HESI Case Study: HIV & TB – Flashcards
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How Should the nurse respond?
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Your partner may stay but he needs to wear a mask.
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What teaching should the nurse implement?
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TB is spread through the air.
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What information should the nurse provide to the UAP on infection control practices?
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Possible TB requires negative pressure room.
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The nurse notices a UAP about to Jeff's room to deliver a meal tray w/o wearing any protective apparel. What info should the nurse provide to the UAP?
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Healthcare workers need to wear a mask when entering the room of patient suspected of having TB.
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What tasks can the nurse delegate to the UAP?
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Tell Jeff the sputum will be collected in the morning, set sputum collection cups by bedside, document time and date when each sputum sample is collected.
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What activity should Jeff do in the morning upon wakening?
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Obtain the first of three sputum samples for lab testing.
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The nurse should based her response about the right of a nurse to refuse to care for clients w/ HIV?
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The nurse may refuse to care for a patient in which the risk outweighs a nurse's responsibility to care for a patient or if the care conflicts with the nurse's ethical standards.
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How should the nursing supervisor respond to the nurse who does not want to care for Jeff?
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I understand you want to protect your children. Please tell me your concerns about taking care of patient with HIV.
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What statement shows that Jeff understands why he is at risk for TB?
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My T-helper cells are diminished from HIV and those cells are needed to fight HIV.
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How should the nurse preceptor respond?
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This is not always true. 5mm induration is considered positive in an HIV positive client.
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How should the nurse respond?
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To be most effective, HIV medications should be taken on different schedules.
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How should the nurse respond?
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The main purpose of these medications is to block the replication of the HIV virus.
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What information should the nurse teach Jeff about rifampin/isoniazid/pyrazinamide?
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Rifampin can stain urine,stool, saliva, sweat and tears reddish-orange. Liver function test should be monitored and conducted. Supplemental B6 may be prescribed and avoid foods high in tyramine while taking rifampin.
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What is the priority nursing diagnosis for Jeff at this time?
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Risk for opportunistic infections related to decreased immune function.
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What information should the nurse give the UAP?
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Following standard precautions will minimize exposure to blood and body fluids
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What should the nurse say to the UAP?
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I see you are wearing a gown, mask, gloves, and googles before going into the patient's room. Please help me understand this choice.
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Which assessment by the nurse is indicative of oral candidiasis?
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white-yellow patches on the tongue or oral mucosa
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What instruction should the nurse give Jeff about liquid nystatin?
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Place suspension in mouth and swish for several minutes before swallowing.
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To achieve the improvement of Jeff's nutrition, what should the nurse perform for nursing interventions?
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Consult w/ Jeff for food preferences, weight daily and monitor for wasting syndrome, and monitor for oral thrush and diarrhea.
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Since Jeff has thrush in addition to anorexia and fatigue which food best contributes to improving Jeff's condition?
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Milk shake
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Which tasks should be delegated to the UAP?
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weigh jeff before breakfast, measure urine output and count and record watery stools.
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What is the priority nursing diagnosis?
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deficit fluid volume
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Which action should the nurse take first?
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Take Jeff's BP to assess for postural hypotension.
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What is the gtt/min?
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42
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How should the nurse respond?
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If used correctly and consistently, latex condoms are highly effective in preventing transmission of HIV
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What resource can be provided for Jeff in the event that this complication occurs?
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Access to a registered dietitian
