A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
Administering an IM injection.
Completing a dressing change.
Administering an intermittent IV bolus medication.
Talking to the client at the bedside.
The Correct Answer is B
Choice A rationale
Administering an IM injection does not typically require a gown as personal protective equipment unless there is a risk of exposure to blood or body fluids.
Choice B rationale
Completing a dressing change requires a gown to protect against potential exposure to blood or body fluids.
Choice C rationale
Administering an intermittent IV bolus medication does not typically require a gown unless there is a risk of exposure to blood or body fluids.
Choice D rationale
Talking to the client at the bedside does not require a gown as there is no risk of exposure to blood or body fluids.
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Correct Answer is D
Explanation
Choice A rationale
Sound lateralizing to the right ear during the Rinne test does not indicate conductive hearing loss in the left ear. This result suggests that the right ear may have better hearing or that there is an issue with the left ear, but it does not specifically diagnose conductive hearing loss.
Choice B rationale
Sound lateralizing to the left ear during the Rinne test indicates that the left ear is perceiving the sound better, which could be due to conductive hearing loss in the left ear. However, this option does not provide a definitive result for conductive hearing loss.
Choice C rationale
Air conduction being greater than bone conduction in the left ear is a normal finding and does not indicate conductive hearing loss. In conductive hearing loss, bone conduction is typically better than air conduction.
Choice D rationale
Air conduction being less than bone conduction in the left ear is indicative of conductive hearing loss. This result means that the sound is being conducted through the bones of the skull more effectively than through the air, which is a hallmark of conductive hearing loss.
Correct Answer is C
Explanation
Choice A rationale
Erythema and edema of the affected ear are more commonly associated with external otitis (swimmer’s ear) rather than otitis media. Otitis media involves the middle ear, not the external ear canal.
Choice B rationale
Pain when manipulating the affected ear lobe is also indicative of external otitis. In otitis media, the pain is usually deeper and not affected by manipulation of the ear lobe.
Choice C rationale
Tugging on the affected ear lobe is a common sign in toddlers with otitis media. This behavior is due to the discomfort and pressure in the middle ear caused by the infection.
Choice D rationale
Clear drainage from the affected ear is not typical of otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a ruptured eardrum.