patient's routines and find adherence
cues that fit into the patient's life circumstances.
Correct answer: d
Rationale: The best approach to improve adherence
to a treatment regimen is to learn about the patient's
life and assist with problem solving within the
confines of that life.
The nurse is providing postoperative care for a 30-
year-old female patient after an appendectomy. The
patient has tested positive for human
immunodeficiency virus (HIV). What type of
precautions should the nurse observe to prevent the
transmission of this disease?
a. Droplet precautions
b. Contact precautions
c. Airborne precautions
d. Standard precautions
d. Standard precautions
Standard precautions are indicated for prevention of
transmission of HIV to the health care worker. HIV
is not transmitted by casual contact or respiratory
droplets. HIV may be transmitted through sexual
intercourse with an infected partner, exposure to
HIV-infected blood or blood products, and perinatal
transmission during pregnancy, at delivery, or
though breastfeeding.
A 52-year-old female patient was exposed to human
immunodeficiency virus (HIV) 2 weeks ago through
sharing needles with other substance users. What
symptoms will the nurse teach the patient to report
that would indicate the patient has developed an
acute HIV infection?
a. Cough, diarrhea, headaches, blurred vision,
muscle fatigue
d. Night sweats, fatigue, fever, and persistent
generalized lymphadenopathy
c. Oropharyngeal candidiasis or thrush, vaginal
candidal infection, or oral or genital herpes
d. Flu-like symptoms such as fever, sore throat,
swollen lymph glands, nausea, or diarrhea
d. Flu-like symptoms such as fever, sore throat,
swollen lymph glands, nausea, or diarrhea
Clinical manifestations of an acute infection with
HIV include flu-like symptoms between 2 to 4
weeks after exposure. Early chronic HIV infection
clinical manifestations are either asymptomatic or
include fatigue, headache, low-grade fever, night
sweats, and persistent generalized lympadenopathy.
Intermediate chronic HIV infection clinical
manifestations include candidal infections, shingles,
oral or genital herpes, bacterial infections, Kaposi
sarcoma, or oral hairy leukoplakia. Late chronic
HIV infection or acquired immunodeficiency
syndrome (AIDS) includes opportunistic diseases
(infections and cancer).
The nurse is monitoring the effectiveness of
antiretroviral therapy (ART) for a 56-year-old man
with acquired immunodeficiency syndrome (AIDS).
What laboratory study result indicates the
medications have been effective?
a. Increased viral load
b. Decreased neutrophil count
c. Increased CD4+ T cell count
d. Decreased white blood cell count
c. Increased CD4+ T cell count
Antiretroviral therapy is effective if there are
decreased viral loads and increased CD4+ T cell
counts.
A 62-year-old patient has acquired
immunodeficiency syndrome (AIDS), and the viral
load is reported as undetectable. What patient
teaching should be provided by the nurse related to
this laboratory study result?
a. The patient has the virus present and can transmit
the infection to others.
b. The patient is not able to transmit the virus to
others through sexual contact.
c. The patient will be prescribed lower doses of
antiretroviral medications for 2 months.
d. The syndrome has been cured, and the patient
will be able to discontinue all medications.
a. The patient has the virus present and can transmit
the infection to others.
In human immunodeficiency virus (HIV) infections,
viral loads are reported as real numbers of
copies/μL or as undetectable. "Undetectable"
indicates that the viral load is lower than the test is
able to report. "Undetectable" does not mean that
the virus has been eliminated from the body or that
the indivi
A patient who has vague symptoms of fatigue,
headaches, and a positive test for human
immunodeficiency virus (HIV) antibodies using an
enzyme immunoassay (EIA) test. What instructions
should the nurse give to this patient?
a. "The EIA test will need to be repeated to verify
the results."
b. "A viral culture will be done to determine the
progression of the disease."
c. "It will probably be 10 or more years before you
develop acquired immunodeficiency syndrome
(AIDS)."
d. "The Western blot test will be done to determine
whether acquired immunodeficiency syndrome
(AIDS) has developed."
ANS: A
After an initial positive EIA test, the EIA is
repeated before more specific testing such as the
Western blot is done. Viral cultures are not usually
part of HIV testing. It is not appropriate for the
nurse to predict the time frame for AIDS
development. The Western blot tests for HIV
antibodies, not for AIDS.
A patient who has a positive test for human
immunodeficiency virus (HIV) antibodies is
admitted to the hospital with Pneumocystis jiroveci
pneumonia (PCP) and a CD4+ T-cell count of less
than 200 cells/L. Based on diagnostic criteria
established by the Centers for Disease Control and
Prevention (CDC), which statement by the nurse is
correct?
a. "The patient meets the criteria for a diagnosis of
an acute HIV infection."
b. "The patient will be diagnosed with
asymptomatic chronic HIV infection."
c. "The patient has developed acquired
immunodeficiency syndrome (AIDS)."
d. "The patient will develop symptomatic chronic
HIV infection in less than a year."
ANS: C
Development of PCP meets the diagnostic criterion
for AIDS. The other responses indicate earlier
stages of HIV infection than is indicated by the PCP
infection.
A patient with a positive rapid antibody test result
for human immunodeficiency virus (HIV) is
anxious and does not appear to hear what the nurse
is saying. What action by the nurse is most
important at this time?
a. Teach the patient about the medications available
for treatment.
b. Inform the patient how to protect sexual and
needle-sharing partners.
c. Remind the patient about the need to return for
retesting to verify the results.
d. Ask the patient to notify individuals who have
had risky contact with the patient.
ANS: C
After an initial positive antibody test, the next step
is retesting to confirm the results. A patient who is
anxious is not likely to be able to take in new
information or be willing to disclose information
about HIV status of other individuals.
A patient who is diagnosed with acquired
immunodeficiency syndrome (AIDS) tells the nurse,
"I feel obsessed with thoughts about dying. Do you
think I am just being morbid?" Which response by
the nurse is best?
a. "Thinking about dying will not improve the
course of AIDS."
b. "It is important to focus on the good things about
your life now."
c. "Do you think that taking an antidepressant might
be helpful to you?"
d. "Can you tell me more about the kind of thoughts
that you are having?"
ANS: D
More assessment of the patient's psychosocial status
is needed before taking any other action. The
statements, "Thinking about dying will not improve
the course of AIDS" and "It is important to focus on
the good things in life" discourage the patient from
sharing any further information with the nurse and
decrease the nurse's ability to develop a trusting
relationship with the patient. Although
antidepressants may be helpful, the initial action
should be further assessment of the patient's
feelings.
A pregnant woman with a history of asymptomatic
chronic human immunodeficiency virus (HIV)
infection is seen at the clinic. The patient states, "I
am very nervous about making my baby sick."
Which information will the nurse include when
teaching the patient?
a. The antiretroviral medications used to treat HIV
infection are teratogenic.
b. Most infants born to HIV-positive mothers are
not infected with the virus.
c. Because she is at an early stage of HIV infection,
the infant will not contract HIV.
d. It is likely that her newborn will become infected
with HIV unless she uses antiretroviral therapy
(ART)
ANS: B
Only 25% of infants born to HIV-positive mothers
develop HIV infection, even when the mother does
not use ART during pregnancy. The percentage
drops to 2% when ART is used. Perinatal
transmission can occur at any stage of HIV
infection (although it is less likely to occur when
the viral load is lower). ART can safely be used in
pregnancy, although some ART drugs should be
avoided.
Which patient exposure by the nurse is most likely
to require postexposure prophylaxis when the
patient's human immunodeficiency virus (HIV)
status is unknown?
a. Needle stick with a needle and syringe used to
draw blood
b. Splash into the eyes when emptying a bedpan
containing stool
c. Contamination of open skin lesions with patient
vaginal secretions
d. Needle stick injury with a suture needle during a
surgical procedure
ANS: A
Puncture wounds are the most common means for
workplace transmission of blood-borne diseases,
and a needle with a hollow bore that had been
