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
Headaches and blurred vision are not specific to stage I Lyme disease. These symptoms can occur in many other conditions and are not the primary indicators of early Lyme disease.
Choice B rationale
Tremors and weakness are not typical early signs of Lyme disease. These symptoms are more associated with neurological involvement, which occurs in later stages of the disease.
Choice C rationale
Rash symptoms, specifically erythema migrans (a bull’s-eye rash), are the hallmark of stage I Lyme disease. This rash appears at the site of the tick bite and is a key diagnostic feature.
Choice D rationale
Painful joints are more commonly seen in later stages of Lyme disease when the infection has spread and caused more systemic involvement.
Correct Answer is D
Explanation
Choice A rationale
A productive cough is not a typical finding in early-stage Hodgkin’s lymphoma. Respiratory symptoms are more commonly associated with other conditions.
Choice B rationale
Bone and joint pain are not typical findings in early-stage Hodgkin’s lymphoma. These symptoms are more commonly associated with other conditions such as metastatic cancer or rheumatoid arthritis.
Choice C rationale
Intermittent hematuria is not a typical finding in early-stage Hodgkin’s lymphoma. Hematuria is more commonly associated with urinary tract infections or kidney conditions.
Choice D rationale
Enlarged lymph nodes are a common finding in early-stage Hodgkin’s lymphoma. This condition is characterized by the presence of Reed-Sternberg cells in the lymph nodes, leading to their enlargement.