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A client who is HIV/AIDS positive has a prescription for laboratory tests to be performed. What precautions should the nurse observe whenever there is a risk of exposure to the blood and body fluids of an infected client?
- A. Avoid any physical contact with the client.
- B. Avoid cleaning up spilled urine and feces.
- C. Wear barrier garments for as long as possible after leaving a client's room.
- D. Transport the specimens of body fluids in leak-proof containers.
Correct Answer: D
Rationale: Whenever there is a risk of exposure to the blood and body fluids of an infected client, the nurse should transport these specimens in leak-proof containers. The nurse need not avoid physical contact with the client or cleaning the client's urine or stools. Barrier garments, such as face shields and glasses, should be removed soon after leaving a client's room.
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The nurse administers an injection to a client with AIDS. When finished, the nurse attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse?
- A. Obtain counseling.
- B. Call the lab to draw the nurse's blood.
- C. Fill out a risk management report.
- D. Report the incident to the supervisor.
Correct Answer: D
Rationale: Because post exposure protocols can reduce the risk of HIV infection if initiated promptly, nurses must immediately report any needlestick or sharp injury to a supervisor. Obtaining counseling will occur after all other procedures are adhered to. The lab will draw blood from the client if required for documentation and other blood transmitted disorders.
A client requires a blood transfusion for anemia and tells the nurse, 'I don't want a transfusion because I don't want to get AIDS.' Which is the best response from the nurse to the client?
- A. It's always a possibility.'
- B. You don't want to die, do you?'
- C. The blood is screened, and your risk is one in two million.'
- D. If you don't have the transfusion, you are taking a greater risk.'
Correct Answer: C
Rationale: Before 1984, blood and blood products were a major source of HIV transmission. Since then, an HIV screening test known as nucleic acid testing (NAT) is performed on all blood and plasma donations. Although screening donated blood for HIV antibodies reduces the risk of transfusion-related infection with HIV, it is not flawless. The Verywell Health's website states that the risk for HIV infection in the United States from a blood transfusion is approximately one in two million units of blood. Informing the client that transmission is always a possibility does not provide any information that will be relevant to the decision. The other responses are nontherapeutic and, therefore, should not be used as a response to the client's statement.
A client is considering beginning sexual relations and wants to know the best way to be protected from a sexually transmitted infection and HIV. What is the best response by the nurse?
- A. Using a latex condom and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV.'
- B. Using a diaphragm with spermicidal jelly will kill the bacteria and viruses that transmit STIs and HIV.'
- C. Using a lamb skin condom will be the most effective way to decrease transmission of STIs and HIV.'
- D. Douching immediately after intercourse will be the most effective way to kill bacteria and viruses.'
Correct Answer: A
Rationale: Using a latex condom with spermicide is one of the most effective ways to reduce the risk of HIV infection. Condoms are available for both men and women. A diaphragm would not be the most effective way because there is no protection for the penis or vagina. A lamb skin condom is not effective to prevent the transmission of HIV. Douching after intercourse is not an effective method to avoid transmission and does not offer protection from secretions that are already present.
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluid(s) does the nurse inform them will transmit the virus? Select all that apply.
- A. Semen
- B. Urine
- C. Breast milk
- D. Blood
- E. Vaginal secretions
Correct Answer: A,C,D,E
Rationale: There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform what?
- A. p24 antigen test for confirmation of diagnosis.
- B. Western blot test for confirmation of diagnosis.
- C. polymerase chain reaction test for confirmation of diagnosis.
- D. T4-cell count for confirmation of diagnosis.
Correct Answer: B
Rationale: The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.