contaminated with the patient's blood would be a
high-risk situation. The other situations described
would be much less likely to result in transmission
of the virus.
STDs
A nurse is teaching a client with genital herpes.
Education for this client should include an
explanation of:
a) why the disease is transmittable only when
visible lesions are present.
b) the need for the use of petroleum products.
c) the option of disregarding safer-sex practices
now that he's already infected.
d) the importance of informing his partners of the
disease.
D
Katrina Sterrett, a 26-year-old preschool teacher, is
being seen by a physician who is part of the
internist group where you practice nursing. She is
undergoing her annual physical and is having many
lab tests done as a condition of her employment and
upcoming wedding. She is returning for her results
and is devastated to learn that she has the sexually-
transmitted infection, gonorrhea. What would
contribute to her ignorance of her condition?
a) Being asymptomatic
b) All options are correct
c) Being sexually inactive
d) Knowing the signs and symptoms of STIs
A
Within the free clinic where you practice nursing,
you hold weekly sexual education classes open to
the public. Within the classroom, you communicate
the CDC's numbers for the incidence of STIs and
their impact upon public health. Which is the
fastest-spreading bacterial STI in the United States?
a) Gonorrhea
b) Chlamydia
c) Herpes simplex 1
d) HPV
B infection with:
A nurse is caring for a client diagnosed with a
chlamydia infection. The nurse teaches the client
about disease transmission and advises the client to
inform his sexual partners of the infection. The
client refuses, stating, "This is my business and I'm
not telling anyone. Beside, chlamydia doesn't cause
any harm like the other STDs." How should the
nurse proceed?
a) Do nothing because the client's sexual habits
place him at risk for contracting other STDs.
b) Educate the client about why it's important to
inform sexual contacts so they can receive
treatment.
c) Inform the health department that this client
contracted an STD.
d) Inform the client's sexual contacts of their
possible exposure to chlamydia.
B their own without any treatment."
A nurse is teaching a health class to a group of
clients likely to be at highest risk for gonorrhea.
What is the age range of the clients?
a) 60 to 70 years
b) 15 to 24 years
c) 25 to 29 years
d) 30 to 45 years
B
A 16-year-old patient comes to the free clinic and is
diagnosed with primary syphilis. The patient states
that she contracted this disease by holding hands
with someone who has syphilis. What is the most
appropriate nursing diagnosis for this patient?
a) Alteration in comfort related to impaired skin
integrity
b) Fear related to complications
c) Noncompliance with treatment regimen related to
age
d) Knowledge deficit related to modes of
transmission
D
A 22-year-old patient has presented to her primary
care provider for her scheduled Pap smear.
Abnormal results of this diagnostic test may imply
a) human papillomavirus (HPV).
b) Chlamydia trachomatis.
c) Candida albicans.
d) Trichomonas vaginalis.
A
A female college student is distressed at the recent
appearance of genital warts, an assessment finding
that her care provider has confirmed as attributable
to human papillomavirus (HPV) infection. Which of
the following information should the nurse give the
patient?
a) "It's important to start treatment soon, so you will
be prescribed pills today."
b) "I'd like to give you an HPV vaccination if that's
okay with you."
c) "There is a chance that these will clear up on
d) "Unfortunately, this is going to greatly increase
your chance of developing pelvic inflammatory
disease."
C
A client is being treated for gonorrhea. Which agent
would the nurse expect the physician to prescribe?
a) Tetracycline
b) Ceftriaxone
c) Penicillin
d) Levofloxacin
B c) Chlamydia
A client with a history of HSV-2 infection asks the
nurse about future sexual activity. Which of the
following responses would be most appropriate?
a) "Inform all potential sexual partners about the
infection, even if it is inactive.".
b) "Use a condom during sexual activity if the
infection becomes active again."
c) "If the infection has healed, you probably don't
have to use a condom."
d) "Refrain from all sexual activity until you don't
have another outbreak for a year."
A infected with chlamydia as well."
A male client reports urethral pain and a creamy
yellow, bloody discharge from the penis. The nurse
associates these characteristics with which of the
following sexually transmitted infections?
a) Gonorrhea
b) Candidiasis
c) Chancroid
d) Trichomoniasis
A
A client with primary syphilis is allergic to
penicillin. The nurse would expect the physician to
order which agent?
a) Podophyllum resin
b) Tetracycline
c) Ceftriaxone
d) Acyclovir
B nurse expect to include as the most common STI in
After teaching a group of students about sexually
transmitted infections (STIs), the instructor
determines that additional teaching is necessary
when the students identify which STI as curable
with treatment?
a) Syphillis
b) Gonorrhea
d) Genital herpes
D
A student nurse is caring for a male patient
diagnosed with gonorrhea. The patient is receiving
ceftriaxone and doxycycline. The nursing instructor
asks the student why the patient is receiving two
antibiotics. What is the student nurse's best
response?
a) "This combination of medications will eradicate
the infection faster than a single antibiotic."
b) "Many people infected with gonorrhea are
c) "The combination of these two antibiotics
reduces the risk of reinfection."
d) "There are many resistant strains of gonorrhea, so
more than one antibiotic may be required for
successful treatment."
B
A client is diagnosed as being in the primary stage
of syphilis? Which of the following would the nurse
expect as a finding?
a) Palmar rash
b) Development of gummas
c) Development of central nervous system lesions
d) Genital chancres
D
The nurse is preparing a presentation for a local
community group about sexually transmitted
infections (STIs). Which of the following would the
the United States?
a) Chlamydia
b) Syphilis
c) Genital herpes
d) Gonorrhea
A
A patient has herpes simplex 2 viral infection
(HSV-2). The nurse recognizes that which of the
following should be included in teaching the
patient?
a) The virus causes "cold sores" of the lips.
b) Treatment is focused on relieving symptoms.
c) The virus may be cured with antibiotics.
d) The virus when active may not be contracted
during intercourse.
B
A male patient comes to the clinic and is diagnosed
with gonorrhea. Which symptom most likely
prompted him to seek medical attention?
a) Painful red papules on the shaft of the penis
b) Foul-smelling discharge from the penis
c) Rashes on the palms of the hands and soles of the
feet
d) Cauliflower-like warts on the penis
B c) Genital herpes
Max Thornton, a 24-year-old chef, is being seen by
a physician at the urology group where you practice
nursing. He has developed a painless ulcer on his
penis and is rather concerned about his health. The
urologist will be communicating his diagnosis of
syphilis and prescribing treatment. What is the
typical span of time between infection and
developing symptoms with syphilis?
a) 14 days
b) 21 days
c) 35 days
d) 28 days
B d) You can expect other outbreaks, each of which
A client is diagnosed with chlamydia and is
distraught. "How can I have this problem? I don't
have any symptoms!" she says. The nurse teaches
the client that the percentage of women with
chlamydia who are asymptomatic is as high as
a) 100%
b) 75%
c) 50%
d) 25%
B
A nurse is teaching a community health class of
women and explains that a sexually transmitted
infection (STI) is associated with an increased risk
of infertility in women. Which of the following
STIs would the nurse identify?
a) Herpes simplex
b) Syphilis
c) Chlamydia
d) Gonorrhea
C
An instructor is teaching a group of students about
the incidence of sexually transmitted infections
(STIs) and those that must be reported by law. The
instructor determines that the students have
understood the information when they state that
which STI must be reported?
a) Syphilis
b) Condylomata acuminata
d) Hepatitis B
A
A client with genital herpes asks the nurse about
what to expect with the infection. Which of the
following responses would be most appropriate?
a) Once you take the medication, the infection will
be gone for good.
b) You might have to try several different
medications before finding one that works.
c) Even though you don't have symptoms, you
could still spread the infection.
will be longer than the first.
C
When obtaining the health history from a client,
which factor would lead the nurse to suspect that
the client has an increased risk for sexually
transmitted infections (STIs)?

