Diya Coaching Centre for Nurses

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Unit-17_Test-1_Answers

1. Correct Answer: 4
Rationale: Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia.
The client should routinely be assessed for signs and symptoms of infection. The client should also have
ongoing monitoring of a number of parameters because of the nature and side effects of the medication,
including blood glucose, blood urea nitrogen, serum creatinine, complete blood cell count, liver function
studies, and serum calcium and magnesium levels.

2. Correct Answer: 1
Rationale: A common side effect of this medication is agranulocytopenia and anemia. The nurse
carefully monitors CBC results for these changes. With early infection or in the client who is
asymptomatic, CBC levels are monitored monthly for 3 months, then every 3 months thereafter. In clients
with advanced disease, they are monitored every 2 weeks for the first 2 months, and then once a month if
the medication is tolerated well.

3. Correct Answer: 2
Rationale: A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis in the
AIDS client, which is potentially fatal. The medication may have to be discontinued. The medication is
also hepatotoxic and can result in liver failure.

4. Correct Answer: 2
Rationale: Foscavir is very toxic to the kidneys. Serum creatinine is monitored before therapy, 2 to 3
times per week during induction therapy, and at least weekly during maintenance therapy. It also may
cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus these levels are also
measured with the same frequency.

5. Correct Answer: 1
Rationale: Common adverse effects of this medication are agranulocytopenia and anemia. The nurse
monitors CBC results for these changes. The BUN, creatinine, and potassium levels are unrelated to this
medication.

6. Correct Answer: 2
Rationale: Because Foscavir is toxic to the kidneys, serum creatinine is monitored before therapy, 2 to 3
times per week during induction therapy, and at least weekly during maintenance therapy. It may also
cause decreased levels of calcium, magnesium, phosphorus, and potassium, so these are monitored with
the same frequency.

7. Correct Answer: 4
Rationale: Eosinophils attack and destroy foreign particles that have been coated with antibodies of the
IgE class. Their usual target is helminths (parasitic worms). Basophils mediate immediate hypersensitivity
reactions. Dendritic cells perform the same antigen-presenting task, as do the macrophages. Neutrophils
phagocytize foreign particles, such as bacteria.

8. Correct Answer: 1
Rationale: Active immunity lasts much longer and is more effective at preventing subsequent infections
than passive immunity. The active immunity lasts for years and can be easily reactivated by a booster dose
of antigen. Passively received human antibodies have a half-life of about 30 days. Protection from active
immunity takes 5 to 14 days to develop after the first exposure to the antigen and 1 to 3 days after
subsequent exposures. Passive immunity provides protection immediately.

9. Correct Answer: 2

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Rationale: A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis in the
AIDS client, which is potentially fatal. The medication may have to be discontinued. The medication is
also hepatotoxic, and can result in liver failure.

10. Correct Answer: 2

Rationale: This medication is toxic to both the pancreas and the liver. A serum amylase level that is
increased to 1.5 to 2 times normal may signify pancreatitis and may be potentially fatal in the AIDS client.
Therefore, the nurse monitors the results of amylase and liver function studies closely. Options 1 , 3, and 4
are unrelated to this medication.

11. Correct Answer: 4

Rationale: The liver contains a large number of macrophages called Kupffer's cells. These cells help
filter blood by phagocytizing microorganisms and other foreign particles passing through the liver. Options
1, 2, and 3 are incorrect.

12. Correct Answer: 4

Rationale: Natural resistance, also called innate inherited immunity, is that immunity with which a
person is born. It does not require prior exposure to the antigen. Acquired immunity includes all antigen-
specific immunities that a person develops during a lifetime.

13. Correct Answer: 1

Rationale: A common side effect of this medication therapy is agranulocytopenia and anemia. The nurse
monitors the CBC results for these changes. Options 2, 3, and 4 are unrelated to the use of this medication.

14. Correct Answer: 4

Rationale: Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia.
The client should be routinely monitored for signs and symptoms of infection. Options 1, 2, and 3 are
inaccurate interpretations.

15. Correct Answer: 3

Rationale: Zalcitabine slows the progression of acquired immunodeficiency virus (AIDS) by improving
the CD4 cell count. A CBC with differential may be done as part of an ongoing monitoring of the status of
the client with AIDS and to detect adverse effects of other medications. The ELISA and Western blot tests
are performed to diagnose AIDS initially.

