Ati nproo 2100 exam unit 3 fundamentals exam
Total Questions : 35
Showing 25 questions, Sign in for moreA nurse is caring for a client who has HIV and a CD4-T-cell count of 150/mm³. Which of the following conditions should the nurse monitor the client for?
Explanation
A. Hepatitis is a concern for individuals with HIV, but it is not specifically indicated by a low CD4-T-cell count.
B. A CD4-T-cell count of 150/mm³ indicates severe immunosuppression, making the client highly susceptible to opportunistic infections like tuberculosis, which is common in individuals with HIV.
C. While gonorrhea is a risk for sexually active individuals, it is not specifically related to the low CD4-T-cell count.
D. Chlamydia is also a sexually transmitted infection, but similar to gonorrhea, it is not directly linked to the immunocompromised state indicated by the CD4-T-cell count.
Which class of antiretroviral drugs targets the stage of the HIV lifecycle by inhibiting RNA from forming DNA?
Explanation
A. Fusion Inhibitors work by preventing the virus from entering the host's cells but do not inhibit RNA from forming DNA.
B. Integrase Inhibitors block the integration of viral DNA into the host's DNA but do not directly inhibit the reverse transcription process.
C. Nucleoside Reverse Transcriptase Inhibitors (NRTIs) inhibit reverse transcriptase, the enzyme responsible for converting viral RNA into DNA, thus directly targeting this crucial stage of the HIV lifecycle.
D. Protease Inhibitors inhibit the protease enzyme involved in the maturation of the virus but do not affect the reverse transcription process.
A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?
Explanation
A. A phlebotomist collecting blood from clients who have HIV is at the greatest risk due to the potential for exposure to infected blood, especially if safety precautions are not properly followed.
B. A nurse working for an insurance company collecting urine samples is at a lower risk, as urine is not a primary mode of HIV transmission.
C. A personal trainer working with a client who has HIV may be at risk if there are open wounds, but the risk is less compared to healthcare workers directly handling blood.
D. An occupational therapist working with a client who has HIV may have some exposure risk, but it is significantly lower than that of a phlebotomist who handles blood samples.
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
Explanation
A. Stridor is a high-pitched sound indicating upper airway obstruction and is a critical sign of anaphylaxis requiring immediate intervention to secure the airway.
B. Hypotension is a serious condition that occurs during anaphylaxis, but the priority is to address the airway obstruction first.
C. Urticaria (hives) is a common symptom of an allergic reaction but is not life-threatening and can be addressed after more severe symptoms.
D. Vomiting may occur during anaphylaxis but is not the most urgent finding when airway compromise is present.
A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication?
Explanation
A. Cortisol levels are not directly affected by furosemide; monitoring for adrenal function is not a priority.
B. Bicarbonate levels are not specifically monitored for clients on furosemide; this medication's main effect does not relate directly to bicarbonate balance.
C. Albumin levels are not primarily affected by furosemide; although low albumin can affect fluid status, it is not the critical monitoring focus.
D. Potassium levels should be monitored because furosemide is a loop diuretic that can lead to hypokalemia, which is a common and significant side effect due to increased renal excretion of potassium.
A nurse is caring for a client who was sexually assaulted. An assessment of the client indicates that they might have been exposed to human immunodeficiency virus (HIV). Which of the following questions is most important to ask the client?
Explanation
A. While knowing the location of the assault may be relevant for police reports, it does not directly pertain to the client’s health and potential exposure to HIV.
B. Permission to contact the police is important for legal reasons, but the priority is to address the client's health needs first.
C. Identifying the individual who assaulted the client is critical for assessing the risk of HIV exposure and determining the need for post-exposure prophylaxis (PEP). This question directly impacts the client’s immediate health care.
D. Understanding the day and time of the assault is useful for legal documentation but is less critical than assessing potential exposure to HIV.
A 65-year-old female presents with confusion, headache, and muscle weakness. Her sodium level is 120 mEq/L. Which of the following interventions is most appropriate based on her condition?