a) Hive-like rash for the past 2 days
b) Clear vaginal discharge
c) Weight gain of 5 lbs in one year
d) Five different sexual partners
D c) Pain on urination
The nurse is giving a presentation about chlamydia
to a group of adult women. The nurse would
emphasize the need for annual screening for this
infection in all sexually active women younger than
which age?
a) 26
b) 35
c) 18
d) 32
A penis
A nurse is assessing a woman with vaginal
discharge. The nurse suspects bacterial vaginosis
when the client states which of the following?
a) "The discharge is yellowish but thin."
b) "I noticed a strange fishy odor during my
period."
c) "The discharge looks almost like cottage cheese."
d) "I've been experiencing some really intense
itching."
B c) Human papillomavirus
A nurse is developing a plan of care for a female
client experiencing her first outbreak of genital
herpes. Which nursing diagnosis would the nurse
most likely identify as the priority?
a) Acute pain related to the development of the
genital lesions
b) Deficient knowledge related to the disease and its
transmission
c) Ineffective coping related to the increased stress
associated with the infection
d) Hyperthermia related to body's response to an
infectious process
A D) "I do not need to worry about spreading this
The nurse is gathering data from a male client who
is suspected of having gonorrhea. Which of the
following would the nurse most likely find?
a) Testicular pain
b) Purulent rectal discharge
d) Skin rash
C
A nurse is assisting with a physical examination of
a male client. Which of the following signs and
symptoms is most clearly suggestive of primary
genital herpes?
a) Emergence of hard, painless nodules on the shaft
of the penis
b) Presence of purulent, whitish discharge from the
c) Production of cloudy, foul-smelling urine
d) Itching, pain, and the emergence of pustules on
the penis
D
A nurse is providing care to a client with chlamydia.
The nurse anticipates that the client will also receive
treatment for which of the following?
a) Mycoplasma
b) Trichomoniasis
d) Gonorrhea
D
When teaching a patient infected with HIV
regarding transmission of the virus to others, which
of the following statements made by the patient
would identify a need for further education?
A) "I will need to isolate any tissues I use so as not
to infect my family."
B) "I will notify all of my sexual partners so they
can get tested for HIV."
C) "Unprotected sexual contact is the most common
mode of transmission."
virus to others by sweating at the gym."
A
A hospital has seen a recent increase in the
incidence of hospital-acquired infections (HAIs).
Which of the following measures should be
prioritized in the response to this trend?
A) Use of gloves during patient contact
B) Frequent and thorough hand washing
C) Prophylactic, broad-spectrum antibiotics
D) Fitting and appropriate use of N95 masks
B resistant to reinfection."
Standard precautions should be used when
providing care for
A) All patients regardless of diagnosis.
B) Pediatric and gerontologic patients.
C) Patients who are immunocompromised.
D) Patients with a history of infectious diseases.
A A) Chlamydia is frequently comorbid with HIV.
A patient comes to the clinic after being informed
by a sexual partner of possible recent exposure to
syphilis. The nurse will examine the patient for
which of the following characteristic findings of
syphilis in the primary clinical stage?
A) Chancre
B) Alopecia
C) Condylomata lata
D) Regional adenopathy
A to first suspect
Teaching for patients with a sexually transmitted
disease (STD) would include (select all that apply)
A) Treatment of sexual partner is important.
B) Douching may help provide relief of itching.
C) Cotton undergarments are preferred over
synthetic materials.
D) Sexual abstinence is indicated during the
communicable phase of the disease.
E) Condoms should be used during as well as after
treatment during sexual activity.
A,C,D,E
A 22-year-old male is being treated at a college
health care clinic for gonorrhea. Which of the
following teaching points should the nurse include
in patient teaching?
A) "While being treated for the infection, you will
not be able to pass this infection on to your sexual
partner."
B) "While you're taking your antibiotics, you will
need to abstain from participating in sexual activity
or drinking alcohol."
C) "It's important to complete your full course of
antibiotics in order to ensure that you become
D) "The symptoms of gonorrhea will resolve on
their own, but it is important for you to abstain from
sexual activity while this is occurring."
B
Screening for chlamydia is recommended for young
women because
B) Chlamydial infections may progress to sepsis.
C) Untreated chlamydial infections can lead to
infertility.
D) Chlamydial infections are treatable only in the
early stages of infection.
C
A 30-year-old female patient has sought care
because of the recent appearance of itchy lesions on
her vulva, some of which have recently burst. The
patient's description of her problem would lead you
A) HIV.
B) Gonorrhea.
C) Chlamydia.
D) Genital herpes.
D
The physical assessment and history of a 29-year-
old female patient are indicative of human
papillomavirus (HPV) infection. You would
perform patient teaching related to
A) Gardasil.
B) Antibiotic therapy.
C) Wart removal options.
D) Treatment with antiviral drugs.
C
A client is diagnosed as being in the primary stage
of syphilis? Which of the following would the nurse
expect as a finding?
a) Development of gummas
b) Palmar rash
c) Genital chancres
d) Development of central nervous system lesions
C d) Grieving related to the poor prognosis of the
A client with genital herpes simplex infection asks
the nurse, "Will I ever be cured of this infection?"
Which response by the nurse would be most
appropriate?
a) "All you need is a dose of penicillin and the
infection will be gone."
b) "There is a new vaccine available that prevents
the infection from returning."
c) "Once you have the infection, you develop an
immunity to it."
d) "There is no cure, but drug therapy helps to
reduce symptoms and recurrences."
D A
A client visits the nurse complaining of diarrhea
every time they eat. The client has AIDS and wants
to know what they can do to stop having diarrhea.
What should the nurse advise?
a) Reduce food intake.
b) Encourage large, high-fat meals.
c) Avoid residue, lactose, fat, and caffeine.
d) Increase the intake of iron and zinc.
C d) "I should avoid being around other people who
A client is prescribed didanosine (Videx) as part of
his highly active antiretroviral therapy (HAART).
Which instruction would the nurse emphasize with
this client?
a) "You should take the drug with an antacid."
b) "It doesn't matter if you take this drug with or
without food."
c) "Be sure to take this drug about 1/2 hour before
or 2 hours after you eat."
d) "When you take this drug, eat a high-fat meal
immediately afterwards."
C b) CD count > 100/mm
When developing the plan of care for a client with a
primary immunodeficiency, which nursing
diagnosis would be the priority?
a) Risk for infection related to altered immune cell
function
b) Impaired skin integrity related to persistent deep
skin abscesses
c) Anxiety related to an inherited disorder
condition
A
A group of students are reviewing class material on
sexually transmitted infections in preparation for a
test. The students demonstrate understanding of the
material when they identify which of the following
as the cause of condylomata?
a) Human papilloma virus
b) Haemophilus ducreyi bacillus
c) Herpes virus
d) Treponema pallidum
After teaching a client with immunodeficiency
about ways to prevent infection, the nurse
determines that teaching was successful when the
client states which of the following?
a) "I will clean my kitchen counter with hot water."
b) "Alcohol is good to clean any skin areas that are
dry or chafed."
c) "I should avoid eating cooked fruits and
vegetables."
have an infection."
D
A 45-year-old waitress with a history of IV drug use
also is HIV-positive. She has been following her
antiretroviral medication regimen faithfully and is
doing well. She's attending college to get a social
work degree and is focused on a bright future. In
her regular CD counts, what factor will indicate she
has progressed from HIV to AIDS?
a) CD count > 200/mm
c) CD count < 200/mm
d) CD count < 100/mm
C b) History of fungal diaper rash
A patient comes to the free clinic complaining of
urethral discharge. On assessment, the nurse notes
that the patient is feverish. During the assessment,
the patient admits to having unprotected sex. The
nurse suspects the patient may have a diagnosis of
what?
a) HIV
b) Chlamydia
c) Syphilis
d) Gonorrhea
D b) Avoidance of the use of tampons
A female client with an anal gonorrheal infection
experiences painful bowel elimination and a
purulent rectal discharge. The nurse would expect to
find which of the following once the microorganism
disseminates throughout the body?
a) Painful joints
b) Intermenstrual bleeding
c) Sore throat
d) Painful urination
A c) the option of disregarding safer-sex practices
Which information would be most appropriate for a
nurse to provide to a client who has never used a
condom?
a) A condom can be used, even if it is old, so long
as the pack is unopened.
b) A new condom should be used for each sex act.
c) Cheap condoms of any brand can be used based
on monetary constraints.
d) A fresh condom should be unrolled over a limp
penis before it becomes erect.
B term, monogamous relationship, regardless of
A mother brings her young child to the clinic for an
evaluation of an infection. The mother states, "He's
been taking antibiotics now for more than 2 months
and still doesn't seem any better. It's like he's always
sick." During the history and physical examination,
which of the following would alert the nurse to
suspect a primary immunodeficiency?
a) Superficial wound on the child's left leg
c) Ten ear infections in the past year
d) Weight within age-appropriate parameters
C
A student nurse is doing clinical hours at an
OB/GYN clinic. The student is helping to develop a
plan of care for a patient with gonorrhea has
presented at the clinic. The student knows that the
care plan for this patient should be include what in
the treatment of gonorrhea?
a) Concurrent treatment for chlamydia
c) Vaginal smears every 6 months
d) Radiation therapy to destroy cancerous cells
A
A nurse is teaching a client with genital herpes.
Education for this client should include an
explanation of:
a) why the disease is transmittable only when
visible lesions are present.
b) the need for the use of petroleum products.
now that he's already infected.
d) the importance of informing his partners of the
disease.
D ~ Importance of informing his partners of the
disease.
Clients with genital herpes should inform their
partners of the disease to help prevent transmission.
Petroleum products should be avoided because they
can cause the virus to spread. The notion that
genital herpes is only transmittable when visible
lesions are present is false. Anyone not in a long-
current health status, should follow safer-sex
practices.
A 22-year-old patient has presented to her primary
care provider for her scheduled Pap smear.
Abnormal results of this diagnostic test may imply
infection with:
a) human papillomavirus (HPV).
b) Chlamydia trachomatis.
c) Candida albicans.
d) Trichomonas vaginalis.
A ~ human papillomavirus (HPV)
Although a Pap smear does not test directly for
HPV, dysplasia of cervical cells is strongly
associated with HPV infection. An abnormal Pap
smear is not indicative of chlamydial infection,
trichomoniasis, or candidiasis.
A female college student is distressed at the recent
appearance of genital warts, an assessment finding
that her care provider has confirmed as attributable
to human papillomavirus (HPV) infection. Which of
the following information should the nurse give the
patient?
a) "It's important to start treatment soon, so you will
be prescribed pills today."
b) "I'd like to give you an HPV vaccination if that's
okay with you."
c) "There is a chance that these will clear up on
their own without any treatment."
d) "Unfortunately, this is going to greatly increase
your chance of developing pelvic inflammatory
disease."
C ~ There is a chance that these will clear up on
their own without any tx
Genital warts may resolve spontaneously, although
this does not preclude recurrence. Pharmacologic
treatments are topical and vaccination is ineffective
after infection has occurred. HPV infection is not
correlated with pelvic inflammatory disease (PID).
The physical assessment and history of a 29-year-
old female patient are indicative of human
papillomavirus (HPV) infection. You would
perform patient teaching related to
A) Gardasil.
B) Antibiotic therapy.
C) Wart removal options.
D) Treatment with antiviral drugs.
C ~ Wart removal options
The HPV vaccine (Gardasil) is ineffective in cases
of existing HPV, whereas neither antiviral nor
antibiotic drugs are effective treatments. Patient
teaching should focus on the various options for
physically removing the warts.
A 21-year-old college student has come to see the
nurse practitioner for treatment of a vaginal
