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
Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.
Choice B rationale
Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.
Choice C rationale
Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.
Choice D rationale
Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.
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.