NCLEX Review about Immune System

Disorders

weeks to be tested because testing before

this time is not reliable

1. An older adult with no known cognitive

impairment residing in a long-term care
facility suddenly becomes disoriented and
confused. There are no signs of extremity
weakness or other neurological changes.
Based on these observations, the nurse
would focus the assessment in which
priority body systems?
a) pulmonary and renal systems
b) reproductive and endocrine system
c) integumentary and neurological systems
d) cardiovascular and gastrointestinal
systems

2) D - A blood test is available to detect

Lyme disease; however, the test is not
reliable if performed before 4 to 6 weeks
following the tick bite. Antibody formation
takes place in the following manner.
Immunoglobulin M is detected 3 to 4 weeks
after Lyme disease onset, peaks at 6 to 8
weeks, and then gradually disappears;
immunoglobulin G is detected 2 to 3 months
after infection and may remain elevated for
years. Options A, B, and C are incorrect.

1) A - Changes in mental status and

confusion are commonly associated with
infections in the older adult. Assessments of
the pulmonary and renal systems would be
the priority. The older adult is at risk for
pneumonia. The lungs should be auscultated
for decreased breath sounds and other
adventitious sounds. Urinary tract infections
are also common in older adults, especially
women. Flank pain with frequency and
urgency are symptoms. The urine should be
monitored for cloudiness, odor, and other
changes indicating hematuria. Based on the
data in the question, the body systems
identified in options B, C, and D are not the
priority.
2. A female client arrives at the health care
clinic and tells the nurse that she was just
bitten by a tick and would like to be tested
for Lyme disease. The client tells the nurse
that she removed the tick and flushed it
down the toilet. Which of the following
nursing actions is most appropriate?
a) refer the client for blood test immediately
b) inform the client that there is no test
available for Lyme disease
c) tell the client that testing is not necessary
unless arthralgia develops
d) instruct the client to return in 4 to 6

3. Following diagnosis of stage I Lyme

disease, the nurse would anticipate that
which of the following will be part of the
treatment plan for the client?
a) no treatment unless symptoms develop
b) a 3-week course of oral antibiotic
therapy
c) daily oatmeal baths for 2 weeks
d) treatment with intravenously administered
antibiotics
3) B - Prevention, public education, and
early diagnosis are vital to the control and
treatment of Lyme disease. A 3-week course
of oral antibiotic therapy is recommended
during stage I. Later stages of Lyme disease
may require therapy with intravenously
administered antibiotics, such as penicillin
G. Options A and C are incorrect.
4. A Cub Scout leader, who is a nurse
preparing a group of Cub Scouts for an
overnight camping trip, instructs the scouts
about the methods to prevent Lyme disease.
Which statement by one of the Cub Scouts
indicates a need for further instructions?
a) I need to bring a hat to wear during the
trip
b) I should wear long-sleeved tops and long
pants
c) I should not use insect repellents
because it will attract the ticks

d) I need to wear closed shoes and socks that

can be pulled up over my pants
4) C - In the prevention of Lyme disease,
individuals need to be instructed to use an
insect repellent on the skin and clothes when
in an area where ticks are likely to be found.
Long-sleeved tops and long pants, closed
shoes, and a hat or cap should be worn. If
possible, heavily wooded areas or areas with
thick underbrush should be avoided. Socks
can be pulled up and over the pant legs to
the prevent ticks from entering under
clothing.
5. The client with acquired
immunodeficiency syndrome is diagnosed
with cutaneous Kaposi's sarcoma. Based on
this diagnosis, the nurse understands that
this has been confirmed by which of the
following?
a) swelling in the genital area
b) swelling in the lower extremities
c) punch biopsy of the cutaneous lesions
d) appearance of reddish-blue lesions noted
on the skin
5) C - Kaposis 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 and then to the face and oral
mucosa. They can move to the lymphatic
system, lungs, and gastrointestinal 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 gastrointestinal lesions.
6. Which of the following individuals is
least likely at risk for the development of
Kaposi's sarcoma?
a) A kidney transplant client
b) a male with a history of same-gender
partners
c) a client receiving anti-neoplastic
medications

