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 C
Explanation
Choice A reason: This is not the best intervention because it is timeconsuming and may not be feasible in some situations. Writing down the message can also be impersonal and may not convey the tone or emotion of the speaker. The nurse should use verbal communication as much as possible and supplement it with nonverbal cues, such as gestures, facial expressions, and eye contact.
Choice B reason: This is an incorrect intervention because it can be annoying and ineffective. Talking loudly in the impaired ear can cause discomfort and distortion of the sound. It can also damage the remaining hearing in the ear. The nurse should not shout or raise their voice, but rather speak at a normal volume and enunciate clearly.
Choice C reason: This is the best intervention because it enhances the quality and clarity of the verbal message. Speaking slowly and clearly while facing the client allows the client to see the nurse's mouth movements and facial expressions, which can help them understand the words and the meaning. The nurse should also avoid covering their mouth or chewing gum while speaking.
Choice D reason: This is not the best intervention because it can be inconvenient and impractical. Talking in a regular voice in the good ear may require the nurse to move around the client or position themselves in a certain way. It can also make the client feel isolated or singled out. The nurse should try to communicate with the client in a way that is comfortable and respectful for both parties.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Polyuria is the production of abnormally large amounts of urine, which can be caused by various factors, such as diabetes, kidney disease, or diuretics. Polyuria is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not affect the urinary system directly, unless the inflammation is located in the kidneys or bladder.
Choice B reason: Edema is the swelling of tissues due to excess fluid accumulation, which can be caused by various factors, such as heart failure, liver disease, or venous insufficiency. Edema is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not cause fluid retention, but rather fluid leakage from the blood vessels into the interstitial spaces.
Choice C reason: Heat is an expected finding in a client with inflammation, which is the body's response to injury or infection. Heat is caused by the increased blood flow to the inflamed area, which brings more oxygen and nutrients to the damaged tissues. Heat also helps to kill or inhibit the growth of microorganisms that may cause infection.
Choice D reason: Erythema is an expected finding in a client with inflammation, which is the body's response to injury or infection. Erythema is the redness of the skin due to the dilation of the blood vessels in the inflamed area, which increases the blood flow and the delivery of oxygen and nutrients to the damaged tissues. Erythema also helps to signal the presence of inflammation and attract immune cells to the site.
Choice E reason: Pain is an expected finding in a client with inflammation, which is the body's response to injury or infection. Pain is caused by the stimulation of the nerve endings by chemical mediators, such as histamine, prostaglandins, and bradykinin, that are released by the inflamed tissues. Pain also helps to alert the client of the injury or infection and to limit the movement or use of the affected area.
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