A nurse is providing direction to a nursing assistant who will be caring for a client with human immunodeficiency virus (HIV) and receiving azidothymidine (AZT) antiretroviral therapy. The nurse should instruct the nursing assistant to implement which of the following actions?
Isolation gown
Contact isolation
Standard precautions
Respiratory isolation
The Correct Answer is C
A. Isolation gown: Isolation gowns are used as part of contact precautions or airborne precautions for specific infectious diseases that require additional transmission-based precautions beyond standard precautions. However, standard precautions are generally sufficient for caring for clients with HIV receiving antiretroviral therapy.
B. Contact isolation: Contact isolation is used for patients with known or suspected infections that can be transmitted by direct or indirect contact with the patient or their environment. HIV does not require contact isolation unless there are additional infections or conditions present that warrant contact precautions.
C. Standard precautions: Standard precautions are the basic infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient. This includes practices such as hand hygiene, the use of personal protective equipment (e.g., gloves, gown, mask, eye protection) when indicated, and safe injection practices. Standard precautions should be used for all patients, including those with HIV, to prevent the transmission of infectious agents.
D. Respiratory isolation: Respiratory isolation is used for patients with known or suspected respiratory infections that are transmitted through respiratory droplets. HIV is not transmitted through respiratory droplets and does not require respiratory isolation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Allergic rhinitis: This is a common manifestation of a type I hypersensitivity reaction, often involving nasal congestion, sneezing, and itching.
B. Cough: While a cough can occur, it is not as specific or common in the context of systemic type I hypersensitivity reactions as the other options.
C. Hypotension: Hypotension can occur due to vasodilation and increased vascular permeability, which are hallmarks of systemic anaphylaxis.
D. Wheezing: Wheezing results from bronchoconstriction, a common feature in systemic type I hypersensitivity reactions, such as anaphylaxis.
E. Urticaria: Urticaria (hives) is a common skin manifestation of a type I hypersensitivity reaction, characterized by itchy, raised welts on the skin.
Correct Answer is B
Explanation
A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.
B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.
C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.
D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.
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