A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

The client's meal tray includes ice cream with fresh fruit.

The client's meal tray contains hard boiled eggs.

The client has artificial flowers in the room.

The client is assigned to a room with negative airflow.

Answer and Explanation

The Correct Answer is A

Care of a client with HIV and neutropenia requires strict infection prevention because reduced neutrophil counts severely impair the body’s ability to fight bacterial and fungal pathogens. In this immunocompromised state, exposure to contaminated food, water, or environmental sources significantly increases the risk of opportunistic infections. Dietary and environmental restrictions are implemented to minimize exposure to microorganisms commonly found in raw or unprocessed items. Nursing care focuses on identifying sources of contamination that may introduce pathogens into the client’s system.

Rationale:
A. Fresh fruit on ice cream increases infection risk because raw, unwashed produce can harbor bacteria, parasites, or fungi that are dangerous for a neutropenic client. In a client with Neutropenia, even low-level contamination can lead to severe systemic infection due to impaired immune response. This is why neutropenic precautions often include avoidance of raw fruits and vegetables unless properly cooked or sterilized.

B. Hard-boiled eggs are considered safe because they are fully cooked and do not typically harbor viable pathogens when properly prepared and stored. Protein sources like fully cooked eggs are often encouraged in neutropenic diets to maintain nutritional status without increasing infection risk. Therefore, this does not contribute to increased infection risk.

C. Artificial flowers are generally considered safe because they do not contain soil or water that can support bacterial or fungal growth. While they may collect dust if not cleaned, they are not a significant infection source compared to real plants or fresh flowers. The main concern in neutropenic precautions is avoiding live plants and stagnant water, not artificial decorations.

D. A negative airflow room does not increase infection risk for the client but is inappropriate for neutropenic (protective) isolation. Negative pressure rooms are used to prevent airborne pathogen spread from the client to others (e.g., tuberculosis). Neutropenic clients instead require positive pressure environments to protect them from external contaminants, so this is a setup issue rather than a direct infection risk factor.

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Correct Answer is D

Explanation

Intermittent self-catheterization is used in clients with neurogenic bladder to ensure regular and complete bladder emptying, reduce urinary retention, and prevent complications such as infection or bladder distention. Proper technique focuses on maintaining asepsis, preventing urethral trauma, and ensuring safe urine drainage. Client education includes hygiene practices, lubrication, timing of catheterization, and correct handling of equipment. Adherence to sterile or clean technique is essential to reduce the risk of urinary tract infection.

Rationale:
A. Securing the catheter to the leg is not part of intermittent self-catheterization because the catheter is removed immediately after urine drainage. This step is typically used with indwelling catheters, not intermittent procedures. Therefore, this statement reflects a misunderstanding of the procedure.

B. Performing the procedure without lubricating the catheter is incorrect because lubrication is essential to reduce friction and prevent urethral trauma. Inadequate lubrication increases pain, irritation, and risk of mucosal injury. Proper lubrication is a key component of safe catheter insertion.

C. Waiting until the bladder is completely full is incorrect because intermittent catheterization should be performed on a regular schedule rather than waiting for significant bladder distention. Overfilling the bladder can lead to discomfort, urinary reflux, and increased risk of infection or autonomic dysreflexia in susceptible clients.

D. Wearing gloves during the procedure demonstrates correct understanding because it helps reduce the introduction of microorganisms into the urinary tract. In clean intermittent self-catheterization for conditions such as Neurogenic bladder, glove use is an important infection-prevention measure that supports safe technique and reduces the risk of urinary tract infection.

A. Remind client to be NPO prior to surgery. B. Administer Rh, D immune globin prior to surgery. C. Explain the surgical procedure to the client. D. Prepare client for insertion of 18-gauge peripheral IV prior to surgery. E. Verify consent form is signed by the client. F. Obtain a complete blood count. G. Assist with administration of AB positive blood products if needed.

Correct Answer is ["A","D","E","F"]

Explanation

Preoperative nursing care for a client scheduled for laparoscopic management of a confirmed Ectopic pregnancy focuses on stabilizing the client, ensuring surgical readiness, and preventing perioperative complications such as hemorrhage and aspiration. The client has a tubal pregnancy confirmed by ultrasound with declining β-hCG levels, requiring urgent surgical intervention. Nursing priorities include airway safety, vascular access for rapid fluid or blood administration, verification of informed consent, and baseline laboratory evaluation to guide intraoperative management.

Rationale:

A. Reminding the client to remain NPO is essential to reduce the risk of aspiration during general anesthesia. Laparoscopic surgery requires sedation or general anesthesia, which depresses protective airway reflexes. Ensuring an empty stomach decreases the likelihood of regurgitation and aspiration pneumonia during induction of anesthesia.

B. Administering Rh immune globulin prior to surgery is not appropriate at this time without provider order and timing consideration. Rh immune globulin is typically given after delivery or significant fetal-maternal hemorrhage, not preoperatively. The priority is surgical stabilization rather than prophylactic administration at this stage.

C. Explaining the surgical procedure to the client is not the nurse’s role because informed consent and procedural explanation are the responsibility of the provider. The nurse may reinforce understanding but should not introduce or explain the procedure in detail. This could interfere with the legal consent process

D. Preparing for insertion of an 18-gauge peripheral IV is critical because ectopic pregnancy surgery carries a risk of sudden hemorrhage. A large-bore IV line allows rapid administration of fluids, medications, and blood products if needed. This ensures immediate vascular access for hemodynamic stabilization during surgery.

E. Verifying that the consent form is signed is a key legal and safety requirement before any surgical procedure. The nurse ensures that informed consent has been obtained, properly documented, and matches the planned procedure. This confirms patient understanding and protects autonomy before anesthesia is initiated.

F. Obtaining a complete blood count is necessary to establish baseline hematologic status before surgery. The client already demonstrates mild anemia, which may worsen if intraoperative bleeding occurs. Hemoglobin, hematocrit, and platelet levels guide perioperative planning and readiness for possible transfusion.

G. Administering AB positive blood products is inappropriate due to ABO and Rh incompatibility. The client is B negative, and transfusion with incompatible blood could trigger a severe hemolytic reaction. If transfusion becomes necessary, properly matched B negative or O negative blood must be used instead.

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A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a neurogenic bladder and a prescription for intermittent urinary self-catheterizations. Which of the following statements by the client shows an understanding of the teaching?

Correct Answer is D

Explanation

The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3. The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","D","E","F"]

Explanation

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