A nurse is preparing to administer 2 medications via client's NG tube. Which of the following actions should the nurse take?

A) Use a moisturizing soap to clean the skin around the client's stoma:
Using a moisturizing soap is not recommended for cleaning the skin around the stoma. Moisturizing soaps can leave a residue that may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with warm water and mild soap that does not contain lotions, fragrances, or oils. This helps ensure the skin is clean and dry, promoting better adhesion of the skin barrier.

B) Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma:
The opening in the skin barrier should be about 1/8 inch (approximately 0.32 cm) larger than the stoma's diameter, not 1.27 cm (0.5 in) larger. A larger opening can cause the skin barrier to fit too loosely, leading to leakage and skin irritation. The skin barrier should fit snugly around the stoma to prevent any leakage and protect the surrounding skin.

C) Empty the client's ostomy pouch before removing the skin barrier:
It is essential to empty the ostomy pouch before removing the skin barrier to prevent fecal material from spilling or leaking during the appliance change. This helps maintain cleanliness, reduces the risk of skin irritation, and makes the procedure more comfortable for both the client and the nurse.

D) Change the client's ostomy appliance 1 hour after breakfast:
There is no specific time required after breakfast to change the ostomy appliance. The timing of appliance changes should be based on the client's individual needs and lifestyle, and it is more important to change the appliance when necessary (e.g., when the pouch is full or when the skin barrier is no longer intact) rather than adhering to a specific time after meals.

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.