A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend?

Encourage the client to increase participation in community social activities

Prepare the client to begin highly active antiretroviral therapy (HAART)

Provide routine analgesia to minimize episodes of breakthrough pain

Promote client weight gain of one to two pounds per week

Answer and Explanation

The Correct Answer is C

Explanation:

A. Encourage the client to increase participation in community social activities:

While social activities can be beneficial for overall well-being, including mental and emotional aspects, at the end of life for a client with HIV, the focus shifts towards palliative care and symptom management. Encouraging social activities may not directly address the client's immediate end-of-life needs.

B. Prepare the client to begin highly active antiretroviral therapy (HAART):

Starting or continuing highly active antiretroviral therapy (HAART) may not be appropriate at the end of life. HAART is typically used to manage HIV infection and prolong life expectancy by controlling viral replication. However, at the end of life, the focus shifts towards comfort care rather than aggressive treatment aimed at extending life.

C. Provide routine analgesia to minimize episodes of breakthrough pain:

This intervention is more aligned with the principles of end-of-life care. Providing routine analgesia helps manage pain effectively, which is crucial for improving the client's comfort and quality of life during this stage.

D. Promote client weight gain of one to two pounds per week:

Weight gain may not be a priority at the end of life, especially if the client is experiencing advanced HIV disease or complications. Instead of focusing on weight gain, the emphasis should be on optimizing comfort, managing symptoms, and enhancing quality of life.

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Correct Answer is C

Explanation

Explanation:

A. "I will keep my walker at the end of my bed."

Keeping the walker at the end of the bed is generally a good practice for accessibility and mobility support, especially for clients who use walkers to assist with walking. However, this statement alone does not directly address falls prevention strategies or indicate a comprehensive understanding of home safety measures related to falls.

B. "I will place an area rug at the entry of my bathroom."

Placing an area rug at the entry of the bathroom can actually increase the risk of falls rather than prevent them. Area rugs are common tripping hazards, especially in areas where water or moisture may be present (like bathrooms). This statement indicates a potential misunderstanding of falls prevention strategies because it suggests an action that could contribute to falls rather than prevent them.

C. "I will place a bath seat in my shower to use when I bathe."

This statement demonstrates a clear understanding of falls prevention strategies. Placing a bath seat in the shower is a proactive measure to enhance safety during bathing, as it provides stability and reduces the risk of slipping and falling on wet surfaces. Using assistive devices like a bath seat is recommended for individuals with a history of falls or balance issues.

D. "I will keep the fluorescent ceiling light on in my room at night."

Keeping the room well-lit at night is beneficial for falls prevention, as adequate lighting can help individuals see potential hazards and navigate their environment safely. While this statement reflects a general awareness of falls prevention principles related to lighting, it is not as specific or directly related to falls prevention during activities like bathing (as mentioned in option C).

A. Material safety data sheets B. Evidence-based practice C. Client medical records D. Facility policy and procedures

Correct Answer is B

Explanation

Explanation:

A. Material safety data sheets:

Material safety data sheets (MSDS) are documents that provide information about the properties of chemicals and substances, including hazards, handling, storage, and emergency procedures. While MSDS are crucial for ensuring safe handling of materials, they primarily focus on chemical safety and may not provide detailed guidance on specimen collection protocols. Therefore, while MSDS are essential references for safety, they are not the primary source for revising specimen collection protocols.

B. Evidence-based practice:

Evidence-based practice (EBP) involves integrating the best available evidence from research studies, clinical expertise, and patient values and preferences to make informed decisions about patient care. For revising protocols, nurses should rely heavily on evidence-based guidelines and research literature related to specimen collection techniques, safety measures, accuracy, and quality assurance. EBP ensures that protocols are based on the latest scientific evidence, leading to improved patient outcomes and quality of care.

C. Client medical records:

Client medical records contain detailed information about individual patients, including their medical history, diagnoses, treatments, and laboratory results. While medical records are valuable for understanding specific patient needs and conditions, they are not typically used as primary sources for developing or revising unit-wide protocols. However, reviewing medical records may provide insights into specific challenges or issues related to specimen collection for certain patients.

D. Facility policy and procedures:

Facility policy and procedures manuals outline the organization's guidelines, protocols, and standards of practice for various aspects of patient care, including specimen collection. Nurses should refer to facility policies and procedures to understand existing protocols, safety measures, documentation requirements, and quality control processes related to specimen collection. While facility policies are important references, they may need to be updated based on current evidence and best practices, which is where evidence-based practice comes into play.

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A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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