Review the electronic health record. Complete the diagram by selecting from the choices below to specify what isolation precaution the client requires, 2 actions the nurse should take to address the isolation, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for correct choices
• Standard precautions: Clients with HIV who are asymptomatic and not showing signs of infection require standard precautions. These precautions are used for all patients to prevent transmission of bloodborne pathogens and other infections, regardless of diagnosis. Standard precautions focus on protecting healthcare workers and preventing cross-contamination.
• Wear gloves when anticipating contact with bodily fluids: Gloves prevent exposure to blood, bodily fluids, and other potentially infectious materials. This is a fundamental part of standard precautions, reducing the risk of transmission of HIV and other pathogens during routine care.
• Perform hand hygiene before and after client care: Hand hygiene is the most effective method for preventing the spread of infections. Washing hands before and after patient contact is critical for protecting both the client and healthcare personnel, and is a key component of standard precautions.
• Viral load: Monitoring viral load in clients with HIV provides information about the effectiveness of antiretroviral therapy and disease progression. It helps guide clinical decisions and assess risk for opportunistic infections.
• Surgical site: Post-operative clients are at risk for surgical site infections. Monitoring the surgical site ensures early detection of infection, redness, drainage, or delayed healing, which is crucial for a client with compromised immunity.
Rationale for incorrect choices
• Place the client in a negative-pressure airflow room: Negative-pressure rooms are required for airborne precautions, such as tuberculosis or measles, not for asymptomatic HIV. Using such rooms unnecessarily can strain resources and is not indicated in this scenario.
• Place client in a private room: While private rooms may be used for client comfort, standard precautions do not mandate isolation unless there is a specific infectious risk. HIV alone does not require a private room.
• Administer anti-fungal medications: There is no evidence of fungal infection in this asymptomatic client. Prophylactic antifungal therapy is not indicated and could cause unnecessary side effects.
• Contact precautions: Contact precautions are required for infections that can be transmitted via direct or indirect contact (e.g., MRSA, C. difficile). This client has no active infectious condition requiring contact isolation.
• Droplet precautions: Droplet precautions are used for respiratory infections that spread via large droplets (e.g., influenza, pertussis). This client is not symptomatic and does not require droplet precautions.
• Airborne precautions: Airborne precautions are reserved for infections transmitted via small airborne particles (e.g., tuberculosis, measles, varicella). Asymptomatic HIV is not airborne, so these precautions are unnecessary.
• Sputum production: Monitoring sputum is relevant for clients with respiratory infections or pulmonary concerns. This client has no respiratory symptoms and sputum monitoring is not indicated.
• Serum electrolytes: Routine electrolyte monitoring is not specifically related to infection control or HIV management in this stable post-operative client.
• Urine output: While important in certain contexts, urine output does not specifically assess infection risk or progression of HIV in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
• Disinfecting a client's counter before administering oral medications: This practice reduces the number of microorganisms on surfaces to prevent infection, which is the principle of medical asepsis. It focuses on cleanliness and reducing contamination rather than creating a completely sterile environment.
• Covering the client and surrounding area with sterile drapes: Sterile drapes create a sterile field and prevent contamination of surgical or invasive sites. This is a key component of surgical asepsis, ensuring that instruments, supplies, and the environment remain free from microorganisms during procedures.
• Covering mouth and nose with a sleeve or elbow when coughing or sneezing: This prevents the spread of pathogens via droplets and maintains a clean environment. It is a basic principle of medical asepsis, which aims to reduce infection transmission through routine hygiene practices.
• Allowing only sterile-to-sterile contact: Maintaining a sterile field requires that sterile items only touch other sterile items. This is fundamental to surgical asepsis, preventing introduction of microorganisms during invasive procedures. Any break in sterile technique increases the risk of infection.
• Using sterile packaging for instruments and supplies: Sterile packaging preserves sterility until use, which is critical for surgical asepsis. It ensures that instruments and supplies remain free from microorganisms until the moment of use in invasive procedures.
• Using an autoclave to sterilize surgical instruments: Autoclaving uses high-pressure steam to destroy all microorganisms, achieving complete sterility. This process is a core component of surgical asepsis, making instruments safe for invasive procedures.
Correct Answer is B
Explanation
A. Perform exercises until you feel pain in the joint: Active ROM exercises should not cause pain, as pain can indicate joint injury, inflammation, or overextension. Exercising into pain may worsen tissue damage and reduce adherence. Discomfort signals the need to stop or modify movement.
B. Move each joint until there is resistance and then stop: Active ROM exercises are performed to the point of resistance, which reflects the joint’s normal anatomic limit. This maintains joint flexibility, circulation, and muscle function without stressing ligaments or joint capsules. Stopping at resistance helps prevent injury.
C. Expose the entire body to observe overall movement: Only the joint being exercised needs to be exposed to preserve client comfort and dignity. Full-body exposure is unnecessary for ROM instruction. Observation can be effectively performed one joint at a time.
D. Perform exercises rapidly to increase muscle strength: Rapid movements increase the risk of joint strain and muscle injury, especially in clients with limited mobility. Active ROM focuses on maintaining flexibility and joint motion rather than building strength. Movements should be slow, controlled, and deliberate.
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