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 B
Explanation
Choice A rationale
Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.
Choice B rationale
Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.
Choice C rationale
Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.
Choice D rationale
Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.
Correct Answer is C
Explanation
Choice A rationale
White drainage on the eyelids is not a normal finding and should be reported to the surgeon. However, this is not a standard discharge instruction but rather a sign of potential infection.
Choice B rationale
Sleeping on the abdomen is not recommended after cataract surgery as it can increase pressure on the eye and disrupt healing. Patients are usually advised to sleep on their back or the unaffected side.
Choice C rationale
Avoiding lifting anything heavier than 4.5 kg (10 lb) for 1 week is a standard instruction to prevent increased intraocular pressure and ensure proper healing of the surgical site.
Choice D rationale
Bending at the waist to pick up objects can increase intraocular pressure and should be avoided. Patients are advised to bend at the knees instead.