NLE Practice Test

1. The knows that a positive diagnosis for HIV infection is made based on;

A history of high-risk sexual behaviors

Positive ELISA and Western blot tests

Evidence of extreme weight loss and high fever

Identification of an associated opportunistic infection

A positive diagnosis for HIV infection is made based on positive ELISA and Western blot tests. ELISA (enzyme-linked immunosorbent assay) is a screening test that detects antibodies to HIV in the blood. If the ELISA test is positive, it is confirmed with a Western blot test, which is a more specific test that detects specific HIV proteins. The combination of positive results from both tests is conclusive evidence of HIV infection. The other options mentioned, such as high-risk sexual behaviors, extreme weight loss and high fever, and identification of an associated opportunistic infection, may be indicative of HIV infection but are not sufficient for a definitive diagnosis.

Explanation

A positive diagnosis for HIV infection is made based on positive ELISA and Western blot tests. ELISA (enzyme-linked immunosorbent assay) is a screening test that detects antibodies to HIV in the blood. If the ELISA test is positive, it is confirmed with a Western blot test, which is a more specific test that detects specific HIV proteins. The combination of positive results from both tests is conclusive evidence of HIV infection. The other options mentioned, such as high-risk sexual behaviors, extreme weight loss and high fever, and identification of an associated opportunistic infection, may be indicative of HIV infection but are not sufficient for a definitive diagnosis.

2. A client is admitted with cellulites of the left teg a temperature of 103°F. The physician orders IV antibiotics. Before instituting this therapy, the nurse should;

Determine whether the client has allergies

Apply a warm, moist dressing over the area

Measure the amount of swelling in the client's leg

Obtain the results of the culture and sensitivity tests

Before starting IV antibiotics, it is important for the nurse to determine whether the client has any allergies. This is because some antibiotics may cause allergic reactions in certain individuals. By assessing the client's allergies, the nurse can ensure that the prescribed antibiotics are safe for the client to receive. This step is crucial in preventing any potential adverse reactions or complications from the antibiotic therapy.

Explanation

Before starting IV antibiotics, it is important for the nurse to determine whether the client has any allergies. This is because some antibiotics may cause allergic reactions in certain individuals. By assessing the client's allergies, the nurse can ensure that the prescribed antibiotics are safe for the client to receive. This step is crucial in preventing any potential adverse reactions or complications from the antibiotic therapy.

3. A tuberculin skin test with purified protein derivative (PP!) tuberculin is performed as part of a routine physical examination. The nurse should instruct the client to make an appointment so the test can be read in:

3 days

5 days

7 days

10 days

The tuberculin skin test is used to determine if a person has been exposed to tuberculosis. After the test is administered, the nurse needs to wait a specific amount of time before reading the results. This waiting period allows for the development of any redness or swelling at the site of the test, which indicates a positive result. In the case of a tuberculin skin test with purified protein derivative (PPD) tuberculin, the test should be read 48 to 72 hours (3 days) after it is administered. This is the optimal time frame for accurate interpretation of the results.

Explanation

The tuberculin skin test is used to determine if a person has been exposed to tuberculosis. After the test is administered, the nurse needs to wait a specific amount of time before reading the results. This waiting period allows for the development of any redness or swelling at the site of the test, which indicates a positive result. In the case of a tuberculin skin test with purified protein derivative (PPD) tuberculin, the test should be read 48 to 72 hours (3 days) after it is administered. This is the optimal time frame for accurate interpretation of the results.

4. Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:

Obtain vita! signs

Stop the transfusion

Assess the pain further

Increase the flow of normal saline

If a client complains of lumbar pain halfway through the administration of a unit of blood, it is important to stop the transfusion. Lumbar pain could be a sign of a transfusion reaction or an adverse event related to the blood transfusion. Stopping the transfusion allows the nurse to assess the client's condition further and take appropriate actions to address any potential complications.

Explanation

If a client complains of lumbar pain halfway through the administration of a unit of blood, it is important to stop the transfusion. Lumbar pain could be a sign of a transfusion reaction or an adverse event related to the blood transfusion. Stopping the transfusion allows the nurse to assess the client's condition further and take appropriate actions to address any potential complications.

5. When taking the blood pressure of a client who has AIDS the nurse must;

Wear dean gloves

Use barrier techniques

Wear a mask and gown

Wash the hands thoroughly

When taking the blood pressure of a client who has AIDS, it is important for the nurse to wash their hands thoroughly. This is because AIDS is a bloodborne disease, and proper hand hygiene is crucial in preventing the transmission of any infectious agents. Washing hands thoroughly with soap and water helps to remove any potential pathogens that may be present on the nurse's hands, reducing the risk of spreading the infection to themselves or other patients. Wearing gloves, using barrier techniques, and wearing a mask and gown may also be necessary depending on the specific situation, but washing hands is a fundamental practice that should always be followed.