Explanation
A. Administering hypertonic saline (3% NaCl) is appropriate for treating severe hyponatremia, as it helps to raise sodium levels safely. Restricting water intake is also necessary to prevent further dilution of sodium.
B. Fluid restriction with a loop diuretic may not be effective in this scenario and can worsen the hyponatremia by causing further fluid loss without addressing the sodium levels.
C. Isotonic saline is not indicated for correcting severe hyponatremia, and encouraging oral fluid intake could exacerbate the condition.
D. Increasing oral sodium intake is not sufficient for immediate correction of severe hyponatremia and does not address the acute nature of the client’s symptoms.
A nurse is educating a client who has HIV about the infection process. Which of the following features of the virus should the nurse explain can result in opportunistic infection?
Explanation
A. The conversion of RNA into DNA is a critical step in the HIV lifecycle, but it does not directly lead to opportunistic infections; instead, it allows the virus to integrate into the host’s genome.
B. Having reverse transcriptase enzyme is a characteristic of retroviruses like HIV that facilitates replication, but it does not cause opportunistic infections directly.
C. HIV containing a single strand of genetic material is a feature of its classification as a retrovirus but is not related to the risk of opportunistic infections.
D. The ability of HIV to target and destroy CD4 lymphocytes is the key reason for opportunistic infections. CD4 cells are crucial for the immune response, and their depletion leads to immunosuppression, making the client susceptible to infections that would not typically affect an individual with a healthy immune system.
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Explanation
A. Flushing of the skin is not typical in hypovolemic shock; rather, the skin is usually cool and clammy due to vasoconstriction.
B. Oliguria, or decreased urine output, is expected in hypovolemic shock as the kidneys receive less blood flow, leading to reduced urine production.
C. Bradypnea is not a common finding in hypovolemic shock; instead, tachypnea (increased respiratory rate) is typically observed due to compensatory mechanisms for hypoxia and acidosis.
D. Hypertension is not expected in hypovolemic shock; instead, the client typically presents with hypotension due to decreased blood volume and pressure.
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg, and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base balances?
Explanation
A. Respiratory acidosis is characterized by a low pH (7.32) and an elevated PaCO2 (48 mm Hg), indicating that the body is unable to eliminate CO2 effectively, leading to acid retention. The HCO3 level is within normal limits, suggesting that there is not a metabolic compensation occurring yet.
B. Metabolic alkalosis would present with a high pH and elevated bicarbonate levels, which is not the case here.
C. Respiratory alkalosis typically shows a high pH and low PaCO2, indicating hyperventilation, which does not align with the current findings.
D. Metabolic acidosis would show a low pH with a low HCO3, which is not supported by the HCO3 level of 23 mEq/L in this case.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L
Explanation
A. Respiratory acidosis is indicated by the low pH (7.22) and elevated PaCO2 (68 mm Hg), demonstrating that CO2 is retained due to hypoventilation (as seen with a respiratory rate of 7/min). The bicarbonate level is within normal range, suggesting no metabolic compensation is present.
B. Metabolic acidosis would be indicated by a low pH and low bicarbonate level, which is not the case here since the bicarbonate is normal at 26 mEq/L.
C. Metabolic alkalosis would present with a high pH and high HCO3, which does not match these values.
D. Respiratory alkalosis would show a high pH and low PaCO2, which is contrary to the provided ABG results.
A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client's blood pressure has been steadily decreasing over the past 2 hours. Which of the following categories of shock should the nurse recognize is occurring?
Explanation
A. Obstructive shock occurs when blood flow is physically obstructed, such as in cases of pulmonary embolism or cardiac tamponade, which is not indicated here as the cause is blood loss.
B. Septic shock is related to infection and systemic inflammatory response, not directly caused by blood loss.
C. Hypovolemic shock is caused by a significant loss of blood volume, leading to decreased blood pressure, which directly relates to the client losing 800 mL of blood during surgery. This condition results in inadequate perfusion and oxygen delivery to tissues.
