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 B

Explanation

A. A patient who is lying on wrinkled sheets: Wrinkled sheets can cause pressure injuries, but they do not directly lead to shearing.

B. A patient who is pulled up in the bed by the nurse: Shearing occurs when the skin remains in place while underlying tissues move, often when a patient is dragged up in bed instead of lifted. This can damage skin layers and underlying tissues.

C. A patient who is frequently incontinent: Incontinence increases the risk of moisture-associated skin damage and pressure injuries but is not directly related to shearing.

D. A patient who is noted to have slough tissue: The presence of slough (dead tissue in a wound) indicates existing tissue damage but does not suggest an increased risk of shearing.

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

Naxlex Comprehensive Predictor Exams

Which of the following patients are at highest risk for developing a skin injury caused by shearing?

Correct Answer is B

Explanation

A nurse enters a patient's room and finds that the patient has fallen on the way to the bathroom. What action should be implemented first?

Correct Answer is A

Explanation

The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. What expectations does the nurse have when developing the relationship?

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

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

A client is having difficulty having a bowel movement laying on the bedpan. What is the physiologic reason for this problem?

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 providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

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?

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?