Question

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme- linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

Answer 1

Correct Answers:

Western blot analysis

Rationale :

🟦 The Western blot analysis is used to confirm HIV infection after a positive ELISA screening test.

🟦 ELISA is highly sensitive but can yield false-positive results, making confirmatory testing essential.

🟦 Western blot detects specific antibodies to HIV proteins, increasing diagnostic accuracy.

🟦 A positive Western blot establishes a definitive HIV diagnosis.

🟦 This two-step testing process ensures reliable and valid results for the client.

CD4+ T-cell count

🟦 This test measures immune system function, not HIV confirmation.

🟦 It is used for disease staging and monitoring, not diagnosis.

Quantitative RNA assay

🟦 This test measures the amount of virus in the blood.

🟦 It is used to monitor treatment effectiveness, not confirm initial diagnosis.

Viral load test

🟦 Viral load assesses HIV replication activity after diagnosis.

🟦 It does not confirm the presence of HIV antibodies.

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Answer 2

Correct Answers:

Postoperative delirium

Rationale :

🟦 Postoperative delirium is an acute, temporary disturbance in consciousness and cognition that commonly occurs in older adults after surgery.

🟦 It is characterized by sudden onset disorientation, fluctuating attention, and altered awareness.

🟦 Anesthesia, pain, infection, sleep disruption, and medications are frequent precipitating factors.

🟦 Symptoms often resolve as the underlying cause is treated, distinguishing it from chronic cognitive disorders.

🟦 Early recognition allows timely interventions to improve safety and recovery outcomes.

Dementia

🟦 Dementia involves a gradual, progressive decline in cognitive function over time.

🟦 It is not sudden or temporary following surgery.

Alzheimer’s disease

🟦 Alzheimer’s disease is a chronic neurodegenerative condition with irreversible progression.

🟦 Symptoms do not present acutely after a surgical event.

Postoperative cognitive dysfunction

🟦 This condition presents as subtle, longer-term cognitive changes weeks to months after surgery.

🟦 It is not marked by abrupt disorientation in the immediate postoperative period.

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Answer 3

Correct Answers:

Instruct the client to eat cooked foods only,

Rationale :

🟦 Immunosuppressed clients have a reduced ability to fight infection, requiring measures that minimize exposure to pathogens.

🟦 Eating cooked foods only reduces the risk of foodborne illnesses from bacteria or parasites found in raw foods.

🟦 Restricting visitors with active infections prevents transmission of communicable diseases to a vulnerable client.

🟦 These precautions directly reduce environmental and interpersonal sources of infection.

🟦 Incorporating these measures into the plan of care supports infection prevention and patient safety.

Dispose of all linen in the trash after use.

🟦 Soiled linen should be placed in designated laundry bags, not trash.

🟦 Proper linen handling prevents cross-contamination while maintaining facility protocols.

Don a mask, gloves, and gown.

🟦 Full PPE is not required unless the client is on specific isolation precautions.

🟦 Standard precautions are sufficient in most immunosuppressed-care situations.

Limit the client from bathing daily.

🟦 Daily bathing supports skin integrity and hygiene, reducing infection risk.

🟦 Limiting bathing can actually increase microbial growth on the skin.

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Answer 4

Correct Answers:

Wearing male and/or female condoms during sexual activity can prevent HIV transmission,

Rationale :

🟦 Condom use is a proven and effective method for reducing HIV transmission during sexual activity.

🟦 Condoms act as a physical barrier that prevents exchange of blood, semen, and vaginal fluids.

🟦 Consistent and correct use significantly lowers the risk of sexual transmission of HIV.

🟦 Both male and female condoms provide protection when used properly.

🟦 Teaching condom use empowers individuals to engage in safer sexual practices.

HIV is only transmitted through sexual contact like other STIs.

🟦 HIV is transmitted through blood, semen, vaginal fluids, rectal fluids, and breast milk.

🟦 It can also be spread through needle sharing and perinatal exposure, not only sexual contact.

HIV can be transmitted through saliva, so it is important to limit kissing.

🟦 Saliva does not transmit HIV unless blood is present in significant amounts.

🟦 Casual contact such as kissing does not pose a transmission risk.

Only IV drug users are at risk of getting HIV because it is transmitted by blood only.

🟦 HIV affects individuals across all populations and risk groups.

🟦 Sexual transmission remains one of the most common routes of infection.

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Answer 5

Correct Answers:

Night sweats

Rationale :

🟦 Clients with AIDS commonly experience night sweats due to chronic infection and immune system dysfunction.

