HESI NUR 209 Medical Surgical Nursing II ||Verified
Exam!! Questions and Answers Practice Questions
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Exam!!!
The nurse is instructing an unlicensed health care worker
on the care of a client with human immune deficiency virus
(HIV) who also has active genital herpes. Which statement
by the health care worker indicates effective teaching of
Standard Precautions?
A. "I need to know my HIV status, so I must get tested
before caring for any clients."
B. "Putting on a gown and gloves will cover up the itchy
sores on my elbows."
C. "Washing my hands and putting on a gown and gloves
is what I must do before starting care."
D. "I will wash my hands before going into the room, and
then will put on a gown and gloves only for direct contact
with the client's genitals." - Answer-C. "Washing my hands
and putting on a gown and gloves is what I must do before
starting care."
Standard Precautions include whatever personal
protective equipment (PPE) is necessary for the
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prevention of transmission of HIV and genital herpes.
Knowing HIV status is important for preventing
transmission of HIV, but is not a Standard Precaution.
Health care workers with weeping dermatitis should not
provide direct client care regardless of the use of a gown
and gloves. Unlicensed health care workers cannot make
the determination of what is required for PPE or Standard
Precautions.
Which statement made to the nurse by a health care
worker assigned to care for a client with human immune
deficiency virus (HIV) indicates a breach of confidentiality
and requires further education by the nurse?
A. "I told family members they need to wash their hands
when they enter and leave the room."
B. "The other health care worker and I were out in the
hallway discussing our concern about getting HIV from our
client."
C. "Yes, I understand the reasons why I have to wear
gloves when I bathe the client."
D. "The client's spouse told me she got HIV from a blood
transfusion." - Answer-B. "The other health care worker
and I were out in the hallway discussing our concern about
getting HIV from our client."
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Discussing this client's illness outside of the client's room
is a breach of confidentiality and requires further education
by the nurse. Instruction on handwashing to family
members or friends is not a breach of confidentiality.
Understanding the reasons for wearing gloves recognizes
Standard Precautions in direct care and is not a breach of
confidentiality. Relaying a direct conversation to the nurse
is not a breach of confidentiality.
When preparing a client newly diagnosed with human
immune deficiency virus (HIV) and the significant other for
discharge, which explanation by the nurse accurately
describes proper condom use?
A. "Condoms should be used when lesions are present on
the penis."
B. "Always position the condom with a space at the tip of
an erect penis."
C. "Make sure it fits loosely to allow for penile erection."
D. "Use adequate lubrication, such as petroleum jelly." -
Answer-B. "Always position the condom with a space at
the tip of an erect penis."
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Positioning the condom with a space at the tip of the erect
penis allows for the collection of semen at the tip of the
condom. Condoms must be used by HIV-infected people
at all times for sexual activity, with or without the presence
of lesions. Condoms should be applied on an erect penis
and should fit snugly, leaving space without air at the tip.
Lubricants should be water-based only.
The home health nurse is making an initial home visit to a
client currently living with family members after being
hospitalized with pneumonia and newly diagnosed with
acquired immune deficiency syndrome (AIDS). Which
statement by the nurse best acknowledges the client's fear
of discovery by his family?
A. "Do you think that I could post a sign on your bedroom
door for everyone about the need to wash their hands?"
B. "Is there somewhere private in the home where we can
go and talk?"
C. "I hope that all of your family members know about your
disease and how you need to be protected, because you
have been so sick."
D. "It is your duty to protect your family members from
getting AIDS." - Answer-B. "Is there somewhere private in
the home where we can go and talk?"