Nokea
A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next?
- A. Flush the wound site with chlorhexidine.
- B. Report to the emergency department or employee health department.
- C. Apply a hydrocolloid dressing to the wound site.
- D. Follow up with the nurses primary care provider.
Correct Answer: B
Rationale: After initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. Flushing is recommended, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended. Following up with the nurses own primary care provider would require an unacceptable delay.
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A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
- A. Position the patient in the high Fowlers position whenever possible.
- B. Temporarily eliminate animal protein from the patients diet.
- C. Make sure the patient eats at least two servings of raw fruit each day.
- D. Obtain a stool culture to identify possible pathogens.
Correct Answer: D
Rationale: A stool culture should be obtained to determine the possible presence of microorganisms that cause diarrhea. Patients should generally avoid raw fruit when having diarrhea. There is no need to avoid animal protein or increase the height of the patients bed.
A nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
- A. Ineffective Airway Clearance
- B. Impaired Oral Mucous Membranes
- C. Imbalanced Nutrition: Less than Body Requirements
- D. Activity Intolerance
Correct Answer: A
Rationale: Although all these nursing diagnoses are appropriate for a patient with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the patient with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns.
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action?
- A. Assess the patient for additional signs and symptoms of Kaposis sarcoma.
- B. Review the patients most recent viral load and CD4+ count.
- C. Place the patient on respiratory isolation and inform the physician.
- D. Perform oral suctioning to reduce the patients risk for aspiration.
Correct Answer: C
Rationale: These signs and symptoms are suggestive of tuberculosis, not Kaposis sarcoma; prompt assessment and treatment is necessary. There is no indication of a need for oral suctioning and the patients blood work will not reflect the onset of this opportunistic infection.
An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurses best response?
- A. There is no way to know that for certain, but we do know that your baby has a one in four chance of being born with HIV.
- B. Your physician is likely the best one to ask that question.
- C. If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to worry about it now.
- D. Its possible that your baby could contract HIV, either before, during, or after delivery.
Correct Answer: D
Rationale: Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breast-feeding. There is no evidence that the infants risk is 25%. Deferral to the physician is not a substitute for responding appropriately to the patients concern. Downplaying the patients concerns is inappropriate.
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
- A. Serum albumin level
- B. Weight history
- C. White blood cell count
- D. Body mass index
- E. Blood urea nitrogen (BUN) level
Correct Answer: A,B,D,E
Rationale: Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the patients ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment.