A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

Wear an N95 respirator.

Insert an indwelling urinary catheter to monitor urinary output.

Monitor the client's vital signs every 8 hr.

Use a dedicated stethoscope.

Answer and Explanation

The Correct Answer is D

A. Wearing an N95 respirator is not necessary when caring for a client with neutropenia due to HIV unless the client has respiratory symptoms or is undergoing procedures that generate aerosols.

B. Inserting an indwelling urinary catheter should be avoided unless necessary, as it can

introduce the risk of infection, which is particularly concerning in clients with neutropenia.

C. Monitoring vital signs every 8 hours may not provide sufficient frequency for detecting changes in a client with neutropenia who may be at risk for rapid deterioration.

D. Using a dedicated stethoscope helps prevent the spread of infection to other clients by avoiding cross-contamination, which is especially important when caring for a client with neutropenia who is at increased risk of infection.

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Correct Answer is C

Explanation

A. While hydrogen peroxide has some disinfectant properties, it is not as effective as other agents like chlorine bleach for cleaning surfaces contaminated with blood.

B. Isopropyl alcohol is effective against many pathogens but may not be as effective as chlorine bleach specifically for bloodborne pathogens.

C. Chlorine bleach is an effective agent for cleaning surfaces contaminated with blood and other bodily fluids, as it has strong disinfectant properties.

D. Chlorhexidine is primarily used as an antiseptic for skin preparation and may not be as effective for surface cleaning of blood contamination.

A. Insert an indwelling catheter if the client has not voided in 3 hr. B. Obtain the abdominal girth now and every 4 hr. C. Assess and document the level of consciousness every hour. D. Measure the amount of gastric drainage every 2 hr. E. None F. None

Correct Answer is A

Explanation

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.

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