infection. Physical assessment reveals inflammation
of the vagina and vulva, and vaginal discharge has a
cottage cheese appearance. These findings are
consistent with:
a. candidiasis
b. trichomoniasis
c. bacterial vaginosis
d. Chlamydia
A ~ The signs and symptoms of candidiasis include
inflammation of the vagina and vulva and a cottage
cheese appearance to the vaginal discharge
TUBERCULOSIS
The nurse suspects that a client is at risk for
tuberculosis. Which risk factor should the nurse
assess in this client? (Select all that apply.)
A. Sharing clothes with an infected individual
B. Living in a poorly ventilated environment
C. Using injection drugs
D. Being an immigrant to the United States
E. Having a compromised immune system
Answer: B, C, D, E
The nurse prepares educational material on the
development of tuberculosis for a group of new
nurses. In which order should the nurse explain the
disease process develops?
- (1) WBCs surround bacteria
- (2)Tubercle forms and caseous necrosis occurs
-(3)Droplet nuclei enter the lungs and the bacteria
multiply
-(4)Scar tissue forms around tubercle and the lesion
calcifies
-(5)Mycobacterium tuberculosis in droplet nuclei
enter the air
5, 3, 1, 2, 4,
A client has a 6-mm area that is slightly red and soft
to the touch at the site of a PPD (Mantoux) test.
Which finding should the nurse document for this
client?
A. Negative response
B. Positive response if the client had an abnormal
chest x-ray
C. Positive response
D. Indeterminate response
answer: A
An older adult client experiencing a cough,
hemoptysis, night sweats, anorexia, and weakness
reports being told of having tuberculosis when
younger. Which reason should the nurse suspect is
responsible for the client's current symptoms?
A. New-onset tuberculosis
B. Reactivation tuberculosis
C. Skeletal tuberculosis
D. Dormant tuberculosis
Answer: B
A client with tuberculosis experiences shortness of
breath, hypoxia, cyanosis, and subcutaneous
emphysema. Which pathophysiologic change
should the nurse suspect as causing this client's
symptoms?
A. Rupture of tuberculosis lesion
B. Encapsulation of the bacilli
C. Reactivation tuberculosis
D. Miliary tuberculosis
answer: A
The infection control nurse is teaching the staff at a
long-term care facility after a recent outbreak of
tuberculosis. Which element of infection control
should the nurse include in the teaching? (Select all
that apply.)
A. Implementation of universal screening
B. Use of airborne precautions
C. Treatment of clients with suspected or confirmed
disease
D. Administration of the bacille Calmette-Guérin
(BCG) vaccine to residents
E. Identification of infected individuals
Answer: B, C, E
The nurse in a community clinic is asked to
determine which clients require tuberculosis testing.
Which individual should the nurse recommend for
this screening? (Select all that apply.)
A. An individual with close contacts who already
have or are suspected to have tuberculosis
B. An individual who is a resident or staff member
of a long-term residential facility
C. An individual who had the bacille Calmette-
Guérin (BCG) vaccine
D. An individual that has had PPD
E. An individual infected with HIV or at high risk
for HIV infection
Answer: A, B, E
As the nurse reviews the history of a client admitted
in labor, the nurse notes that the client has inactive
tuberculosis. Which should the nurse include in the
plan of care for this client?
A. The client will be allowed to breastfeed the
infant.
B. Once delivered, the infant will be placed on
prophylactic treatment.
C. Direct contact should be avoided until the client
is noninfectious.
D. Pharmacologic therapy for the client should be
initiated immediately.
Answer: A
The nurse is caring for a child diagnosed with
tuberculosis infection. Which risk factor should the
nurse identify that would greatly increase the risk
for progression to disease? (Select all that apply.)
A. Presence of HIV infection
B. Genetic factors
C. Age less than 2 years
D. Virulence of the organism
E. Magnitude of the infection
Answer: A, C
The nurse visits the home of a client with
tuberculosis. Which action should the nurse teach
family members to take during the first 2 weeks of
treatment to prevent the spread of the infection to
other family members?
A. Be compliant with the medication regimen.
B. Ensure that housemates of the client are tested
and receive prophylactic treatment if indicated.
C. Use disposable tissues to contain respiratory
secretions.
D. Emphasize the importance of maintaining good
general health through diet and exercise.
Answer: C
The nurse is providing care to a client who has been
diagnosed with tuberculosis. Which diagnostic test
should the nurse expect to be prescribed prior to
initiating antibiotic treatment? (Select all that
apply.)
A. Polymerase chain reaction (PCR)
B. Intradermal PPD (Mantoux) test
C. Sputum culture
D. Tine test
E. Sputum smear
Answer: A, C, E
The public health nurse is training a nurse on
tuberculin skin testing. Which information about the
Mantoux test should the public health nurse include
in the training? (Select all that apply.)
A. "PPD (0.1 mL) is injected intradermally into the
dorsal aspect of the forearm."
B. "The test is read within 48 to 72 hours."
C. "This test is less accurate than the T-SPOT test."
D. "Ten tuberculin units are injected."
E. "Diameter of induration is recorded in
millimeters."
Answer: B, E
The nurse is preparing teaching for a client newly
diagnosed with tuberculosis. Which drug generally
used in initial treatment should the nurse include in
the session? (Select all that apply.)
A. Isoniazid
B. Amikacin
C. Pyrazinamide
D. Rifampin
E. Ethambutol
Answer: A, C, D, E
The nurse instructs a client with tuberculosis on the
medication rifampin. Which client statement
indicates teaching has been effective? (Select all
that apply.)
A. "I should take rifampin on an empty stomach."
B. "I need to monitor my vision daily by reading a
newspaper."
C. "I should not take aspirin while I am taking
rifampin."
D. "I should not be frightened if my urine changes
to an orange-red color; it is a normal side effect."
E. "I need to take pyridoxine (vitamin B6) along
with the rifampin."
Answer: A, C, D
The nurse is planning care for a client who is
homeless. The client is prescribed four drugs to
treat tuberculosis. Which action should the nurse
take to ensure compliance with this medication
therapy? (Select all that apply.)
A. Ask the healthcare provider to consider
hospitalizing the client for initial treatment to
ensure compliance.
B. Work collaboratively with other healthcare team
members to identify barriers or challenges.
C. Tailor teaching concerning the drugs to the needs
of the client.
D. Assess the client's understanding of the disease
process, and identify misperceptions and emotional
reactions.
E. Reduce the number of drugs and the duration of
taking the medicine to accommodate the client's
transient situation.
Answer: B, C, D
The nurse is identifying interventions for a client
with tuberculosis. Which nursing intervention
should the nurse identify to address the risk of
infecting others? (Select all that apply.)
A. Providing verbal and written instructions about
when to take the medications
B. Informing all personnel who have contact with
the client of the diagnosis
C. Teaching the client how to avoid transmitting the
disease to others
D. Assessing self-care abilities and support systems
E. Teaching the client why it is important to comply
with prescribed treatments for the whole course of
therapy
Answer: B, C, E
The nurse is reviewing data collected during the
assessment of a client with tuberculosis. Which
nursing diagnosis should the nurse select for this
client? (Select all that apply.)
A. Infection, Risk for
B. Health: Community, Deficient
C. Resilience, Impaired
D. Fatigue
E. Resilience, Impaired
Answer: A, B, C, D
The nurse is preparing a plan of care for a client
diagnosed with tuberculosis. Which goal and
outcome should the nurse identify for this client?
(Select all that apply.)
A. The client will demonstrate behaviors that reduce
the risk of spreading the disease to others.
B. The client with active tuberculosis complies with
prescribed therapies, symptoms resolve, and chest
x-rays improve.
C. The client with latent infection completes
therapy and does not develop active tuberculosis.
D. The client will have the resources necessary to
obtain required supplies and medications.
E. The client will articulate required treatment and
follow-up care.
Answer: A, D, E
The nurse instructs a client with tuberculosis on
prescribed medication. Which finding should the
nurse instruct the client to report to the healthcare
provider? (Select all that apply.)
A. Yellow tint to sclera
B. Sudden weight gain
C. Hemoptysis
D. Orange tint to sweat
E. Chest pain
Answer: A, B, C, E
The nurse is assessing a client with tuberculosis.
Which should the nurse focus on during this
assessment? (Select all that apply.)
A. Presence of cough
B. Difficulty breathing
C. Skin color
D. Carbon dioxide level
E. Nasal congestion
Answer: A, B, C
The right forearm of a client who had a purified
protein derivative (PPD) test for tuberculosis is
reddened and raised about 3mm where the test was
given. This PPD would be read as having which of
the following results?
A) Indeterminate
B) Needs to be redone
C) Negative
D) Positive
C
This test would be classed as negative. A 5 mm
raised area would be a positive result if a client was
HIV+ or had recent close contact with someone
diagnosed with TB. Indeterminate isn't a term used
to describe results of a PPD test. If the PPD is
reddened and raised 10mm or more, it's considered
positive according to the CDC.
A client with primary TB infection can expect to
develop which of the following conditions?
a) Active TB within 2 weeks
b) Active TB within 1 month
c) A fever that requires hospitalization
d) A positive skin test
d)
A primary TB infection occurs when the bacillus
has successfully invaded the entire body after
entering through the lungs. At this point, the bacilli
are walled off and skin tests read positive. However,
all but infants and immunosuppressed people will
remain asymptomatic. The general population has a
10% risk of developing active TB over their
lifetime, in many cases because of a break in the
body's immune defenses. The active stage shows
the classic symptoms of TB: fever, hemoptysis, and
night sweats.
A client was infected with TB 10 years ago but
never developed the disease. He's now being treated
for cancer. The client begins to develop signs of
TB. This is known as which of the following types
of infection?
a) active infection
b) primary infection
c) super infection
d) tertiary infection
a)
Some people carry dormant TB infections that may
develop into active disease. In addition, primary
sites of infection containing TB bacilli may remain
inactive for years and then activate when the client's
resistance is lowered, as when a client is being
treated for cancer. There's no such thing as tertiary
infection, and superinfection doesn't apply in this
case.
A client has active TB. Which of the following
symptoms will he exhibit?
A) Chest and lower back pain
B) Chills, fever, night sweats, and hemoptysis
C) Fever of more than 104*F and nausea
D) Headache and photophobia
B)
Typical signs and symptoms are chills, fever, night
sweats, and hemoptysis. Chest pain may be present
from coughing, but isn't usual. Clients with TB
typically have low-grade fevers, not higher than
102*F. Nausea, headache, and photophobia aren't
usual TB symptoms.
Which of the following diagnostic tests is definitive
for TB?
A D
Chest x-ray
B been infected with TB since his last skin test
Mantoux test
C D)
Sputum culture
D A client with a positive skin test for TB isn't
Tuberculin test
C)
The sputum culture for Mycobacterium tuberculosis
is the only method of confirming the diagnosis.
Lesions in the lung may not be big enough to be
seen on x-ray. Skin tests may be falsely positive or
falsely negative.
A client with a positive Mantoux test result will be
sent for a chest x-ray. For which of the following
reasons is this done?
A
To confirm the diagnosis
B
To determine if a repeat skin test is needed
C
To determine the extent of the lesions
D
To determine if this is a primary or secondary
infection
C)
If the lesions are large enough, the chest x-ray will
show their presence in the lungs. Sputum culture
confirms the diagnosis. There can be false-positive
and false-negative skin test results. A chest x-ray
can't determine if this is a primary or secondary
infection.
A chest x-ray should a client's lungs to be clear. His
Mantoux test is positive, with a 10mm if induration.
His previous test was negative. These test results
are possible because:
A
He had TB in the past and no longer has it.
B
He was successfully treated for TB, but skin tests
always stay positive
C
He's a "seroconverter", meaning the TB has gotten
to his bloodstream
He's a "tuberculin converter," which means he has
showing signs of active disease. To help prevent the
development of active TB, the client should be sent home, although he'll continue to take the
treated with isoniazid, 300 mg daily, for how long? antitubercular drugs for 9 to 12 months.