d) an individual working in an
environment in which he or she is exposed
to asbestos
6) D - Kaposis sarcoma is a vascular
malignancy that presents as a skin disorder
and is a common acquired
immunodeficiency syndrome indicator.
Malignancy is seen most frequently in men
with a history of same-gender partners.
Although the cause of Kaposis sarcoma is
not known, it is considered to be caused by
an alteration or failure in the immune
system. The renal transplantation client and
the client receiving antineoplastic
medications are at risk for
immunosuppression. Exposure to asbestos is
not related to the development of Kaposis
sarcoma.
7. The nurse prepares to give a bath and
change the bed linens on a client with
cutaneous Kaposi's sarcoma lesions. The
lesions are open and draining a scant amount
of serous fluid. Which of the following
would the nurse incorporate into the plan
during the bathing of this client?
a) wearing gloves
b) wearing a gown and gloves
c) wearing a gown, gloves, and a mask
d) wear a gown and gloves to change the
bed linens and gloves only for the bath
7) B - Gowns and gloves are required if the
nurse anticipates contact with soiled items
such as those with wound drainage or is
caring for a client who is incontinent with
diarrhea or a client who has an ileostomy or
colostomy. Masks are not required unless
droplet or airborne precautions are
necessary. Regardless of the amount of
wound drainage, a gown and gloves must be
worn.
8. A client is suspected of having systemic
lupus erythematosus. The nurse monitors the
client, knowing that which of the following
is one of the initial characteristic signs of
systemic lupus erythematosus?
a) weight gain

b) subnormal temperature
c) elevated red blood cell count
d) rash on the face across the bridge of
the nose and on the cheeks
8) D
- Skin lesions or rash on the face across the
bridge of the nose and on the cheeks is an
initial characteristic sign of systemic lupus
erythematosus (SLE). Fever and weight loss
may also occur. Anemia is most likely to
occur later in SLE.
9. The nurse provides home care instructions
to a client with systemic lupus
erythematosus and tells the client about
methods to manage fatigue. Which
statement by the client indicates a need for
further instructions?
a) I should take hot baths because they
are relaxing
b) I should sit whenever possible to
conserve my energy
c) I should avoid long periods of rest
because it causes joint stiffness
d) I should do some exercises, such as
walking, when I am not fatigued
9) A - To help reduce fatigue in the client
with systemic lupus erythematosus, the
nurse should instruct the client to sit
whenever possible, avoid hot baths (because
they exacerbate fatigue), schedule moderate
low-impact exercises when not fatigued, and
maintain a balanced diet. The client is
instructed to avoid long periods of rest
because it promotes joint stiffness.
10. The client with acquired
immunodeficiency syndrome has raised,
dark purplish-colored lesions on the trunk of
the body. The nurse anticipates that which of
the following procedures will be done to
confirm whether these lesions are caused by
Kaposi's sarcoma?
a) skin biopsy
b) lung biopsy
c) western blot
d) enzyme-linked immunosorbent assay
10) A - The skin biopsy is the procedure of

choice to diagnose Kaposis sarcoma, which

frequently complicates the clinical picture of
the client with acquired immunodeficiency
syndrome. Lung biopsy would confirm
Pneumocystis jiroveci infection. The
enzyme-linked immunosorbent assay and
Western blot are tests to diagnose human
immunodeficiency virus status.
11. The client with acquired
immunodeficiency syndrome has a
respiratory infection from Pneumocystis
jiroveci and a nursing diagnosis of Impaired
Gas Exchange written in the plan of care.
Which of the following indicates that the
expected outcome of care has nor yet been
achieved?
a) client limits fluid intake
b) client has clear breath sounds
c) client expectorates secretions easily
d) client is free of complaints of shortness of
breath
11) A - 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 client stating that
breathing is easier and is coughing 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.
12. A client with pemphigus is being seen in
the clinic regularly. The nurse plans care
based on which of the following descriptions
of this condition?
a) the presence of tiny red vesicles
b) an autoimmune disease that causes
blistering in the epidermis
c) the presence of skin vesicles found along
the nerve caused by a virus
d) the presence of red, raised papules and
large plaques covered by silvery scales
12) B
- Pemphigus is an autoimmune disease that
causes blistering in the epidermis. The client
has large flaccid blisters (bullae). Because

