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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.
B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.
C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.
D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.
Correct Answer is C
Explanation
A. Security and Privacy: While security and privacy are critical in electronic health records (EHR), they do not directly relate to improving documentation efficiency. Security measures protect client data from unauthorized access but do not necessarily enhance the speed of documentation.
B. Gamification: Gamification involves using game-like elements (e.g., rewards, challenges) to engage users. While it may be useful in staff training, it does not directly facilitate documentation of critical changes in client conditions.
C. Data Analytics: Data analytics helps in tracking trends, identifying high-risk patients, and improving documentation efficiency. By setting up real-time alerts and decision-support tools, the system can assist nurses in capturing critical changes efficiently.
D. Copy and Paste: While copy-and-paste functionality can save time, it is often discouraged in healthcare documentation due to the risk of carrying forward outdated or inaccurate information.
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