A A client is diagnosed with active TB and started on

10 to 14 days triple antibiotic therapy. What signs and symptoms
B would the client show if therapy is inadequate?
2 to 4 weeks
C A
3 to 6 months Decreased shortness of breath
D B
9 to 12 months Improved chest x-ray
C
D) Nonproductive cough
D
Because of the increased incidence of resistant Positive acid-fast bacilli in a sputum sample after 2
strains of TB, the disease must be treated for up to months of treatment
24 months in some cases, but treatment typically
lasts for 9-12 months. Isoniazid is the most common D)
medication used for the treatment of TB, but other
antibiotics are added to the regimen to obtain the Continuing to have acid-fast bacilli in the sputum
best results. after 2 months indicated continued infection.

A client with a productive cough, chills, and night
sweats is suspected of having active TB. The
physician should take which of the following
actions?
A To evaluate his condition
Admit him to the hospital in respiratory isolation
B To determine his compliance
Prescribe isoniazid and tell him to go home and rest
C To prevent spread of the disease
Give a tuberculin test and tell him to come back in
48 hours and have it read
D
Give a prescription for isoniazid, 300 mg daily for 2
weeks, and send him home
A)
The client is showing s/s of active TB and, because
of the productive cough, is highly contagious. He
should be admitted to the hospital, placed in
respiratory isolation, and three sputum cultures
should be obtained to confirm the diagnosis. He
would most likely be given isoniazid and two or
three other antitubercular antibiotics until the
diagnosis is confirmed, then isolation and treatment
would continue if the cultures were positive for TB.
After 7 to 10 days, three more consecutive sputum
cultures will be obtained. If they're negative, he
would be considered non-contagious and may be
A client diagnosed with active TB would be
hospitalized primarily for which of the following
reasons?
A
B
C
D
To determine the need for antibiotic therapy
C)
The client with active TB is highly contagious until
three consecutive sputum cultures are negative, so
he's put in respiratory isolation in the hospital.
A community health nurse is conducting an
educational session with community members
regarding TB. The nurse tells the group that one of
the first symptoms associated with TB is:
A
A bloody, productive cough
B
A cough with the expectoration of mucoid sputum
C
Chest pain
D A nurse is caring for a client diagnosed with TB.
Dyspnea Which assessment, if made by the nurse, would not
be consistent with the usual clinical presentation of
B) TB and may indicate the development of a
concurrent problem?
One of the first pulmonary symptoms includes a
slight cough with the expectoration of mucoid A
sputum. Nonproductive or productive cough
B
Isoniazid (INH) and rifampin (Rifadin) have been Anorexia and weight loss
prescribed for a client with TB. A nurse reviews the C
medical record of the client. Which of the Chills and night sweats
following, if noted in the client's history, would D
require physician notification? High-grade fever

