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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

A. Elbows and behind the ears B. Coccyx and back of the skull C. Heels and trochanter D. Sacrum and ischium

Correct Answer is D

Explanation

A. Elbows and behind the ears: These areas are not primary pressure points in a seated position.

B. Coccyx and back of the skull: The coccyx is a pressure point when lying down, but this patient is sitting most of the time.

C. Heels and trochanter: Heels are at risk in supine patients, but this patient is primarily sitting.

D. Sacrum and ischium: The sacrum and ischium (sit bones) bear the most pressure in a seated position, making them highly vulnerable to skin breakdown.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

Correct Answer is C

Explanation

A nurse is caring for an older adult patient with chronic obstructive pulmonary disease. The patient always remains in a sitting position to help them breathe more easily. Based on this information, what area on the patient's body should be frequently assessed for skin breakdown?

Correct Answer is D

Explanation

A student nurse is assigned a patient to provide care for throughout the day. Which of the following actions would violate client confidentiality?

The student nurse has identified that the patient is a risk for falling and has implemented fall precautions. What action taken by the student would require further teaching from the clinical faculty?

What are three positive results of meaningful use compliance in the Electronic Health Record?

A student nurse is assessing their patient who is NPO due to a recent surgery. The provider comes in the room to see the patient and states that the patient is cleared to start a full liquid diet. What is the best action by the student nurse?

The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a healthcare-associated infection?

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?