A nurse is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which type of precaution should be used when providing direct care?

Standard

Droplet

Contact

Behavioral

Answer and Explanation

The Correct Answer is A

A. Standard precautions should be used for all patients, including those with AIDS, as they are designed to prevent the transmission of infections regardless of the patient's diagnosis. This includes the use of gloves, hand hygiene, and proper disposal of sharps.

B. Droplet precautions are specific to diseases that are spread through respiratory droplets, which is not the primary concern in AIDS management.

C. Contact precautions are used for infections that can be transmitted through direct contact with the patient or contaminated surfaces, but are not routinely required for AIDS patients unless they have co-infections.

D. Behavioral precautions are not a recognized category for infection control in clinical settings.

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Correct Answer is C

Explanation

A. Nitroprusside is a vasodilator and is not used for managing ICP; it can increase intracranial pressure if not carefully monitored.

B. Furosemide is a diuretic but is less effective for ICP reduction compared to hypertonic saline or mannitol.

C. Hypertonic saline (3% Normal Saline) is used to reduce intracranial pressure by drawing fluid out of the brain tissue and into the bloodstream, which can help prevent cerebral edema.

D. Norepinephrine is a vasopressor and is not used specifically to manage intracranial pressure.

A. T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air B. T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air C. T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air D. T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Correct Answer is B

Explanation

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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A nurse is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which type of precaution should be used when providing direct care?

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Naxlex Comprehensive Predictor Exams

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate a prescription for which of the following medications to manage increases in intracranial pressure (ICP)?

Correct Answer is C

Explanation

The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Correct Answer is B

Explanation

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