🟦 Advanced HIV leads to opportunistic infections and inflammatory responses that trigger fever and sweating, especially at night.

🟦 Night sweats are a classic systemic manifestation seen as the disease progresses from HIV to AIDS.

🟦 This finding often occurs alongside weight loss, fatigue, and recurrent infections.

🟦 Recognizing night sweats helps nurses assess disease severity and progression.

Increased hemoglobin

🟦 Clients with advanced HIV/AIDS are more likely to develop anemia, not elevated hemoglobin.

🟦 Bone marrow suppression and chronic illness contribute to reduced red blood cell production.

Increased WBC count

🟦 AIDS is associated with immune suppression, particularly decreased CD4+ T cells.

🟦 White blood cell counts are often low or impaired, not elevated.

Weight gain

🟦 Advanced HIV/AIDS commonly leads to weight loss and wasting syndrome.

🟦 Poor appetite, malabsorption, and increased metabolic demands prevent weight gain.

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Answer 6

Correct Answers:

Sexual assault
Use of intravenous drugs
Unprotected sexual activity
Exposure of blood or body fluids of a person with HIV

Rationale :

🟦 HIV is transmitted through blood, semen, vaginal fluids, rectal fluids, and breast milk, making certain exposures high risk.

🟦 Unprotected sexual activity allows direct exchange of infectious body fluids, significantly increasing transmission risk.

🟦 Intravenous drug use can spread HIV through shared needles and syringes contaminated with blood.

🟦 Sexual assault places individuals at high risk due to forced exposure and lack of protective measures.

🟦 Exposure to infected blood or body fluids through open wounds or mucous membranes is a recognized route of transmission.

Smoking marijuana

🟦 Marijuana use does not directly involve exposure to infectious body fluids.

🟦 It is not a direct biological risk factor for HIV transmission.

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Answer 7

Correct Answers:

1 tsp

Rationale :

🟦 In medication administration, 1 teaspoon (tsp) equals 5 mL.

🟦 The prescription instructs the client to take 5 mL orally.

🟦 Converting milliliters to teaspoons ensures accurate home dosing.

🟦 Giving more or less than 1 tsp would result in overdosing or underdosing.

🟦 Teaching correct measurement promotes medication safety and effectiveness.

5 tsp

🟦 This would equal 25 mL, which is far above the prescribed dose.

🟦 Excess dosing increases the risk of adverse effects.

0.5 tsp

🟦 This equals 2.5 mL, which is only half of the ordered dose.

🟦 Underdosing can reduce therapeutic effectiveness.

2.5 tsp

🟦 This equals 12.5 mL, exceeding the prescribed amount.

🟦 Incorrect volume can lead to medication errors.

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Answer 8

Correct Answers:

Use a new sponge each time the surgical site is scrubbed.

Rationale :

🟦 Using a new sponge for each pass prevents reintroducing microorganisms onto the cleansed skin.

🟦 This technique reduces the risk of contaminating the surgical site during preparation.

🟦 Each outward stroke removes microorganisms from the incision area, and a fresh sponge maintains aseptic integrity.

🟦 Reusing a sponge can spread organisms back toward the incision, increasing infection risk.

🟦 This practice aligns with surgical asepsis standards to minimize postoperative infections.

Shaving the client’s hair near the surgical site

🟦 Shaving can cause micro abrasions that increase the risk of infection.

🟦 Hair removal, if necessary, is done with clippers, not razors.

Scrubbing the surgical site starting at the outer edge and moving inward

🟦 Skin preparation should begin at the incision site and move outward.

🟦 Moving inward can bring contaminants back toward the surgical area.

Cleansing the surgical site with a povidone-iodine solution

🟦 Antiseptic solutions may vary based on provider preference and patient allergies.

🟦 The critical safety principle is proper technique, not the specific solution alone.

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Answer 9

Correct Answers:

A phlebotomist who collects blood from clients who have HIV

Rationale :

🟦 HIV is transmitted through blood and certain body fluids, making direct blood exposure a significant risk factor.

🟦 A phlebotomist routinely performs venipuncture, which carries a risk of needlestick injury.

🟦 Accidental exposure to HIV-infected blood through sharps is a well-documented occupational hazard.

🟦 Even with standard precautions, the nature of blood collection places phlebotomists at higher relative risk than other roles listed.

🟦 This makes phlebotomy one of the highest-risk healthcare tasks for HIV transmission.