the blisters are in the epidermis, they have a

thin 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 A describes eczema, option C
describes herpes zoster, and option D
describes psoriasis.
13. The nurse is providing dietary
instructions to the client with systemic lupus
erythematosus. Which of the following
dietary items would the nurse instruct the
client to avoid?
a) steak
b) turkey
c) broccoli
d) cantaloupe
13) A - The client with systemic lupus
erythematosus (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.
14. A client calls the nurse in the emergency
room and tells the nurse that he was just
stung by a bee while gardening. The client is
afraid of a severe reaction because the
client's neighbor experienced such a reaction
just 1 week ago. The appropriate nursing
action is to:
a) advise the client to soak the site in
hydrogen peroxide
b) ask the client if ever sustained a bee
sting in the past
c) tell the client to call an ambulance for
transport to the emergency room
d) tell the client no to worry about the sting
unless difficulty with breathing occurs
14) B - In some types of allergies, a reaction
occurs only on second and subsequent
contacts with the allergen. The appropriate
action, therefore, would be to ask the client
if he ever received a bee sting in the past.

Option A is not appropriate advice. Option C

is unnecessary. The client should not be told
not to worry.
15. The nurse is assisting in administering
immunizations at a health care clinic. The
nurse understands that an immunization will
provide:
a) protection from all disease
b) innate immunity from disease
c) natural immunity from disease
d) acquired immunity from disease
15) D - Acquired immunity can occur by
receiving an immunization that causes
antibodies to a specific pathogen to form.
Natural (innate) immunity is present at birth.
No immunization protects the client from all
diseases.
16. The nurse is assigned to care for a client
with systemic lupus erythematosus. The
nurse plans care, knowing that this disorder
is a(n):
a) local rash that occurs as a result of allergy
b) disease caused by overexposure to
sunlight
c) inflammatory disease of collagen
contained in connective tissue
d) disease caused by the continuous release
of histamine in the body
16) C - Systemic lupus erythematosus is an
inflammatory disease of collagen in
connective tissue. Options A, B, and D are
not associated with this disease.
17. The nurse is assigned to care for a client
admitted to the hospital with a diagnosis of
systemic lupus erythematosus. The nurse
reviews the physician's orders, expecting to
note that which type of medication is
prescribed?
a) antibiotic
b) antidiarrheal
c) corticosteroid
d) opioid analgesic
17) C - Treatment of systemic lupus
erythematosus is based on the systems
involved and symptoms. Treatment normally

consists of anti-inflammatory drugs,

corticosteroids, and immunosuppressants.
Options A, B, and D are not standard
components of medication therapy.
18. The community health nurse is
conducting a research study and is
identifying clients in the community at risk
for latex allergy. Which client population is
at most risk for developing this type of
allergy?
a) hairdressers
b) the homeless
c) children in day care centers
d) individuals living in a group home
18) A - Individuals at risk for developing a
latex allergy include health care workers,
individuals who work in the rubber industry
or those who have had multiple surgeries,
have spina bifida, wear gloves frequently,
such as food handlers, hairdressers, and auto
mechanics, or are allergic to kiwis, bananas,
pineapples, tropical fruits, grapes, avocados,
potatoes, hazelnuts, and water chestnuts.
19. The home care nurse is performing an
assessment on a client who has been
diagnosed with an allergy to latex. In
determining the client's risk factors
associated with the allergy, the nurse
questions the client about an allergy to
which food item?
a) eggs
b) milk
c) yogurt
d) bananas
19) D - Individuals who are allergic to
kiwis, bananas, pineapples, tropical fruits,
grapes, avocados, potatoes, hazelnuts, and
water chestnuts are at risk for developing a
latex allergy. This is thought to be to the
result of a possible cross-reaction between
the food and the latex allergen. Options A,
B, and C are unrelated to latex allergy.
20. The home care nurse is assigned to visit
a client who has returned home from the
emergency room following treatment for a
sprained ankle. The nurse notes that the

