When planning care for a patient with HIV, which of the following precautions should be implemented?
Standard
Droplet
Contact
Airborne
The Correct Answer is A
Choice A reason: This statement is correct, as standard precautions are the minimum level of infection control practices that should be applied to all patients, regardless of their diagnosis or presumed infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe handling of sharps and contaminated items, and environmental cleaning. Standard precautions are sufficient for most patients with HIV, unless they have other infections that require additional precautions.
Choice B reason: This statement is incorrect, as droplet precautions are not required for patients with HIV, unless they have other infections that are transmitted by respiratory droplets, such as influenza, pertussis, or meningitis. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorting with other patients with the same infection, and limiting the movement of the patient outside the room.
Choice C reason: This statement is incorrect, as contact precautions are not required for patients with HIV, unless they have other infections that are transmitted by direct or indirect contact, such as Clostridioides difficile, scabies, or herpes simplex virus. Contact precautions include wearing gloves and gowns when entering the patient's room, placing the patient in a private room or cohorting with other patients with the same infection, and dedicating patient-care equipment to the patient or disinfecting it before use on another patient.
Choice D reason: This statement is incorrect, as airborne precautions are not required for patients with HIV, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as burping the infant after feeding is not a nursing intervention, but a normal practice to prevent gas and discomfort. The nurse should encourage the mother to burp the infant gently after each feeding, and to avoid overfeeding or underfeeding the infant.
Choice B reason: This statement is incorrect, as giving five milliliters of water is not a nursing intervention, but a harmless amount of fluid for the infant. The nurse should inform the mother that water is not necessary for the infant, as breast milk or formula provides enough hydration and nutrition. However, the nurse should also reassure the mother that a small amount of water will not harm the infant.
Choice C reason: This statement is incorrect, as wrapping the infant during feeding is not a nursing intervention, but a comforting measure for the infant. The nurse should support the mother's bonding with the infant, and suggest ways to make the feeding experience more pleasant and relaxing for both of them. The nurse should also monitor the infant's temperature and avoid overheating.
Choice D reason: This statement is correct, as giving thirty milliliters of water is a nursing intervention that indicates a need for further education and guidance. The nurse should explain to the mother that giving too much water to the infant can cause water intoxication, which can lead to hyponatremia, seizures, or even death. The nurse should also teach the mother the signs and symptoms of water intoxication, such as irritability, lethargy, vomiting, or swelling.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as weight alone is not a reliable indicator of overweight or obesity in children and adolescents, as it does not account for the variations in growth, age, sex, and body composition. The nurse should use weight in conjunction with other measures, such as height, BMI, and growth charts, to assess the nutritional status and health risks of the child.
Choice B reason: This statement is incorrect, as height alone is not a reliable indicator of overweight or obesity in children and adolescents, as it does not account for the variations in growth, age, sex, and body composition. The nurse should use height in conjunction with other measures, such as weight, BMI, and growth charts, to assess the nutritional status and health risks of the child.
Choice C reason: This statement is incorrect, as body surface area (BSA) is not a recommended method of screening for overweight or obesity in children and adolescents, as it is not widely used or validated in this population. BSA is a measure of the total area of the skin, which can be calculated using various formulas based on weight and height. BSA is mainly used for dosing certain medications, such as chemotherapy, and for estimating the metabolic rate.
Choice D reason: This statement is correct, as body mass index (BMI) is the recommended method of screening for overweight or obesity in children and adolescents, as it is a simple and standardized measure of body fatness that can be used for comparison across different populations and age groups. BMI is calculated by dividing the weight in kilograms by the height in meters squared. The nurse should use the BMI-for-age percentile charts to interpret the BMI value and classify the child as underweight, healthy weight, overweight, or obese
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