Dry skin (xerosis) can lead to itching (pruritus). What statement by the client indicates a need for further teaching about dry skin?

Choice A reason: Using standard precautions is a practice that is recommended to prevent HIV transmission, because it is a set of guidelines that apply to all clients, regardless of their infection status, and that aim to prevent the exposure to blood, body fluids, or other potentially infectious materials. Standard precautions include hand hygiene, use of personal protective equipment, safe handling and disposal of sharps, environmental cleaning, and respiratory hygiene.

Choice B reason: Double gloving is not a practice that is recommended to prevent HIV transmission, because it is not proven to be more effective or safer than single gloving. Double gloving is a technique that involves wearing two pairs of gloves, one over the other, which may provide some extra protection against needlestick injuries or glove punctures, but may also reduce the tactile sensitivity, dexterity, or comfort of the wearer. Double gloving is not a routine practice, but rather an option for certain situations, such as highrisk procedures, long surgeries, or known HIVpositive clients.

Choice C reason: Applying hand sanitizer to gloves during cares is not a practice that is recommended to prevent HIV transmission, because it is not appropriate or hygienic. Applying hand sanitizer to gloves during cares is a practice that can damage the integrity and effectiveness of the gloves, as the alcohol or other chemicals can degrade the material, cause holes, or reduce the fit of the gloves. Applying hand sanitizer to gloves during cares can also create a false sense of security, as the gloves may still be contaminated or ineffective. Hand sanitizer should be applied to the hands before and after wearing gloves, not to the gloves themselves.

Choice D reason: Wearing a mask within three feet of the client is not a practice that is recommended to prevent HIV transmission, because it is not necessary or relevant. Wearing a mask within three feet of the client is a practice that is part of the droplet precautions, which are used to prevent the transmission of infections that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. HIV is not transmitted by respiratory droplets, but rather by sexual contact, blood, or other body fluids. Wearing a mask within three feet of the client may not provide any protection against HIV, and may also cause stigma or discrimination.

Choice A reason: Determine whether it is temporary or permanent is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Determining whether the compromised immunity is temporary or permanent is an important assessment, but it should be done after ensuring the safety and infection prevention of the client. Compromised immunity can be temporary or permanent, depending on the cause, such as medication, disease, or genetic disorder.

Choice B reason: Take the client's vital signs every four hours is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Taking the client's vital signs every four hours is an important monitoring, but it should be done after ensuring the safety and infection prevention of the client. Vital signs can indicate the general health status and the presence of infection or inflammation, such as fever, tachycardia, or hypotension.

Choice C reason: Teach the family members to receive the flu shot annually is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Teaching the family members to receive the flu shot annually is an important education, but it should be done after ensuring the safety and infection prevention of the client. The flu shot is a vaccine that can protect the family members and the client from influenza, which can be a serious and potentially fatal infection for people with compromised immunity.

Choice D reason: Wash hands before entering the client's room is the nurse's priority action for a client with compromised immunity, because it is the most urgent and relevant. Washing hands before entering the client's room is a basic and essential infection prevention measure, which can protect the client from exposure to pathogens that can cause infection. People with compromised immunity have a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection.