Question

A nurse is caring for a client who has HIV.

Answer 1

Correct Answers

Blank 1 Correct Option: sepsis
Blank 2 Correct Option: malnutrition

Rationale :

⭐ Sepsis risk The client has HIV with pneumonia due to Pneumocystis jirovecii, a serious opportunistic infection. Immunosuppression from HIV (CD4 count 400, trending low) and a low WBC count increase the risk of systemic infection and sepsis.

⭐ Malnutrition risk The client has lost 15 lb in 3 months, reports anorexia, diarrhea, and oral ulcers, all of which impair nutritional intake and absorption. Malnutrition further weakens the immune system and complicates recovery.

⭐ Why not tuberculosis While HIV increases TB risk, the current findings and sputum culture confirm Pneumocystis pneumonia, not tuberculosis.

⭐ Why not hemorrhage The platelet count is within normal range, so there is no immediate risk of bleeding or hemorrhage.

⭐ Clinical focus The nurse should closely monitor for signs of septic progression (fever, hypotension, tachycardia) and initiate interventions to support nutritional intake such as high-protein, high-calorie meals and oral care for ulcers.

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Answer 2

Correct Answers:

Obtain a central venous pressure.

Rationale :

⭐ Clients with extensive full-thickness burns experience massive fluid shifts into interstitial spaces, leading to hypovolemia and burn shock, which makes accurate cardiovascular monitoring essential.

⭐ Central venous pressure (CVP) directly reflects right atrial pressure and intravascular volume status, guiding safe and effective fluid resuscitation.

⭐ Cuff blood pressure can be unreliable because peripheral vasoconstriction, edema, or burns interfere with accuracy.

⭐ Pulse pressure palpation provides only a rough estimate of circulation and does not adequately monitor hemodynamic stability in critically ill burn patients.

⭐ Pulmonary artery pressure monitoring requires a Swan-Ganz catheter, which is highly invasive and not the standard first choice; CVP is safer and more practical for routine cardiovascular monitoring in burn care.

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Answer 3

Correct Answers:

AMI is mediated by antibodies produced by B-lymphocytes.

Rationale :

⭐ Definition — Antibody-mediated immunity (AMI), also called humoral immunity, is driven by B-lymphocytes, which differentiate into plasma cells that produce antibodies (immunoglobulins).

⭐ Antibody function — These antibodies bind to antigens, marking them for neutralization, opsonization, or complement activation, protecting the body from infection.

⭐ Not NK cells — Natural killer cells are part of cell-mediated innate immunity, not antibody-mediated immunity.

⭐ Not T-lymphocytes — T cells primarily regulate the cell-mediated immune response, while humoral/AMI is B-cell dependent.

⭐ Broad defense — AMI protects against bacteria, viruses, and toxins, not just viral infections, making it a critical component of adaptive immunity.

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Answer 4

Correct Answers:

The client needs total nursing care.

Rationale :

⭐ The Glasgow Coma Scale (GCS) ranges from 3 to 15, with 15 being fully alert and oriented, and 3 indicating the deepest level of coma.

⭐ A score of 6 indicates severe neurological impairment, meaning the client is not able to function independently and requires total nursing care.

⭐ The score reflects compromised eye opening, verbal response, and motor response, showing the client is not capable of purposeful interaction with the environment.

⭐ A client who is alert and oriented would have a GCS of 15, not 6.

⭐ A score of 3 represents a deep coma; while 6 is critically low, it is above the threshold for total unresponsiveness, but still requires intensive monitoring and full support.

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Answer 5

Correct Answers:

2.5

Rationale :

⭐ Desired dose is 20 mg.

⭐ Stock solution is 40 mg in 5 mL.

⭐ Calculation gives 2.5 mL as the correct volume to administer.

⭐ Safe practice — Always round to the nearest tenth, and avoid trailing zeros to prevent errors.

⭐ Double-check — Verify the concentration and prescribed frequency before administration.

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Answer 6

Correct Answers:

Minimize skin exposure to moisture
Use pillows to keep heels off the bed surface

Rationale :

⭐ Moisture control is essential to prevent maceration of the skin. Incontinence and perspiration are major risk factors for skin breakdown, so keeping the skin clean and minimizing exposure to moisture helps maintain skin integrity.

⭐ Heel offloading with pillows or devices prevents continuous pressure on the calcaneus, which is highly vulnerable to ischemia and ulcer formation in immobile clients.

⭐ A turning schedule every 2 hours, not 4 hours, is the standard of care to redistribute pressure and prevent ischemic injury. Four-hour intervals are too long for clients at high risk.

