NU350: Ch 5, 6, 11, 14

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? "Thinking about dying will not improve the course of AIDS." "Do you think that taking an antidepressant might be helpful?" "Can you tell me more about the thoughts that you are having?" "It is important to focus on the good things about your life now."

"Can you tell me more about the thoughts that you are having?"

Which statement, if made by an older adult patient, would be of most concern to the nurse in planning care? "I prefer to manage my life without much help from other people." "I take three different medications for my heart and joint problems." "I don't go on daily walks anymore since I had pneumonia 3 months ago." "I set up my medications in a marked pillbox so I don't forget to take them."

"I don't go on daily walks anymore since I had pneumonia 3 months ago."

A patient who has frequent migraines tells the nurse, "My life feels chaotic and out of control. I could not manage if anything else happens." Which response should the nurse make initially? "Regular exercise may get your mind off the pain." "Guided imagery can be helpful in regaining control." "Tell me more about how your life has been recently." "Your previous coping resources can be helpful to you now."

"Tell me more about how your life has been recently."

The nurse is advising a patient who was exposed 4 days ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen-antibody test has just been reported as negative for HIV. What information should the nurse give to this patient? "You will need to be retested in 2 weeks." "You do not need to fear infecting others." "We won't know for about 10 years if you have HIV infection." "With no symptoms and this negative test, you do not have HIV."

"You will need to be retested in 2 weeks."

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ count of less than 200 cells/uL. Based on diagnostic criteria established by the centers for disease control and Prevention, which statement by the nurse is correct?

"the patient has developed acquired immunodeficiency syndrome" (AIDS)

A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories perday. If the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

2140 calories

Which patient is most likely to need long-term nursing care management? 72-yr-old who had a hip replacement after a fall at home 64-yr-old who developed sepsis after a ruptured peptic ulcer 76-yr-old who had a cholecystectomy and bile duct drainage 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

An older patient reports having "no energy" and feeling increasingly weak. The patient has lost 12 pounds over the past year. Which action should the nurse take initially? a. Ask the patient about daily dietary intake. b. Schedule regular range-of-motion exercise. c. Describe normal changes associated with aging. d. Discuss long-term care placement with the patient.

A

The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would support both the patient's self-management and the goal of medication adherence? a. Use a marked pillbox to set up the patient's medications. b. Discuss the option of moving to an assisted living facility. c. Remind the patient about the importance of taking medications. d. Visit the patient daily to administer the prescribed medications.

A

The home health nurse visits an older patient with mild forgetfulness. Which new information is of most concern to the nurse in planning care? a. The patient has lost 10 lb (4.5 kg) during the past month. b. The patient tells the nurse that a close friend recently died. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient's son uses a marked pillbox to setup the patient's medications weekly.

A

The nurse should plan to use a wet-to-dry dressing for which patient? A patient who has a pressure injury with pink granulation tissue. A patient who has a surgical incision with pink, approximated edges. c. A patient who has a full-thickness burn filled with dry, black material. d. A patient who has a wound with purulent drainage and dry brown areas.

A patient who has a wound with purulent drainage and dry brown areas.

The nurse is caring for a patient living with asymptomatic chronic HIV infection (HIV). Which prophylactic measures will the nurse include in the plan of care? (Select all that apply.) A. Hepatitis B vaccine B. Pneumococcal vaccine C. Influenza virus vaccine D. Trimethoprim-sulfamethoxazole E. Varicella zoster immune globulin

A, B, C

Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient? (Select all that apply.) A. Assess for depression. B. Review laboratory results. C. Determine food preferences. D. Inspect teeth and oral mucosa. E. Ask about transportation needs.

A, B, D, E

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan? (Select all that apply.) A. Antibiotics may sometimes be prescribed to prevent infection. B. Continue taking antibiotics until all of the prescription is gone. C. Unused antibiotics that are more than a year old should be discarded. D. Antibiotics are effective in treating influenza associated with high fevers. E. Hand washing is effective in preventing many viral and bacterial infections.

