A client arrives speaking only Spanish. What is the priority nursing intervention?

Choice A reason: Using standard precautions is a practice that is recommended to prevent HIV transmission, because it is a set of guidelines that apply to all clients, regardless of their infection status, and that aim to prevent the exposure to blood, body fluids, or other potentially infectious materials. Standard precautions include hand hygiene, use of personal protective equipment, safe handling and disposal of sharps, environmental cleaning, and respiratory hygiene.

Choice B reason: Double gloving is not a practice that is recommended to prevent HIV transmission, because it is not proven to be more effective or safer than single gloving. Double gloving is a technique that involves wearing two pairs of gloves, one over the other, which may provide some extra protection against needlestick injuries or glove punctures, but may also reduce the tactile sensitivity, dexterity, or comfort of the wearer. Double gloving is not a routine practice, but rather an option for certain situations, such as highrisk procedures, long surgeries, or known HIVpositive clients.

Choice C reason: Applying hand sanitizer to gloves during cares is not a practice that is recommended to prevent HIV transmission, because it is not appropriate or hygienic. Applying hand sanitizer to gloves during cares is a practice that can damage the integrity and effectiveness of the gloves, as the alcohol or other chemicals can degrade the material, cause holes, or reduce the fit of the gloves. Applying hand sanitizer to gloves during cares can also create a false sense of security, as the gloves may still be contaminated or ineffective. Hand sanitizer should be applied to the hands before and after wearing gloves, not to the gloves themselves.

Choice D reason: Wearing a mask within three feet of the client is not a practice that is recommended to prevent HIV transmission, because it is not necessary or relevant. Wearing a mask within three feet of the client is a practice that is part of the droplet precautions, which are used to prevent the transmission of infections that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. HIV is not transmitted by respiratory droplets, but rather by sexual contact, blood, or other body fluids. Wearing a mask within three feet of the client may not provide any protection against HIV, and may also cause stigma or discrimination.

Choice A reason: This is not the correct answer because a skin infection is not transmitted by airborne droplets. A skin infection is usually caused by bacteria, fungi, or parasites that invade the skin and cause inflammation, redness, itching, or pus. A skin infection can be contagious by direct contact with the infected area or by sharing personal items, such as towels, clothing, or razors. The client with a skin infection should be placed in isolation for contact precautions, which involve wearing gloves and gowns and using disposable equipment.

Choice B reason: This is the correct answer because a fever with cough can be a sign of a respiratory infection that is transmitted by airborne droplets. A respiratory infection is caused by viruses, bacteria, or fungi that infect the lungs, throat, or nose and cause symptoms such as fever, cough, sore throat, or difficulty breathing. A respiratory infection can be contagious by inhaling the tiny droplets that are released when the infected person coughs, sneezes, or talks. The client with a respiratory infection should be placed in isolation for airborne precautions, which involve wearing a respirator mask and placing the client in a negative pressure room.

Choice C reason: This is not the correct answer because a rash is not transmitted by airborne droplets. A rash is a change in the color, texture, or appearance of the skin that can be caused by various factors, such as allergies, infections, medications, or injuries. A rash can be contagious by direct contact with the affected skin or by sharing personal items, such as clothing, bedding, or sports equipment. The client with a rash should be placed in isolation for contact precautions, which involve wearing gloves and gowns and using disposable equipment.

Choice D reason: This is not the correct answer because heart palpitations are not transmitted by airborne droplets. Heart palpitations are the sensation of having a fast, irregular, or pounding heartbeat that can be caused by various factors, such as stress, anxiety, caffeine, nicotine, or heart conditions. Heart palpitations are not contagious and do not require isolation. The client with heart palpitations should be evaluated for the underlying cause and treated accordingly.