Title: ASN 210 W4 HIV, IMMUNE INFECTIONS
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I

Q: The nurse is caring for a client diagnosed with human immune deficiency virus. The client’s CD4+ cell count is 399/mm<sup>3</sup>. What action by the nurse is best?
- Counsel the client on safer sex practices/abstinence.
- Encourage the client to abstain from alcohol.
- Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
- Help the client plan high-protein/iron meals.
A: Counsel the client on safer sex practices/abstinence.
If right: This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.
If wrong: This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.

Q: The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest?
- Anal intercourse
- Masturbation
- Oral sex
- Vaginal intercourse
A: Anal intercourse
If right: Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.
If wrong: Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.

Q: The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?
- Consistent use of Standard Precautions
- Double-gloving before body fluid exposure
- Labeling charts and armbands “HIV+”
- Wearing a mask within 3 feet of the client
A: Consistent use of Standard Precautions
If right: According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.
If wrong: According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.

Q: A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm<sup>3</sup> and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first?
- Initiate Droplet Precautions for the client.
- Notify the provider about the CD4+ results.
- Place the client under Airborne Precautions.
- Use Standard Precautions to provide care.
A: Place the client under Airborne Precautions.
If right: Since this client’s CD4+ cell count is low, he or she may have <i>anergy</i>, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.
If wrong: Since this client’s CD4+ cell count is low, he or she may have <i>anergy</i>, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

Q: A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states “Whew! I was really worried about that result.” What action by the nurse is most important?
- Assess the client’s sexual activity and patterns.
- Express happiness over the test result.
- Remind the client about safer sex practices.
- Tell the client to be retested in 3 months.
A: Assess the client’s sexual activity and patterns.
If right: The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client’s sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.
If wrong: The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client’s sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.

Q: A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?
- Ask the client about travel to any foreign countries.
- Assess the client for adherence to the drug regimen.
- Determine if the client has any new sexual partners.
- Request information about new living quarters or pets.
A: Assess the client for adherence to the drug regimen.
If right: Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this client’s viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.
If wrong: Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this client’s viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.

Q: A client is hospitalized with <i>Pneumocystis jiroveci </i>pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?
- Administer sleeping medication.
- Perform most activities for the client.
- Increase the client’s oxygen during activity.
- Pace activities, allowing for adequate rest.
A: Pace activities, allowing for adequate rest.
If right: This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client’s activity.
If wrong: This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client’s activity.

Q: A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem?
- Chooses high-protein food
- Has decreased oral discomfort
- Eats 90% of meals and snacks
- Has a weight gain of 2 pounds/1 month
A: Has a weight gain of 2 pounds/1 month
If right: The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.
If wrong: The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.

Q: A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi’s sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?
- Adhering to Standard Precautions
- Assessing tolerance to dressing changes
- Performing hand hygiene before and after care
- Disposing of soiled dressings properly
A: Disposing of soiled dressings properly
If right: All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.
If wrong: All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.

Q: A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management?
- “Infusions will be scheduled every 3 to 4 weeks.”
- “Treatment is aimed at treating specific infections.”
- “Unfortunately, there is no effective treatment.”
- “You will need many immunoglobulin A infusions.”
A: “Treatment is aimed at treating specific infections.”
If right: Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.
If wrong: Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.

Q: An HIV-positive client is admitted to the hospital with <i>Toxoplasma gondii</i> infection. Which action by the nurse is most appropriate?
- Initiate Contact Precautions.
- Place the client on Airborne Precautions.
- Place the client on Droplet Precautions.
- Use Standard Precautions consistently.
A: Use Standard Precautions consistently.
If right: <i>Toxoplasma gondii</i> infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.
If wrong: <i>Toxoplasma gondii</i> infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.

Q: A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best?
- Assess the client for support systems.
- Determine if a clergy member would help.
- Explain legal requirements to tell sex partners.
- Offer to tell the family for the client.
A: Assess the client for support systems.
If right: This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.
If wrong: This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.

Q: A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the “AIDS guy” and wondering how the client contracted the disease. What action by the nurse is best?
- Confront the staff members about unethical behavior.
- Ignore the behavior; they will stop on their own soon.
- Report the behavior to the unit’s nursing management.
- Tell the client that other staff members are talking about him or her.
A: Confront the staff members about unethical behavior.
If right: The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.
If wrong: The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.

Q: A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client’s partner is listed as the emergency contact, but the client’s mother insists that she should be listed instead. What action by the nurse is best?
- Contact the social worker to assist the client with advance directives.
- Ignore the mother; the client does not want her to be involved.
- Let the client know, gently, that nurses cannot be involved in these disputes.
- Tell the client that, legally, the mother is the emergency contact.
A: Contact the social worker to assist the client with advance directives.
If right: The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.
If wrong: The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.

Q: A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?
- Consult with the pharmacy about drug interactions.
- Ensure that the client understands the new medications.
- Give the new drugs without considering the old ones.
- Schedule all medications at standard times.
A: Consult with the pharmacy about drug interactions.
If right: The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.
If wrong: The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.

Q: A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?
- Auscultating the lungs
- Assessing mucous membranes
- Listening to bowel sounds
- Performing a neurologic examination
A: Assessing mucous membranes
If right: Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the client’s mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.
If wrong: Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the client’s mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.

Q: A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best?
- “Gabapentin can be used as an antidepressant too.”
- “I have no idea why you should be taking this drug.”
- “This drug helps treat the pain from nerve irritation.”
- “You are at risk for seizures due to fungal infections.”
A: “This drug helps treat the pain from nerve irritation.”
If right: Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.
If wrong: Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.

Q: A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first?
- Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm<sup>3</sup> and a temp of 102.4° F (39.1° C)
- Client with Bruton’s agammaglobulinemia who is waiting for discharge teaching
- Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion
- Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
A: Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm<sup>3</sup> and a temp of 102.4° F (39.1° C)
If right: A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.
If wrong: A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

Q: An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug?
- “Truvada does not reduce the need for safe sex practices.”
- “This drug has been taken off the market due to increases in cancer.”
- “Truvada reduces the number of HIV tests you will need.”
- “This drug is only used for postexposure prophylaxis.”
A: “Truvada does not reduce the need for safe sex practices.”
If right: Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.
If wrong: Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.

Q: The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection?
- Colonization by host bacteria
- Gastrointestinal secretions
- Inflammatory processes
- Skin and mucous membranes
A: Skin and mucous membranes
If right: The skin and mucous membranes are the <i>most</i> important barrier against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.
If wrong: The skin and mucous membranes are the <i>most</i> important barrier against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.

Q: A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?
- Auditing staff members’ hand hygiene practices
- Ensuring clients are placed in appropriate isolation
- Establishing a policy to remove urinary catheters quickly
- Teaching staff members about infection control methods
A: Auditing staff members’ hand hygiene practices
If right: All methods will help prevent infection; however, health care workers’ lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.
If wrong: All methods will help prevent infection; however, health care workers’ lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.

Q: A student nurse asks why brushing clients’ teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?
- “It mechanically removes biofilm on teeth.”
- “It’s easier to clean all surfaces with a brush.”
- “Oral care is important to all our clients.”
- “Toothbrushes last longer than oral swabs.”
A: “It mechanically removes biofilm on teeth.”
If right: Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.
If wrong: Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.

Q: A client is admitted with possible sepsis. Which action should the nurse perform first?
- Administer antibiotics.
- Give an antipyretic.
- Place the client in isolation.
- Obtain specified cultures.
A: Obtain specified cultures.
If right: Prior to administering antibiotics, the nurse obtains the ordered cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The client may or may not need isolation.
If wrong: Prior to administering antibiotics, the nurse obtains the ordered cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The client may or may not need isolation.

Q: A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?
- Consult with the provider about obtaining stool cultures.
- Delegate frequent perianal care to unlicensed assistive personnel.
- Place the client on NPO status until the diarrhea resolves.
- Request a prescription for an anti-diarrheal medication.
A: Consult with the provider about obtaining stool cultures.
If right: Hospitalized clients who have three or more stools a day for 2 or more days are suspected of having infection with <i>Clostridium difficile. </i>The nurse should inform the practitioner and request stool cultures. Frequent perianal care is important and can be delegated but is not the priority. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Anti-diarrheal medication may or may not be appropriate, and the diarrhea serves as the portal of exit for the infection.
If wrong: Hospitalized clients who have three or more stools a day for 2 or more days are suspected of having infection with <i>Clostridium difficile. </i>The nurse should inform the practitioner and request stool cultures. Frequent perianal care is important and can be delegated but is not the priority. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Anti-diarrheal medication may or may not be appropriate, and the diarrhea serves as the portal of exit for the infection.