A, B, E

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

A, D, B, C

An adult patient who is hospitalized after a motorcycle crash tells the nurse, "I didn't sleep last night because I worried about missing work at my new job and losing my insurance coverage." Which patient problem is appropriate to include in the plan of care? a. Anxiety b. Difficulty coping c. Disturbed body image d. Knowledge deficit

Anxiety

An alert older patient who takes multiple medications for chronic cardiac and pulmonary diseases lives with a daughter who works during the day. During a clinic visit, the patient tells the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. In planning care for this patient, which problem should the nurse consider as the priority? a. Risk for injury b. Social isolation c. Caregiver strain d. Difficulty coping

A. The patient's age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Problems with social isolation, caregiver strain, or difficulty coping are not physiologic priorities. Drug-drug interactions could cause the most harm to the patient and are therefore the priority.

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? Monitor white blood cell counts. Check the skin for areas of redness. Measure the temperature every 2 hours. Ask about feelings of fatigue or malaise.

Ask about feelings of fatigue or malaise

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? Age Lifestyle Symptoms Sexual orientation

Age

A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse plans to try providing music to help the patient relax. Which action is best for the nurse to take? Use music composed by Mozart. Play music that does not have words. Ask the patient about music preferences. Select music that has 60 to 80 beats/minute.

Ask the patient about music preferences.

The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition? Have the family select an LTC facility that is relatively new. Ask the patient's preference for the choice of an LTC facility. Explain the reasons for the need to live in LTC to the patient. Request that the patient be placed in a private room at the facility.

Ask the patient's preference for the choice of an LTC facility.

A family caregiver tells the home health nurse, "I feel like I can never get away to do anything for myself." Which action by the nurse would directly address this concern? Assist the caregiver in finding respite services. Assure the caregiver that the work is appreciated. Encourage the caregiver to discuss feelings openly with the nurse. Tell the caregiver that family members provide excellent patient care.

Assist the caregiver in finding respite services.

The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the priority for the nurse to include in the discharge plan for this patient? a. Teach the patient how to assess and care for the foot infection. b. Refer the patient to social services for assessment of resources. c. Schedule the patient to return to outpatient services for foot care. d. Give the patient written information about shelters and meal sites.

B

Which method should the nurse use to obtain a complete assessment of an older patient? a. Review the patient's health record for previous assessments. b.Use a geriatric assessment instrument to evaluate the patient. c. Ask the patient to write down medical problems and medications. d. Interview both the patient and the primary caregiver for the patient.

B The most complete information about the patient will be obtained by using an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the medical record, interviews with the patient and caregiver, and written information by the patient are all included in a comprehensive geriatric assessment.

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea? (Select all that apply.) A. Mask B. Gown C. Gloves D. Shoe covers E. Eye protection

B, C

A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just received news that the driver of the car died from multiple injuries. Which assessment findings should the nurse consider to be possible physiologic reactions to the stressful news? (Select all that apply.) A. Bradycardia B. Decreased appetite C. Epigastric discomfort D. Decreased respiratory rate E. Elevated blood glucose levels

B, C, E

Which intervention should the nurse implement to provide optimal care for an older patient who is hospitalized with pneumonia? a. Use a standardized geriatric care plan. b. Plan for transfer to a long-term care facility c. Consider the preadmission functional abilities. d. Minimize physical activity during hospitalization.

C

Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? A. Teach the patient to have all prescriptions filled at the same pharmacy. B. Make a schedule for the patient as a reminder of when to take each medication. C. Ask the patient to bring all medications, supplements, and herbs to each appointment. D. Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements.

C

When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? a. Mechanism of action of anticoagulant therapy b. Effect of atherosclerosis on cerebral blood vessels c. Symptoms indicating that the patient should contact the health care provider d. Impact of the patient's family history on likelihood of developing a serious stroke

C. One of the priority tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to take if these symptoms occur. The other information may also be included in patient teaching but is not as essential in the patient's self-management of the illness.

A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? Change the patient's bedding frequently. Apply a hydrocolloid dressing over the injury. Change the patient's position every 1 to 2 hours. Record the size and appearance of the injury weekly.

Change the patient's position every 1 to 2 hours.

A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). The patient denies any discomfort. Which action by the nurse is appropriate? Apply a cooling blanket. Notify the health care provider. Check the patient's temperature again in 4 hours. Give acetaminophen prescribed as-needed for pain.

Check the patient's temperature again in 4 hours.

A patient who has just relocated to a long-term care facility is exhibiting signs of stress related to the move. Which action should the nurse include in the plan of care? A. Remind the patient that making changes is usually stressful. B. Discuss the reason for the move to the facility with the patient C. Restrict family visits until the patient is accustomed to the facility. D. Have staff members write notes welcoming the patient to the facility.