16. Correct Answer: 4

Rationale: Generally an ESR value of 30 to 40 mm/hour indicates mild inflammation, 40 to 70 mm/hour
indicates moderate inflammation, and 70 to 150 mm/hour indicates severe inflammation.

17. Correct Answer: 2

Rationale: Pemphigus vulgaris is an autoimmune disease that causes blistering in the epidermis. The
clients have large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a very tiny
covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may
have crusting areas instead of intact blisters. Option 1 describes herpes zoster. Option 3 describes psoriasis,
and option 4 describes eczema.

18. Correct Answer: 2

Rationale: Foscavir is very toxic to the kidneys. Serum creatinine is monitored prior to therapy, 2 to 3
times per week during induction therapy, and at least weekly during maintenance therapy. It can also cause
decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels are also measured
with the same frequency.

19. Correct Answer: 4

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Rationale: Frequent side effects of pentamidine include leukopenia, thrombocytopenia, and anemia. The
client should be routinely assessed for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate
interpretations.

20. Correct Answer: 4

Rationale: The antinuclear antibody test measures the titer of antibodies that destroy the nuclei cells and
cause tissue death. When the fluorescent method is used, the test is sometimes referred to as FANA. If this
test is positive, a value greater than 1.8 will be present. The other options are incorrect

21. Correct Answer: 1

Rationale: The correct procedure for needle disposal is to dispose of uncapped needles and sharps in a
hard-wall, puncture-resistant container, immediately after use. Needles are not recapped.

22. Correct Answer: 1

Rationale: Zalcitabine is an antiretroviral (nucleoside reverse transcriptase inhibitor) used to manage
HIV infection with other antiretrovirals. It has also been used as a single agent in clients who are intolerant
of other regimens. It can cause serious liver damage, and liver function studies should be monitored
closely. Options 2, 3, and 4 are not specifically associated with the use of this medication.

23. Correct Answer: 1

Rationale: Because neutropenia and thrombocytopenia are the most frequent side effects of ganciclovir,
the nurse monitors for signs and symptoms of bleeding and implements the same precautions that are used
for a client receiving anticoagulant therapy. The medication does not have to be taken on an empty
stomach or without food, and it should not be taken with an antacid. The medication may cause
hypoglycemia; it does not cause hyperglycemia.

24. Correct Answer: 4

Rationale: SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on
the cheeks and the bridge of nose is a key sign of SLE. Option 1 is found in sickle cell anemia. Options 2
and 3 are found in many conditions and are not associated with SLE.

25. Correct Answer: 2

Rationale: Stavudine is an antiretroviral (protease inhibitor) used in the management of HIV infection in
clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause
peripheral neuropathy, and the nurse should closely monitor the client's gait and ask the client about
paresthesia.

26. Correct Answer: 4

Rationale: Hematologic monitoring should be done every 2 weeks in the client taking zidovudine. If
severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of
bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The
administration of prednisone may further alter the immune function. Epogen is administered to clients
experiencing anemia.

27. Correct Answer: 1

Rationale: To maximize absorption, the medication should be administered with water on an empty
stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be
administered with skim milk, coffee, tea or a low-fat meal. It is not administered with a large meal. The
medication should be stored at room temperature and protected from moisture, because moisture can
degrade the medication.

28. Correct Answer: 4

Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who
work with manufacturing latex products; females; individuals with spina bifida; persons who wear gloves

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frequently, such as food handlers, hairdressers, and auto mechanics; and persons allergic to kiwis, bananas,
pineapples, passion fruits, avocados, and chestnuts.

29. Correct Answer: 3

Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that
change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis
through the upper body then to the face and oral mucosa. It can move to the lymphatic system, lungs, and
gastrointestinal (Gl) tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum,
or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and Gl lesions.
Options 1, 2, and 4 are incorrect.

30. Correct Answer: 1

Rationale: The test for rheumatoid factor measures the presence of unusual antibodies of the IgG and
IgM type that develop in a number of connective tissue diseases. The other options are incorrect.

31. Correct Answer: 2

Rationale: Ocular toxicity is an adverse reaction to the use of hydroxychloroquine sulfate. An eye
examination should be performed when medication therapy is started and after 6 months of therapy.
Options 1, 3, and 4 are unrelated to the use of this medication.

