A nurse is providing direction to a nursing assistant who will be caring for a client with human immunodeficiency virus (HIV) and receiving azidothymidine (AZT) antiretroviral therapy. The nurse should instruct the nursing assistant to implement which of the following actions?

Isolation gown

Contact isolation

Standard precautions

Respiratory isolation

Answer and Explanation

The Correct Answer is C

A. Isolation gown: Isolation gowns are used as part of contact precautions or airborne precautions for specific infectious diseases that require additional transmission-based precautions beyond standard precautions. However, standard precautions are generally sufficient for caring for clients with HIV receiving antiretroviral therapy.

B. Contact isolation: Contact isolation is used for patients with known or suspected infections that can be transmitted by direct or indirect contact with the patient or their environment. HIV does not require contact isolation unless there are additional infections or conditions present that warrant contact precautions.
C. Standard precautions: Standard precautions are the basic infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient. This includes practices such as hand hygiene, the use of personal protective equipment (e.g., gloves, gown, mask, eye protection) when indicated, and safe injection practices. Standard precautions should be used for all patients, including those with HIV, to prevent the transmission of infectious agents.
D. Respiratory isolation: Respiratory isolation is used for patients with known or suspected respiratory infections that are transmitted through respiratory droplets. HIV is not transmitted through respiratory droplets and does not require respiratory isolation.

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Correct Answer is D

Explanation

A. Empty the drainage from the pleuravac at the end of each shift: This is not a standard practice. Chest tube drainage systems typically have a built-in mechanism to handle drainage, and monitoring and recording the output is essential.

B. Report serosanguinous drainage in the pleuravac: Serosanguinous drainage (a mix of blood and serous fluid) can be expected in a hemothorax, especially initially. Reporting is necessary if there are significant changes in the amount or type of drainage.

C. Milk the chest tube every 4 hours to dislodge clotted blood: Milking or stripping the chest tube is generally not recommended as it can create high negative pressures that can damage lung tissue.

D. Assist with coughing and deep breathing exercises every hour: Encouraging coughing and deep breathing helps prevent atelectasis and promotes lung expansion, which is crucial for recovery from a hemothorax.

A. Encourage mouth care before and after meals. B. Monitor the client for changes in mental status. C. Assess the client's laboratory work for increased calcium levels. D. Advise the client to keep a food diary. E. Instruct the client to drink extra fluids between meals.

Correct Answer is ["A","B","D","E"]

Explanation

A. Encouraging mouth care before and after meals helps maintain oral hygiene, which is essential for appetite stimulation and preventing oral infections.

B. Monitoring the client for changes in mental status is important as malnutrition can lead to cognitive impairment and changes in mental status.

C. Assessing the client's laboratory work for increased calcium levels may not be directly related to malnutrition due to cancer. Elevated calcium levels are more commonly associated with conditions like hyperparathyroidism or certain cancers, but it's not typically a direct consequence of malnutrition.

D. Advising the client to keep a food diary helps track food intake, identify any patterns related to malnutrition, and guide dietary interventions.

E. Instructing the client to drink extra fluids between meals helps prevent dehydration, especially if the client's intake is compromised due to malnutrition or cancer-related treatments.

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A nurse is providing direction to a nursing assistant who will be caring for a client with human immunodeficiency virus (HIV) and receiving azidothymidine (AZT) antiretroviral therapy. The nurse should instruct the nursing assistant to implement which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a chest tube in place for treatment of a hemothorax. The nurse should prioritize which nursing intervention when caring for this client?

Correct Answer is D

Explanation

A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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