A nurse is assisting with the plan of care for10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
Administer granulocyte colony stimulating factor.
Monitor the infant's lymphocyte count.
Initiate droplet precautions.
Educate the infant's guardians about exchange transfusions.
The Correct Answer is B
A) Administer granulocyte colony stimulating factor: Granulocyte colony-stimulating factor (G-CSF) is used to stimulate white blood cell production in certain conditions like neutropenia. However, in an infant with HIV, the primary concern is the HIV progression and monitoring for complications rather than administering G-CSF. It is not routinely used for infants with HIV unless there is a specific indication such as neutropenia.
B) Monitor the infant's lymphocyte count: Monitoring the infant’s lymphocyte count is an appropriate and essential intervention. HIV affects the immune system by targeting CD4+ T lymphocytes, so tracking the lymphocyte count will help gauge the progression of the disease and the effectiveness of the treatment. It is vital to assess the infant’s immune status, as HIV can lead to a weakened immune system and increase susceptibility to infections.
C) Initiate droplet precautions: Droplet precautions are typically required for infections like influenza or certain respiratory illnesses. HIV is not transmitted via droplets; it is primarily transmitted through blood, sexual contact, and from mother to child during childbirth or breastfeeding. Therefore, droplet precautions are not necessary for this infant.
D) Educate the infant's guardians about exchange transfusions: Exchange transfusions are generally not a routine intervention for infants with HIV unless there is a specific complication like severe hyperbilirubinemia or other hematologic conditions. The focus for infants with HIV is on managing antiretroviral therapy (ART) and preventing infections, rather than performing exchange transfusions. Educating the guardians about ART and infection prevention would be more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Inject 15 units of air into the regular insulin vial:
When drawing insulin from both NPH (a long-acting insulin) and regular insulin (a short-acting insulin), the nurse should first inject air into the NPH insulin vial (which is the intermediate-acting insulin) and then inject air into the regular insulin vial. This technique helps to prevent contamination of the regular insulin vial with NPH insulin. After injecting air into the regular insulin vial, the nurse would then withdraw the regular insulin first and then the NPH insulin to avoid contamination of the regular insulin with the NPH insulin.
B) Withdraw 10 units of NPH insulin:
This action is premature, as the nurse has not yet injected air into the regular insulin vial. The correct sequence involves injecting air into both vials before withdrawing any insulin. Therefore, withdrawing NPH insulin at this stage is not the correct next step.
C) Verify the dosage with another nurse:
While verifying the insulin dosage with another nurse is a good practice for ensuring medication safety, this action is not the immediate next step after injecting air into the NPH insulin vial. The priority is to follow the correct sequence of air injection into the vials before withdrawing the insulin. Verification can occur after the insulin is drawn.
D) Place the cap over the needle:
Placing the cap over the needle is a safety step that is generally performed after withdrawing the insulin and preparing the injection. However, this is not the next step in the process of mixing or drawing insulin, so it is not the correct action to take at this point.
Correct Answer is D
Explanation
A) Steatotic liver disease: Steatotic liver disease, or fatty liver disease, is typically associated with excess fat in the liver, often linked to alcohol use, obesity, or diabetes. While it can affect liver function, it is not primarily associated with deficiencies in iron and vitamin B12. Therefore, this condition is not directly related to the lab findings of low iron and vitamin B12.
B) Leukemia: Leukemia is a type of cancer that affects the blood and bone marrow, leading to abnormal white blood cell production. While leukemia can cause anemia as a secondary effect due to bone marrow dysfunction, it is not typically characterized by deficiencies in both iron and vitamin B12 simultaneously. The lab findings are more consistent with a nutritional or absorption issue rather than leukemia.
C) Hepatitis: Hepatitis refers to inflammation of the liver, usually caused by a viral infection or other factors. While hepatitis can lead to various blood abnormalities, it is not specifically linked to both iron and vitamin B12 deficiencies. Hepatitis more commonly affects liver function and may cause jaundice, but it does not directly explain low iron and B12 levels.
D) Anemia: Both iron and vitamin B12 are essential for the production of healthy red blood cells. Iron deficiency can lead to iron-deficiency anemia, and vitamin B12 deficiency can cause pernicious anemia. Therefore, low levels of both iron and vitamin B12 suggest the possibility of anemia, and the nurse should monitor the client for signs and symptoms of this condition, such as fatigue, pallor, and weakness.
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