The licensed practical nurse/licensed vocational nurse (LPN/LVN) is watching a nursing student administer medications to a patient with HIV. Which action by the student requires correction by the nurse?
The student wears gloves when administering the medication
The student washes her hands before and after administering the medication.
The student recaps the needle and places it in the sharps container.
The student uses a needleless system to administer the medication.
The Correct Answer is A
A. The student wears gloves when administering the medication: Wearing gloves is part of standard precautions for administering medications.
B. The student washes her hands before and after administering the medication: Hand hygiene is essential before and after care for all patients, including those with HIV.
C. The student recaps the needle and places it in the sharps container: Requires correction; recapping needles increases the risk of accidental needle sticks and is not recommended. The correct practice is to dispose of needles directly in a sharps container without recapping.
D. The student uses a needleless system to administer the medication: Needleless systems reduce the risk of needle-stick injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Slow respirations: Tachypnea, not slow respirations, is more likely during a transfusion reaction.
B. Bradycardia: Tachycardia is more common due to the body's response to stress or inflammation.
C. Hypertension: Hypotension is more typical in severe reactions.
D. Fever/chills: Fever and chills are hallmark signs of febrile or hemolytic transfusion reactions due to the immune system's response to foreign antigens.
Correct Answer is D
Explanation
A. Release of memory T-cells: Memory T-cells are involved in Type IV delayed hypersensitivity, not Type I reactions.
B. Organ rejection: Organ rejection is associated with Type IV hypersensitivity reactions, not Type I.
C. Damage to blood vessels: This is more characteristic of Type III hypersensitivity reactions.
D. Release of histamine: Type I hypersensitivity reactions, such as anaphylaxis and allergic rhinitis, are triggered by the release of histamine from mast cells after IgE-mediated sensitization.
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