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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. A client with edematous lower extremities: Edema requires positioning to promote venous return and reduce swelling, but it does not pose an immediate threat to oxygenation or life. While important, it is lower priority compared with acute respiratory compromise.

B. A client who has discomfort: Discomfort is important to address to maintain comfort and prevent agitation, but it is a lower priority than airway or breathing concerns. Pain management can be incorporated after addressing urgent physiologic needs.

C. A client who reports dyspnea: Dyspnea indicates impaired oxygenation and potential respiratory compromise. Prioritizing this client aligns with the ABC (Airway, Breathing, Circulation) principle, as maintaining adequate oxygenation is life-sustaining and requires immediate intervention.

D. A client with an order to turn every 2 hours: Scheduled turning prevents skin breakdown and pressure injuries but is a preventive measure. It is not more urgent than addressing a client experiencing dyspnea, which poses an immediate risk to safety and health.

A. "I will encourage him to walk daily so his muscles get stronger." B. "I will ensure he inserts his dentures so he can eat well during the day." C. "I will remind him to shift in his chair at least every two hours." D. "I will change his incontinence brief about every eight hours or so."

Correct Answer is D

Explanation

A. "I will encourage him to walk daily so his muscles get stronger.": Ambulation improves circulation, reduces prolonged pressure on bony prominences, and supports muscle strength needed for repositioning. Regular movement is a key preventive strategy for pressure injury development. Mobility also enhances overall skin integrity.

B. "I will ensure he inserts his dentures so he can eat well during the day.": Adequate nutrition supports tissue repair, immune function, and skin resilience. Proper denture use promotes sufficient caloric and protein intake. Nutrition is a foundational component of pressure injury prevention.

C. "I will remind him to shift in his chair at least every two hours.": Regular repositioning redistributes pressure and restores capillary blood flow to compressed tissues. While chair-bound clients often benefit from more frequent shifts, this practice still reflects appropriate preventive awareness. Pressure relief is essential for skin protection.

D. "I will change his incontinence brief about every eight hours or so.": Prolonged moisture exposure from urine or stool increases skin maceration and susceptibility to breakdown. Incontinence care requires frequent brief changes and prompt skin cleansing. Moisture management is critical in preventing pressure injuries.

View Question and Answer

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

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients who need positioning. Which client should the nurse prioritize?

Correct Answer is C

Explanation

The nurse provided discharge teaching to the client's family on preventing pressure injuries at home. Which statement made by the family member indicates a need for further instruction?

Correct Answer is D

Explanation

The nurse is caring for a client who is on airborne precautions. What action should the nurse take when using personal protective equipment (PPE)?

What is the most important action to prevent the transmission of microorganisms in the hospital setting?

The nurse plans care for a client with a wound. What action should the nurse incorporate into the client's care plan to minimize discomfort during wound care?

Review the electronic health record. The nurse is preparing the client for discharge. After the nurse provides education about the use of a cane, which statement by the client indicates understanding?

A nurse completes an assessment of a client just admitted from the emergency department. Which assessment finding(s) should concern the nurse? Select all that apply.

The nurse cares for a group of clients. Which client should the nurse prioritize?

The nurse is preparing to provide wound care for a group of clients in the outpatient setting. The nurse understands which action is considered best practice when providing wound care?

Complete the following sentence by choosing from the list of options. A pressure injury that presents with only dropdownis classified as a dropdownpressure injury.