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 B
Explanation
A. Document how many inches the tube has been inserted: While documentation of the tube insertion depth is important, it is not the highest priority immediately after intubation. Ensuring proper placement and ventilation take precedence.
B. Auscultate both lungs for the presence of breath sounds: This is the priority action to confirm that the endotracheal tube is correctly placed in the trachea and that both lungs are being ventilated adequately. Absence of breath sounds on one side could indicate mainstem intubation or displacement of the tube.
C. Secure the endotracheal tube to prevent dislodgement: Securing the tube is important, but it should be done after confirming proper placement and ventilation.
D. Obtain a chest x-ray to ensure correct tube placement: While a chest x-ray is often performed after intubation to confirm tube placement, it is not the immediate priority. Auscultation provides more immediate feedback on the effectiveness of ventilation.
Correct Answer is A
Explanation
A. "My sense of smell is taking a long time to return.": This statement indicates a misunderstanding because, after a total laryngectomy, the sense of smell is significantly impaired or lost due to the inability to breathe through the nose. The client needs further teaching to understand that this change is likely permanent.
B. "Breathing through my stoma has diminished my sense of smell.": This statement is accurate as the stoma bypasses the nasal passages, reducing the sense of smell.
C. "I can't smell what I eat, but hope to enjoy eating in the future.": This shows an understanding that the sense of smell is impaired but expresses a positive outlook on enjoying food in other ways.
D. "I am happy to have a mild sense of taste despite no sense of smell.": This statement indicates an understanding of the sensory changes post-laryngectomy and reflects realistic expectations.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.