A nurse is assigned care of a patient who has HIV.
Which of the following infection control precautions should the nurse plan to use while caring for this patient?
Airborne precautions
Standard precautions
Droplet precautions
Contact precautions
The Correct Answer is B
Choice A rationale
Airborne precautions are used for diseases that are spread by tiny droplets caused by coughing and sneezing. HIV is not spread through the air, so airborne precautions are not necessary.
Choice B rationale
Standard precautions are used for all patient care. They’re based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. HIV is transmitted by direct or indirect contact with infected blood or body fluids. Therefore, the nurse should plan to implement standard precautions when caring for this patient.
Choice C rationale
Droplet precautions are used for diseases that are spread by large droplets caused by coughing, sneezing, talking, or procedures such as suctioning and bronchoscopy. HIV is not spread through these methods, so droplet precautions are not necessary.
Choice D rationale
Contact precautions are used for diseases that are spread by direct contact with the patient or indirect contact with environmental surfaces or patient care items. HIV is not spread through casual contact, so contact precautions are not necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Irrigating the nasogastric tube with tap water is not recommended. Tap water is not sterile and can introduce bacteria into the stomach, potentially causing infection.
Choice B rationale
Marking abdominal girth once daily is not sufficient for a client who is postoperative following peritoneal lavage for peritonitis. This client is at risk for complications such as abscess formation and bowel obstruction, which can cause rapid changes in abdominal girth. Therefore, abdominal girth should be measured more frequently.
Choice C rationale
Placing the client in a high Fowler’s position is the correct intervention. This position, which involves the client sitting up at an angle of 45 to 60 degrees, can help reduce pressure on the abdominal area, promote better lung expansion, and facilitate drainage of gastric contents, thus reducing the risk of aspiration.
Choice D rationale
Ambulating the client twice daily is not appropriate in this case. The client has just undergone a major abdominal surgery and has a nasogastric tube and closed-suction drains in place. Early ambulation may not be feasible due to the risk of dislodging the drains or causing pain and discomfort.
Correct Answer is A
Explanation
Choice A rationale
Dark-colored urine is a common symptom of dehydration. When a person is dehydrated, their kidneys try to conserve water by concentrating the urine, which can make it appear darker. Choice B rationale
High blood pressure is not typically associated with dehydration. In fact, dehydration can sometimes lead to low blood pressure due to a decrease in blood volume.
Choice C rationale
Distended neck veins are not typically a symptom of dehydration. They are more commonly associated with conditions that cause fluid overload, such as heart failure.
Choice D rationale
Moist skin is not typically a symptom of dehydration. In fact, one of the symptoms of severe dehydration can be dry, cool skin.
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