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The parent of a young adult recently diagnosed as being HIV positive calls the clinic in a panic saying, 'My son just cut himself shaving, and there is blood all over the bathroom. What should I do?' How should the nurse respond?
- A. Tell the parent to call 911 and ask for the Hazmat Team to come and assist.
- B. Suggest that the parent clean the bathroom with hot soapy water while wearing gloves.
- C. Recommend that the parent put on rubber gloves and use household bleach to clean the blood spills.
- D. Tell the parent to put on rubber gloves and clean the area with hydrogen peroxide.
Correct Answer: C
Rationale: Household bleach effectively disinfects HIV in blood spills, and gloves protect the parent, following standard precautions.
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An adult is to have a paracentesis performed today. What should the nurse do before the procedure?
- A. Encourage the client to drink large amounts of fluids
- B. Ask the client to empty her bladder just before the test
- C. Keep the client NPO until after the procedure
- D. Premedicate the client as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Fluid intake, NPO status, or premedication are not immediate pre-procedure priorities.
The nurse understands that the patient with esophageal varices should not be given food such as:
The nurse understands that the patient with esophageal varices should not be given food such as:
- A. Crackers
- B. Purred food
- C. Liquid
- D. Soft
Correct Answer: A
Rationale: Crackers, being rough, can irritate or rupture fragile esophageal varices.
During a home visit, the nurse observes a man who is recovering from a left total hip replacement. Which observation indicates that the client understands his care?
- A. He is sitting in a soft, overstuffed easy chair.
- B. He bends over to pat his cat.
- C. He crosses his legs when sitting.
- D. He holds the cane in his right hand when walking.
Correct Answer: D
Rationale: Holding the cane in the right hand (opposite the affected left hip) provides support and balance, indicating proper care understanding. Soft chairs, bending, or crossing legs risk hip dislocation.
A nurse is assigned to care for a comatose diabetic on IV insulin therapy. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Check the client's level of consciousness
- B. Obtain the regular blood glucose readings
- C. Determine if special skin care is needed
- D. Answer questions from the client's spouse about the plan of care
Correct Answer: B
Rationale: The UAP can safely obtain blood glucose readings, which are routine tasks.
A nurse is administering blood to a patient who has a low hemoglobin count.
The patient asks how long the RBC last in the body? The correct response is:
- A. The life span of RBC is 45 days.
- B. The life span of RBC is 60 days.
- C. The life span of RBC is 90 days.
- D. The life span of RBC is 120 days.
Correct Answer: D
Rationale: Red blood cells have a lifespan of approximately 120 days.