A nurse is caring for a client who has AIDS.
Which of the following solutions should the nurse use to disinfect the client's overbed table following a blood spill?
Hydrogen peroxide.
Bleach.
Isopropyl alcohol.
Chlorhexidine.
The Correct Answer is B
Choice A rationale:
Hydrogen peroxide. Hydrogen peroxide is not the recommended solution for disinfecting surfaces following a blood spill. While it can be used to clean wounds and may have some disinfectant properties, it is not as effective as bleach in destroying bloodborne pathogens.
Choice B rationale:
Bleach. Bleach is the appropriate choice for disinfecting surfaces contaminated with blood. A 10% bleach solution (1 part bleach to 9 parts water) is effective at killing bloodborne pathogens such as HIV and hepatitis B and C viruses. It should be used in healthcare settings to ensure proper disinfection after a blood spill.
Choice C rationale:
Isopropyl alcohol. Isopropyl alcohol is an effective disinfectant for some purposes, but it may not be as effective as bleach against bloodborne pathogens. It is commonly used for cleaning and disinfecting skin before medical procedures but is not the recommended choice for disinfecting surfaces following a blood spill.
Choice D rationale:
Chlorhexidine. Chlorhexidine is an antiseptic solution often used for skin disinfection before surgical procedures or invasive medical interventions. It is not typically used for disinfecting surfaces contaminated with blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"Fidelity involves ensuring that we do no harm to the client." - This statement is not an accurate description of fidelity. Fidelity, in ethical terms, primarily refers to keeping promises and being loyal to clients, rather than preventing harm.
Choice B rationale:
"Fidelity involves making sure clients are able to make their own health care decisions." - While this statement relates to ethical principles, it is more closely associated with the principle of autonomy rather than fidelity. Fidelity is about keeping promises and being trustworthy.
Choice C rationale:
"Fidelity involves keeping promises made to clients." - This is the correct answer. Fidelity is the ethical principle that involves keeping commitments, promises, and agreements made to clients. It emphasizes the importance of honesty, trustworthiness, and integrity in the nurse-patient relationship.
Choice D rationale:
"Fidelity involves treating every client with the same level of respect." - While respecting clients is essential in nursing practice, this statement does not directly address the concept of fidelity. Fidelity is more about keeping promises and being loyal to individual clients rather than a uniform approach to all clients.
Correct Answer is ["D","E","F"]
Explanation
Choice A rationale:
Pedal pulses are a measure of peripheral circulation. A 2+ rating is considered normal, indicating a brisk, expected response. There’s no change in the client’s pedal pulses from Day 1 to Day 5, so this doesn’t require immediate follow-up.
Choice B rationale:
Oxygen saturation is not mentioned in the Nurses’ Notes, so we cannot provide a rationale for this choice.
Choice C rationale:
Breath sounds are an important indicator of respiratory health. The client’s breath sounds are clear and present throughout on both Day 1 and Day 5, which is normal and doesn’t require immediate follow-up.
Choice D rationale:
Respiratory rate is not mentioned in the Nurses’ Notes, but any significant change in respiratory rate could indicate a problem such as infection or pain, and would require immediate follow-up.
Choice E rationale:
The abdominal dressing shows a large amount of serosanguinous drainage on Day 5, compared to a small amount on Day 1. This could indicate a complication such as infection or dehiscence (separation of the wound), especially since the client reported feeling something “popped” at the incision site after coughing. This requires immediate follow-up.
Choice F rationale:
Heart rate is not mentioned in the Nurses’ Notes, but any significant change in heart rate could indicate a systemic response to factors such as pain or infection, and would require immediate follow-up. In summary, while pedal pulses and breath sounds remain normal, the change in the abdominal dressing and potential changes in respiratory rate and heart rate (though not documented here) should be addressed immediately to ensure the client’s health and recovery.
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