"Cover your nose and mouth when you sneeze or cough."
This is an appropriate action because the client is susceptible to illness. However, the priority is to ensure that the caregiver is performing hand hygiene, as this is the largest source of contamination.
"Get rid of all pets in the home."
This is not necessary. However, the client should not touch litter boxes, feces, bird droppings, or water in the fish tank. The nurse should encourage the client to wash hands with soap and water after handling the family pet.
"Wash your hands frequently." (Correct Answer)
Hand hygiene is the single best way to kill germs. The caregiver should wash hands after going to the bathroom and before and after fixing food. The caregiver should also wash hands before and after caring for the client.
"Wash the client's dishes separately."
This is not necessary. All dishes may be washed together.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a Priority Question.
Priority questions use words such as most, best, first, immediate, etc.
STEP 1: Can you identify the topic of the question?
- Preventing infection, AIDS client.
STEP 2: Are the answer choices assessment or implementation?
Assessment vs. Implementation
- "Cover your nose and mouth when you sneeze or cough." Implementation
- "Get rid of all pets in the home." Implementation
- "Wash your hands frequently." Implementation
- "Wash the client's dishes separately." Implementation
Because a mix of assessment and implementation answer choices does not exist, answer choices cannot be eliminated at this step. Move to Step 3.
STEP 3: Apply Maslow: Are the answer choices physical or psychosocial?
Maslow
- "Cover your nose and mouth when you sneeze or cough." Physical
- "Get rid of all pets in the home." Physical
- "Wash your hands frequently." Physical
- "Wash the client's dishes separately." Physical
Because a mix of physical and psychosocial answers does not exist, answer choices cannot be eliminated at this step. Move to Step 4.
STEP 4:Are the answer choices related to ABCs?
ABCs
- "Cover your nose and mouth when you sneeze or cough." N/A
- "Get rid of all pets in the home." N/A
- "Wash your hands frequently." N/A
- "Wash the client's dishes separately." N/A
Because a mix of ABC and non-ABC answer choices does not exist, answer choices cannot be eliminated at this step. Move to Step 5.
STEP 5: What is the outcome of each of the remaining answer choices?
Evaluate the outcome(s)
- "Cover your nose and mouth when you sneeze or cough." This is an appropriate action to avoid exposing the client to infection since the client is immunocompromised but is not the priority over handwashing. Eliminate.
- "Get rid of all pets in the home." This is an unnecessary action; the client should be instructed to avoid litter boxes, feces, bird dropping or water in the fish tank, but this teaching should occur after handwashing. Eliminate.
- "Wash your hands frequently." Teaching the caregiver about handwashing is the priority as it protects both the client from acquiring an infection in this immunocompromised state and the caregiver from becoming infected with HIV via exposure to blood and body fluids or other means of transmission.
- "Wash the client?s dishes separately." This action is not necessary. HIV is not spread by casual contact or from eating utensils. Eliminate.
Select the best choice
Is #3 the correct answer? Yes, handwashing is the most effective means of avoiding the spread of infection.
Does #3 make sense? Yes, the immunocompromised client will not be exposed to additional sources of infection.
