Question

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?

Answer 1

Correct Answers:

A typical course of treatment involves 6 to 9 months of consistent medication use.

Rationale :

🫁 Pulmonary tuberculosis treatment usually requires several antitubercular medications taken consistently for 6 to 9 months.

🫁 Long-term adherence is necessary because TB bacteria grow slowly and are difficult to fully eliminate.

🫁 Stopping medication early can lead to treatment failure, relapse, and drug-resistant TB.

🫁 Clients should be taught to continue therapy even when symptoms improve.

🫁 Directly observed therapy may be used to improve adherence and reduce transmission risk.

Medications will need to be taken for the rest of the client’s life, even if the client feels better.

🫁TB medications are not usually taken for life.

🫁Standard active TB treatment is time-limited but requires consistent completion.

Medications will need to be taken until the Mantoux test is negative.

🫁The Mantoux test can remain positive after TB exposure or infection.

🫁Treatment length is based on the prescribed regimen and clinical response, not conversion to a negative skin test.

The client’s family will also need to take medications to prevent infection.

🫁Family members should be screened for TB exposure.

🫁They only receive medication if testing or risk assessment indicates latent or active TB infection.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Location of the burn

Rationale :

🔥 The location of the burn is the priority because burns to the face and neck can threaten the airway.

🔥 Facial and neck burns increase concern for airway edema, inhalation injury, and respiratory compromise.

🔥 Airway swelling can progress quickly, even if the client is initially breathing adequately.

🔥 Burns involving the face, neck, hands, feet, genitalia, or major joints are considered high-risk.

🔥 The nurse should prioritize airway assessment, breathing pattern, oxygenation, voice changes, soot, singed nasal hairs, and stridor.

Cause of the burn

🔥The cause of the burn is important because chemical, electrical, thermal, and inhalation burns require specific care.

🔥However, immediate airway risk from the face and neck location is the priority.

Associated medical history

🔥Medical history affects healing and overall risk.

🔥 It is not the first priority when the burn location suggests possible airway compromise.

Age of the client

🔥Age influences burn severity, healing, and fluid needs.

🔥However, airway-threatening burn location is more urgent during initial assessment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Restrict visitors who have active infections
Don a mask, gloves, and gown
Instruct the client to eat cooked foods only

Rationale :

Restrict visitors who have active infections

🛡️ Visitors with active infections should be restricted because an immunosuppressed client has reduced ability to fight pathogens.

🛡️ Even minor illnesses in visitors can lead to serious infection in a client with weakened immunity.

🛡️ The nurse should screen visitors for fever, cough, rash, vomiting, diarrhea, or known contagious illness.

🛡️ Limiting exposure reduces the risk of respiratory, gastrointestinal, and skin infections.

🛡️ This precaution protects the client from preventable infection-related complications.

Don a mask, gloves, and gown

🛡️ Using appropriate personal protective equipment helps reduce transmission of microorganisms to the immunosuppressed client.

🛡️ Gloves and gowns help prevent contact transmission from contaminated clothing, hands, or surfaces.

🛡️ A mask may be used according to facility policy or when respiratory exposure risk is present.

🛡️ PPE supports protective isolation and infection prevention for clients with decreased immune defenses.

🛡️ Hand hygiene remains essential before and after all client contact.

Instruct the client to eat cooked foods only

🛡️ Cooked foods are safer for immunosuppressed clients because cooking reduces harmful bacteria and parasites.

🛡️ Raw or undercooked foods can carry organisms that may cause severe infection.

🛡️ The client should avoid raw meat, raw eggs, unpasteurized dairy, and unwashed produce.

🛡️ Food safety is an important part of reducing infection risk in immunocompromised clients.

🛡️ Proper nutrition also supports immune function and tissue repair.

Dispose all linen in trash after use

🛡️Used linen should be handled according to facility infection-control policy, not thrown in the trash.

🛡️Linen is usually placed in designated linen bags to prevent contamination and allow proper processing.

Limit the client from bathing daily

🛡️Daily hygiene should not be restricted unless clinically indicated.

🛡️Bathing helps reduce skin microorganisms and supports infection prevention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

"l will limit my alcohol intake."

Rationale :

🦶 Limiting alcohol intake is important for gout management because alcohol can increase uric acid levels.

🦶 Alcohol, especially beer and spirits, can trigger gout attacks by increasing urate production and reducing uric acid excretion.

🦶 Gout occurs when excess uric acid crystals deposit in joints, causing sudden severe inflammation and pain.

🦶 Clients should also increase fluids as prescribed and limit high-purine foods such as organ meats, certain seafood, and some red meats.

🦶 This statement shows understanding of lifestyle measures that reduce the risk of recurrent gout attacks.

“I will limit my fluid intake to 1 liter per day.”

🦶Clients with gout are usually encouraged to maintain adequate hydration unless contraindicated.

🦶 Fluids help promote uric acid excretion through the kidneys.

“I will take one aspirin every day.”

🦶Aspirin can affect uric acid handling and may worsen gout depending on dose and provider guidance.

🦶The client should not begin daily aspirin for gout unless specifically prescribed.