⭐ Massaging erythematous areas is contraindicated because it can worsen tissue injury by damaging capillaries that are already fragile.

⭐ Powder on the skin can cause dryness, irritation, or clumping that holds moisture against the skin, increasing breakdown risk instead of preventing it.

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Answer 7

Correct Answers:

"It increases their risk of experiencing a stroke."

Rationale :

⭐ Antipsychotic medications are sometimes prescribed for behavioral disturbances in dementia but carry an FDA black box warning for increased risk of cerebrovascular events, including stroke and even death.

⭐ Older adults with dementia are especially vulnerable to vascular side effects, making this risk the most important reason why providers avoid routine use of these drugs.

⭐ While medications can also contribute to sedation and falls, the strongest and most evidence-based concern in dementia care is the stroke risk associated with antipsychotic therapy.

⭐ Nonpharmacologic interventions such as structured routines, environmental adjustments, and caregiver support are the first-line management strategies for agitation in dementia.

⭐ Educating families about these risks promotes safe, evidence-based care and helps them understand why providers avoid unnecessary medications.

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Answer 8

Correct Answers:

Hypoxemia

Rationale :

⭐ Hypoxemia is the earliest and most reliable indicator of fat embolism syndrome because fat globules lodge in pulmonary vessels, impairing gas exchange.

⭐ Clients may present with dyspnea, restlessness, and low oxygen saturation before any visible signs develop.

⭐ Petechiae are a classic sign but occur later in the progression of fat embolism.

⭐ Headache and chest pain can occur, but they are not the first manifestations.

⭐ Prompt recognition of hypoxemia ensures early intervention and prevention of complications.

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Answer 9

Correct Answers:

Increase in the heart rate from 88 to 1 10/min.

Rationale :

⭐ Tachycardia is the earliest compensatory response to blood loss and hypovolemia, indicating that the body is trying to maintain cardiac output.

⭐ Temperature elevation suggests infection, not hypovolemic shock.

⭐ Urinary output of 30 mL/hr is still at the low normal limit, but it is not the most immediate indicator.

⭐ Respiratory rate usually increases in hypovolemic shock, not decreases, making this finding inconsistent.

⭐ Detecting an increase in heart rate allows for rapid fluid resuscitation and shock prevention.

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Answer 10

Correct Answers:

Encourage fluid intake at and between meals.

Rationale :

⭐ Adequate hydration promotes bladder flushing and reduces bacterial growth in the urinary tract.

⭐ Indwelling catheters significantly increase infection risk and should be avoided unless absolutely necessary.

⭐ Offering a bedpan every 2 hr does not address infection prevention and is not a standard intervention.

⭐ Cleansing from back to front increases bacterial transfer from the rectum to the urethra, raising infection risk.

⭐ High fluid intake with proper hygiene is the most effective method to prevent UTIs in spinal cord injury clients.

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Custom- NUR213 Final Assessment SU II 2025 Assessment 1- Excelsior University ADN

No.

1 :
A nurse is caring for a client who has HIV.

Correct Answers

2 :
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

3 :
A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity (AMI). Which of the following information should the nurse confirm about AMI?

4 :
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

5 :
A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a client who has GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
mL

6 :
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

7 :
A nurse is caring for an older adult client who has dementia. The client's family member asks why the provider will not prescribe a medication to calm the client down. Which of the following statements should the nurse make?

8 :
A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which of the following findings should the nurse identify as an early manifestation of fat embolism syndrome?

9 :
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

10 :
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

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Custom- NUR213 Final Assessment SU II 2025 Assessment 1- Excelsior University ADN

No.

1 : A nurse is caring for a client who has HIV.

Correct Answers

2 : A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

3 : A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity (AMI). Which of the following information should the nurse confirm about AMI?

4 : A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

5 : A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a client who has GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)mL

6 : A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

7 : A nurse is caring for an older adult client who has dementia. The client's family member asks why the provider will not prescribe a medication to calm the client down. Which of the following statements should the nurse make?

8 : A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which of the following findings should the nurse identify as an early manifestation of fat embolism syndrome?

9 : A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

10 : A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

1 :
A nurse is caring for a client who has HIV.

2 :
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

3 :
A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity (AMI). Which of the following information should the nurse confirm about AMI?

4 :
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

5 :
A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a client who has GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
mL

6 :
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

7 :
A nurse is caring for an older adult client who has dementia. The client's family member asks why the provider will not prescribe a medication to calm the client down. Which of the following statements should the nurse make?

8 :
A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which of the following findings should the nurse identify as an early manifestation of fat embolism syndrome?

9 :
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

10 :
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?