The nurse has received the following report from the laboratory department regarding their patient admitted with fatigue. See chart below:

Laboratory Test

Reference Range

Patient Results

White Blood Cells

5,000- 10,000/mm3

9,500/mm3

Neutrophil Count

2.500-8,000/mm3

5,200/mm3

HIV

Negative

Positive

What infection control precautions should the nurse implement?

Educate the patient about hand hygiene with alcohol based hand sanitizer.

Notify the patient's spouse about the result and arrange for HIV testing

Provide information on antibiotic therapy to help control the infection.

Initiate contact precautions with gown and gloves.

Answer and Explanation

The Correct Answer is A

A. Educate the patient about hand hygiene with alcohol-based hand sanitizer: Standard precautions apply to all patients, including hand hygiene education. HIV is not transmitted through casual contact.

B. Notify the patient's spouse about the result and arrange for HIV testing: Patient confidentiality must be maintained. The patient should be encouraged to inform their partner, but the nurse cannot disclose the results.

C. Provide information on antibiotic therapy to help control the infection: HIV is a viral infection, not bacterial. Antibiotics do not treat HIV.

D. Initiate contact precautions with gown and gloves: HIV is bloodborne and not spread via casual contact, so contact precautions are not required unless the patient has an open wound or secondary infection.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Straight catheter: A straight catheter is used for intermittent catheterization and cannot bypass a complete obstruction.

B. Indwelling urethral catheter: A urethral catheter may not be able to pass through a completely obstructed urethra.

C. Suprapubic catheter: A suprapubic catheter is placed directly into the bladder through the abdominal wall, bypassing the obstructed urethra, making it the best option for this client.

D. Intermittent urethral catheter: Like a straight catheter, an intermittent urethral catheter will not work if the urethra is completely obstructed.

A. Assess the patient. B. File a safety event report C. Place the patient on fall precautions. D. Get the patient back to bed.

Correct Answer is A

Explanation

A. Assess the patient: The priority action is to assess the patient for injuries before taking any further steps.

B. File a safety event report: This is important but should be done after assessing and ensuring the patient’s safety.

C. Place the patient on fall precautions: While necessary, this is a secondary intervention after assessment and ensuring immediate safety.

D. Get the patient back to bed: Moving the patient before assessing for injuries could worsen potential fractures or other injuries.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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