Nokea
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
- A. Changing the client's linens
- B. Administering oral medications
- C. Taking vital signs
- D. Completing a dressing change
Correct Answer: D
Rationale: The correct answer is D: Completing a dressing change. When completing a dressing change for a client who is HIV positive and postoperative, the nurse should wear a gown as personal protective equipment to prevent potential exposure to blood or body fluids. This is crucial for infection control and to protect both the nurse and the client.
Choice A: Changing the client's linens does not necessarily require wearing a gown unless there is a risk of exposure to blood or body fluids.
Choice B: Administering oral medications does not require wearing a gown as there is no risk of exposure to blood or body fluids.
Choice C: Taking vital signs also does not require wearing a gown unless there is a possibility of exposure to blood or body fluids during the procedure.
In summary, completing a dressing change involves the risk of exposure to blood or body fluids, hence the need for wearing a gown. Other actions listed do not carry the same level of risk, therefore do not require the use of a gown as personal protective
You may also like to solve these questions
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
- A. Atropine
- B. Epinephrine
- C. Magnesium
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Rationale: Atropine is the correct answer because it is the first-line medication for symptomatic bradycardia. It works by blocking the parasympathetic nervous system, increasing heart rate. Epinephrine is used for cardiac arrest, not bradycardia. Magnesium is for torsades de pointes, not bradycardia. Sodium bicarbonate is for metabolic acidosis, not bradycardia.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. CD4-T-cell count 180 cells/mm3
- B. White blood cell count 10,000/mm3
- C. Hemoglobin 12.5 g/dL
- D. Platelet count 200,000/mm3
Correct Answer: A
Rationale: The correct answer is A: CD4-T-cell count 180 cells/mm3. In HIV, monitoring CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates immunosuppression, increasing the risk of opportunistic infections. Therefore, it is the nurse's priority to monitor and ensure the CD4 count remains above critical levels to prevent complications.
Other choices are incorrect because:
B: White blood cell count is important but not as specific to HIV management.
C: Hemoglobin level is important for assessing anemia but not a priority in HIV care.
D: Platelet count is important for clotting but not directly related to HIV progression.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with a ventilated ceiling fan
- C. A room with a window and curtains that close
- D. A shared room with other tuberculosis clients
Correct Answer: A
Rationale: The correct answer is A: A room with air exhaust directly to the outdoor environment. This is the appropriate room assignment for a client with active tuberculosis because it helps prevent the spread of airborne infectious particles. The air exhaust system ensures that contaminated air is not recirculated within the unit, reducing the risk of transmission to other patients and staff.
Choice B (A room with a ventilated ceiling fan) is incorrect because a ceiling fan does not provide sufficient ventilation to prevent the spread of tuberculosis.
Choice C (A room with a window and curtains that close) is also incorrect as it does not address the need for proper ventilation and containment of infectious particles.
Choice D (A shared room with other tuberculosis clients) is clearly incorrect as it would increase the risk of transmission among the clients.
In summary, the correct room assignment for a client with active tuberculosis should prioritize containment and ventilation to minimize the risk of spreading the infection to others.
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
- A. Poor
- B. Favorable
- C. Uncertain
- D. Excellent
Correct Answer: A
Rationale: The correct answer is A: Poor. In stage IV ovarian cancer, the cancer has spread beyond the ovaries to distant organs, resulting in a poor prognosis. The aggressive treatments may help manage symptoms and prolong survival but the overall prognosis remains poor due to the advanced stage of the cancer. Choice B (Favorable) is incorrect because stage IV ovarian cancer has a poor prognosis. Choice C (Uncertain) is incorrect as the prognosis for stage IV ovarian cancer is generally known to be poor. Choice D (Excellent) is incorrect as stage IV ovarian cancer is not associated with an excellent prognosis due to its advanced stage.
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
- A. Check the client's vital signs every 15 min during the transfusion.
- B. Obtain a blood pressure reading every 30 minutes during the transfusion.
- C. Start the transfusion at a rapid rate to improve hemoglobin levels.
- D. Check the client's vital signs every hour during the transfusion.
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.