D. Neurogenic shock results from spinal cord injuries leading to vasodilation and bradycardia, which is not applicable to this scenario.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
Explanation
A. The CD4-T-cell count of 180 cells/mm3 is a critical measure of immune function in an HIV-positive client, indicating progression of the disease and risk for opportunistic infections. Values below 200 cells/mm3 signify the client has progressed to AIDS.
B. A positive Western blot test confirms the presence of HIV but does not indicate the immediate health risk or necessary interventions.
C. A platelet count of 150,000/mm3 is within the normal range, thus not indicative of any urgent concerns.
D. A WBC count of 5,000/mm3 is also within normal limits and does not highlight an immediate issue that needs addressing compared to the CD4 count.
A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?
Explanation
A. Fluid overload is not an allergic reaction but rather a complication of transfusion related to the volume of fluid administered, thus diphenhydramine would not be appropriate.
B. Urticaria, or hives, is a common mild allergic reaction that can occur during blood transfusions. Administering diphenhydramine can help prevent or treat this response.
C. Hemolysis is a serious reaction involving the destruction of red blood cells, often due to blood type incompatibility; it is not alleviated by antihistamines.
D. Fever can occur during transfusions but is typically due to non-specific immune reactions and does not respond to diphenhydramine.
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
Explanation
A. DIC is characterized by a low platelet count due to the consumption of platelets in the coagulation process, not an elevated count.
B. While heparin may be used in the management of DIC in some cases, it is not a lifelong treatment nor a cure for the condition, as DIC results from an underlying condition rather than being a standalone disease.
C. DIC involves the overactivation of the coagulation cascade, leading to the formation of fibrin clots and subsequent consumption of clotting factors and platelets, thus making this statement accurate.
D. DIC is not a genetic disorder but rather a complication often associated with severe infections, trauma, or other conditions, and it is not primarily due to vitamin K deficiency.
Which stage of the HIV lifecycle involves the virus attaching to the host cell membrane?
Explanation
A. Binding is the initial step where the HIV virus attaches to the CD4 receptor on the host cell's surface. This interaction is crucial for the subsequent entry of the virus into the host cell.
B. Integration occurs later in the lifecycle, after the virus has entered the host cell and its RNA is converted to DNA.
C. Fusion refers to the process where the viral envelope fuses with the host cell membrane to allow entry into the cell, which follows the binding stage.
D. Reverse Transcription is the process of converting viral RNA into DNA after the virus has entered the host cell, and is not involved in the attachment phase.
Which of the following signs is most commonly associated with respiratory alkalosis?
Explanation
A. Muscle weakness and confusion are more commonly associated with metabolic or mixed acid-base disturbances rather than respiratory alkalosis specifically.
B. Decreased deep tendon reflexes and hypotension are not typical signs of respiratory alkalosis, which usually involves changes in breathing patterns.
C. Bradycardia and decreased respiratory rate are more likely associated with respiratory acidosis or other conditions, not with respiratory alkalosis.
D. Rapid, shallow breathing, often due to anxiety or panic attacks, is characteristic of respiratory alkalosis. Patients may also report feelings of panic due to the hyperventilation that leads to this condition.
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?
Explanation
A. Abuse refers to the mistreatment of a patient, which does not apply to this scenario as the issue was an error rather than intentional harm.
B. Battery involves intentional and wrongful physical contact with another person; while the wrong medication is harmful, it was not an intentional act of violence.
C. Malpractice is the correct choice because it involves negligence in the professional duties of a healthcare provider, resulting in harm to a patient. The nurse failed to adhere to the standard of care by administering the incorrect medication.
D. Assault refers to the threat of harm or the act of creating fear of harm in another person, which is not applicable in this scenario since the nurse did not threaten the client.
A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?
Explanation
A. Gingivitis is a form of gum disease that can occur in anyone, but it is not specifically related to low CD4-T-cell counts associated with AIDS.
B. Candidiasis, also known as oral thrush, is a fungal infection caused by Candida species. Clients with a significantly decreased CD4-T-cell count are at high risk for opportunistic infections, including candidiasis, due to their compromised immune systems.
C. Xerostomia refers to dry mouth, which can occur for various reasons but is not specifically an infectious condition linked to low CD4 counts.
D. Halitosis, or bad breath, can result from several factors, including poor oral hygiene or underlying health issues, but is not specifically linked to the immune status of a client with AIDS.
A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?
Explanation
A. Oliguria, or decreased urine output, is a common finding in hypovolemia due to reduced renal perfusion and decreased blood flow to the kidneys.
B. Hypertension is unlikely in hypovolemia; instead, clients typically exhibit hypotension due to decreased circulating blood volume.
C. Bradycardia is not a typical finding in hypovolemia; instead, tachycardia is more commonly observed as the body compensates for reduced blood volume.
D. Peripheral edema is associated with fluid overload rather than hypovolemia, as a decrease in blood volume usually leads to less fluid accumulation in the tissues.
A nurse is providing care for a client experiencing obstructive shock. Which of the following diagnoses should the nurse expect?
Explanation
A. Cardiac tamponade is a condition where fluid accumulates in the pericardial space, exerting pressure on the heart and impeding its ability to pump effectively, leading to obstructive shock.
B. Third spacing refers to fluid accumulation in the interstitial spaces but is not a specific diagnosis of obstructive shock.
C. A ruptured aneurysm may lead to hypovolemic shock due to blood loss rather than obstructive shock, which is characterized by physical obstruction to blood flow.
D. Cardiomyopathy is a disease of the heart muscle that affects its ability to pump blood, leading to cardiogenic shock, not obstructive shock.
In which stage of the HIV lifecycle does the enzyme integrase play a crucial role, and what is its function in that stage?
Explanation
A. In the assembly stage, other proteins and enzymes are involved in the packaging of viral components into new virions, not integrase.
B. During the integration stage, integrase is essential as it inserts the newly formed viral DNA into the host's genome, enabling the virus to utilize the host's cellular machinery for replication.
C. Integrase does not participate in the entry stage; this stage is facilitated by other proteins that aid in the fusion of the virus with the host cell membrane.
D. Integrase is not involved in reverse transcription; that process is facilitated by the enzyme reverse transcriptase, which converts viral RNA into DNA.
A patient's ABG shows: pH 7.32. PaCO2 50 mmHg. HCO3 24 mEq/L. What is the correct diagnosis?
Explanation
A. Metabolic acidosis would be indicated by a low pH and a low HCO3, which is not present in this case since HCO3 is normal.
B. The pH of 7.32 indicates acidemia, and a PaCO2 of 50 mmHg suggests respiratory acidosis as the body is retaining carbon dioxide, contributing to the low pH. The HCO3 is normal, indicating that there is no metabolic compensation occurring.
C. Respiratory alkalosis would show a high pH and low PaCO2, which is not the case here.
D. Metabolic alkalosis would present with a high pH and elevated HCO3, which is also not present in these ABG results.
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
Explanation
A. Respiratory alkalosis is characterized by a high pH and low PaCO2, which is not evident in this scenario where the pH is low and PaCO2 is elevated.
B. The low pH of 7.3 indicates acidemia, and the elevated PaCO2 of 50 mm Hg suggests respiratory acidosis, where the body is retaining carbon dioxide, leading to an increase in acidity.
C. Metabolic acidosis would present with a low pH and a normal or decreased PaCO2, which is not the case here since the PaCO2 is elevated.
D. Metabolic alkalosis would show a high pH and elevated HCO3 levels, which is not consistent with the given ABG results.
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?
Explanation
A. Furosemide is a diuretic and is not indicated in the acute management of anaphylaxis.
B. Methylprednisolone is a corticosteroid that may be used later to reduce inflammation but is not the first-line treatment in anaphylaxis.
C. Dobutamine is a medication used to treat heart failure and shock but does not address the acute allergic reaction.
D. Epinephrine is the first-line treatment for anaphylactic shock, as it acts quickly to reverse severe allergic reactions by causing vasoconstriction, bronchodilation, and inhibiting further release of mediators from mast cells.
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