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
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
Correct Answer is C
Explanation
Choice A rationale
Pitting edema of the hands and fingers is not a typical finding in clients with systemic lupus erythematosus (SLE). Edema can occur in SLE, but it is more commonly associated with renal involvement and not specifically pitting edema of the hands and fingers.
Choice B rationale
Subcutaneous nodules on the ulnar side of the arm are more commonly associated with rheumatoid arthritis rather than SLE. SLE does not typically present with subcutaneous nodules.
Choice C rationale
A dry, red rash across the bridge of the nose and on the cheeks, known as a “butterfly rash,” is a classic sign of SLE. This rash is caused by inflammation of the small blood vessels in the skin and is often exacerbated by sun exposure.
Choice D rationale
A grey-colored, non-purpuric papular rash is not characteristic of SLE. The typical rash in SLE is the butterfly rash, which is dry, red, and raised.