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
Applying cool compresses can help reduce swelling and discomfort, but it is not the primary instruction for a client scheduled for retinal detachment surgery.
Choice B rationale
Eye drops to constrict the pupils are not typically prescribed for retinal detachment surgery. The focus is on preventing further detachment and ensuring proper healing.
Choice C rationale
Restricting head movement is crucial to prevent further detachment of the retina and to promote proper healing after surgery. The client should be instructed to avoid sudden or excessive head movements.
Choice D rationale
Keeping both eyes patched is not necessary and may cause unnecessary discomfort and disorientation for the client.
Correct Answer is A
Explanation
Choice A rationale
Administering the medications 5 minutes apart ensures that each medication has enough time to be absorbed without interference from the other. This practice helps to maximize the effectiveness of both medications and reduces the risk of adverse interactions.
Choice B rationale
Touching the tip of the dropper to the sclera of the eye can introduce contaminants and increase the risk of infection. It is important to avoid contact between the dropper and the eye to maintain sterility.
Choice C rationale
Holding pressure on the conjunctival sac for 2 minutes is not necessary for the administration of timolol and pilocarpine eye drops. This practice is more commonly recommended for other types of eye medications to increase absorption.
Choice D rationale
Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. Wearing contact lenses during administration can interfere with the effectiveness of the drops.