A D)
Heart disease
B The client with TB usually experiences cough (non-
Allergy to penicillin productive or productive), fatigue, anorexia, weight
C loss, dyspnea, hemoptysis, chest discomfort or pain,
Hepatitis B chills and sweats (which may occur at night), and a
D low-grade fever.
Rheumatic fever
The nurse obtains a sputum specimen from a client
C) with suspected TB for laboratory study. Which of
the following laboratory techniques is most
Isoniazid and rafampin are contraindicated in clients commonly used to identify tubercle bacilli in
with acute liver disease or a history of hepatic sputum?
injury.
A
A client who is HIV+ has had a PPD skin test. The Acid-fast staining
nurse notes a 7-mm area of induration at the site of B
the skin test. The nurse interprets the results as: Sensitivity testing
C
A Agglutination testing
Positive D
B Dark-field illumination
Negative A)
C
Inconclusive The most commonly used technique to identify
D tubercle bacilli is acid-fast staining. The bacilli have
The need for repeat testing a waxy surface, which makes them difficult to stain
in the lab. However, once they are stained, the stain
A) is resistant to removal, even with acids. Therefore,
tubercle bacilli are often called acid-fast bacilli.
The client with HIV+ status is considered to have
positive results on PPD skin test with an area Which of the following family members exposed to
greater than 5-mm of induration. The client with TB would be at highest risk for contracting the
HIV is immunosuppressed, making a smaller area disease?
of induration positive for this type of client.
A
45-year-old mother
B B)
17-year-old daughter
C A positive PPD test indicates that the client has
8-year-old son been exposed to tubercle bacilli. Exposure does not
D necessarily mean that active disease exists.
76-year-old grandmother
INH treatment is associated with the development
D) of peripheral neuropathies. Which of the following
interventions would the nurse teach the client to
Elderly persons are believed to be at higher risk for help prevent this complication?
contracting TB because of decreased
immunocompetence. Other high-risk populations in A
the US include the urban poor, AIDS, and minority Adhere to a low cholesterol diet
groups. B
Supplement the diet with pyridoxine (vitamin B6)
The nurse is teaching a client who has been C
diagnosed with TB how to avoid spreading the Get extra rest
disease to family members. Which statement(s) by D
the client indicate(s) that he has understood the Avoid excessive sun exposure
nurses instructions? Select all that apply.
B)
A
"I will need to dispose of my old clothing when I INH competes with the available vitamin B6 in the
return home." body and leaves the client at risk for development
B of neuropathies related to vitamin deficiency.
"I should always cover my mouth and nose when Supplemental vitamin B6 is routinely prescribed.
sneezing."
C The nurse should include which of the following
"It is important that I isolate myself from family instructions when developing a teaching plan for
when possible." clients receiving INH and rifampin for treatment for
D TB?
"I should use paper tissues to cough in and dispose
of them properly." A
E Take the medication with antacids
"I can use regular plate and utensils whenever I B
eat." Double the dosage if a drug dose is forgotten
C
B, D, and E Increase intake of dairy products
D
A client has a positive reaction to the PPD test. The Limit alcohol intake
nurse correctly interprets this reaction to mean that D)
the client has:
INH and rifampin are hepatotoxic drugs. Clients
A should be warned to limit intake of alcohol during
Active TB drug therapy. Both drugs should be taken on an
B empty stomach. If antacids are needed for GI
Had contact with Mycobacterium tuberculosis distress, they should be taken 1 hour before or 2
C hours after these drugs are administered. Clients
Developed a resistance to tubercle bacilli should not double the dosage of these drugs because
D of their potential toxicity. Clients taking INH should
Developed passive immunity to TB avoid foods that are rich in tyramine, such as cheese
and dairy products, or they may develop
hypertension.
The public health nurse is providing follow-up care
to a client with TB who does not regularly take his
medication. Which nursing action would be most
appropriate for this client?
A No
Ask the client's spouse to supervise the daily
administration of the medications.
B antitoxin
Visit the clinic weekly to ask him whether he is
taking his medications regularly.
C
Notify the physician of the client's non-compliance
and request a different prescription.
D
Remind the client that TB can be fatal if not taken
properly.
A)
Directly observed therapy (DOT) can be
implemented with clients who are not compliant
with drug therapy. In DOT, a responsible person,
who may be a family member or a health care
provider, observes the client taking the medication.
Visiting the client, changing the prescription, or
threatening the client will not ensure compliance if
the client will not or cannot follow the prescribed
treatment.
The Causative agent of Tuberculosis is said to be:
A
Mycobacterium Tuberculosis
B
Hansen's Bacilli
C Risus sardonicus
Bacillus Anthracis
D 39. What is the name of the condition when a
Group A Beta Hemolytic Streptococcus
A)
TETANUS
29. Why is it important that for a person to develop
tetanus, that the microbe enter parentally
Because it is an anaerobic organism
30. What is the purpose of cleaning a wound with
hydrogen peroxide
It increase the oxygen, which makes the would
aerobic which would kill the bacteria
31. Would that kill endospores
32. What type of immunity is provided by tetanus
Artificial passive immunity
33. Does tetanus vaccine provide lifelong immunity
No, need booster shots every 10 years
34. The name of the toxin that Clostridium tetani
produces
Tetanospasmin
35. What is the effect of tetanospasmin on the
muscles
Constant muscle contraction without opposing
muscles relaxing
36. Tetanus is often misdiagnosed as what disease
during the prodromal stage
Migraine
37. Tetanus is commonly known as another
condition because muscle spasm in the face, what is
the name of this condition
Lockjaw
38. What is another word for sarcastic grin
person's back begins to bow
Opisthotonus
40. People with tetanus commonly die of what
Respiratory distress (drowning in their own vomit)
41. What demographic of people die because dirty
instruments are used to perform circumcisions
Infants (commonly known as tetanus neonatorum)
42. What is put on the wound to cause tetanus
neonatorum
Dirt, dung and ash
43. Where is Clostridium tetani naturally found
Soil or dirt
44. Is tetanus sporadic or epidemic in America
Sporadic
45. What has made tetanus sporadic in America
Vaccination
46. Are antibiotics used in the treatment of tetanus
Yes, along with hydrogen peroxide and antitoxin
Antibodies are able to be produced for any tetanus
case after receive a tetanus toxoid until after a span
of
10 years
Young Children should be given __________ of
Tetanus Toxoid. Typically, the doses begin at ages
_________ months and are completed by ________
months
4 doses, 2-3, 18
Booster shots are given before entering school at
______
11-12 years of age
Public health Department recommends
administering both ________ and ______ when
treating a patient with teanus

A acute, often fatal disease caused by a toxin Toxoid and TIG (Tetatnus Immunglobulin)
produced from a bacterium
Tetanus Will remove toxin that is already in blood stream
TIG
The bacterium that produces the toxin which causes
Tetanus Occasionally, a patient may experience a bad
reaction to a immune globulin. This most likely
Clostridium tetani occurs when the immunoglobulin is administrated
from
Symptoms of Tetanus
a non-human source
muscle stiffness in neck and jaw (lockjaw)
TIG by passive immunization only lasts
Clostridium tetani usually enters the body through a
3 weeks
Wound
In 7-10 days by first active immunization,
Toxins of Tetanus are produced and spread into the Lasts 10 years

bloodstream In 3-5 days by active booster immunization,

Incubation period of Tetanus Lasts 10 years

3 to 21 days Protective level antitoxin from a toxoid vaccine but

eventually memory cells create
Tetanus is not contagious from
Person to Person Antibodies for Tetanus

Vaccine that consists of a formaldehyde treated

toxin
Tetanus toxoid
A 12 year old girl received some deep cuts falling
on the playground, and her parents took her to the
hospital. She hadn't been immunized against
tetanus. To provide her with protection against the
possibility of tetanus now, and in the future, how do
you think the hospital staff should treat her?
Give separate injections of tetanus toxoid and
tetanus antitoxin, one in each arm
In which pairs will the first substance function as an
antigen to elicit a potentially beneficial immune
response and the second substance function as an
antigen to produce a potentially dangerous immune
response?
Toxoid and tetanus antiserum from a horse
Your watching the "the crocodile hunter" and
Steve's just been bitten by a deadly Australian
brown snake, the second most deadly snake in the
world. Terri rushes him to the hospital so he can be
treated with antivenom (antiserum), but the only
type available is from horses. What is the most
important thing that needs to be taken into account
before given the antiserum?
His history of passive immunizations
A typical secondary response is characterized by a
change in antibody level. The type of change differs
from primary response, since it is usually...
faster, higher, and also longer lasting
The type of immunity to tetanus a person has after
treatment with tetanus antisera is...
adaptive (acquired) and due to the activity of
antibodies (antibody-mediated)
Bacteria on your unbroken or intact skin will not
usually produce disease because your skin provides
protection. the immunity provided by your skin is...
innate and nonspecific
Serum sickness can be a serious problem with
which of the following procedures?
passive immunization against tetanus using
antiserum from a horse
A 25 year old man who recently sustained a severe,
dirty cut on his foot has never received any
immunizations. He has never received any
immunization. he had tetanus when he was 7 years
old and was treated with penicillin and tetanus
antiserum (human), and recovered. Which of the
following do you think would be the best was for
him to be treated now?
He should get the tetanus antiserum (human) plus
tetanus toxoid, because he has no immunity to
tetanus
A patient has an order for the Varicella vaccine. It is
most important for the nurse to assess the patient for
A. use of high dose systemic steroids in the past
month.
B. allergy to aspirin.
C. allergy to eggs.
D. history of hypertension.
A
A patient with AIDS was cut by a rusty piece of
metal while walking outside. He recalls that his last
tetanus booster was over 20 years ago. Which
immunization therapy will he receive at this time?
A. He cannot receive any type of immunization
therapy.
B. Tetanus immunoglobulin
C. Tetanus toxoid, adsorbed
D. Tetanus and diphtheria toxoid (Td) booster
B
Parent reluctant to vaccinate a child since the
majority of his friends have been vaccinated;
therefore, no need to vaccinate. As the nurse you:
A. File a report with DHS
B. Understand that organisms which cause disease
are still prevalent in the environment and may cause
illness in this child
C. Counsels parents that their decision may result in
legal action.
D. Notifies the school system that the child is not in
compliance
B
A breastfed newborn is provided immunity by non-pathogenic
which immunoglobulins? Select all that apply: D. A substance which destroys invading organisms

A. IgG C
B. IgM
C. IgA A healthy patient says "Will my immune system be
D. IgE weaker by relying on a vaccine for protection" You
E. IgD respond:

