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 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.
Correct Answer is A
Explanation
Choice A rationale
Shutting off the intravenous infusion is the immediate action to take when a client reports difficulty swallowing during infliximab infusion. This could indicate an infusion reaction or anaphylaxis, which requires immediate cessation of the infusion to prevent further complications.
Choice B rationale
Notifying the primary health care provider is important, but the immediate action should be to stop the infusion to prevent further adverse reactions.
Choice C rationale
Having the client take deep breaths and try to relax is not appropriate in this situation, as it does not address the potential infusion reaction or anaphylaxis.
Choice D rationale
Obtaining a prescription for oral diphenhydramine may be part of the treatment for an infusion reaction, but the immediate action should be to stop the infusion. .