A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement?

Droplet precautions

Standard precautions

Airborne precautions

Contact precautions

Answer and Explanation

The Correct Answer is B

Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.

Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.

Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.

Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.

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Correct Answer is A

Explanation

Choice A reason: Checking the pulse distal to the graft is essential to ensure that the graft is patent and that there is adequate blood flow to the distal extremity. A palpable pulse indicates that the graft is functioning properly and not occluded. The absence of a pulse could signify a serious complication, such as thrombosis or stenosis, which requires immediate attention.

Choice B reason: Keeping the left forearm below the level of the heart is not recommended as it can increase venous pressure and swelling, potentially compromising graft function. The extremity should be kept at or above heart level to promote venous return and reduce the risk of edema.

Choice C reason: Collecting blood specimens from the graft is generally avoided to prevent damage to the graft. Blood draws can be performed from other sites to protect the integrity of the graft.

Choice D reason: Splinting the left forearm is not a standard postoperative care measure for an arteriovenous graft. While protecting the graft from injury is important, immobilization with a splint is not necessary and can impede mobility and circulation.

A. The client requires assistance with getting dressed. B. The client reports numbness of the fingers of the left hand. C. The client reports itching of the left arm. D. The client has a pillow under their left arm.

Correct Answer is B

Explanation

Choice A reason: While requiring assistance with getting dressed is an important consideration in care planning, it is not the most immediate priority. The nurse should ensure that the client's basic needs are met, but this does not represent an acute medical concern.

Choice B reason: The client reporting numbness of the fingers of the left hand is the most urgent priority. Numbness can indicate neurovascular compromise or increased pressure within the cast, which could lead to further injury or complications such as compartment syndrome. Immediate assessment and intervention are required to prevent permanent damage.

Choice C reason: Itching of the left arm under the cast is a common complaint and can be uncomfortable for the client. However, it is not a priority over potential neurovascular compromise. The nurse can provide education on how to safely alleviate itching without compromising the integrity of the cast.

Choice D reason: Having a pillow under the left arm is part of proper positioning to reduce swelling and provide comfort. While it is a part of good nursing care, it is not a priority over signs of neurovascular compromise.

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A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is postoperative following the insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority?

Correct Answer is B

Explanation

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