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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.

No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.

Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.

No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.

Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.

Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.

Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.

A. "I get chest pain from time to time, but it usually resolves with rest." B. "Sometimes when I'm resting, I can feel my heart skip a beat." C. "My feet and ankles have gotten very puffy the last few weeks." D. "Whenever I do any form of exercise, I get very short of breath."

Correct Answer is D

Explanation

A. "I get chest pain from time to time, but it usually resolves with rest.": While chest pain (angina) can occur with aortic stenosis, it is not as specific as the symptom described in option D. Angina could be related to various other cardiac conditions, including coronary artery disease.

B. "Sometimes when I'm resting, I can feel my heart skip a beat.": Palpitations or feeling like the heart skips a beat are common in many cardiac arrhythmias but are not specifically indicative of aortic stenosis.

C. "My feet and ankles have gotten very puffy the last few weeks.": Edema (puffy feet and ankles) is more commonly associated with right-sided heart failure or other conditions like chronic venous insufficiency, not specifically aortic stenosis.

D. "Whenever I do any form of exercise, I get very short of breath.": Dyspnea on exertion is a classic symptom of aortic stenosis. It occurs because the narrowed aortic valve obstructs blood flow from the left ventricle to the aorta, reducing cardiac output and causing exertional symptoms.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

A client is undergoing diagnostic testing for aortic stenosis. What statement by the client during the nurse's interview is most suggestive of this valvular disorder?

Correct Answer is D

Explanation

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