A and C A. The immune system only works in healthy

people
As a Student Nurse you ask the instructor where to B. Vaccines only work for a limited time
find accurate information regarding immunizations. C. The immune system makes antibodies against a
The instructor recommends: germ whether the germ is encountered naturally or
via vaccine
A. Look each drug up in PDR D. Exposure to the natural disease strengthens the
B. Look to CDC website immune system better than a vaccine.
C. Call the drug reps
D. Ask a physician or pharmacist. C

B As a nurse in a primary care office you realize that

Tdap and DTaP are interchangeable for the 6 week
JW is exposed to organism that causes disease. to 6 y/o child
Prescriber prescribes an immunoglobulin to prevent
illness. This is an example of: A. True
B. False
A. Passive Immunity
B. Active Immunity B
C. Acquired Immunity
D. Herd Immunity A patient is to receive medication at 5 mcg/kg/day.
The patient weighs 198 pounds. How many
A micrograms of medication will this patient receive
each day?
PT asks you how to be protected against a particular
disease. You explain acquired/active immunity to A. 450 mcg
the PT in the following way EXCEPT: B. 900 mcg
C. 1000 mcg
A. PT develops the disease D. 225 mcg BID
B. A live, attenuated vaccine is given
C. A vaccine is given produced from killed A
organisms
D. An Immunoglobulin is given A patient will be receiving aldesleukin [IL-2]
(Proleukin), 600,000 IU/kg every 8 hours for 14
D doses. The patient weighs 220 pounds. How many
IU of medication will this patient receive per dose?
You explain to a pt that a vaccine is:
A. 300 million units
A. A medication that prevents an immune response B. 60 million units
B. A serum protein noted with immunologic C. 120 million units
deficiencies. D. 240 million units
C. A suspension of bacteria and viruses that are
B
Two patients arrive at the clinic; one is a young boy
with sickle cell anemia, and another is a 57-year-old
woman with early stages of Hodgkin's disease. The
nurse notices that both patients need the same
vaccine. What vaccine would that be?
A. Varicella virus vaccine (Varivax)
B. Herpes zoster vaccine (Zostavax)
C. Hepatitis B virus vaccine, inactivated
(Recombivax HB)
D. Haemophilus influenzae type b (Hib) vaccine
D had shingles.
The nurse is reviewing principles of immunization.
What type of immunization occurs when antibodies
pass from mother to infant during breastfeeding or
through the placenta during pregnancy?
A. Artificial active immunization
B. Attenuating immunization
C. Natural passive immunization
D. Artificial passive immunization
C answer using one decimal place.)
A sanitation worker has experienced a needle stick
by a contaminated needle that was placed in a trash
can. The employee health nurse expects that which
drug will be used to provide passive immunity to
hepatitis B infection?
A. Haemophilus influenzae type b (Hib)
B. Varicella virus vaccine (Varivax)
C. Hepatitis B immunoglobulin (BayHep B)
D. Hepatitis B virus vaccine (inactivated)
(Recombivax HB)
C
The nurse is reviewing the health history of a new
patient who may need immunizations. Active
immunizations are usually contraindicated in which
patients? (Select all that apply.)
A. Patients with a febrile illness >103
B. Children younger than 1 year of age
C. Elderly patients
D. Patients who are immunosuppressed
E. Those receiving cancer chemotherapy
A, D, E
The nurse is reviewing the information about the
herpes zoster vaccine (Zostavax) before
administering the dose. Which statements about the
vaccine are true? (Select all that apply.)
A. It is a one-time vaccine.
B. The vaccine is recommended for patients 50
years of age and older.
C. The vaccine is given to children to prevent
chickenpox.
D. It is used to prevent postherpetic neuralgia.
E. It is contraindicated in patients who have already
F. The vaccine is used to prevent reactivation of the
zoster virus that causes shingles.
A, B, F
A health care worker will be receiving hepatitis B
immunoglobulin (BayHep B), 0.06 mg/kg IM now
and repeated in 30 days as part of hepatitis B
prophylaxis after a needle stick accident. The
patient weighs 264 pounds. How many milligrams
will the patient receive for each dose? (Record
A. 6.9 mg
B. 7.0 mg
C. 7.1 mg
D. 7.2 mg
D
COMMON CHILD
IMMUNIZATION
Which statement MOST accurately describes the
pharmacodynamics of vaccines?
A. Vaccines work by stimulating the humoral
immune system.
B. Vaccines provide IgG antibodies to protect
against infection.
C. Vaccines prevent the formation of antibodies
against a specific antigen.
D. Vaccines work by suppressing the amino acid
immunoglobulin sequence.
A. Vaccines work by stimulating the hormonal Soreness at the injection site is a common adverse
immune system effect of tetanus toxoid.

Vaccines work by stimulating the humoral immune An allergy to which substance is a contraindication
system, which synthesizes immunoglobulins. They to the administration of an immunizing drug?
also stimulate the formation of antibodies against
their specific antigen, providing active immunity. A. Soy
B. Egg
What is the priority nursing assessment to monitor C. Corn
when administering vaccinations? D. Wheat