Q: A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a client’s bed linens. What action by the UAP requires intervention by the nurse?
- Not using gloves while combing the client’s hair
- Rinsing the client’s commode pan after use
- Shaking dirty linens and placing them on the floor
- Wearing gloves when providing perianal care
A: Shaking dirty linens and placing them on the floor
If right: Shaking dirty linens (or even clean linens) can spread microbes through the air. Placing linens on the floor contaminates the floor surface and can lead to infection spread via shoes. The other actions are appropriate. If the client has a scalp infection or infestation, the UAP should wear gloves; otherwise it is not required.
If wrong: Shaking dirty linens (or even clean linens) can spread microbes through the air. Placing linens on the floor contaminates the floor surface and can lead to infection spread via shoes. The other actions are appropriate. If the client has a scalp infection or infestation, the UAP should wear gloves; otherwise it is not required.

Q: A hospital unit is participating in a bioterrorism drill. A “client” is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the “client”?
- Airborne Precautions
- Contact Precautions
- Droplet Precautions
- Standard Precautions
A: Standard Precautions
If right: Only Standard Precautions are needed. No other special precautions are required for the “client” because inhalation anthrax is not spread person to person.
If wrong: Only Standard Precautions are needed. No other special precautions are required for the “client” because inhalation anthrax is not spread person to person.

Q: Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?
- Assessing skin and mucous membranes
- Consistently using appropriate hand hygiene
- Monitoring daily white blood cell counts
- Teaching visitors not to visit if they are ill
A: Consistently using appropriate hand hygiene
If right: Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare-associated infections are due to staff members’ contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come see the client when they are ill will also help prevent infection, but not to the degree that hand hygiene will.
If wrong: Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare-associated infections are due to staff members’ contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come see the client when they are ill will also help prevent infection, but not to the degree that hand hygiene will.

Q: A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?
- Obtain cultures of the lesions.
- Place the client on Airborne Precautions.
- Prepare to administer antibiotics.
- Provide comfort measures for the rash.
A: Place the client on Airborne Precautions.
If right: This client has manifestations of smallpox, a public health emergency, and should be placed on Airborne Precautions first before other care measures are implemented.
If wrong: This client has manifestations of smallpox, a public health emergency, and should be placed on Airborne Precautions first before other care measures are implemented.

Q: A client has been placed on Contact Precautions. The client’s family is very afraid to visit for fear of being “contaminated” by the client. What action by the nurse is best?
- Explain to them that these precautions are mandated by law.
- Inform them that the infection is the issue, not the client.
- Reassure the family that they will not get the infection.
- Tell the family it is important that they visit the client.
A: Inform them that the infection is the issue, not the client.
If right: Families and clients often have negative reactions to isolation precautions. The nurse can explain that the infection is the problem, not the client, and encourage them to visit because following the precautions will prevent them from acquiring the infection. The other options do not give the family useful information to help them make an informed decision.
If wrong: Families and clients often have negative reactions to isolation precautions. The nurse can explain that the infection is the problem, not the client, and encourage them to visit because following the precautions will prevent them from acquiring the infection. The other options do not give the family useful information to help them make an informed decision.

Q: A nurse is caring for a client who has methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?
- Prepare to administer vancomycin (Vancocin).
- Strictly limit visitors to immediate family only.
- Wash hands only after taking off gloves after care.
- Wear a respirator when handling urine output.
A: Prepare to administer vancomycin (Vancocin).
If right: Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.
If wrong: Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.

Q: A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?
- Ensure that the radiology department is aware of the isolation precautions.
- Plan to travel with the client to ensure appropriate precautions are used.
- No special precautions are needed when this client leaves the unit.
- Notify the physician that the client cannot leave the room for the CT scan.
A: Ensure that the radiology department is aware of the isolation precautions.
If right: Clients in isolation should leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse should ensure that the receiving department is aware of the isolation precautions needed to care for the client. The other options are not needed.
If wrong: Clients in isolation should leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse should ensure that the receiving department is aware of the isolation precautions needed to care for the client. The other options are not needed.

Q: A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?
- Elevate the arm above the level of the heart.
- Order a fan to help cool the client if feverish.
- Place cool, wet cloths on top of the wound.
- Take the client’s temperature every 4 hours.
A: Elevate the arm above the level of the heart.
If right: Elevating the extremity above the level of the heart will help with swelling and pain. Fans are not recommended as they can disperse microbes. Having a cool, wet cloth on the wound may macerate the broken skin. Taking the client’s temperature provides data but does not increase comfort.
If wrong: Elevating the extremity above the level of the heart will help with swelling and pain. Fans are not recommended as they can disperse microbes. Having a cool, wet cloth on the wound may macerate the broken skin. Taking the client’s temperature provides data but does not increase comfort.

Q: A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?
- Document findings and continue monitoring.
- Notify the provider and request antibiotics.
- Place the client in protective isolation.
- Tell the client this signifies inflammation.
A: Notify the provider and request antibiotics.
If right: A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics. Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation.
If wrong: A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics. Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation.

Q: A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best?
- Assess the client frequently for worsening of his or her condition.
- Delegate comfort measures to unlicensed assistive personnel.
- Ensure the client is placed on Contact Precautions.
- Restrict visitors to the immediate family only.
A: Assess the client frequently for worsening of his or her condition.
If right: Meningitis is a disease caused by endotoxins, which are released with cell lysis. Antibiotics often work by lysing cell membranes, which would increase the amount of endotoxin present in the client’s body. The nurse should carefully monitor this client for a worsening of his or her condition. Delegating comfort measures is appropriate for any client. Clients with meningitis are placed on Droplet Precautions, and initiating isolation should have been done on admission. The client does not need to have visitors restricted.
If wrong: Meningitis is a disease caused by endotoxins, which are released with cell lysis. Antibiotics often work by lysing cell membranes, which would increase the amount of endotoxin present in the client’s body. The nurse should carefully monitor this client for a worsening of his or her condition. Delegating comfort measures is appropriate for any client. Clients with meningitis are placed on Droplet Precautions, and initiating isolation should have been done on admission. The client does not need to have visitors restricted.

Q: A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? <b>(Select all that apply.)</b>
- CD4+ cells begin to create new HIV virus particles.
- Antibodies produced are incomplete and do not function well.
- Macrophages stop functioning properly.
- Opportunistic infections and cancer are leading causes of death.
- People with stage 1 HIV disease are not infectious to others.
A: CD4+ cells begin to create new HIV virus particles.; Antibodies produced are incomplete and do not function well.; Macrophages stop functioning properly.; Opportunistic infections and cancer are leading causes of death.
If right: In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.
If wrong: In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

Q: Which findings are AIDS-defining characteristics? <b>(Select all that apply.)</b>
- CD4+ cell count less than 200/mm<sup>3</sup> or less than 14%
- Infection with <i>Pneumocystis jiroveci</i>
- Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV)
- Presence of HIV wasting syndrome
- Taking antiretroviral medications
A: CD4+ cell count less than 200/mm<sup>3</sup> or less than 14%; Infection with <i>Pneumocystis jiroveci</i>; Presence of HIV wasting syndrome
If right: A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm<sup>3 </sup>or less than 14% (even if the total CD4+ count is above 200 cells/mm<sup>3</sup>) or an opportunistic infection such as <i>Pneumocystis jiroveci </i>and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.
If wrong: A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm<sup>3 </sup>or less than 14% (even if the total CD4+ count is above 200 cells/mm<sup>3</sup>) or an opportunistic infection such as <i>Pneumocystis jiroveci </i>and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

Q: A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? <b>(Select all that apply.)</b>
- Clean drinking water
- Cultural beliefs about illness
- Lack of antiviral medication
- Social stigma
- Unknown transmission routes
A: Clean drinking water; Cultural beliefs about illness; Lack of antiviral medication; Social stigma
If right: Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.
If wrong: Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

Q: A client with acquired immune deficiency syndrome (AIDS) is hospitalized with <i>Pneumocystis jiroveci</i> pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority?<i> </i><b>(Select all that apply.)</b>
- Aspartate transaminase, alanine transaminase: elevated
- CD4+ cell count: 180/mm<sup>3</sup>
- Creatinine: 1.0 mg/dL
- Platelet count: 80,000/mm<sup>3</sup>
- Serum sodium: 120 mEq/L
A: Aspartate transaminase, alanine transaminase: elevated; Platelet count: 80,000/mm<sup>3</sup>; Serum sodium: 120 mEq/L
If right: The drug of choice to treat <i>Pneumocystis jiroveci</i> pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal.
If wrong: The drug of choice to treat <i>Pneumocystis jiroveci</i> pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal.

