Nokea
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
- A. The nurse wears face protection, gloves, and a gown when irrigating a wound.
- B. The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves.
- C. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
- D. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.
Correct Answer: C
Rationale: Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same patient. Each of the other listed actions adheres to standard precautions.
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The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
- A. Attach the condom prior to erection.
- B. A condom may be reused with the same partner if ejaculation has not occurred.
- C. Use skin lotion as a lubricant if alternatives are unavailable.
- D. Hold the condom by the cuff upon withdrawal.
Correct Answer: D
Rationale: The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, or cold cream should not be used with condoms because they cause latex deterioration/condom breakage. The condom should be held during withdrawal so it does not come off the penis. Condoms should never be reused.
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.
A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold?
- A. 75 cells/mm^3 of blood
- B. 200 cells/mm^3 of blood
- C. 325 cells/mm^3 of blood
- D. 450 cells/mm^3 of blood
Correct Answer: B
Rationale: When CD4+ T-cell levels drop below 200 cells/mm^3 of blood, the person is said to have AIDS.
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.
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response?
- A. Do you think that you might already have HIV?
- B. Dont worry. Your immune system is likely very healthy.
- C. AIDS isnt transmitted by casual contact.
- D. You cant contract AIDS in a hospital setting.
Correct Answer: C
Rationale: AIDS is commonly transmitted by contact with blood and body fluids. Patients, family, and friends must be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV infection.