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

Choice A reason: Capillary refill is not the nurse's priority assessment for this client, because it is not the most relevant and sensitive indicator of the client's condition. Capillary refill is a test that measures the time it takes for the color to return to the nail bed after applying pressure, which reflects the peripheral circulation and tissue perfusion. Capillary refill can be affected by factors such as temperature, hydration, or vasoconstriction. Capillary refill is not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.

Choice B reason: Radial pulses are not the nurse's priority assessment for this client, because they are not the most relevant and sensitive indicator of the client's condition. Radial pulses are the beats that can be felt at the wrist, which reflect the heart rate and rhythm. Radial pulses can be affected by factors such as activity, emotion, or medication. Radial pulses are not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.

Choice C reason: Lung sounds are the nurse's priority assessment for this client, because they are the most relevant and sensitive indicator of the client's condition. Lung sounds are the noises that can be heard with a stethoscope over the chest, which reflect the air movement and ventilation in the lungs and airways. Lung sounds can reveal the presence of abnormalities, such as crackles, wheezes, or diminished breath sounds, which indicate fluid, inflammation, or obstruction in the lungs or airways. Lung sounds are a specific and reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.

Choice D reason: Skin turgor is not the nurse's priority assessment for this client, because it is not the most relevant and sensitive indicator of the client's condition. Skin turgor is a test that measures the elasticity of the skin, which reflects the hydration and fluid status of the body. Skin turgor can be affected by factors such as age, weight loss, or edema. Skin turgor is not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.

Choice A reason: Flushing the exposed skin with water is the first action that the nurse should take if they are stuck by a needle. This is to reduce the amount of blood or body fluid that may have entered the wound and to prevent infection. The nurse should flush the skin for at least 15 minutes and avoid using soap, antiseptic, or bleach as they may damage the skin or increase the risk of infection.

Choice B reason: Reporting the exposure is the second action that the nurse should take after flushing the exposed skin with water. This is to inform the supervisor, the occupational health department, or the infection control team about the incident and to initiate the postexposure protocol. The nurse should provide the details of the exposure, such as the type and source of the needle, the depth and location of the wound, and the status of the source patient.

Choice C reason: Seeking medical attention is the third action that the nurse should take after reporting the exposure. This is to receive a medical evaluation and treatment, such as testing, prophylaxis, counseling, and followup. The nurse should consult a health care provider as soon as possible and follow the recommendations for preventing or treating any potential infections, such as hepatitis B, hepatitis C, or HIV.

Choice D reason: Completing an incident report is the last action that the nurse should take after seeking medical attention. This is to document the exposure and the actions taken and to identify the causes and the preventive measures for the future. The nurse should fill out the incident report form accurately and objectively and submit it to the appropriate authority. The incident report is not a part of the client's record and should not be mentioned in the client's chart.