A nurse at a long-term care facility is caring for a client who has AIDS. The client accidentally spills the contents of their urinal on the floor.
After cleaning up the spill with soap and water, the nurse should apply a solution of water and which of the following disinfectants to the floor?

This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.

Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.

Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.

Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure

condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.

Normal ranges for heart failure clients are:

• Blood pressure: less than 140/90 mmHg
• Heart rate: 60 to 100 beats per minute
• Respiratory rate: 12 to 20 breaths per minute
• Oxygen saturation: greater than 95%
• Weight: stable or decreasing within 2 to 4 pounds per week

Prepare the client for a cesarean birth.

This is because the client has herpes simplex virus with active lesions, which can be transmitted to the newborn during vaginal delivery and cause serious complications such as neonatal herpes infection. A cesarean birth can prevent this transmission and protect the newborn’s health.

Choice A is wrong because an amnioinfusion is a procedure that involves infusing fluid into the amniotic cavity to increase the volume of amniotic fluid and reduce cord compression.

It is not indicated for a client with herpes simplex virus with active lesions.

Choice C is wrong because ampicillin is an antibiotic that is used to treat bacterial infections, not viral infections such as herpes simplex virus.

Ampicillin will not prevent the transmission of herpes simplex virus to the newborn.

Choice D is wrong because oxytocin is a hormone that stimulates uterine contractions and can be used to augment or induce labor.

It is not indicated for a client with herpes simplex virus with active lesions, as it can increase the risk of transmission to the newborn by prolonging the exposure to infected genital secretions.