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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "I will use a humidifier during the winter months." is not the correct answer, because it indicates a good understanding of dry skin. Using a humidifier during the winter months is a helpful measure to prevent or treat dry skin, as it can increase the moisture level in the air, which can hydrate the skin and reduce the loss of natural oils.
Choice B reason: "I will shower every day in hot water." is the correct answer, because it indicates a need for further teaching about dry skin. Showering every day in hot water is a harmful practice that can worsen dry skin, as it can strip the skin of its natural oils, damage the skin barrier, and cause irritation and inflammation.
Choice C reason: "I will avoid tight belts." is not the correct answer, because it indicates a good understanding of dry skin. Avoiding tight belts is a helpful measure to prevent or treat dry skin, as it can reduce the friction and pressure on the skin, which can prevent skin breakdown and infection.
Choice D reason: "I will drink at least 3000 mL of water daily." is not the correct answer, because it indicates a good understanding of dry skin. Drinking at least 3000 mL of water daily is a helpful measure to prevent or treat dry skin, as it can hydrate the body and the skin, and flush out toxins and waste products.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect statement because it is not based on any assessment or diagnosis. Osteoporosis is a condition that affects the bones, not the joints. It also does not cause fatigue. The nurse should not make assumptions or give advice without proper evaluation.
Choice B reason: This is an incorrect statement because it is dismissive and insensitive. Arthritis is a general term that covers many types of joint inflammation and pain. It is not a simple condition that can be treated with just ibuprofen. The nurse should not minimize the patient's concerns or prescribe medication without a doctor's order.
Choice C reason: This is the correct statement because it shows empathy and interest in the patient's situation. It also helps the nurse gather more information about the onset, duration, frequency, and severity of the pain. This can help the nurse identify possible causes and plan appropriate interventions.
Choice D reason: This is an incorrect statement because it is rude and judgmental. Weight loss may or may not help with joint pain, depending on the underlying cause. The nurse should not blame the patient or make them feel guilty. The nurse should focus on the patient's current symptoms and needs, not their appearance or lifestyle.
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