32. Correct Answer: 4

Rationale: Acyclovir is dispensed as a powder to be reconstituted for IV administration and is given by
slow IV infusion over 1 hour. It is not given as an IV bolus or continuous infusion, or by intramuscular or
subcutaneous injection. To minimize the risk of renal damage, the client should be hydrated during the
infusion and for 2 hours after.

33. Correct Answer: 4

Rationale: The client with Pneumocystis carinii infection usually has cough as the first symptom, which
begins as nonproductive, then progresses to productive. Later signs include fever, dyspnea on exertion, and
finally dyspnea at rest.

34. Correct Answer: 4

Rationale: Invirase is an antiretroviral (protease inhibitor) used in combination with other antiretroviral
medications in the management of HIV infection. It is administered with meals and is best absorbed if the
client consumes high-calorie, high-fat meals. It can cause photosensitivity, and the client is instructed to
avoid sun exposure.

35. Correct Answer: 1

Rationale: Although the most common reaction to this medication is phlebitis and inflammation at the
IV site, reversible nephrotoxicity evidenced by an elevated serum creatinine and blood urea nitrogen levels
can occur in some clients. The cause of nephrotoxicity is the deposition of acyclovir in the renal tubules.
The risk of renal injury is increased by dehydration and by the use of other nephrotoxic medications. The
values identified in the other options are within normal limits.

36. Correct Answer: 1

Rationale: Histoplasmosis usually starts as a respiratory infection in the client with AIDS. It then
becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver. Options 2, 3, and 4
are incorrect.

37. Correct Answer: 2

Rationale: People who are allergic to bananas, avocados, tropical fruits, kiwis, potatoes, and chestnuts
are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the
food and the latex allergen. Options 1, 3, and 4 are unrelated to latex allergy.

38. Correct Answer: 1

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Rationale: Daraprim is an antimalarial and antiprotozoal medication. It is used in the treatment of

toxoplasmosis or Pneumocystis carinii pneumonia. It is not used to treat nausea, vomiting, cardiac
irregularities, or Kaposi's sarcoma.

39. Correct Answer: 3

Rationale: IgM is the first antibody produced in response to antigen. About 7% of the total serum
antibodies are of the IgM class. Because of their size, these antibodies are confined to the blood stream.
Options 1, 2, and 4 are incorrect.

40. Correct Answer: 1

Rationale: B-lymphocytes have the job of making antibodies and mediating humoral immunity. They do
not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is
phagocytosis.

41. Correct Answer: 2

Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a
specific pathogen to form. Natural (innate) immunity is present at birth. There is no immunization that
protects the client from all diseases.

42. Correct Answer: 4

Rationale: Specific immune responses have three main phases. These include the recognition phase, the
activation phase, and the effector phase. Memory is not a feature of an immune response.

43. Correct Answer: 4

Rationale: Chemical barriers include various acids and enzymes found in body fluids. The skin, the
mucous membranes, and the action of cilia lining the respiratory tract are physical barriers.

44. Correct Answer: 3

Rationale: Dapsone may be prescribed for the treatment of toxoplasmosis. The medication is taken
orally on a daily basis. The medication suppresses bone marrow activity and the complete blood count
(CBC) is monitored closely. If the client develops fever, sore throat, purpura, or jaundice, the physician is
notified. Medications are available to treat nausea and vomiting, and the client should not discontinue the
medication if these symptoms occur, but should contact the physician.

45. Correct Answer: 1

Rationale: Toxoids are toxins produced by bacteria that have been altered so that they are no longer
toxic. Their important antigenic receptor sites remain intact, enabling antibodies to be produced to the
antigen-producing toxin. Options 2, 3, and 4 are incorrect.
46. Correct Answer: 2
Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer the
client an antipyretic of choice prior to going to sleep. It is also helpful to keep a change of bed linens and
nightclothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the
pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink.

47. Correct Answer: 4

Rationale: The client in stage 1 (seroconversion) acute HIV infection has laboratory documentation of
HIV positive status, but is asymptomatic. Following introduction of the infection and seroconversion in
stage 1, the client may remain asymptomatic for a period of 6 months to in excess of 10 years (stage 2:
chronic asymptomatic status). The client's T4 cell count is normal during these two stages. The client will
begin to show symptoms in stage 3: symptomatic stage, when the T4 cell count drops below 500/cu mm.
At this time, the client experiences opportunistic infections, including oral lesions (thrush) and skin lesions
(Kaposi's sarcoma). The client may also experience signs of respiratory infection in stage 3.