A. Myalgias B.Egg
B. Anaphylaxis Contraindications to the administration of
C. Symptoms of infection immunizing drugs include allergy to the
D. Pain at the injection site immunization itself or allergy to any of its
components, such as eggs or yeast.
B. Anaphylaxis
The current immunization for tetanus and diphtheria
Anaphylaxis is a potential life-threatening adverse toxoids and pertussis, Tdap, is administered to
reaction to vaccines. Pain and myalgias can occur people in which age range?
but are not life threatening.
A. Younger than 6 years of age
Administration of which substance provides passive B. 11 years of age and older
immunity? C. Any age range
D. In the first 2 years of life
A. Vaccines
B. Toxoids B. 11 years of age and older
C. Antitoxins Currently, DTaP is the preferred preparation for
D. Immunoglobulins primary and booster immunization against these
diseases in children from 6 weeks to 6 years of age
D. Immunoglobulins unless use of the pertussis component is
Vaccines, antitoxins, and toxoids provide active contraindicated. Tdap is the recommended vaccine
immunity by stimulating the humoral immune for adolescents and adults, those over the age of 11
system. Immunoglobulins provide passive years.
immunity by giving the patient substances to fight
specific antigens. Which vaccination was developed to prevent
bacterial meningitis caused by Haemophilus
What teaching would the nurse provide to a client influenzae?
receiving tetanus toxoid?
A. Preener
A. "You will have lifetime immunity from this B. Gardasil
injection." C. Hepatitis B vaccine
B. "Soreness at the injection site is a common D. Hib conjugate vaccine
reaction."
C. "This medication must be repeated weekly for 4 D. Hib conjugate vaccine
weeks." H. influenzae type b (Hib) (HibTITER, ActHIB,
D. "Increase fluid and fiber in your diet to prevent Liquid PedvaxHIB) vaccine is a noninfectious,
constipation." bacteria-derived vaccine. Before this vaccine was
developed, infections caused by Hib were the
B. Soreness at the injection site is a common leading cause of bacterial meningitis in children 3
reaction months to 5 years of age.
Which vaccination is marketed and recommended
in the prevention of a virus that is known to cause
cervical cancer?
A. Herpes zoster vaccine (Zostavax)
B. Papillomavirus vaccine (Gardasil)
C. Pneumococcal vaccine (Prevnar 13)
D. Hepatitis B virus vaccine (Recombivax HB)
B. Papillomavirus Vaccine
Human papillomavirus virus (HPV) is a common
cause of genital warts and cervical cancer. The HPV
vaccine (Gardasil, Cervarix) is the first and only
vaccine known to prevent cancer.
The anthrax vaccine is recommended for which
groups of people? (Select all that apply.)
A. Military personnel
B. Veterinarians
C. Workers who process imported animal hair
D. Emergency department health care providers
A , B, C
People at risk for exposure to the anthrax bacterium
include military personnel, veterinarians, and
workers who process imported animal hair.
The nurse is reviewing the Centers for Disease
Control recommendations for vaccines. The
pneumococcal vaccine (Pneumovax 23) is
recommend for which group
A. Newborn infants
B. Patients who are immunosuppressed
C. Patients who are transplant candidates
D. Smokers between 19 and 64 years old
D. Smokers between the age of 19 and 64
During a routine checkup a 72 year old patient is
advised to receive a influenza vaccine injection. He
questions this saying "I had one last year. Why do I
need another one?" What is the nurses best
response?
A. "The effectiveness of the vaccine wears off after
6 months."
B. "Each year a new vaccine is developed based on
the flu strains that are likely to be in circulation."
C. "When you reach 65 years old, you need booster
shots on an annual basis."
D. "Taking the flu vaccine each year allows you to
build your immunity to a higher level each time."
B. "Each year a new vaccine is developed based on
the flu strains that are likely to be in circulation."
when assessing a patient who will be receiving a
measles vaccine, the nurse will consider which
condition to be a potable contraindication?
A. Anemia
B. Pregnancy
C. Ear infection
D. Common Cold
B. Pregnancy
When giving a vaccine to an infant, the nurse will
tell the mother to expect which adverse effect?
A. Fever over 101F
B. Rash
C. Soreness at the injection site
D. Chills
C. Soreness at the injection site
A 28 year old patient is in the urgent care center
after stepping on a rusty tent nail. The nurse
evaluates the patient's immunity status and notes
that the patient thinks she had her tetanus booster
about 10 years ago, just before starting college.
Which immunization would be most appropriate at
this time?
A. Immunoglobulin Intravenous
B. DTap
C. Tdap
D. No immunizations necessary
C. Tdap
the nurse is providing teaching after an adult
receives a booster immunization. Which adverse
reaction will the nurse immediately report to the
health care provider? (select all that apply)
A. swelling and redness at injection site
B. Fever of 100f
C. joint pain
D. Heat over injection site
E. Rash over the arms, back and chest
F. Shortness of breath
C, E, F
An animal control officer was bitten by a stray dog
that showed signs of rabies. Which statement by the
nurse is correct regarding the treatment for rabies
prophylaxis?
A. "you will receive treatment if you begin to show
symptoms of rabies."
B. "you will receive one oral dose of medication
today, and one more in 1 week."
C. "you will need to receive 3 subcutaneous
injections over the next week."
D. "you will need to receive 5 intramuscular
injections over the next 28 days."
D. You will need to receive 5 intramuscular
injections over the next 28 days
1. The nurse is discussing vaccines with the mother
of a 4-year-old child who attends a day care center
that requires the DTaP vaccine. The mother, who is
pregnant, tells the nurse that she does not want her
child to receive the pertussis vaccine because she
has heard that the disease is "not that serious" in
older children. What information will the nurse
include when discussing this with the mother?
a.
If she gets the vaccine, both she and her 4 year-old
child will be protected.
b.
If the 4-year-old child contracts pertussis, it can be
passed on to her newborn.
c.
The vaccine will not be given to her child while she
is pregnant.
d.
Vaccinating the 4-year-old will provide passive
immunity for her unborn child.
ANS: B
Even though pertussis is not as serious in older
children, it is important to vaccinate children to
prevent the spread of the disease to infants and
others who are not immunized and who are at risk
for significant morbidity and mortality from this
disease. Vaccinating the mother will not protect the
4-year-old from getting pertussis. The DTaP
vaccine may be given to children whose mothers are
pregnant. Vaccinating the child does not confer
passive immunity to the unborn child.
2. A woman who is pregnant tells the nurse she has
not had any vaccines but wants to begin so she can
protect her unborn child. Which vaccine(s) may be
administered to this patient?
a.
Gardasil vaccine
b.
Trivalent influenza vaccine
c.
MMR vaccine
d.
Varivax vaccine
ANS: B
The influenza vaccine is recommended for pregnant
women and should be given. Gardasil is given to
young women who are not yet sexually active. The
MMR is contraindicated because rubella can cause
serious teratogenic effects. Varivax is
contraindicated during pregnancy.
3. A 4-year-old child is receiving amoxicillin
(Amoxil) to treat otitis media and is in the clinic for
a well-child checkup on the last day of antibiotic
therapy. The provider orders varicella (Varivax);
mumps, measles, and rubella (MMR); inactivated
polio (IPV); and diphtheria, tetanus, and acellular
pertussis (DTaP) vaccines to be given. Which action
by the nurse is correct?
a.
Administer the vaccines as ordered.
b.
Discuss giving the MMR vaccine in 4 weeks.
c.
Hold all vaccines until 2 weeks after antibiotic
therapy.
d.
Recommend aspirin for fever and discomfort.
ANS: A
Antibiotic therapy is not generally a
contraindication to the use of vaccines. Vaccines
may be given in cases of mild acute illness or
during the convalescent phase of an illness. All four
vaccines may be given. If the MMR or other live
virus vaccine is not given the same day as the
varicella vaccine, administration of the two
vaccines should be separated by at least 4 weeks.
Aspirin should not be given because of the
increased risk of Reye's syndrome.
4. A patient is preparing to travel with a 4-year-old
child to India in 10 days and is in the clinic to
receive typhoid vaccines. Which vaccines will be
given to the parent and child?
a.
Four capsules of live, oral vaccine to both patients
b.
Four capsules of live, oral vaccine for the parent
and the IM polysaccharide vaccine for the child
c.
Four capsules of live, oral vaccine for the child and
the IM polysaccharide vaccine for the parent
d.
IM polysaccharide for both patients
ANS: D
While the live, oral vaccine may be given to
patients older than 6 years, each capsule must be
taken 48 hours apart with the last capsule given 1
week prior to travel. There would not be enough
time to complete the regimen since the patients
leave in 10 days. Children under age 6 cannot
receive the oral vaccine.
5. A 48-month-old child is scheduled to receive the
following vaccines: MMR, Varivax, IPV, and
DTaP. The child's parents want the child to receive
two vaccines today and the other two in 1 week. To
accommodate the parents' wishes, the nurse will
administer
a.
the DTaP and Varivax today and the MMR and IPV
in 1 week.
b.
the IPV and MMR today and the Varivax and DTaP
in 1 week.
c.
the MMR and DTaP today and the Varivax and IPV
in 1 week.
d.
the MMR and Varivax today and the DTaP and IPV
in 1 week.
ANS: D
If the MMR or other live virus vaccine is not given
the same day as the varicella vaccine,
administration of the two vaccines should be
separated by at least 4 weeks. In the incorrect
answers, the two live virus vaccines are given only
one week apart.
6. A young adult patient is in the clinic to receive a
tetanus vaccine after sustaining a laceration injury.
The nurse learns that the patient, who works in a
day care center, has not had any vaccines for more
than 10 years. Which vaccine will the nurse expect
to administer?
a.
DT
b.
DTaP
c.
Td
d.
Tdap
ANS: D
Persons who work with children should receive
acellular pertussis vaccine. The Tdap is given to
adults. The DTaP is given to children up to age 6.
The DT and Td do not contain pertussis.
7. The nurse is preparing to administer rotavirus
vaccine to a 4-month-old infant. The nurse notes
that the infant received Rotarix vaccine at 2 months
of age. The nurse will plan to administer
a.
Rotarix today.
b.
Rotarix today and again at age 6 months.
c.
Rota Teq today.
d.
Rota Teq today and again at age 6 months.
ANS: A
Patients receiving Rotarix receive 2 doses at age 2
and 4 months only.
8. A provider has ordered Gardasil to be given to a
prepubertal 9-year-old female. The parent asks the
nurse if this vaccine can be postponed until the
child is in high school. The nurse will tell the parent
that Gardasil
a.
is less effective in older adolescents.
b.
is more effective if given before sexual activity
begins.
c.
is more effective if given prior to the hormonal
changes of puberty. compresses. Aspirin is contraindicated in children
d. because of its association with Reye's syndrome.
is not effective if given after the onset of menses. Since these are not serious adverse effects, they do
ANS: B not need to be reported to VAERS. It is not
Gardasil is most effective when the client is not yet necessary to schedule a clinic visit.
sexually active.
11. The provider orders Zostavax for a 60-year-old
9. Which is an example of acquired passive patient. The patient reports having had chicken pox
immunity? as a child. Which action will the nurse take?

a.
Administration of IgG to an unimmunized person
exposed to a disease
b.
Administration of an antigen via an immunization
c.
Inherent resistance to a disease antigen
d.
Immune response to an attenuated virus
ANS: A
Passive immunity occurs without stimulation of an
immune response. Acquired immunity requires
administration of immune globulin. Inherent
resistance to a disease antigen describes the state of
natural immunity, not acquired passive immunity.
The other answers involve stimulation of an
immune response.
10. The parent of a 12-month-old child who has
received the MMR, Varivax, and hepatitis A
vaccines calls the clinic to report redness and
swelling at the vaccine injection sites and a
temperature of 100.3° F. The nurse will perform
which action?
a.
Administer the vaccine as ordered.
b.
Counsel the patient that the vaccine may cause a
severe reaction because of previous exposure.
c.
Hold the vaccine and notify the provider of the
patient's history.
d.
Request an order for a Varivax booster instead of
the Zostavax.
ANS: A
Zostavax is given to boost the immunity to
varicella-zoster virus among recipients. It is not
likely to cause severe reaction secondary to prior
exposure, since the immune response in most
recipients has declined. Zostavax, not Varivax, is
approved for this use.

a.
Recommend aspirin or an NSAID for pain and
fever.
b.
Recommend acetaminophen and cold compresses.
c.
Report these adverse effects to the Vaccine Adverse
Event Reporting System (VAERS).
d.
Schedule an appointment in clinic so the provider
can evaluate the child.

ANS: B

These are common, minor side effects of vaccines

and can be treated with acetaminophen and cold