A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?

Choice A Reason:
"I wish my sexual relationship with my partner was like it was before." This statement indicates a desire to return to the previous state, implying a sense of dissatisfaction or longing for the way things were before the ileostomy surgery, rather than acceptance of the current situation.
Choice B Reason:
"I have my partner empty the bag for me, so I don't have to look at it."While having a partner assist with bag management might indicate some level of adaptation, the statement implies avoidance or discomfort in dealing directly with the ileostomy. It may suggest a lack of full acceptance or adjustment to the presence of the ileostomy.
Choice C Reason:
“I look forward to having normal bowel movements again." This statement expresses a desire to return to the previous bodily function, indicating a longing for the way things were before the surgery rather than complete acceptance of the ileostomy as a new way of managing bowel movements.
Choice D Reason:
"I will attend a support group to help me handle difficulties when they occur." Attending a support group demonstrates a proactive approach toward acceptance and adjustment to living with an ileostomy. It shows the client's willingness to seek support, learn coping strategies, and engage with others facing similar challenges.

Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like heart rate is essential in assessing a client's condition. However, in this scenario, the client's report of hives, itching, and a potential allergic reaction is more indicative of an immediate concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching and hives. However, confirming the severity of the reaction and ensuring there are no life-threatening symptoms such as breathing difficulties is the immediate priority before administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is experiencing difficulty breathing, it indicates a severe allergic reaction that requires immediate intervention and emergency medical attention. Recognizing and addressing potential respiratory distress is of utmost importance in managing an allergic reaction to medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the client's medical history, including allergies, is crucial. However, in this acute situation where the client is already experiencing symptoms of a potential allergic reaction shortly after receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis is the most immediate concern.