client as sent home with crutches that have

rubber axillary pads and needs instructions
regarding crutch walking. On admission
assessment, the nurse discovers that the
client has an allergy to latex. Before
providing instructions regarding crutch
walking, the nurse should:
a) contact the physician
b) cover the crutch pads with cloth
c) call the local medical supply store and ask
for a cane to be delivered
d) tell the client that the crutches must be
removed from the house immediately
20) B - The rubber pads used on crutches
may contain latex. If the client requires the
use of crutches, the nurse can cover the pads
with a cloth to prevent cutaneous contact.
Option 4 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 clients injury. No reason exists to
contact the physician at this time.
21. The home care nurse is ordering dressing
supplies for a client who has an allergy to
latex. The nurse asks the medical supply
personnel to deliver which of the following?
a) elastic bandages
b) adhesive bandages
c) brown ace bandages
d) cotton pads and silk tape
21) D - Cotton pads and plastic or silk tape
are latex-free products. The items identified
in options A, B, and C are products that
contain latex.
22. The camp nurse prepares to instruct a
group of children about Lyme disease.
Which of the following information would
the nurse include in the instructions?
a) Lyme disease is caused by tick carried
by deer
b) Lyme disease is caused by contamination
from cat feces
c) Lyme disease can be contagious through
skin contact with an infected individual

d) Lyme disease can be caused by the

inhalation of spores from bird droppings
22) A - Lyme disease is a multisystem
infection that results from a bite by a tick
carried by several species of deer. Persons
bitten by the Ixodesscapularis or I. pacificus
tick can become infected with the spirochete
Borrelia burgdorferi. Lyme disease cannot
be transmitted from one person to another.
Histoplasmosis is caused by the inhalation
of spores from bat or bird droppings.
Toxoplasmosis is caused by the ingestion of
cysts from contaminated cat feces.
23. The client is diagnosed with stage I
Lyme disease. The nurse assesses the client
for which characteristic of this stage?
a) arthralgias
b) flu-like symptoms
c) enlarged and inflamed joints
d) signs of neurological disorders
23) B - The hallmark of stage I Lyme
disease is the development of a rash within 2
to 30 days of infection, generally at the site
of the tick bite. The rash develops into a
concentric ring, giving it a bulls-eye
appearance. The lesion enlarges up to 50 to
60 cm, and smaller lesions develop farther
away from the original tick bite. In stage I,
most infected persons develop flu-like
symptoms that last 7 to 10 days; these
symptoms may reoccur later. Neurological
deficits occur in stage II. Arthralgias and
joint enlargements are most likely to occur
in stage III.
24. Select the interventions that would apply
in the care of a client at high risk for an
allergic response to a latex allergy. Select all
that apply
a) use non-latex gloves
b) use medications from glass ampules
c) place the client in a private room only
d) do not puncture rubber stoppers with
needles
e) keep a latex-safe supply cart available
in the client's area
f) use a blood pressure cuff from an

electronic device only to measure the blood

pressure
24) A, B, D, E - If a client is allergic to latex
and is at high risk for an allergic response,
the nurse would use nonlatex gloves and
latex-safe supplies, and would keep a latexsafe supply cart available in the clients area.
Any supplies or materials that contain latex
would be avoided. These include blood
pressure cuffs, medications with a rubber
stopper that requires puncture with a needle,
latex-safe syringes, and latex-safe
intravenous tubing. It is not necessary to
place the client in a private room.
25. Amikacin (Amikin) is prescribed for a
client with a bacterial infection. The nurse
instructs the client to contact the physician
immediately if which of the following
occurs?
a) nausea
b) lethargy
c) hearing loss
d) muscle aches
25) C - Amikacin (Amikin) is an
aminoglycoside. Adverse effects of
aminoglycosides include ototoxicity
(hearing problems) confusion,
disorientation, gastrointestinal irritation,
palpitations, blood pressure changes,
nephrotoxicity, and hypersensitivity. The
nurse instructs the client to report hearing
loss to the physician immediately. Lethargy
and muscle aches are not associated with the
use of this medication. It is not necessary to
contact the physician immediately if nausea
occurs. If nausea persists or results in
vomiting, the physician should be notified.
26. The client who is human
immunodeficiency virus seropositive has
been taking zalcitabine (ddC, Hivid) as a
component of treatment. The nurse plans to
monitor which of the following most closely
while the client is taking this medication?
a) platelet count
b) glucose level
c) red blood cell count

d) liver function studies

26) D - Zalcitabine (ddC, Hivid) is an
antiretroviral (nucleoside reverse
transcriptase inhibitor) used to manage
human immunodeficiency virus infection in
combination with other antiretrovirals.
Zalcitabine also has been used as a single
agent in clients who are intolerant of other
regimens. Zalcitabine can cause serious liver
damage, and liver function studies should be
monitored closely. Options A, B, and C are
not associated specifically with the use of
this medication.
27. The nurse is assigned to care for a client
with cytomegalovirus retinitis and acquired
immunodeficiency syndrome who is
receiving foscarnet (Foscavir), an antiviral.
The nurse checks the latest results of which
of the following laboratory studies while the
client is taking this medication?
a) CD4 cell count
b) serum albumin level
c) serum creatinine level
d) lymphocyte count
27) C - Foscarnet (Foscavir) is toxic to the
kidneys. The serum creatinine level is
monitored before therapy, two or three times
per week during induction therapy, and at
least weekly during maintenance therapy.
Foscarnet also may cause decreased levels
of calcium, magnesium, phosphorus, and
potassium. Thus, these levels also are
measured with the same frequency.
28. The client with acquired
immunodeficiency syndrome and
Pneumocystis jiroveci infection has been
receiving pentamidine (Pentam 300). The
client develops a temperature of 101F. The
nurse does further monitoring of the client,
knowing that his sign would most likely
indicate that the:
a) dose of the medication is too low
b) client is experiencing toxic effects of the
medication
c) client has developed inadequacy of
thermoregulation

d) result of another infection caused by

leukopenic effects of the medication
28) D - Frequent side effects of this
medication include leukopenia,
thrombocytopenia, and anemia. The client
should be monitored routinely for signs and
symptoms of infection. Options 1, 2, and 3
are inaccurate interpretations.
29. Saquinavir (Invirase) is prescribed for
the client who is seropositive for human
immunodeficiency virus. The nurse
reinforces medication instructions and tells
the client to:
a) avoid sun exposure
b) eat low-calorie foods
c) eat foods that are low in fat
d) take the medication on an empty stomach
29) A - Saquinavir is an antiretroviral
(protease inhibitor) used with other
antiretroviral medications to manage human
immunodeficiency virus infection.
Saquinavir is administered with meals and is
best absorbed if the client consumes highcalorie, high-fat meals. Saquinavir can cause
photosensitivity, and the nurse should
instruct the client to avoid sun exposure.
30. The client who is human
immunodeficiency virus seropositive has
been taking Stavudine (d4t, Zerit). The nurse
monitors which of the following most
closely while the client is taking this
medication?
a) gait
b) appetite
c) level of consciousness
d) gastrointestinal function
30) A - Stavudine (d4t, Zerit) is an
antiretroviral used to manage human
immunodeficiency virus infection in clients
who do not respond to or who cannot
tolerate conventional therapy. The
medication can cause peripheral neuropathy,
and the nurse should monitor the clients
gait closely and ask the client about
paresthesia.