Explanation

When taking the blood pressure of a client who has AIDS, it is important for the nurse to wash their hands thoroughly. This is because AIDS is a bloodborne disease, and proper hand hygiene is crucial in preventing the transmission of any infectious agents. Washing hands thoroughly with soap and water helps to remove any potential pathogens that may be present on the nurse's hands, reducing the risk of spreading the infection to themselves or other patients. Wearing gloves, using barrier techniques, and wearing a mask and gown may also be necessary depending on the specific situation, but washing hands is a fundamental practice that should always be followed.

6. The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;

Begin a program of aggressive, strict mouth care

Avoid traumatic injuries and exposure to any infection

Increase oral fluid intake to a minimum of 3000 ml daily

Report any unusual muscle cramps or tingling sensations in the extremities

The correct answer is to avoid traumatic injuries and exposure to any infection. This is because pancytopenia caused by chemotherapy results in a decrease in all blood cell types, including white blood cells which are responsible for fighting off infections. Therefore, it is important for the client to avoid any situations that may lead to injuries or infections, as their immune system is compromised. This includes taking precautions to prevent falls or accidents, practicing good hygiene, and avoiding contact with sick individuals. By doing so, the client can reduce the risk of developing complications from infections or injuries.

Explanation

The correct answer is to avoid traumatic injuries and exposure to any infection. This is because pancytopenia caused by chemotherapy results in a decrease in all blood cell types, including white blood cells which are responsible for fighting off infections. Therefore, it is important for the client to avoid any situations that may lead to injuries or infections, as their immune system is compromised. This includes taking precautions to prevent falls or accidents, practicing good hygiene, and avoiding contact with sick individuals. By doing so, the client can reduce the risk of developing complications from infections or injuries.

7. An elderly client develops severe bone barrow depression from chemotheraphy for cancer of the prostate. The nurse should;

Monitor for signs of alopecia

Increase dally intake of fluids

Monitor Intake and output of fluids

Use a soft toothbrush for oral hygiene

Chemotherapy can cause severe bone marrow depression, which can lead to a decrease in the production of blood cells. This can result in a weakened immune system and an increased risk of infection. Using a soft toothbrush for oral hygiene is important because it helps prevent injury to the gums and oral tissues, reducing the risk of infection.

Explanation

Chemotherapy can cause severe bone marrow depression, which can lead to a decrease in the production of blood cells. This can result in a weakened immune system and an increased risk of infection. Using a soft toothbrush for oral hygiene is important because it helps prevent injury to the gums and oral tissues, reducing the risk of infection.

8. Following multiple bee stings, a client has an anaphylactic reaction. The nurse is aware that the symptoms the client is experiencing are caused by;

Respiratory depression and cardiac standstill

Bronchial constriction and decreased peripheral resistance

Decreased cardiac out and dilation of major biood vessels

Constriction of capillaries and decreased peripheral circulation

The client is experiencing an anaphylactic reaction, which is a severe allergic reaction. One of the main symptoms of anaphylaxis is bronchial constriction, which causes difficulty in breathing. Additionally, anaphylaxis can also cause decreased peripheral resistance, leading to a drop in blood pressure. These symptoms are consistent with the client's presentation and are caused by bronchial constriction and decreased peripheral resistance.

Explanation

The client is experiencing an anaphylactic reaction, which is a severe allergic reaction. One of the main symptoms of anaphylaxis is bronchial constriction, which causes difficulty in breathing. Additionally, anaphylaxis can also cause decreased peripheral resistance, leading to a drop in blood pressure. These symptoms are consistent with the client's presentation and are caused by bronchial constriction and decreased peripheral resistance.

9. A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask:

"Have you bee sexually active lately?"

"Do you have a sore throat at the present time?"

"Have you been exposed recently to anyone with an infection?"

"When did you first notice that your temperature had gone up?"

The correct answer is "When did you first notice that your temperature had gone up?" This question is the most appropriate because it directly addresses the client's complaint of a low-grade fever. By asking when the client first noticed the increase in temperature, the nurse can gather information about the duration and progression of the fever, which can help in assessing possible causes. The other options are not as relevant to the client's symptoms and may not provide as much useful information in determining the cause of the fever.

Explanation

The correct answer is "When did you first notice that your temperature had gone up?" This question is the most appropriate because it directly addresses the client's complaint of a low-grade fever. By asking when the client first noticed the increase in temperature, the nurse can gather information about the duration and progression of the fever, which can help in assessing possible causes. The other options are not as relevant to the client's symptoms and may not provide as much useful information in determining the cause of the fever.

10. The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;

Has intercourse with just the spouse

Makes a donation of a pint of whole blood

Limits sexual contact to those without HIV antibodies

Uses a'condom each time there is a sexual intercourse

Making a donation of a pint of whole blood does not put an individual at risk for exposure to HIV because blood donation centers follow strict screening procedures to ensure that donated blood is free from HIV and other infectious diseases.

Explanation

Making a donation of a pint of whole blood does not put an individual at risk for exposure to HIV because blood donation centers follow strict screening procedures to ensure that donated blood is free from HIV and other infectious diseases.