The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?

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Question 1 of 9

The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?

Correct Answer: A

Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious. Incorrect choices: B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC. C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV. D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.

Question 2 of 9

The examiner shines a light in the patient’s eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner’s finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?

Correct Answer: B

Rationale: The correct answer is B: PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation. This documentation reflects a comprehensive assessment of the pupils' response to light and accommodation. The pupils constricting from 4 to 2 mm bilaterally in response to light indicates they are reactive. Additionally, the eyes turning inward when focusing on a near object shows accommodation. Choice A is not the best option because it only mentions the pupil size without capturing other important aspects of the assessment. Choice C is too vague, as it does not specify the exact response of the pupils. Choice D is incorrect because it does not provide a detailed description of the pupils' response to both light and accommodation. Therefore, option B is the most appropriate choice as it encompasses all the necessary components of the assessment.

Question 3 of 9

Which of the ff. is a normal hemoglobin value?

Correct Answer: C

Rationale: The correct answer is C: 12 to 18 g/100mL. Normal hemoglobin values typically range from 12 to 18 g/100mL in adults. This range reflects the normal concentration of hemoglobin in the blood and is commonly used as a reference range in clinical practice. Choices A, B, and D are incorrect because they do not fall within the typical normal range for hemoglobin levels. Choice A (38% to 48%) is a percentage range, not a direct measurement of hemoglobin concentration. Choice B (48 to 54 mg%) and Choice D (27 to 36 g/dL) are outside the normal range for hemoglobin levels in adults. Therefore, the most appropriate and accurate choice among the options provided is C (12 to 18 g/100mL) based on standard reference values for hemoglobin concentration in the blood.

Question 4 of 9

Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the

Correct Answer: D

Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). Mr. Reyea's complaint of hearing ringing noises indicates a potential issue with his auditory function, which is primarily governed by the Vestibulocochlear nerve. This nerve is responsible for transmitting sound and balance information from the inner ear to the brain. The other choices, A: Frontal lobe, B: Six cranial nerve (abducent), and C: Occipital lobe, are not directly associated with auditory function or the perception of ringing noises in the ear.

Question 5 of 9

Wilma knew that the maximum time when suctioning James is

Correct Answer: C

Rationale: The correct answer is C (30 seconds) because the maximum recommended time for suctioning a patient is typically around 10-15 seconds for each pass. Prolonged suctioning can lead to tissue damage, hypoxia, and increased risk of infection. In this case, given the patient's symptoms and medical history (vomiting, weight loss, dehydration, hypotension), it is crucial to limit suction time to prevent further complications. Choices A, B, and D are incorrect as they exceed the safe duration for suctioning and increase the risk of harm to the patient. Choice D, in particular, is significantly longer than the recommended time and could pose serious risks to the patient's health in this situation.

Question 6 of 9

The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:

Correct Answer: C

Rationale: The correct answer is C: Fine needle aspiration. This procedure involves inserting a thin needle into the lump to extract cells for examination. It provides a definitive diagnosis of breast cancer by analyzing the cells for cancerous features. Breast self-examination (A) is a screening tool but cannot confirm a diagnosis. Mammography (B) is used for screening and detecting abnormalities but also requires further testing for diagnosis. Chest x-ray (D) is not used to diagnose breast cancer.

Question 7 of 9

Which of the ff. does the nurse understand are the reasons a patient with pulmonary edema is given morphine sulphate? i.To reduce anxiety iv.To increase BP ii.To relieve chest pain v.To reduce preload and afterload iii.To strengthen heart contractions

Correct Answer: C

Rationale: The correct answer is C because morphine sulfate is given to a patient with pulmonary edema to reduce anxiety (i) and to reduce preload and afterload (v). Morphine sulfate does not increase blood pressure (ii), relieve chest pain (iii), or strengthen heart contractions (iv) in the context of pulmonary edema. Choice A is incorrect because it includes increasing BP, which is not a reason for giving morphine sulfate in this case. Choice B is incorrect because it includes strengthening heart contractions, which is not a reason for administering morphine sulfate. Choice D is incorrect because it includes relieving chest pain, which is not a primary purpose of giving morphine sulfate to a patient with pulmonary edema.

Question 8 of 9

A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?

Correct Answer: D

Rationale: The correct answer is D: Involve the son in the plan of care as much as possible. This is important for several reasons. Firstly, involving the son promotes family-centered care, which can improve patient outcomes. Secondly, the son may provide valuable insights into the patient's preferences and needs. Thirdly, it can help reduce the patient's confusion by providing familiar support. Option A is incorrect as it disregards the potential benefits of involving family members. Option B is incorrect as it focuses on the patient's rest without considering the emotional support the son may provide. Option C is incorrect as it assumes the gender of the family member matters more than their relationship to the patient.

Question 9 of 9

Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?

Correct Answer: D

Rationale: Rationale: 1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system. 2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema. 3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution. Summary: A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration. B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect. C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect. D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid

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