A client has acquired immunodeficiency syndrome (AIDS). Which of these assessment findings indicate possible infection? (Select all that apply.)

Temperature: 101.3 degrees Fahrenheit

Oxygen saturation: 97% on room air

Respirations: 22 breaths per minute

Purulent drainage

Client ambulates 20 feet

Answer and Explanation

Correct Answer : A,D

Choice A reason: A temperature of 101.3 degrees Fahrenheit is a sign of fever, which is a common symptom of infection. Clients with AIDS have a weakened immune system and are more susceptible to opportunistic infections. Fever indicates that the body is trying to fight off an infection.

Choice B reason: An oxygen saturation of 97% on room air is within the normal range and does not indicate infection. Oxygen saturation measures the percentage of hemoglobin that is bound to oxygen in the blood. A low oxygen saturation may indicate respiratory problems, such as pneumonia, which is a common infection in clients with AIDS.

Choice C reason: A respiratory rate of 22 breaths per minute is slightly above the normal range of 12 to 20 breaths per minute, but it does not necessarily indicate infection. Respiratory rate may vary depending on factors such as activity level, stress, pain, or anxiety. A high respiratory rate may indicate respiratory distress, which could be caused by infection or other conditions.

Choice D reason: Purulent drainage is a thick, yellowgreen, or brown pus that indicates infection. It may come from a wound, an abscess, or a body cavity. Purulent drainage is a sign of inflammation and infection and should be reported to the health care provider.

Choice E reason: A client's ability to ambulate 20 feet is not related to infection. Ambulation is a measure of mobility and function and may be affected by factors such as pain, fatigue, or muscle weakness. Ambulation does not reflect the presence or absence of infection.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Candidiasis is an opportunistic infection associated with AIDS. Candidiasis is a fungal infection caused by Candida species, which normally live in the mouth, throat, vagina, and intestines. In people with AIDS, the immune system is weakened and cannot control the growth of Candida, leading to oral thrush, esophagitis, vaginitis, or systemic candidiasis.

Choice B reason: Hodgkin's lymphoma is not an opportunistic infection associated with AIDS. Hodgkin's lymphoma is a type of cancer that affects the lymphatic system, which is part of the immune system. It is characterized by the presence of ReedSternberg cells, which are abnormal lymphocytes. The exact cause of Hodgkin's lymphoma is unknown, but it is not related to any specific infection.

Choice C reason: Pneumocystis jiroveci pneumonia is an opportunistic infection associated with AIDS. Pneumocystis jiroveci pneumonia is a fungal infection caused by Pneumocystis jiroveci, which normally lives in the lungs of healthy people without causing any symptoms. In people with AIDS, the immune system is weakened and cannot prevent the invasion of Pneumocystis jiroveci, leading to pneumonia, which is a serious and potentially fatal lung infection.

Choice D reason: Clostridium difficile is not an opportunistic infection associated with AIDS. Clostridium difficile is a bacterial infection caused by Clostridium difficile, which normally lives in the colon of healthy people without causing any problems. In some cases, the use of antibiotics can disrupt the normal balance of bacteria in the colon and allow Clostridium difficile to overgrow and produce toxins, leading to diarrhea, colitis, or pseudomembranous colitis. This infection can affect anyone, regardless of their HIV status.

Choice E reason: NonHodgkin's lymphoma is an opportunistic infection associated with AIDS. NonHodgkin's lymphoma is a type of cancer that affects the lymphatic system, which is part of the immune system. It is characterized by the presence of abnormal lymphocytes, which may be B cells, T cells, or natural killer cells. NonHodgkin's lymphoma is associated with several infections, such as EpsteinBarr virus, human herpesvirus 8, hepatitis C virus, and human Tcell leukemia virus, which may trigger the transformation of lymphocytes in people with AIDS.

A. Call the provider B. Place the client in the lithotomy position C. Raise the head of the bed D. Obtain pain medication

Correct Answer is C

Explanation

Choice A reason: Calling the provider is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Calling the provider is a communication intervention, not a respiratory intervention. Calling the provider is an important action, but it should be done after raising the head of the bed, and with accurate and complete information.

Choice B reason: Placing the client in the lithotomy position is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Placing the client in the lithotomy position is a positioning intervention, not a respiratory intervention. Placing the client in the lithotomy position is a specific action that is used for pelvic examinations or procedures, not for improving oxygenation.

Choice C reason: Raising the head of the bed is the intervention that the nurse should perform first, because it is the most urgent and relevant action. Raising the head of the bed is a respiratory intervention, not a communication, positioning, or analgesic intervention. Raising the head of the bed is a simple and effective action that can improve the client's breathing, oxygenation, and comfort.

Choice D reason: Obtaining pain medication is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Obtaining pain medication is an analgesic intervention, not a respiratory intervention. Obtaining pain medication is an important action, but it should be done after raising the head of the bed, and with a medical order and a proper route.

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A client has acquired immunodeficiency syndrome (AIDS). Which of these assessment findings indicate possible infection? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

What are opportunistic infections associated with acquired immunodeficiency syndrome (AIDS)? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is assessing a client's vital signs. The oxygen saturation is 85%. What intervention should the nurse perform first?

Correct Answer is C

Explanation

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