Q: A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? <b>(Select all that apply.)</b>
- Apply oral anesthetic gels before meals.
- Assist the client with oral care every 2 hours.
- Offer the client frequent sips of cool drinks.
- Provide the client with alcohol-based mouthwash.
- Remind the client to use only a soft toothbrush.
A: Assist the client with oral care every 2 hours.; Offer the client frequent sips of cool drinks.; Remind the client to use only a soft toothbrush.
If right: The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.
If wrong: The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.

Q: A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? <b>(Select all that apply.)</b>
- Assessing the client’s fluid and electrolyte status
- Assisting the client to get out of bed to prevent falls
- Obtaining a bedside commode if the client is weak
- Providing gentle perianal cleansing after stools
- Reporting any perianal abnormalities
A: Assisting the client to get out of bed to prevent falls; Obtaining a bedside commode if the client is weak; Providing gentle perianal cleansing after stools; Reporting any perianal abnormalities
If right: The UAP can assist the client with getting out of bed, obtain a bedside commode for the client’s use, cleanse the client’s perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.
If wrong: The UAP can assist the client with getting out of bed, obtain a bedside commode for the client’s use, cleanse the client’s perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

Q: A client with acquired immune deficiency syndrome and esophagitis due to <i>Candida</i> fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? <b>(Select all that apply.)</b>
- Assess the client’s mouth and throat.
- Determine if the client has a stiff neck.
- Ensure that the consent form is on the chart.
- Maintain NPO status as prescribed.
- Percuss the client’s abdomen.
A: Assess the client’s mouth and throat.; Ensure that the consent form is on the chart.; Maintain NPO status as prescribed.
If right: Oral <i>Candida</i> fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client’s mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.
If wrong: Oral <i>Candida</i> fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client’s mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.

Q: The student nurse caring for clients understands that which factors must be present to transmit infection? <b>(Select all that apply.)</b>
- Colonization
- Host
- Mode of transmission
- Portal of entry
- Reservoir
A: Host; Mode of transmission; Portal of entry; Reservoir
If right: Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors.
If wrong: Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors.

Q: Which statements are true regarding Standard Precautions? <b>(Select all that apply.)</b>
- Always wear a gown when performing hygiene on clients.
- Sneeze into your sleeve or into a tissue that you throw away.
- Remain 3 feet away from any client who has an infection.
- Use personal protective equipment as needed for client care.
- Wear gloves when touching client excretions or secretions.
A: Use personal protective equipment as needed for client care.; Wear gloves when touching client excretions or secretions.
If right: Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you should also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet away from clients is also not part of Standard Precautions.
If wrong: Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you should also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet away from clients is also not part of Standard Precautions.

Q: The student nurse learns that effective antimicrobial therapy requires which factors to be present? <b>(Select all that apply.)</b>
- Appropriate drug
- Proper route of administration
- Standardized peak levels
- Sufficient dose
- Sufficient length of treatment
A: Appropriate drug; Proper route of administration; Sufficient dose; Sufficient length of treatment
If right: In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.
If wrong: In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.

Q: A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? <b>(Select all that apply.)</b>
- Admit the client to a negative-airflow room.
- Maintain a distance of 3 feet from the client at all times.
- Order specialized masks/respirators for caregiving.
- Other than wearing gloves, no special actions are needed.
- Wash hands with chlorhexidine after providing care.
A: Admit the client to a negative-airflow room.; Order specialized masks/respirators for caregiving.
If right: A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot distance is required for Droplet Precautions. Chlorhexidine is used for clients with a high risk of infection.
If wrong: A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot distance is required for Droplet Precautions. Chlorhexidine is used for clients with a high risk of infection.

Q: A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? <b>(Select all that apply.)</b>
- Age-related decrease in immune function
- Decreased cough and gag reflexes
- Diminished acidity of gastric secretions
- Increased lymphocytes and antibodies
- Thinning skin that is less protective
A: Age-related decrease in immune function; Decreased cough and gag reflexes; Diminished acidity of gastric secretions; Thinning skin that is less protective
If right: Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, and fewer lymphocytes and antibodies.
If wrong: Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, and fewer lymphocytes and antibodies.

Q: A client with an infection has a fever. What actions by the nurse help increase the client’s comfort? <b>(Select all that apply.)</b>
- Administer antipyretics around the clock.
- Change the client’s gown and linens when damp.
- Offer cool fluids to the client frequently.
- Place ice bags in the armpits and groin.
- Provide a fan to help cool the client.
A: Change the client’s gown and linens when damp.; Offer cool fluids to the client frequently.
If right: Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.
If wrong: Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.