Nokea
A client requests to change rooms after overhearing that their roommate is positive for the human immunodeficiency virus (HIV). The nurse should take which appropriate action?
- A. Relocate the client to a private room
- B. Ask the client to elaborate on their concern
- C. Notify the risk manager of the request
- D. Place an additional divider in-between the two beds
Correct Answer: B
Rationale: Asking the client to elaborate addresses potential misconceptions about HIV transmission, which occurs via blood or bodily fluids, not casual contact. Relocation, risk management, or dividers are unnecessary.
You may also like to solve these questions
The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030 . What action should the nurse take?
- A. Assess the surgical wound
- B. Collect blood cultures
- C. Administer oxygen at 2 L/minute
- D. Encourage by-mouth (PO) fluids
Correct Answer: C
Rationale: Changes in vital signs post-surgery may indicate respiratory or circulatory compromise. Administering oxygen at 2 L/minute is a prudent initial action to support oxygenation while further assessment occurs. Wound assessment, blood cultures, or fluids require specific clinical indications.
A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client
- A. withdrawing from alcohol and is malnourished.
- B. receiving methylprednisolone for an asthma exacerbation.
- C. has an external urinary catheter device for urinary incontinence.
- D. receiving total parenteral nutrition (TPN) via a central line
Correct Answer: D
Rationale: TPN via a central line poses the highest infection risk due to the invasive device and nutrient-rich solution.
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)?
- A. Glycosylated hemoglobin (HbA1c) of 7.2% [5.7-6.4%]
- B. International Normalized Ratio (INR) of 3.5 [0.9-1.2 seconds]
- C. Hematocrit (Hct) of 42% [Male: 42-52% Female: 37-47%]
- D. Blood urea nitrogen (BUN) level of 5 [10-20 mg/dL]
Correct Answer: B
Rationale: An INR of 3.5 indicates a high bleeding risk, critical for surgical safety, and must be reported to the PHCP. Elevated HbA1c, normal hematocrit, and low BUN are less urgent but may still require attention.
The nurse is caring for a 10-year-old child on the pediatric unit. The nurse, when caring for this age group, should be aware that:
- A. The child will do something for another person if that person does something for the child.
- B. The child now follows social standards for the good of all.
- C. The child wants to follow the rules because of a need to be seen as 'good.'
- D. The child finds satisfaction in following rules.
Correct Answer: C
Rationale: 10-year-olds are in Kohlberg’s conventional stage, seeking approval by following rules to be seen as 'good.' Reciprocity, societal good, or intrinsic satisfaction are less applicable.
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)?
- A. Glycosylated hemoglobin (HbA1c) of 7.2% [5.7-6.4%]
- B. International Normalized Ratio (INR) of 3.5 [0.9-1.2 seconds]
- C. Hematocrit (Hct) of 42% [Male: 42-52% Female: 37-47%]
- D. Blood urea nitrogen (BUN) level of 5 [10-20 mg/dL]
Correct Answer: B
Rationale: An INR of 3.5 indicates a high bleeding risk, critical for surgical safety, and must be reported to the PHCP. Elevated HbA1c, normal hematocrit, and low BUN are less urgent but may still require attention.