31. The client with acquired

immunodeficiency syndrome has begun
therapy with zidovudine (Retrovir,
azidothymidine, AZT, ZDV). The nurse
carefully monitors which of the following
laboratory results during treatment with this
medication?
a) blood culture
b) blood glucose level
c) blood urea nitrogen level
d) complete blood count
31) D - Common side effects of this
medication therapy are leukopenia and
anemia. The nurse monitors the complete
blood count results for these changes.
Options A, B, and C are unrelated to the use
of this medication.
32. The nurse is reviewing the results of
serum laboratory studies drawn on a client
with acquired immunodeficiency syndrome
who is receiving didanosine (Videx). The
nurse interprets that he client may have the
medication discontinued by the physician if
which of the following significantly elevated
results is noted?
a) serum protein level
b) blood glucose level
c) serum amylase level
d) serum creatinine level
32) C - Didanosine (Videx) can cause
pancreatitis. A serum amylase level that is
increased to 1.5 to 2 times normal may
signify pancreatitis in the client with
acquired immunodeficiency syndrome and is
potentially fatal. The medication may have
to be discontinued. The medication is also
hepatotoxic and can result in liver failure.
33. The nurse is caring for a post-renal
transplantation client taking cyclosporin
(Sandimmune, Gengraf, Neoral). Th nurse
notes an increase in one of he client's vital
signs and the client is complaining of a
headache. What is the vital sign that is most
likely increased?
a) pulse
b) respiration

c) blood pressure
d) pulse oximetry
33) C - Hypertension can occur in a client
taking cyclosporine (Sandimmune, Gengraf,
Neoral) and, because this client is also
complaining of a headache, the blood
pressure is the vital sign to be monitoring
most closely. Other adverse effects include
infection, nephrotoxicity, and hirsutism.
Options A, B, and D are unrelated to the use
of this medication.
34. Ketoconazole (Nizoral) is prescribed for
a client with a diagnosis of candidiasis.
Select the interventions that the nurse
includes when administering this
medication. Select all that apply
a) restrict fluid intake
b) instruct the client to avoid alcohol
c) monitor liver function studies
d) administer the medication with a antacid
e) instruct the client to avoid exposure to
the sun
f) administer the medication on an empty
stomach
34) B, C, E - Ketoconazole (Nizoral) is an
antifungal medication. It is administered
with food (not on an empty stomach) and
antacids are avoided for 2 hours after taking
the medication to ensure absorption. The
medication is hepatotoxic and the nurse
monitors liver function studies. The client is
instructed to avoid exposure to the sun
because the medication increases
photosensitivity. The client is also instructed
to avoid alcohol. There is no reason for the
client to restrict fluid intake. In fact, this
could be harmful to the client.
35. The nurse has an order to begin
administering foscarnet (Foscavir) to the
client with cytomegalovirus retinitis and
acquired immunodeficiency syndrome
(AIDS). The nurse assesses the latest results
of which laboratory study prior to
administering the dose?
a) serum albumin level
b) serum creatinine level

c) CD4 count
d) lymphocyte count
35) B - Foscarnet (Foscavir) is very toxic to
the kidneys. The serum creatinine level is
monitored prior to therapy, two or three
times weekly 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.
36. A home care nurse provides instructions
to a client with systemic lupus
erythematosus (SLE) about measures to
manage fatigue. Which statement by the
client indicates the need for further
instruction?
a) I need to avoid long periods of rest
b) I need to sit whenever possible
c) I should take a hot bath every evening
d) I should engage in moderate low-impact
exercise when I am not tired
36) C - 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 not
to rest for long periods because it promotes
joint stiffness.
37. A nurse is reviewing the results of serum
laboratory studies for a client with acquired
immunodeficiency syndrome (AIDS) who is
receiving didanosine (Videx). The nurse
interprets that the client may have the
medication discontinued by the physician if
which of the following laboratory test results
is significantly elevated?
a) serum cholesterol level
b) serum amylase level
c) blood glucose concentration
d) serum protein concentration
37) B - A serum amylase level that is
increased 1.5 to 2 times normal may signify

