The nurse is applying standard precautions in the care of a patient who has a history of human immunodeficiency virus. What key element of standard precaution?

Using appropriate personal protective equipment (PPE).

Placing patient in positive pressure isolation room

Placing patient in contact precautions

Wearing gloves at all times.

Answer and Explanation

The Correct Answer is A

A. Using appropriate personal protective equipment (PPE): Standard precautions include the use of PPE such as gloves, masks, gowns, and eye protection when caring for all patients, regardless of their known or suspected infectious status. This helps prevent the transmission of pathogens between the patient and the healthcare provider.

B. Placing patient in positive pressure isolation room: Placing a patient in a positive pressure isolation room is not a component of standard precautions. Positive pressure rooms are typically used for patients with compromised immune systems to protect them from exposure to airborne pathogens. Standard precautions should be followed regardless of the patient's room type.

C. Placing patient in contact precautions: Contact precautions involve specific measures to prevent the transmission of pathogens through direct or indirect contact with the patient or their environment. While contact precautions may be necessary for certain infectious diseases, they are not a component of standard precautions.

D. Wearing gloves at all times: While wearing gloves is part of standard precautions, it is not the only key element. Standard precautions also include other forms of PPE such as masks, gowns, and eye protection, as well as other infection control practices such as hand hygiene and environmental cleaning.

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Correct Answer is C

Explanation

A. Perform doppler evaluation once daily: While Doppler evaluation is valuable for assessing blood flow and detecting vascular abnormalities, performing it only once daily may not provide adequate monitoring, especially during the critical early postoperative period. More frequent assessments are necessary to ensure optimal graft function and to promptly identify any complications.

B. Assess for compartment syndrome every 2 hours: While assessing for compartment syndrome is important, performing assessments every 2 hours may not be necessary unless specific risk factors or clinical indications are present. Continuous monitoring for signs and symptoms of compartment syndrome is essential, but the frequency of assessment should be based on the patient's condition and the surgeon's orders.

C. Assess pulse of affected extremity every 15 minutes until stable: After popliteal bypass graft surgery, assessing the pulse of the affected extremity every 15 minutes until stable is crucial. Frequent pulse checks help monitor graft patency and perfusion to detect early signs of graft failure or ischemia. This high-frequency assessment allows for prompt identification of vascular compromise and timely intervention to prevent graft thrombosis or occlusion. Once the pulse is stable and adequate perfusion is confirmed, the frequency of pulse checks can be adjusted according to the patient's condition and clinical guidelines.

D. Palpate the affected leg for pain every shift: Palpating the affected leg for pain every shift is an important component of postoperative assessment. However, relying solely on pain assessment once per shift may not provide timely detection of complications or changes in the patient's condition, especially during the immediate postoperative period when close monitoring is necessary. Frequent and ongoing assessment of pain, along with other vital signs and clinical indicators, is essential for comprehensive postoperative care.

A. Review serum electrolytes B. Request the patient's food diary C. Place the patent on bed rest D. Observing vital signs

Correct Answer is A

Explanation

A. Review serum electrolytes: Muscle cramps can be associated with electrolyte imbalances, such as hypokalemia (low potassium levels), which can occur as a side effect of ARB medications. Therefore, reviewing the patient's serum electrolyte levels, including potassium, can help identify any abnormalities that may be contributing to the muscle cramps. If hypokalemia is present, appropriate interventions such as potassium supplementation or adjustment of the ARB dosage may be necessary to alleviate the muscle cramps.

B. Request the patient's food diary: While assessing the patient's food diary may provide information about their dietary habits and potential factors contributing to muscle cramps (such as dehydration or inadequate nutrient intake), it may not directly address the potential electrolyte imbalance associated with ARB use. Therefore, while obtaining a food diary may be relevant, it is not the priority action in this scenario.

C. Place the patient on bed rest: Placing the patient on bed rest is not indicated solely based on complaints of muscle cramps. Muscle cramps can have various causes, and restricting the patient's activity may not address the underlying issue. Additionally, bed rest could lead to other complications such as deconditioning or venous thromboembolism, which are not warranted in this situation.

D. Observing vital signs: While monitoring vital signs is a routine nursing intervention, it may not directly address the patient's complaint of muscle cramps. Vital signs may be relevant in assessing overall health status, but they may not provide specific information about the cause of muscle cramps or guide appropriate interventions.

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The nurse is applying standard precautions in the care of a patient who has a history of human immunodeficiency virus. What key element of standard precaution?

Nursing Test Bank

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