D

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a. Escharb b. Slough c. Maceration d. Undermining

D Undermining

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? Obtain wound cultures. Document the assessment. Notify the health care provider. Assess the wound every 2 hours.

Document the assessment.

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? Elevate the ankle above heart level. Apply a warm moist pack to the ankle. Ask the patient to try bearing weight on the ankle. Assess the ankle's passive range of motion (ROM).

Elevate the ankle above heart level.

Eight years after seroconversion, a patient with human immunodeficiency virus infection has a CD4+ cell count of 800/μL and an undetectable viral load. What should be included in the plan of care at this time? Encourage adequate nutrition, exercise, and sleep. Teach about the side effects of antiretroviral agents. Explain opportunistic infections and antibiotic prophylaxis. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

Encourage adequate nutrition, exercise, and sleep.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? Instruct the patient to apply ice to the neck. Tell the patient a secondary infection is present. Explain to the patient that this is an expected finding. Request that an antibiotic be prescribed for the patient.

Explain to the patient that this is an expected finding.

An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? Notify an elder protective services agency about possible abuse. Make a referral for a home assessment visit by the home health nurse. Have the family member stay in the waiting area while the patient is assessed. Ask the patient how the injury occurred and observe the family member's reaction.

Have the family member stay in the waiting area while the patient is assessed.

An older adult who takes medications for coronary artery disease and hypertension is newly diagnosed with HIV infection and is starting antiretroviral therapy. Which information will the nurse include in patient teaching? Many drugs interact with antiretroviral medications. HIV infections progress more rapidly in older adults. Less frequent CD4+ level monitoring is needed in older adults. Hospice care is available for patients with terminal HIV infection.

Many drugs interact with antiretroviral medications.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? The antiretroviral medications used to treat HIV infection are teratogenic. Most infants born to HIV-positive mothers are not infected with the virus. Because it is an early stage of HIV infection, the infant will not contract HIV. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).

Most infants born to HIV-positive mothers are not infected with the virus.

Which patient who has arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? Patient whose rapid HIV-antibody test is positive. Patient whose latest CD4+ count has dropped to 250/μL. Patient who has had 10 liquid stools in the last 24 hours. Patient who has nausea from prescribed antiretroviral drugs.

Patient who has had 10 liquid stools in the last 24 hours.

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? CD4+ cell count How the patient obtained HIV Patient's tolerance for potential medication side effects Patient's ability to follow a complex medication regimen

Patient's ability to follow a complex medication regimen

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? Methods to prevent perinatal HIV transmission. Ways to sterilize needles used by injectable drug users. Prevention of HIV transmission between sexual partners. Means to prevent transmission through blood transfusions.

Prevention of HIV transmission between sexual partners.

An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate? Start an IV line to administer antihypertensive medications. Recheck the blood pressure after the patient has been assessed. Discuss the need for hospital admission to control blood pressure. Teach the patient about the stroke risk associated with hypertension.

Recheck the blood pressure after the patient has been assessed.

A patient informed of a positive rapid screening test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? Inform the patient about the available treatments. Teach the patient how to manage a possible drug regimen. Remind the patient to return for retesting to verify the results. Ask the patient to identify those persons who had intimate contact.

Remind the patient to return for retesting to verify the results.

After receiving a change-of-shift report, which patient should the nurse assess first? The patient who has multiple leg wounds with eschar to be debrided. The patient receiving chemotherapy who has a temperature of 102° F. The patient who requires analgesics before a scheduled dressing change. The newly admitted patient with a stage 4 pressure injury on the coccyx.

The patient receiving chemotherapy who has a temperature of 102° F.

The nurse is caring for a patient who is living with human immunodeficiency virus (HIV) and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? The patient reports feeling "constantly tired." The patient reports having no side effects from the medications. The patient is unable to explain the effects of atorvastatin (Lipitor). The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.

a. Obtain cultures of the wound.

