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 A
Explanation
Choice A rationale
A CD4-T-cell count of 180 cells/mm³ indicates severe immunosuppression in a client with HIV, making them highly susceptible to opportunistic infections. This is a critical value that requires immediate attention to prevent life-threatening complications.
Choice B rationale
A positive Western blot test confirms the presence of HIV antibodies but does not indicate the current immune status or the urgency of the client’s condition.
Choice C rationale
Platelets at 150,000/mm³ are within the normal range and do not indicate an immediate threat to the client’s health.
Choice D rationale
A WBC count of 5,000/mm³ is within the normal range and does not indicate an immediate threat to the client’s health.
Correct Answer is C
Explanation
Choice A rationale
Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.
Choice B rationale
Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.
Choice C rationale
Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.
Choice D rationale
Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.