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When caring for a patient with AIDS, which of the following nursing actions would be the most appropriate for infection control?
- A. Wear gloves at all times
- B. Wear gown and mask at all times
- C. Wear gloves for blood/body fluid contact
- D. Wear a mask during patient contact times
Correct Answer: C
Rationale: The most appropriate nursing action for infection control when caring for a patient with AIDS is to wear gloves for blood/body fluid contact. HIV, the virus that causes AIDS, is primarily spread through exposure to infected blood or body fluids. Therefore, wearing gloves when there is a potential for blood or body fluid contact is crucial in preventing the transmission of the virus. Wearing gloves at all times may not be necessary if there is no direct contact with blood or body fluids, and wearing a gown and mask at all times may not be indicated unless there is a specific need based on the situation. Wearing a mask during patient contact times may also not be necessary unless there is a risk of exposure to respiratory secretions.
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The nurse is conducting a staff in-service on renal ultrasounds. Which statement describes this diagnostic test?
- A. Computed tomography uses external radiation to visualize the renal system.
- B. Visualization of the renal system is accomplished without exposure to radiation or radioactive isotopes.
- C. Contrast medium and x-rays allow for visualization of the renal system.
- D. External radiation for x-ray films is used to visualize the renal system, before, during, and after voiding.
Correct Answer: B
Rationale: Renal ultrasound is a non-invasive imaging technique that uses high-frequency sound waves to produce images of the kidneys and surrounding structures. Unlike computed tomography (CT) scans (Choice A) or intravenous pyelograms (Choice C) which may involve exposure to radiation or contrast medium, renal ultrasounds do not expose the patient to radiation or radioactive isotopes, making it a safe option for imaging the renal system. Ultrasounds are commonly used to assess kidney size, detect kidney stones, evaluate blood flow to the kidneys, and diagnose various renal conditions, such as hydronephrosis or renal cysts.
Which finding requires immediate attention in a child with glomerulonephritis?
- A. Sleeping most of the day with BP 170/90.
- B. Urine output of 190 mL in 8 hours with Coca-Cola-colored urine.
- C. Severe headache and photophobia.
- D. Refusal to eat with poor appetite.
Correct Answer: C
Rationale: A severe headache with photophobia may indicate hypertensive encephalopathy; this requires prompt evaluation.
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
- A. lubricate the walls of the intestinal tract
- B. soften the fecal mass and lubricate the walls of the rectum and colon
- C. reduce bacterial content of the fecal mass
- D. coat the walls of the intestines to prevent irritation by the hardened fecal mass
Correct Answer: B
Rationale: The rationale for administering the oil retention enema first in this case is to help soften the fecal mass and lubricate the walls of the rectum and colon. This will make it easier for the impacted stool to be passed, reducing the risk of injury or discomfort during the procedure. The oil enema acts as a lubricant, making it easier for the hardened fecal mass to be expelled from the body without causing damage to the intestinal walls. Additionally, the oil enema helps to soften the fecal mass, further aiding in its removal.
The nurse notes the first stool of a newborn is black and tarry. Which term is used to describe this type of stool?
- A. Meconium
- B. Transitional
- C. Miliaria
- D. Milk stool
Correct Answer: A
Rationale: Meconium is the term used to describe the first stool of a newborn. This stool is black and tarry in appearance. Meconium is made up of materials ingested by the fetus while in the uterus, such as mucus, amniotic fluid, and cells shed from the stomach and intestines. It is typically passed by a newborn within the first few days of life before transitioning to transitional stools, which are greenish-brown in color, and eventually to normal milk stools as the baby starts feeding on breast milk or formula.
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: In a client with end-stage acquired immunodeficiency syndrome (AIDS) manifesting with profound Cryptosporidium infection, fluid replacement is crucial for managing the symptoms and complications. Cryptosporidium infection can cause severe diarrhea and dehydration, leading to significant fluid loss. Therefore, the primary focus of care in this situation should be on maintaining adequate hydration through fluid replacement. This is essential for preventing further complications and supporting the client's overall health and well-being. Pain management, antiretroviral therapy, and high-calorie intake may be important aspects of care in other situations but are not the priority in managing a client with severe Cryptosporidium infection and dehydration.