The nurse is admitting an acutely ill, older patient to the hospital. Which action should the nurse take? a. Speak slowly and loudly while facing the patient. b. Perform a physical assessment before interviewing the patient. c. Ask a family member to go home and retrieve the patient's cane. d. Begin care by obtaining a detailed medical history from the patient.

b

Which patient would benefit from education about HIV preexposure prophylaxis (PrEP)? a. A 23-yr-old woman living with HIV infection. b. A 52-yr-old recently single woman just diagnosed with chlamydia. c. A 33-yr-old hospice worker who received a needle stick injury 3 hours ago.d. A 60-yr-old male in a monogamous relationship with an HIV-uninfected partner.

b. A 52-yr-old recently single woman just diagnosed with chlamydia.

The nurse will perform which action for a wet-to-dry dressing change on a patient's stage 3 sacral pressure injury? a. Pour sterile saline onto the new dry dressings after packing the wound. b. Administer a prescribed PRN oral analgesic 30 minutes before the change. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Soak the old dressings with sterile saline 30 minutes before the dressing change.

b. Administer a prescribed PRN oral analgesic 30 minutes before the change.

The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient's needs? a. Suggest that the patient move closer to health care providers. b. Obtain extra medications for the patient to last for 4 to 6 months. c. Ensure transportation to appointments with the health care provider. d. Assess the patient for chronic diseases that are unique to rural areas.

c

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

c. Discuss a change in antiretroviral therapy.

The nurse performs a comprehensive assessment of an older patient who is considering admission to an assisted living facility. Which question is the most important for the nurse to ask? a. "Have you had any recent infections?" b. "How frequently do you see a doctor?" c. "Do you have a history of heart disease?" d. "Are you able to prepare your own meals?"

d. "Are you able to prepare your own meals?" The patient's functional abilities, rather than the presence of an acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient.

A patient who uses injectable illegal drugs asks the nurse how to prevent acquired immunodeficiency syndrome (AIDS). Which response by the nurse is most accurate? a. "Clean drug injection equipment before each use." "Ask those who share equipment to be tested for HIV." "Consider participating in a needle-exchange program." "Avoid sexual intercourse when using injectable drugs."

"Consider participating in a needle-exchange program."

A hospitalized patient with diabetes tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating." Which response by the nurse is accurate? "The liver is not able to metabolize glucose as well during stressful times." "Your diet at the hospital is the most likely cause of the increased glucose." "The stress of illness causes release of hormones that increase blood glucose." "It is probably coincidental that your blood glucose is higher when you are ill."

"The stress of illness causes release of hormones that increase blood glucose."

An obese female patient who had enjoyed active outdoor activities is stressed because osteoarthritis in her hips now limits her activity. Which action by the nurse will best assist the patient to cope with this situation? a. Have the patient practice frequent relaxation breathing b. Encourage the patient to lose weight to improve symptoms. c. Ask the patient what outdoor activities she misses the most. d. Teach the patient to use imagery for reducing pain and stress

Encourage the patient to lose weight to improve symptoms.

Which nursing action will be most useful in assisting a young adult to adhere to a newly prescribed antiretroviral therapy (ART) regimen? Give the patient detailed information about possible medication side effects. Remind the patient of the importance of taking the medications as scheduled. Help the patient develop a schedule to decide when the drugs should be taken. Encourage the patient to join a support group for adults who are HIV positive.

Help the patient develop a schedule to decide when the drugs should be taken.

A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? Dry gauze dressing Nonadherent dressing Hydrocolloid dressing Transparent film dressing

Hydrocolloid dressing

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? Low serum albumin level Serosanguineous drainage Deep red and moist wound bed Cobblestone wound appearance

Low serum albumin level

A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. When planning postoperative interventions to promote wound healing, what is the nurse's highest priority? Maintaining the patient's blood glucose within a normal range Ensuring that the patient has an adequate dietary protein intake Giving antipyretics to keep the temperature less than 102° F (38.9° C) Redressing the surgical incision with a dry, sterile dressing twice daily

Maintaining the patient's blood glucose within a normal range

Which exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? Bite to the arm that does not result in open skin Splash into the eyes while emptying a bedpan containing stool Needle stick with a needle and syringe used for a venipuncture Contamination of open skin lesions with patient vaginal secretions

Needle stick with a needle and syringe used for a venipuncture

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? Nystatin tablet Oral acyclovir (Zovirax) Aerosolized pentamidine (NebuPent) Oral tenofovir AF/emtricitabine/bictegravir (Biktarvy)

Oral tenofovir AF/emtricitabine/bictegravir (Biktarvy)

A patient is extremely anxious a few minutes before having a biopsy on a femoral lymph node. Which technique should the nurse recommend that the patient use during the procedure? Yoga stretching Guided imagery Relaxation breathing Mindfulness meditation

Relaxation breathing

The nurse will assess an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? Palpate over the suprapubic area. Inspect for abdominal distention. Question the patient about hematuria. Request the patient empty the bladder.