pancreatitis from the medication, which can

be potentially fatal. The medication may
have to be discontinued. The medication
also is hepatotoxic, which can result in liver
failure. Options A, C, and D are not
associated with this medication.
38. A client with acquired
immunodeficiency syndrome (AIDS) who is
taking zidovudine (Retrovir) 200 mg orally
three times daily has severe neutropenia
noted on the follow-up laboratory studies.
The nurse interprets that which of the
following is likely to occur at this point?
a) prednisone (Deltasone) probably will be
added to the medication regimen
b) epoetin (Epogen) probably will be
added to the medication regimen
c) the medication dose probably will be
reduced
d) the medication probably will be
discontinued until laboratory results
indicated bone marrow recovery
38) B - Hematological monitoring should be
done every 2 weeks in the client taking
zidovudine. If severe anemia or severe
neutropenia develops, treatment should be
discontinued until evidence of bone marrow
recovery is noted. If anemia or neutropenia
is mild, a reduction in dosage may be
sufficient. The administration of prednisone
may further alter the immune function.
Epoetin alfa is administered to clients
experiencing anemia.
39. A client with human immunodeficiency
virus (HIV) infection is taking indinavir
(Crixivan). The nurse plans to tell the client
which of the following when providing
instructions about the use of this
medication?
a) take the medication with water on an
empty stomach
b) take the medication with a high-fat snack
c) take the medication with the large meal of
the day
d) store the medication in the refrigerator
39) A - 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.
40. A client is receiving acyclovir (Zovirax)
by the intravenous (IV) route for treatment
of cytomegalovirus (CMV) infection. After
reconstituting the powder dispensed by the
pharmacy, the nurse administers this
medication by:
a) continuous IV infusion over 12 hours
b) continuous IV infusion over 24 hours
c) rapid IV bolus over 5 minutes
d) slow IV infusion over 1 hour
40) D - Acyclovir is dispensed as a powder
to be reconstituted for IV administration and
is administered 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 the infusion.
41. A nurse is monitoring a client with
herpes simplex virus who is receiving
intravenous (IV) acyclovir (Zovorax).
Which of the following laboratory results
would be of concern as a possible adverse
effect of this medication?
a) blood urea nitrogen (BUN) of 36 mg/dL
b) platelet count of 300,000 cells/mm3
c) white blood cell count of 6000 cells/mm3
d) red blood cell count of 5.2 million
cells/mm3
41) A - Although the most common adverse
reactions with this medication are phlebitis
and inflammation at the IV site, reversible
nephrotoxicity evidenced by an elevated
serum creatinine and BUN levels can occur
in some clients. The cause of nephrotoxicity

is 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 B, C, and D are within
normal limits.
42. A client with acquired
immunodeficiency syndrome (AIDS) is
receiving ganciclovor (Cytovene). The nurse
takes which priority nursing action in caring
for this client?
a) ensuring that the client uses an electric
razor for shaving
b) administering the medication with an
antacid
c) monitoring for signs of hyperglycemia
d) administering the medication without
food
42) A - Because ganciclovir causes
neutropenia and thrombocytopenia as the
most frequent side effects, the nurse
monitors for signs and symptoms of
bleeding and implements the same
precautions as for a client receiving
anticoagulant therapy. The medication does
not have to be taken on an empty stomach or
without food and should not be taken with
an antacid. The medication may cause
hypoglycemia, but not hyperglycemia.
43. A client with acquired
immunodeficiency syndrome (AIDS) has
been started on therapy with zidovudine also
called azidothymidine (AZT)(Retrovir). The
nurse monitors the results of which
laboratory blood study for adverse effects of
therapy?
a) complete blood count (CBC)
b) blood urea nitrogen (BUN) level
c) creatinine level
d) potassium concentration
43) A - Common adverse effects of this
medication are agranulocytopenia and
anemia. The nurse monitors the CBC results
for these changes. BUN, creatinine, and
potassium are unrelated to this medication.

44. A client with acquired

immunodeficiency syndrome (AIDS) is
receiving didanosine (Videx). The nurse
reviewing the client's laboratory results
should most closely monitor serum levels of:
a) cholesterol
b) amylase
c) glucose
d) protein
44) B - This medication is toxic to both the
pancreas and the liver. A serum amylase
level that is increased 1.5 to 2 times normal
may signify pancreatitis and may be
potentially fatal in the client with AIDS.
Therefore, the nurse monitors the results of
amylase and liver function studies closely.
Options A, C, and D are unrelated to this
medication.
45. A client is receiving zalcitabine (Hivid).
The nurse plans to monitor the results of
which study to determine the effectiveness
of this medication?
a) enzyme-linked immunosorbent assay
(ELISA)
b) western blot
c) CD4+ cell count
d) complete blood cell (CBC) count with
differential
45) C - Zalcitabine slows the progression of
acquired immunodeficiency syndrome
(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
the Western blot are performed to diagnose
AIDS initially.
46. A client with acquired
immunodeficiency syndrome (AIDS) has a
nursing diagnosis of Imbalanced nutrition:
less than body requirements. The nurse
plans which of the following goals with this
client?
a) consume foods and beverages that are
high in glucose

b) plan large menus and cook meals in

advance
c) eat low-calorie snacks between meals
d) eat small, frequent meals throughout
the day
46) D - The client should eat small, frequent
meals throughout the day. The client also
should take in nutrient-dense and highcalorie meals and snacks rather than those
that are high in glucose only. The client is
encouraged to eat favorite foods to keep
intake up and plan meals that are easy to
prepare. The client can also avoid taking
fluids with meals to increase food intake
before satiety sets in.
47. A client with acquired
immunodeficiency syndrome (AIDS) is
experiencing shortness of breath related to
Pneumocystis jiroveci pneumonia. Which
measure should the nurse include in the plan
of care to assist the client in performing
activities of daily living?
a) provide supportive care with hygiene
needs
b) provide meals and snacks with highprotein, high calorie, and high-nutritional
value
c) provide small, frequent meals
d) offer low microbial foods
47) A - Providing supportive care with
hygiene needs as needed reduces the client's
physical and emotional energy demands and
conserves energy resources for other
functions such as breathing. Options B, C,
and D are important interventions for the
client with AIDS but do not address the
subject of activities of daily living. Option B
will assist the client in maintaining
appropriate weight and proper nutrition.
Option C will assist the client in tolerating
meals better. Option D will decrease the
client's risk of infection.
48. A client who was tested for human
immunodeficiency virus (HIV) after a recent
exposure had a negative result. During the

post-test counseling session, the nurse tells

the client which of the following?
a) the test should be repeated in 6 months
b) this ensures that the client is not infected
with the HIV virus
c) the client no longer needs to protect
himself from sexual partners
d) the client probably has immunity to the
acquired immunodeficiency virus
48) A - A negative test result indicates that
no HIV antibodies were detected in the
blood sample. A repeated test in 6 months is
recommended because false-negative test
results have occurred early in the infection.
Options B, C, and D are incorrect.
49. A client is diagnosed with late stage
human immunodeficiency virus (HIV), and
the client and family are extremely upset
about the diagnosis. The priority
psychosocial nursing intervention for the
client and family is to:
a) tell the client and family to stop smoking
because it will predispose the client to
respiratory infections
b) tell the client and family that raw or
improperly washed foods can produce
microbes
c) encourage the client and family to
discuss their feelings about the disease
d) advise the client to avoid becoming
pregnant because of the risk of transmission

of the infection
49) C - The priority psychosocial nursing
intervention for the client and family is to
encourage the client and family to discuss
their feelings about the disease. Options A,
B, and D identify physiological not
psychosocial concerns.
50. A client is diagnosed with human
immunodeficiency virus (HIV) infection.
The nurse prepares a care plan for the client,
knowing that HIV is primarily a condition in
which:
a) immunosuppression occurs and is
indicated by a T4 lymphocyte count of
less than 200/mm3
b) bacterial infection occurs, causing
weakness
c) fungal infection occurs, causing a rash
and pruritus
d) protozoan infection occurs, causing a
fever and nonproductive cough
50) A - HIV infection causes
immunosuppression and is indicated by a T4
lymphocyte count of less than 200/mm3.
Although bacterial, fungal, and protozoal
infection can occur, these occur as
opportunistic infections as a result of the
immunosuppression.