“I will closely follow a high-purine diet.”

🦶A high-purine diet can increase uric acid production and worsen gout.

🦶Clients should limit high-purine foods to reduce flare risk.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Heart rate
Edema
Urine color
Pedal pulses

Rationale :

Heart rate

🔴 The client’s heart rate increased from 92/min to 108/min, which requires immediate follow-up after pelvic and hip fractures.

🔴 Tachycardia can be an early sign of pain, internal bleeding, hypovolemia, shock, or worsening tissue injury.

🔴 Pelvic fractures are concerning because they can be associated with significant internal bleeding.

🔴 When tachycardia occurs with cool extremities, delayed capillary refill, and decreased pedal pulses, poor perfusion should be suspected.

🔴 The nurse should reassess pain, bleeding risk, circulation, blood pressure trends, urine output, and notify the provider.

Edema

🔴 The client’s sacral and iliac edema increased to 2+, which requires immediate follow-up.

🔴 Worsening edema after trauma can indicate soft tissue injury, bleeding, inflammation, or impaired circulation.

🔴 Increased swelling around the pelvis and hip can contribute to compression of surrounding blood vessels and nerves.

🔴 This finding is more concerning because the client also has cool lower extremities and reduced peripheral pulses.

🔴 The nurse should assess the affected area, compare extremities, monitor neurovascular status, and report worsening swelling.

Urine color

🔴 Dark reddish-brown urine after pelvic trauma requires immediate follow-up because it may indicate blood in the urine.

🔴 Pelvic fractures can be associated with urinary tract injury, including bladder or urethral trauma.

🔴 The client was unable to void and had bladder distention, which increases concern for urinary obstruction or injury.

🔴 Reddish-brown urine may also suggest muscle breakdown or bleeding, both of which require prompt evaluation.

🔴 The nurse should monitor urine output, catheter drainage, pain, vital signs, and notify the provider immediately.

Pedal pulses

🔴 The client’s pedal pulses decreased from +2 to +1 bilaterally, which requires immediate follow-up.

🔴 Decreased pulses indicate possible impaired peripheral perfusion after trauma.

🔴 This is especially concerning because the lower extremities are cool and capillary refill is delayed at 6 seconds.

🔴 Poor circulation can lead to tissue ischemia if not addressed quickly.

🔴 The nurse should perform frequent neurovascular checks, compare both extremities, and report changes promptly.

Oxygen saturation

🔴Oxygen saturation was 95% on Day 1, and no abnormal Day 2 oxygen saturation value is provided.

🔴Without evidence of hypoxia or respiratory decline, this is not one of the four immediate follow-up findings listed.

Temperature

🔴 The client’s temperature increased from 36.4°C to 37.2°C, but it remains within the expected range.

🔴 This does not require immediate follow-up compared with signs of possible bleeding, urinary injury, and impaired perfusion.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Massaging her legs

Rationale :

🩸 The client should avoid massaging the legs because it can dislodge an existing clot and cause a pulmonary embolism.

🩸 Postoperative clients are at increased risk for venous thromboembolism due to immobility, tissue injury, and venous stasis.

🩸 If a clot is present, pressure from massage can move the thrombus into circulation.

🩸 The nurse should encourage safe prevention measures such as ankle exercises, early ambulation, hydration as prescribed, and sequential compression devices if ordered.

🩸 Leg pain, swelling, warmth, redness, sudden dyspnea, chest pain, or tachycardia should be reported immediately.

Flexing her ankles

🩸Ankle flexion is a safe action that promotes venous return and helps reduce venous stasis.

🩸It is commonly encouraged after surgery to prevent clot formation.

Elevating her feet

🩸Elevating the feet can help promote venous return and reduce dependent swelling.

🩸 It is not unsafe unless contraindicated by the client’s condition.

Ambulating soon after surgery

🩸Early ambulation is one of the best ways to prevent postoperative VTE.

🩸It improves circulation and reduces the risk of clot formation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Headache

Rationale :

💉 A headache after spinal anesthesia can indicate a complication called post-dural puncture headache.

💉 This occurs when cerebrospinal fluid leaks from the puncture site, causing decreased CSF pressure.

💉 The headache is often worse when sitting or standing and improves when lying flat.

💉 The nurse should assess severity, position changes, nausea, neck stiffness, photophobia, and notify the provider if symptoms are significant.

💉 Management can include fluids, caffeine, analgesics, bed rest, or an epidural blood patch if prescribed.

Numbness in the legs

💉 Temporary leg numbness is expected immediately after spinal anesthesia.

💉It should gradually resolve as the anesthetic wears off.

Absence of urge to void

💉Urinary retention or decreased urge to void can occur temporarily after spinal anesthesia.

💉The nurse should monitor bladder status, but this is a common expected effect rather than the best complication listed.

Hiccoughs

💉Hiccoughs are not a classic complication of spinal anesthesia.

💉They are not as concerning as a post-dural puncture headache.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers

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

Rationale :

Sepsis

🦠 The client is at risk for sepsis because HIV weakens immune function, and the client has evidence of an active opportunistic infection.