Request the patient empty the bladder.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? Skin flushing Muscle cramps Rising body temperature Decreasing blood pressure

Rising body temperature

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? Blood glucose of 136 mg/dL Separation of proximal wound edges Oral temperature of 101° F (38.3° C) Patient reports increased incisional pain

Separation of proximal wound edges

A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury? Stage 1 Stage 2 Stage 3 Stage 4

Stage 3

The registered nurse (RN) is caring for a patient who is living with HIV and admitted with tuberculosis. Which task can the RN delegate to unlicensed assistive personnel (UAP)? Teach the patient how to dispose of tissues with respiratory secretions. Stock the patient's room with the necessary personal protective equipment. Interview the patient to obtain the names of family members and close contacts. Tell the patient's family members the reason for the use of airborne precautions.

Stock the patient's room with the necessary personal protective equipment.

The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? Plan daily activities based on the individual patient needs and desires. Obtain information about food and medication allergies from patients. Take blood pressures daily and document in individual patient records. Teach family members how to cope with patients who are cognitively impaired.

Take blood pressures daily and document in individual patient records.

After the home health nurse teaches a patient's family member about how to care for a sacral pressure injury, which finding indicates that additional teaching is needed? The family member uses a lift sheet to reposition the patient. The family member uses clean tap water to clean the wound. The family member dries the wound using a hair dryer on a low setting. The family member places contaminated dressings in a plastic grocery bag.

The family member dries the wound using a hair dryer on a low setting.

A new nurse performs a dressing change on a patient's stage 2 left heel pressure injury. Which action by the new nurse indicates a need for further teaching about pressure injury care? The new nurse cleans the injury with half-strength peroxide. The new nurse applies a hydrocolloid dressing on the injury. The new nurse irrigates the pressure injury with saline using a 30-mL syringe. The new nurse inserts a sterile cotton-tipped applicator into the pressure injury.

The new nurse cleans the injury with half-strength peroxide.

A middle-aged male patient with usually well-controlled hypertension and diabetes visits the clinic. Today he has a blood pressure of 174/94 mm Hg and a blood glucose level of 190 mg/dL. What patient information may indicate that additional intervention by the nurse is needed? The patient indicates that he monitors his blood glucose several times each day. The patient states that he takes his prescribed antihypertensive medications daily. The patient reveals that both of his parents have high blood pressure and diabetes. The patient reports that he and his wife are disputing custody of their 8-yr-old son.

The patient reports that he and his wife are disputing custody of their 8-yr-old son.

When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing? The patient has had the injuries for 6 months. The patient takes oral hypoglycemic agents daily. The patient states that the injuries are very painful. The patient has several incisions that formed keloids.

The patient takes oral hypoglycemic agents daily.

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/VN)? The patient who was just admitted after suturing of a full-thickness arm wound. The patient who just reported increased tenderness and swelling in a leg wound. The patient who requires teaching about home care for an open draining abdominal wound. The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury.

The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury.

A patient with human immunodeficiency virus (HIV) infection has developed Cryptosporidium parvum infection. Which outcome would be appropriate for the nurse to include in the plan of care? The patient will be free from injury. The patient will receive immunizations. The patient will have adequate oxygenation. The patient will maintain intact perineal skin.

The patient will maintain intact perineal skin.

A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm, but the nurse who is giving her preoperative instructions observes that the patient is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take? Ask the health care provider for a psychiatric referral. Focus teaching on preventing postoperative complications. Try to calm the patient before repeating information about the surgical process. Encourage the patient to combine the hysterectomy surgery with bladder repair.

Try to calm the patient before repeating information about the surgical process.

An older adult being admitted is assessed at high risk for falls. Which action should the nurse take first? Use a bed alarm system on the patient's bed. Administer the prescribed PRN sedative medication. Ask the health care provider to order a vest restraint. Position the patient in a geriatric recliner with locking tray.

Use a bed alarm system on the patient's bed.

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? Viral load testing Enzyme immunoassay Rapid HIV antibody testing Immunofluorescence assay

Viral load testing