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 D
Explanation
A. Dyspnea on exertion: Dyspnea on exertion is a common symptom in clients with heart failure and may indicate worsening heart function. While it warrants monitoring and potential intervention, it is not as urgent as rapid weight gain.
B. Increased urination: Increased urination may be expected with the use of diuretics, as they promote the excretion of excess fluid from the body. This finding is not typically concerning unless accompanied by other symptoms.
C. Weight gain of 2 pounds in a week: A weight gain of 2 pounds in a week may indicate fluid retention, but it is not as concerning as a rapid weight gain over a shorter period.
D. Weight gain of 3 pounds in 24 hours: A rapid weight gain of 3 pounds in 24 hours is significant and may indicate fluid overload, potentially leading to exacerbation of heart failure symptoms. It should be reported promptly to the healthcare provider for further evaluation and management.
Correct Answer is D
Explanation
A. "After the surgery, I will have to be careful with heavy lifting for a few weeks": This statement demonstrates understanding of postoperative precautions, as heavy lifting can strain the surgical site and delay healing.
B. "I know that after the surgery, I will only have one testicle left": This statement indicates awareness of the surgical procedure and its potential outcomes, which is accurate.
C. "I will have to take antibiotics as prescribed by my doctor to prevent infection": This statement reflects understanding of the importance of antibiotic therapy to prevent postoperative infection, which is correct.
D. "I will need to avoid showering for a month after the surgery": This statement is incorrect.
Avoiding showering for a month after surgery is unnecessary and could lead to poor hygiene and potential complications such as infection. The client should be educated that showering is typically allowed after surgery, but they should avoid soaking the incision site in water until it has healed properly.
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