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 ["C","D","E"]
Explanation
A) Instruct another nurse to record the prescription in the medical record:
The nurse receiving a telephone prescription is responsible for ensuring the prescription is recorded correctly in the medical record. It is not appropriate to delegate this responsibility to another nurse. The nurse should personally document the prescription to ensure accuracy and clarity.
B) Withhold the medication until the provider signs the prescription:
The nurse should not withhold the medication solely based on the provider's signature. Telephone prescriptions are valid once they are received and documented accurately by the nurse. The prescription must be signed by the provider as soon as possible, but withholding medication is not warranted unless there are other concerns with the prescription.
C) Ask the provider to spell out the name of the medication:
When receiving a telephone prescription, the nurse should ask the provider to spell out the name of the medication to avoid errors. Medication names, especially those that sound similar, need to be communicated clearly to ensure correct medication administration. This action helps prevent misinterpretation or confusion, ensuring patient safety.
D) Record the date and time of the telephone prescription:
Recording the date and time of the telephone prescription is essential for accurate documentation and legal purposes. This step ensures that there is a clear record of when the prescription was given and that the provider’s order is traceable in the client’s medical record. It also assists in meeting legal and institutional documentation requirements.
E) Request that the provider confirm the read-back of the prescription:
The nurse should read back the prescription to the provider to confirm accuracy. This action is part of the "read-back" process, a safety measure used to verify that the prescription has been communicated correctly and understood by both the nurse and the provider. This step helps reduce the risk of medication errors.
Correct Answer is B
Explanation
A) "A child who has leukemia and an absolute neutrophil count of 200/mm³ (2,500 to 8,000/mm³)."
This child is at significant risk for infection due to a severely low neutrophil count, indicating severe neutropenia. Discharge planning for this child would be inappropriate at this time since they need intensive monitoring and care to manage their immunocompromised status and prevent infections.
B) "A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin."
This child is appropriate for discharge planning. A new diagnosis of type 1 diabetes requires thorough teaching for the family and child about blood glucose monitoring, insulin administration, dietary adjustments, and emergency management. While the child is receiving IV insulin in the hospital, once stabilized, they can be discharged with proper education and support to manage their condition at home.
C) "An adolescent who has cystic fibrosis and is receiving their yearly tune-up."
A cystic fibrosis "tune-up" refers to a period of treatment, often including IV antibiotics and respiratory therapy, to help manage the chronic condition. Since this is part of ongoing care and not an acute issue, discharge planning is not immediately appropriate until the "tune-up" is complete, and the adolescent has stabilized.
D) "An infant who has respiratory syncytial virus (RSV) and a respiratory rate of 70/min."
This infant is at risk for respiratory distress and requires close monitoring. A respiratory rate of 70/min in an infant is elevated, and the child may need additional respiratory support. Discharge planning should not be initiated until the infant's condition improves and they are stable enough to handle care at home.
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