48. Correct Answer: 3

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Rationale: Cotton pads and plastic or silk tape are latex-free products. The items identified in options 1,
2, and 4 are all products that contain latex.

49. Correct Answer: 4

Rationale: The immune system has five major types of cells: B lymphocytes (B cells), helper T
lymphocytes (CD4 cells), cytolytic T lymphocytes (CD8 cells, CTLs), macrophages, and dendritic cells.

50. Correct Answer: 4

Rationale: 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 fact that the client
states that breathing is easier, coughs 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.

51. Correct Answer: 3

Rationale: Peyer's patches are lymphoid nodules located in the small intestine where T cells congregate.
These organs are most important in the secondary immune response, although they play a role in the
primary immune response as well. These organs may enlarge as they become highly active in the immune
response. Options 1, 2, and 4 are incorrect.

52. Correct Answer: 2

Rationale: Pads used on crutches contain latex. If the client requires the use of crutches, the nurse can
cover the pads with a cloth to prevent cutaneous contact. Option 3 is inappropriate and may alarm the
client. The nurse cannot order a cane for a client. Additionally, this type of assistive device may not be
appropriate, considering this client's injury. There is no reason to contact the physician at this time.

53. Correct Answer: 1

Rationale: Interferon is produced by several types of cells and is effective against a wide variety of
viruses. It works on the host cells to induce protection and differs from an antibody, which inactivates
viruses found outside the cells.

54. Correct Answer: 4

Rationale: The ESR can confirm inflammation or infection anywhere in the body. It is particularly
useful for connective tissue disease because the value directly correlates with the degree of inflammation
and later with the severity of the disease. The other options are incorrect.

55. Correct Answer: 2

Rationale: The LE cell prep may be performed on a client suspected of SLE. It may also be used to
screen for progressive systemic sclerosis but is primarily used to screen for SLE. The other options are not
associated with this diagnostic test.

56. Correct Answer: 2

Rationale: Phagocytosis, an important nonspecific immune response, is a process in which the particle is
ingested and digested by a cell. Options 1, 3, and 4 are incorrect.

57. Correct Answer: 2

Rationale: If the results of two ELISA tests are positive, the Western blot is done to confirm the
findings. If the result of the Western blot is positive, then the client is considered to be positive for HIV
and infected with the HIV virus. Options 1, 3, and 4 are incorrect.

58. Correct Answer: 3

Rationale: Mucosal exposure to latex can occur on contact with latex condoms. The nurse would most
appropriately provide instructions to the client about the need to avoid the use of condoms unless they are

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latex-free. There is no reason to avoid outdoor activities or sunlight. There is also no reason to avoid
parties; however, the client should be informed that certain kinds of balloons are made of latex.

59. Correct Answer: 1

Rationale: The major serum antibody is IgG, constituting about 70% of the total circulating antibodies.
It is antiviral, antibacterial, and effective against toxins. IgA makes up about 21% of the total circulating
antibodies. IgM is the first antibody produced in response to antigen and makes up about 7% of the total
serum antibodies. IgE accounts for only about 0.5% of the total antibody level in the blood.

60. Correct Answer: 3

Rationale: To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit
whenever possible, to avoid hot baths, to schedule moderate low-impact exercises when not fatigued, and
to maintain a balanced diet. The client is instructed to avoid long periods of rest because they promote joint
stiffness.

61. Correct Answer: 1

Rationale: In most types of allergies, a reaction occurs only on second and subsequent contacts with the
allergen. The most appropriate action therefore, would be to ask the client if he or she ever received a bee
sting in the past. Option 2 is unnecessary. Option 3 is not appropriate advice. The client should not be told
not to worry.

62. Correct Answer: 3

Rationale: In the inflammatory response, neutrophils appear in the area of injury in 30 to 60 minutes.
Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as
microorganisms. Options 1, 2, and 4 are not actions of the neutrophils.

63. Correct Answer: 3

Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma, which frequently
complicates the clinical picture of the client with AIDS. Lung biopsy would confirm Pneumocystis carinii
infection. The ELISA and Western blot are tests to diagnose HIV status.

64. Correct Answer: 2

Rationale: The client with immune deficiency has inadequate immune bodies or their absence, and is at
risk for infection. The priority nursing intervention is to protect the client from infection. Options 1, 3, and
4 may be components of care but are not the priority.

