Which practice is recommended to prevent human immune deficiency virus (HIV) transmission?

Using standard precautions

Double gloving

Applying hand sanitizer to gloves during cares

Wearing a mask within three feet of the client

Answer and Explanation

The Correct Answer is A

Choice A reason: Using standard precautions is a practice that is recommended to prevent HIV transmission, because it is a set of guidelines that apply to all clients, regardless of their infection status, and that aim to prevent the exposure to blood, body fluids, or other potentially infectious materials. Standard precautions include hand hygiene, use of personal protective equipment, safe handling and disposal of sharps, environmental cleaning, and respiratory hygiene.

Choice B reason: Double gloving is not a practice that is recommended to prevent HIV transmission, because it is not proven to be more effective or safer than single gloving. Double gloving is a technique that involves wearing two pairs of gloves, one over the other, which may provide some extra protection against needlestick injuries or glove punctures, but may also reduce the tactile sensitivity, dexterity, or comfort of the wearer. Double gloving is not a routine practice, but rather an option for certain situations, such as highrisk procedures, long surgeries, or known HIVpositive clients.

Choice C reason: Applying hand sanitizer to gloves during cares is not a practice that is recommended to prevent HIV transmission, because it is not appropriate or hygienic. Applying hand sanitizer to gloves during cares is a practice that can damage the integrity and effectiveness of the gloves, as the alcohol or other chemicals can degrade the material, cause holes, or reduce the fit of the gloves. Applying hand sanitizer to gloves during cares can also create a false sense of security, as the gloves may still be contaminated or ineffective. Hand sanitizer should be applied to the hands before and after wearing gloves, not to the gloves themselves.

Choice D reason: Wearing a mask within three feet of the client is not a practice that is recommended to prevent HIV transmission, because it is not necessary or relevant. Wearing a mask within three feet of the client is a practice that is part of the droplet precautions, which are used to prevent the transmission of infections that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. HIV is not transmitted by respiratory droplets, but rather by sexual contact, blood, or other body fluids. Wearing a mask within three feet of the client may not provide any protection against HIV, and may also cause stigma or discrimination.

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Correct Answer is C

Explanation

Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.

Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.

A. Polyuria B. Edema C. Heat D. Erythema E. Pain

Correct Answer is ["A","B"]

Explanation

Choice A reason: Polyuria is the production of abnormally large amounts of urine, which can be caused by various factors, such as diabetes, kidney disease, or diuretics. Polyuria is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not affect the urinary system directly, unless the inflammation is located in the kidneys or bladder.

Choice B reason: Edema is the swelling of tissues due to excess fluid accumulation, which can be caused by various factors, such as heart failure, liver disease, or venous insufficiency. Edema is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not cause fluid retention, but rather fluid leakage from the blood vessels into the interstitial spaces.

Choice C reason: Heat is an expected finding in a client with inflammation, which is the body's response to injury or infection. Heat is caused by the increased blood flow to the inflamed area, which brings more oxygen and nutrients to the damaged tissues. Heat also helps to kill or inhibit the growth of microorganisms that may cause infection.

Choice D reason: Erythema is an expected finding in a client with inflammation, which is the body's response to injury or infection. Erythema is the redness of the skin due to the dilation of the blood vessels in the inflamed area, which increases the blood flow and the delivery of oxygen and nutrients to the damaged tissues. Erythema also helps to signal the presence of inflammation and attract immune cells to the site.

Choice E reason: Pain is an expected finding in a client with inflammation, which is the body's response to injury or infection. Pain is caused by the stimulation of the nerve endings by chemical mediators, such as histamine, prostaglandins, and bradykinin, that are released by the inflamed tissues. Pain also helps to alert the client of the injury or infection and to limit the movement or use of the affected area.

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Which practice is recommended to prevent human immune deficiency virus (HIV) transmission?

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Naxlex Comprehensive Predictor Exams

A client on bedrest complains of pain and burning in the right calf area. What is the nurse's next action?

Correct Answer is C

Explanation

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Correct Answer is ["A","B"]

Explanation

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