A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? (Select all that apply.)
Gown
Gloves
Mask
Hair cover
Goggles
Correct Answer : A,B
Choice A reason: Wearing a gown is a correct action, because it protects the nurse's clothing and skin from exposure to the client's body fluids.
Choice B reason: Wearing gloves is a correct action, because it protects the nurse's hands from contact with the client's body fluids and reduces the risk of transmission of HIV.
Choice C reason: Not needed unless there's risk of respiratory exposure, which is not indicated here. AIDS is not spread via airborne particles.
Choice D reason: Wearing a hair cover is an incorrect action, because it is not necessary for standard precautions or contact precautions, which are the types of isolation required for a client who has AIDS and is incontinent of stool.
Choice E reason: Only needed if splashing of body fluids into the eyes is likely (not typical when simply changing linens).
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Correct Answer is B
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should obtain sample menus from the dietitian to give to the client after assessing the client's food preferences, needs, and goals. The sample menus should be individualized and tailored to the client's lifestyle, culture, and preferences.
Choice B reason: This is the first action, because the nurse should ask the client to identify the types of foods she prefers before providing any dietary teaching. This can help the nurse to determine the client's current eating habits, knowledge, and readiness to learn. It can also help the nurse to establish rapport and trust with the client, and to involve the client in the decision-making process.
Choice C reason: This is an important action, but not the first one. The nurse should identify the recommended range for the client's blood glucose level after assessing the client's food preferences, needs, and goals. The recommended range for the blood glucose level depends on the type, dose, and timing of the medication, the frequency and intensity of the exercise, and the carbohydrate intake of the client.
Choice D reason: This is an important action, but not the first one. The nurse should discuss long-term complications that can result from nonadherence to the dietary plan after assessing the client's food preferences, needs, and goals. The long-term complications of diabetes mellitus include cardiovascular disease, kidney disease, nerve damage, eye damage, and foot problems. The nurse should explain the benefits of following the dietary plan and the risks of not following it.
Correct Answer is D
Explanation
Choice A reason: This is a false statement, because adults do not receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox. Herpes zoster is caused by the reactivation of the varicella-zoster virus, which remains dormant in the nerve cells after a primary infection with chickenpox.
Choice B reason: This is a false statement, because herpes zoster is not prevented by the MMR vaccine, which protects against measles, mumps, and rubella. Herpes zoster is prevented by the varicella vaccine, which is given separately from the MMR vaccine.
Choice C reason: This is a false statement, because a client who has herpes zoster is contagious if blisters are present on the skin. The blisters contain the varicella-zoster virus, which can be transmitted through direct contact or airborne droplets.
Choice D reason: This is the correct statement, because herpes zoster is contagious to people who have never had chickenpox. People who have never had chickenpox can contract the varicella-zoster virus from a person who has herpes zoster and develop chickenpox as a primary infection.
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