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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect answer because a pathogenic infection is caused by a microorganism that can cause disease in a healthy host. Pathogens are usually able to overcome the host's immune defenses and cause symptoms and damage. Examples of pathogenic infections are strep throat, tuberculosis, and malaria.
Choice B reason: This is the correct answer because an opportunistic infection is caused by a microorganism that normally does not cause disease in a healthy host, but can take advantage of a weakened immune system and cause serious illness. Opportunistic infections are common and often lifethreatening complications of HIV infection, as the virus destroys the CD4 cells that help fight infections. Examples of opportunistic infections are pneumocystis pneumonia, candidiasis, and toxoplasmosis.
Choice C reason: This is an incorrect answer because a nosocomial infection is acquired in a health care setting, such as a hospital, clinic, or nursing home. Nosocomial infections are usually caused by microorganisms that are resistant to antibiotics and can spread easily among patients and staff. Examples of nosocomial infections are methicillinresistant Staphylococcus aureus (MRSA), Clostridioides difficile (C. diff), and urinary tract infections.
Choice D reason: This is an incorrect answer because a root cause infection is not a valid term in medical terminology. A root cause is the underlying factor or reason that leads to a problem or outcome. A root cause analysis is a process of identifying and addressing the root causes of a problem or event, such as an infection, to prevent recurrence and improve quality and safety.
Correct Answer is A
Explanation
Choice A reason: Wearing a gown is the correct answer, because it is the appropriate PPE for contact precautions, which are required for clients who have MRSA. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious infections in the skin, blood, lungs, or other organs. MRSA can be transmitted by direct or indirect contact with the infected wound or contaminated surfaces. Wearing a gown can protect the nurse's clothing and skin from exposure to MRSA.
Choice B reason: Wearing sterile gloves is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. Sterile gloves are used for sterile procedures, such as inserting a catheter or changing a dressing, not for routine assessments, such as checking the pulse. Wearing sterile gloves can be wasteful and unnecessary, and it does not provide adequate protection from MRSA.
Choice C reason: Wearing a PAPR mask is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. PAPR stands for powered airpurifying respirator, and it is a type of mask that filters the air and provides positive pressure to the wearer. PAPR masks are used for airborne precautions, which are required for clients who have diseases that can be spread through the air, such as tuberculosis or measles, not for clients who have MRSA.
Choice D reason: Wearing a surgical mask is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. Surgical masks are used for droplet precautions, which are required for clients who have diseases that can be spread through respiratory droplets, such as influenza or pertussis, not for clients who have MRSA.
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