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?
Administering an intermittent IV bolus medication
Talking to the client at the bedside
Administering an IM injection
Completing a dressing change
The Correct Answer is D
A. Administering an IV bolus medication does not typically require gowning unless there is a risk of exposure to bodily fluids.
B. Talking to the client does not necessitate wearing a gown, as it does not pose a risk of exposure.
C. Administering an IM injection may require gloves but not necessarily a gown unless there is a risk of splashing.
D. Completing a dressing change involves potential exposure to bodily fluids, so wearing a gown is appropriate for infection control.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","F","H"]
Explanation
A. The WBC count is elevated at 15,000/mm³, which indicates leukocytosis. In a child with leukemia, this could suggest a potential relapse or an ongoing infection, which requires prompt evaluation by the provider.
B. The hemoglobin level is at the lower limit of normal (10 g/dL). This can indicate anemia, which is significant in a child with a history of leukemia and may require further investigation or intervention.
C. While the ongoing upper respiratory infection is concerning, it is less urgent than the other findings. The nurse should monitor this but may not need to report it as a critical finding compared to the child's acute symptoms.
D. The presence of clear breath sounds is expected; however, they should be reported in the context of the child's respiratory distress and the associated findings.
E. An oxygen saturation of 92% on room air is below the normal range and indicates hypoxia. This is a critical finding that requires immediate attention from the provider.
F. Subcostal retractions indicate increased work of breathing and respiratory distress, which is an urgent assessment finding that must be communicated to the provider.
G. While the respiratory rate is relevant, the specific number was not provided, and unless it indicates significant distress or abnormality, it may not be a priority report compared to the other findings.
H. The presence of petechiae is concerning, especially in a child with a history of leukemia. This could indicate thrombocytopenia or another hematological issue, which requires further evaluation by the provider.
Correct Answer is ["A","B","D"]
Explanation
A. Providing written information about the medication is important for ensuring the parents understand the treatment plan and can reference it later.
B. Discussing the potential adverse effects of the medication prepares the parents for what to monitor in their child and when to seek help.
C. Stopping the medication when the child feels better is incorrect, as it is essential to complete the full course of antibiotics to prevent resistance and recurrence of infection.
D. Explaining the reason why the child is taking the medication helps parents understand its importance and can enhance adherence to the treatment plan.
E. Advising against using a kitchen spoon for administering the medication is important, as it can lead to incorrect dosing; proper dosing devices should be used instead.
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