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NurseDive Free Nursing Practice Question
A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring this client?
A. Airborne precautions
Airborne precautions are used for infections that are transmitted via small respiratory droplets, such as tuberculosis or measles. HIV is not transmitted through the airborne route; it primarily spreads through blood, semen, vaginal fluids, and breast milk.
B. Standard precautions.
Standard precautions. Standard precautions are the fundamental principles of infection control that should be applied to all patients regardless of their diagnosis. They involve treating all blood, body fluids, non-intact skin, and mucous membranes as potentially infectious. These precautions include hand hygiene, using personal protective equipment (PPE) as appropriate, safe injection practices, and handling and disposing of sharps properly. Since HIV is primarily transmitted through blood and body fluids, standard precautions effectively prevent the transmission of the virus.
C. Droplet precautions
Droplet precautions are implemented for illnesses transmitted by larger respiratory droplets, such as influenza or pertussis. HIV is not primarily spread through respiratory droplets; hence, droplet precautions are not necessary for HIV.
D. Contact precautions
Contact precautions are used for infections that are transmitted by direct or indirect contact with the patient or their environment, like MRSA or C. difficile. While there might be some situations where contact precautions could be warranted for a person with HIV (like if they have an additional infection requiring contact precautions), the standard mode of transmission for HIV does not necessitate contact precautions on its own.
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Similar Questions
A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings show the nurse expect?
A. Hyperactive reflexes
Hypokalemia usually causes muscle weakness, decreased deep tendon reflexes, and cramps, not hyperreflexia.
B. Extreme thirst
While dehydration might be a consequence of vomiting and diarrhea, extreme thirst is not a typical symptom specifically related to hypokalemia. It's more associated with the body's response to fluid loss.
C. Weak, irregular pulse
Potassium is essential for cardiac conduction. Hypokalemia can cause dysrhythmias, irregular pulse, and weak heart contractions due to decreased excitability of myocardial cells.
D. Hyperactive bowel sounds
Hyperactive bowel sounds might be present in clients with gastrointestinal issues like diarrhea, but they are not directly caused by hypokalemia. They are more likely a consequence of the underlying gastrointestinal condition causing the electrolyte imbalance.
Full Explanation
A. Hypokalemia usually causes muscle weakness, decreased deep tendon reflexes, and cramps, not hyperreflexia.
B. While dehydration might be a consequence of vomiting and diarrhea, extreme thirst is not a typical symptom specifically related to hypokalemia. It's more associated with the body's response to fluid loss.
C. Potassium is essential for cardiac conduction. Hypokalemia can cause dysrhythmias, irregular pulse, and weak heart contractions due to decreased excitability of myocardial cells.
D. Hyperactive bowel sounds might be present in clients with gastrointestinal issues like diarrhea, but they are not directly caused by hypokalemia. They are more likely a consequence of the underlying gastrointestinal condition causing the electrolyte imbalance.
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?
A. Measure abdominal girth daily
Measure abdominal girth daily Monitoring the abdominal girth is essential as it can help assess changes in abdominal distension, which may indicate the effectiveness of the decompression or a potential complication. A sudden increase in abdominal girth might indicate inadequate decompression or worsening obstruction.
B. Maintain the client in Fowler's position.
Maintain the client in Fowler's position. Positioning the client in a semi-Fowler's or high Fowler's position can aid in reducing pressure on the abdomen, enhancing comfort, and potentially assisting in the passage of gas or fluids through the obstructed area. However, this position choice might vary based on the client's comfort and condition.
C. Moisten the client's lips with lemon-glycerin swabs.
Moisten the client's lips with lemon-glycerin swabs. Maintaining oral hygiene and providing comfort measures like moistening the lips can prevent drying and discomfort due to mouth breathing or reduced oral intake. Lemon-glycerin swabs are often used to hydrate and provide a refreshing sensation.
D. Use sterile water to irrigate the nasogastric tube.
Use sterile water to irrigate the nasogastric tube. Sterile water is the appropriate solution for irrigating a nasogastric tube to prevent introducing bacteria or contaminants into the client's gastrointestinal system. It helps maintain the patency of the tube and ensures the cleanliness of the system.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which of the following conditions as a complication TPN?
A. Aspiration
Aspiration , which involves inhaling stomach contents into the lungs, is a potential complication in clients receiving enteral feedings. TPN, being an intravenous route of nutrition, doesn't directly carry the risk of aspiration.
B. Polyuria
Polyuria Excessive urination (polyuria) is more commonly associated with kidney issues, diabetes, or other metabolic conditions. It's less likely to be a direct complication of TPN.
C. Abdominal distention
Abdominal distention Abdominal distention can occur as a complication of TPN due to various reasons such as fluid overload, electrolyte imbalances, or impaired absorption. It can also result from inadequate adjustment of the TPN solution or an inappropriate infusion rate. Monitoring for signs of abdominal distention is crucial as it may signify issues with the administration or tolerance of TPN.
D. Stomatitis
Stomatitis Stomatitis, or inflammation of the mouth or oral cavity, is not a common complication directly related to TPN. It's more often associated with factors like poor oral hygiene, chemotherapy, or infections.