The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client's blood and body fluids, the nurse uses standard precautions, which include:

Correct Answer: A

Rationale: Standard precautions are infection control practices designed to prevent transmission of diseases like AIDS. When handling a client's blood and body fluids, it is important to use standard precautions. Wearing gloves to empty a bedpan is an appropriate practice to prevent direct contact with blood and body fluids. This helps protect the nurse from exposure to infectious agents. Other options like wearing a gown, gloves, and protective eyewear for obtaining a urine specimen via catheterization or disposing of needles uncapped do not align with standard precautions for handling blood and body fluids in a client with AIDS. Similarly, wearing gloves when applying eyedrops is not necessary for preventing transmission of bloodborne pathogens in this context.

Correct Answer: A

Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various organs in the body. One of the classic signs of SLE is the presence of a facial rash in the shape of a butterfly over the cheeks and bridge of the nose. This rash is known as a malar rash and is often one of the first visible symptoms of the disease. Weight loss and difficulty urinating are not typical signs of SLE.

Correct Answer: B

Rationale: The laboratory study monitored for a patient receiving heparin therapy is the Partial Thromboplastin Time (PTT). Heparin is an anticoagulant medication that works by inhibiting clot formation. PTT measures the intrinsic pathway of the coagulation cascade, which is affected by heparin administration. Monitoring the PTT helps ensure that the patient's blood is at the appropriate level of anticoagulation and reduces the risk of bleeding or clot formation.

Correct Answer: A

Rationale: Encouraging a high fluid intake, typically around 3 to 4 liters daily, is an intervention that can help minimize complications related to hypercalcemia. Adequate hydration helps prevent the formation of kidney stones, a common complication of hypercalcemia. The increased fluid intake can also promote renal excretion of excess calcium, aiding in its elimination from the body. Additionally, adequate hydration supports overall kidney function and can help prevent renal damage that may result from high calcium levels.

Correct Answer: A

Rationale: The decreased white blood cell count (WBC) in the blood tests indicates a potential for infection. White blood cells are crucial for fighting off infections in the body. A decrease in WBC count can result in an impaired immune response, making the individual more susceptible to infections. Therefore, the nurse should prioritize the nursing diagnosis of "Potential for infection" to address the heightened risk of infection in the adult with anemia. It is important to monitor for signs and symptoms of infection, provide appropriate hygiene measures, and implement interventions to prevent infections in this individual.