the nurse is caring for a client who has just tested positive for hiv the client asks the nurse not to tell anyone outside of the care team about his
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Nursing Elites

NCLEX-PN

Nclex PN Questions and Answers

1. The client asks the nurse not to tell anyone outside of the care team about his positive HIV diagnosis. What response is most appropriate?

Correct answer: “Because this is a communicable disease, it may need to be reported to the CDC.”

Rationale: The most appropriate response is C: “Because this is a communicable disease, it may need to be reported to the CDC.” It is important to uphold patient confidentiality, but in the case of certain communicable diseases like HIV, there are legal requirements for mandatory reporting to public health authorities such as the CDC. Option A is incorrect because it violates patient confidentiality and does not consider legal obligations. Option B, while respecting the client's wishes, may not align with the legal requirement for reporting certain communicable diseases. Option D is inappropriate as it dismisses the client's concerns and rights regarding their health information.

2. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?

Correct answer: “I am sorry, but it is not safe for you to wear the crucifix during this test.”

Rationale: No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.

3. Which of the following statements by a client indicates adequate understanding of preparation for a lipoprotein fractionation test?

Correct answer: “I cannot eat for 12 hours before the test.”

Rationale: The correct statement regarding preparation for a lipoprotein fractionation test is that the client cannot eat for 12 hours before the test. It is important to note that the client can drink an unrestricted amount of water. Limiting fluid intake is not necessary for this test. There is no need for the client to ingest a lipid solution as part of the preparation. Therefore, the other choices are incorrect.

4. How far should the enema tube be inserted for a client to have a flatus-reducing enema?

Correct answer: 4 inches.

Rationale: The correct answer is to insert the enema tube 4 inches. Enema tubing must be passed beyond the internal sphincter, which is typically around 4 inches in an adult. Inserting the tube only 2 inches is not far enough to reach this point. On the other hand, inserting the tube 6 or 8 inches is too far and might cause trauma to the bowel, which is unnecessary for a flatus-reducing enema. Therefore, the correct insertion depth of the enema tube is crucial to ensure effectiveness and safety in providing the intended treatment.

5. Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:

Correct answer: reinforce the dressing.

Rationale: Serosanguinous drainage is expected after a classic cholecystectomy resection. The appropriate intervention is to reinforce the dressing to maintain pressure and promote clot formation. Changing the dressing prematurely increases the risk of infection as it disturbs the wound. Applying an abdominal binder is not indicated as it can interfere with visualizing the dressing and assessing for any signs of bleeding or infection. Notifying the physician is not necessary at this point unless there are signs of excessive bleeding or other concerning symptoms.

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