A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?

Choice A reason: Flu-like symptoms and night sweats

The initial symptoms of HIV infection often resemble those of the flu. These symptoms, known as acute retroviral syndrome (ARS) or primary HIV infection, typically occur within 2 to 4 weeks after the virus enters the body. Common symptoms include fever, chills, night sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, and a rash. These symptoms are the body’s natural response to the virus and indicate that the immune system is reacting to the infection. Night sweats, in particular, are a common symptom during the early stages of HIV infection.

Choice B reason: Fungal and bacterial infections

Fungal and bacterial infections are more commonly associated with later stages of HIV infection, particularly when the immune system has been significantly weakened. As HIV progresses and the immune system deteriorates, individuals become more susceptible to opportunistic infections, which are infections that occur more frequently and are more severe in people with weakened immune systems. These infections are not typically seen in the initial stages of HIV infection.

Choice C reason: Pneumocystis lung infection

Pneumocystis pneumonia (PCP) is a serious infection that occurs in people with weakened immune systems, including those with advanced HIV/AIDS. It is caused by the fungus Pneumocystis jirovecii. PCP is not an initial symptom of HIV infection but rather a complication that can arise when the immune system is severely compromised. This infection is more indicative of the later stages of HIV, particularly when the CD4 cell count drops significantly.

Choice D reason: Kaposi’s sarcoma

Kaposi’s sarcoma is a type of cancer that forms in the lining of blood and lymph vessels. It is caused by the human herpesvirus 8 (HHV-8) and is commonly associated with advanced HIV infection or AIDS. Kaposi’s sarcoma presents as purple, red, or brown blotches or tumors on the skin and can also affect internal organs. This condition is not an initial symptom of HIV infection but rather a manifestation of severe immune system damage in the later stages of the disease.

Choice A reason:

Administer 50,000 units of heparin by IV bolus every 12 hours: This dosage is incorrect and potentially dangerous. Heparin dosing must be carefully calculated based on the patient’s weight and coagulation test results. Standard practice involves adjusting the dose according to the aPTT levels to maintain therapeutic anticoagulation.

Choice B reason:

Have vitamin K available on the nursing unit: Vitamin K is the antidote for warfarin, not heparin. The antidote for heparin is protamine sulfate. Having the correct antidote available is crucial for managing potential bleeding complications associated with heparin therapy.

Choice C reason:

Use tubing specific for heparin sodium when administering the infusion: While it is important to use appropriate tubing for any IV medication, there is no specific tubing required exclusively for heparin sodium. Standard IV tubing is typically sufficient.

Choice D reason:

Check the activated partial thromboplastin time (aPTT) every 6 hours: This is correct. Monitoring aPTT levels is essential when administering a continuous heparin infusion. The aPTT test measures the time it takes for blood to clot and helps ensure that the heparin dose is within the therapeutic range. Regular monitoring helps prevent both under- and over-anticoagulation, reducing the risk of clotting or bleeding complications.