Casual contact does not transmit HIV.

🟦 Working as a personal trainer involves no exposure to blood or high-risk body fluids.

🟦 HIV is not spread through sweat, touch, or shared exercise equipment.

Urine is not a transmission route.

🟦 Collecting urine samples does not involve infectious HIV concentrations.

🟦 HIV is not transmitted through urine in routine care settings.

Therapeutic contact does not pose blood exposure risk.

🟦 Occupational therapy focuses on rehabilitation and mobility, not invasive procedures.

🟦 Without blood exposure, the risk of HIV transmission remains extremely low.

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Answer 10

Correct Answers:

Use hand sanitizers for hand hygiene when caring for the child.

Rationale :

🟦 Standard precautions are used when caring for clients with HIV, and hand hygiene is the most important measure.

🟦 Alcohol-based hand sanitizers are effective for routine hand hygiene when hands are not visibly soiled.

🟦 HIV is not transmitted through casual contact, sweat, or touch.

🟦 Proper hand hygiene protects both the nurse and the child without unnecessary isolation.

🟦 This approach supports safe, non-stigmatizing, and family-centered care.

Sweat does not transmit HIV.

🟦 HIV is not spread through sweat, saliva, or casual skin contact.

🟦 Gloves are only required when contact with blood or certain body fluids is anticipated.

Limiting contact is unnecessary and inappropriate.

🟦 Restricting contact can contribute to stigmatization and emotional harm.

🟦 Children with HIV should receive normal therapeutic interaction.

Droplet precautions are not indicated.

🟦 HIV is not an airborne or droplet-spread infection.

🟦 Additional isolation precautions are not required beyond standard precautions.

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☑️ Custom- 212 Exam 3 Immune System and Periop-BECKFIELD COLLEGE

No.

1 :
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme- linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

2 :
A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?

3 :
A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

4 :
A community health nurse is providing teaching about HIV prevention. What prevention measure should the nurse include in the teaching.

5 :
A nurse is caring for a client who has HIV infection dementia and has progressed to AIDS. Which of the following findings should the nurse expect?

6 :
A school nurse is providing education to a group of adolescents about HIV. Which of the following risk factors of HIV should the nurse include in the education? (Select all that apply.)

7 :
A nurse is providing teaching to a client Who has a prescription for amoxicillin 5 mL PO. HOW many teaspoons (tsp) should the nurse instruct the client to take?

8 :
A nurse is performing a skin preparation for a client who is scheduled for surgery. Which of the following actions should the nurse take?

9 :
A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?

10 :
A nurse is caring for a 6-year-old child who has HIV. Which of the following actions should the nurse take?

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☑️ Custom- 212 Exam 3 Immune System and Periop-BECKFIELD COLLEGE

No.

1 : A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme- linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

2 : A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?

3 : A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

4 : A community health nurse is providing teaching about HIV prevention. What prevention measure should the nurse include in the teaching.

5 : A nurse is caring for a client who has HIV infection dementia and has progressed to AIDS. Which of the following findings should the nurse expect?

6 : A school nurse is providing education to a group of adolescents about HIV. Which of the following risk factors of HIV should the nurse include in the education? (Select all that apply.)

7 : A nurse is providing teaching to a client Who has a prescription for amoxicillin 5 mL PO. HOW many teaspoons (tsp) should the nurse instruct the client to take?

8 : A nurse is performing a skin preparation for a client who is scheduled for surgery. Which of the following actions should the nurse take?

9 : A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?

10 : A nurse is caring for a 6-year-old child who has HIV. Which of the following actions should the nurse take?

1 :
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme- linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

2 :
A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?

3 :
A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

4 :
A community health nurse is providing teaching about HIV prevention. What prevention measure should the nurse include in the teaching.

5 :
A nurse is caring for a client who has HIV infection dementia and has progressed to AIDS. Which of the following findings should the nurse expect?

6 :
A school nurse is providing education to a group of adolescents about HIV. Which of the following risk factors of HIV should the nurse include in the education? (Select all that apply.)

7 :
A nurse is providing teaching to a client Who has a prescription for amoxicillin 5 mL PO. HOW many teaspoons (tsp) should the nurse instruct the client to take?

8 :
A nurse is performing a skin preparation for a client who is scheduled for surgery. Which of the following actions should the nurse take?

9 :
A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?

10 :
A nurse is caring for a 6-year-old child who has HIV. Which of the following actions should the nurse take?