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. It is painful to sit on a bedpan. Discomfort may be a factor, but pain alone does not explain the difficulty in having a bowel movement.
B. The position encourages the Valsalva maneuver. The Valsalva maneuver (straining against a closed airway) can occur in any position, but posture is the primary problem here.
C. The position does not facilitate downward pressure. The seated position allows for gravity and proper abdominal muscle engagement, making defecation easier. Lying down does not facilitate intra-abdominal pressure.
D. The cause is unknown and requires further study. The relationship between position and defecation is well understood in physiology.

A. “Tell me about your support system at home." B. "What treatment options has your doctor spoke with you about?"" C. “I am sure you are scared. Everything will be okay." D. “This must be a hard time for you. How are you coping."

Correct Answer is C

Explanation

A. "Tell me about your support system at home." This is an open-ended, therapeutic question that encourages the patient to discuss their support network.

B. "What treatment options has your doctor spoken with you about?" This is an appropriate way to assess the patient's understanding of their diagnosis and plan of care.

C. “I am sure you are scared. Everything will be okay." This statement is nontherapeutic because it offers false reassurance and dismisses the patient’s emotions rather than acknowledging their concerns.

D. "This must be a hard time for you. How are you coping?" This is an empathetic statement that acknowledges the patient's feelings and invites them to express their emotions.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

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

Correct Answer is C

Explanation

The student nurse is conducting a health history for a patient recently diagnosed with cancer. What statement made by the student would require remediation by the clinical faculty?

Correct Answer is C

Explanation

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