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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.

B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.

C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.

D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.

A. 4 B. 1 C. 2 D. 8

Correct Answer is D

Explanation

Determine the dose per administration:

1000 mg ÷ 250 mg/capsule = 4 capsules per dose

Calculate the total per day:

Since the order is every 12 hours, the medication is given twice a day
4 capsules per dose × 2 doses per day = 8 capsules per day

View Question and Answer

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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

While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?

Correct Answer is A

Explanation

Order: Ampicillin 1000 mg PO every 12 hours Available: Ampicillin 250 mg capsules How many capsules will you administer per day?

Correct Answer is D

Explanation

A patient has called the nurse to help them ambulate to the bathroom. The nurse assists the patient to a dangling position on the bed and applied the gait belt. Upon standing, the patient reports that they are feeling very dizzy. What is the next best action by the nurse?

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?

The nurse is providing indwelling catheter care for a patient who is uncircumcised. What intervention will help prevent a catheter associated urinary tract infection?

The nurse is assessing the patient's output for the shift. What finding is most concerning?

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?

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

Which of the following clients should avoid the use of cold therapy?

A nurse is admitting a client to a geriatric medicine unit. Which action would the nurse implement to reduce the clients risk for falling?