🦠 The sputum culture shows Pneumocystis jirovecii, and the chest x-ray shows pneumonia with infiltrates in the right lower lobe.

🦠 The client also has concerning systemic findings, including fever, tachycardia, tachypnea, low WBC count, and decreased oxygen saturation.

🦠 A reduced CD4-T-cell count of 400 cells/mm³ shows impaired immune protection, increasing the risk that infection can spread into the bloodstream.

🦠 The nurse should monitor for worsening fever, hypotension, altered mental status, increased respiratory distress, and other signs of systemic infection.

Malnutrition

🦠The client is at risk for malnutrition because of significant weight loss of 15 lb over 3 months, anorexia, diarrhea, and difficulty eating.

🦠Oral ulcers can make chewing and swallowing painful, reducing the client’s ability to maintain adequate nutritional intake.

🦠Chronic diarrhea can cause fluid loss, nutrient loss, electrolyte imbalance, and poor absorption.

🦠HIV increases metabolic demand, especially when infection is present, which can worsen nutritional depletion.

🦠The nurse should monitor weight trends, intake, hydration status, albumin/prealbumin if ordered, oral lesions, and need for nutritional support.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

"Move objects away from the client."

Rationale :

🔷 During a seizure, the first priority is protecting the client from injury while allowing the seizure to run its course safely.

🔷 Moving objects away prevents the client from striking hard furniture, equipment, or sharp items during uncontrolled motor activity.

🔷 The nurse should teach the family to lower the client to the floor if possible, protect the head, loosen tight clothing, and maintain a clear surrounding area.

🔷 Safety measures reduce the risk of head trauma, fractures, soft-tissue injury, and airway compromise.

🔷 After the seizure, the client should be placed in a side-lying position to promote drainage of secretions and reduce aspiration risk.

“Restrain the client.”

🔷Restraining a client during a seizure can cause muscle injury, joint dislocation, fractures, or soft-tissue trauma because the movements are involuntary.

🔷The correct approach is to protect the client from injury, not to stop the seizure physically.

“Place the client on his back.”

🔷Supine positioning increases the risk for aspiration, especially if saliva, vomiting, or secretions are present.

🔷Side-lying positioning is safer after the seizure because it helps keep the airway open.

“Insert a padded tongue blade into the client’s mouth.”

🔷Nothing should be placed in the mouth during a seizure because it can damage teeth, injure the gums, or obstruct the airway.

🔷The client cannot “swallow the tongue,” so mouth insertion is unsafe and outdated practice.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

"Eat four small meals each day."

Rationale :

🟢 GERD occurs when gastric contents reflux into the esophagus due to decreased lower esophageal sphincter tone or increased gastric pressure.

🟢 Eating smaller, more frequent meals decreases stomach distention and reduces pressure that pushes acid upward.

🟢 Large meals delay gastric emptying and increase the likelihood of heartburn, regurgitation, and esophageal irritation.

🟢 Clients should also avoid foods that worsen reflux, including fatty foods, spicy foods, caffeine, chocolate, peppermint, and alcohol.

🟢 Dietary control is an important lifestyle intervention because it reduces acid exposure and helps prevent complications such as esophagitis.

“Sleep on your left side.”

🟢Left-side sleeping may reduce reflux in some clients, but the more important standard teaching is to avoid large meals and elevate the head of the bed.

🟢This statement is not the best answer compared with reducing meal size.

“Wait to go to bed for 1hr after eating.”

🟢Clients with GERD should avoid lying down for 2 to 3 hours after meals to allow gastric emptying.

🟢Waiting only 1 hour is usually not enough to prevent reflux.

“Drink milk to soothe your stomach.”

🟢Milk may provide temporary relief but can later stimulate gastric acid secretion.

🟢It is not recommended as a reliable long-term GERD management strategy.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Custom NUR213 Final Assessment SP II 2026

No.

1 :
A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?

2 :
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

3 :
A nurse is creating a plan of care for an immunosuppressed client. Which of the following precautions should the nurse include in the plan? (Select All that Apply.)

4 :
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

5 :
A nurse is caring for a client in the emergency department (ED).

Answer Options

6 :
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

7 :
A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

8 :
A nurse is caring for a client who has HIV.

Correct Answers

9 :
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

10 :
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?

Connect With Us

Custom NUR213 Final Assessment SP II 2026

No.

1 : A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?

2 : A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

3 : A nurse is creating a plan of care for an immunosuppressed client. Which of the following precautions should the nurse include in the plan? (Select All that Apply.)

4 : A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

5 : A nurse is caring for a client in the emergency department (ED).

Answer Options

6 : A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

7 : A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

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

Correct Answers

9 : A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

10 : A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?

1 :
A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?

2 :
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

3 :
A nurse is creating a plan of care for an immunosuppressed client. Which of the following precautions should the nurse include in the plan? (Select All that Apply.)

4 :
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

5 :
A nurse is caring for a client in the emergency department (ED).

6 :
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

7 :
A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

8 :
A nurse is caring for a client who has HIV.

9 :
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

10 :
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?