65. Correct Answer: 3

Rationale: Specific immunity is the second line of defense against infection and is able to identify
specific antigens. This type of immunity reacts differently to different antigens, and the response must be
learned and developed. Options 1, 2, and 4 identify nonspecific immunity.

66. Correct Answer: 1

Rationale: The AIDS client with nausea and vomiting should avoid fatty products such as diary products
and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous
foods should be avoided, since they aggravate nausea. Foods are best tolerated either cold or at room
temperature.

67. Correct Answer: 3

Rationale: The initial action would be to maintain a patent airway. The client would then receive
epinephrine. Corticosteroids may also be prescribed. The client will need to be instructed about wearing a
Medic-Alert bracelet, but this is not the initial action.

68. Correct Answer: 1

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Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is a
characteristic sign of SLE. Fever and fatigue may potentially occur before and during exacerbation.
Anemia is most likely to occur in SLE.

69. Correct Answer: 2

Rationale: Abstinence is the safest way to avoid HIV infection. The next most reliable method is
participation in a mutually monogamous relationship. The use of latex condoms is considered safe,
because the latex prevents the transmission of the HIV virus as long as the condom is used properly and
remains in place. The use of "natural skin" condoms is not considered safe because the pores in the
condom are large enough for the virus to pass through.

70. Correct Answer: 2

Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease of
all cell types. This is probably caused by a direct attack of all blood cells or bone marrow by immune
complexes. The other options are incorrect.

71. Correct Answer: 4

Rationale: The client with SLE is at risk for cardiovascular disorders, such as coronary artery disease
and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking
cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and
cholesterol intake.

72. Correct Answer: 4

Rationale: The client with RA typically complains of fatigue, generalized weakness, anorexia, and a
weight loss of 2 or 3 pounds early in the disease.

73. Correct Answer: 1

Rationale: Although the most common adverse reaction to this medication is phlebitis and inflammation
at the intravenous site, reversible nephrotoxicity evidenced by an elevated serum creatinine and blood urea
nitrogen levels can occur in some clients. The nephrotoxicity is due to the deposition of acyclovir in the
renal tubules. The risk of renal injury is increased by dehydration and by the use of other nephrotoxic
medications. The values identified in options 2, 3, and 4 are within normal limits.

74. Correct Answer: 4

Rationale: Systematic lupus erythematosus (SLE) is a chronic inflammatory disease that affects multiple
body systems. A butterfly rash on the cheeks and the bridge of nose is a key sign of SLE. Option 1 is found
in sickle cell anemia. Options 2 and 3 are found in many conditions and are not associated with SLE.

75. Correct Answer: 4

Rationale: Natural resistance, also called innate inherited immunity, is that immunity with which a
person is born. Natural resistance does not require prior exposure to the antigen. Acquired immunity
includes all antigen-specific immunities that a person develops during a lifetime.

76. Correct Answer: 1

Rationale: B lymphocytes have the job of making antibodies and mediating humoral immunity. They do
not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is
phagocytosis.

77. Correct Answer: 4

Rationale: The immune system has five major types of cells: B lymphocytes (B cells), helper T
lymphocytes (CD4 cells), cytolytic T lymphocytes (CD8 cells), macrophages, and dendritic cells.

78. Correct Answer: 1

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Rationale: A common side effect of zidovudine is agranulocytopenia and anemia. The nurse carefully
monitors the complete blood cell count results for these changes. With early infection or in the client who
is asymptomatic, complete blood cell count levels are monitored monthly for 3 months and then every 3
months thereafter. In clients with advanced disease, the complete blood cell count is monitored every 2
weeks for the first 2 months and then once a month if the medication is tolerated well.

79. Correct Answer: 2

Rationale: Abstinence is the safest way to avoid human immunodeficiency virus infection. Another
reliable method is participation in a mutually monogamous relationship. The use of latex condoms is
considered safe because the latex prevents the transmission of the human immunodeficiency virus as long
as the condom is used properly and remains in place. The use of "natural skin" condoms is not considered
safe because the pores in the condom are large enough for the virus to pass through.

80. Correct Answer: 1

Rationale: The client with acquired immunodeficiency syndrome who has nausea and vomiting should
avoid fatty products such as diary products and red meat. Meals should be small and frequent to lessen the
chance of vomiting. The client should avoid spices and odorous foods because they aggravate nausea.
Foods are best tolerated cold or at room temperature.

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