A patient diagnosed with HIV-II is admitted to the hospital presenting symptoms of fever, night sweats, and a severe cough.
The laboratory results show a CD4+ cell count of 180/mm and a negative tuberculosis (TB) skin test conducted 4 days prior.
What is the first action the nurse should take?
Inform the primary health care provider about the CD4+ results.
Implement Airborne Precautions for the patient.
Initiate Droplet Precautions for the patient.
Provide care using Standard Precautions.
The Correct Answer is D
Rationale for Choice A:
While it's important for the primary healthcare provider to be informed about the CD4+ results, it's not the first action the nurse should take. The priority is to implement appropriate infection control measures to protect the patient, other patients, and healthcare staff.
CD4+ cell count is a crucial indicator of the patient's immune status. A count of 180/mm is significantly low, suggesting a weakened immune system and increased vulnerability to infections. However, informing the provider alone doesn't directly address the immediate need for infection control.
Rationale for Choice B:
Airborne Precautions are specifically used for patients with known or suspected airborne infections, such as tuberculosis, measles, or varicella. These precautions involve the use of negative pressure rooms and N95 respirators.
In this case, the patient's TB skin test was negative, indicating no evidence of active tuberculosis infection. Implementing Airborne Precautions unnecessarily could lead to excessive resource utilization and potential stigmatization of the patient.
Rationale for Choice C:
Droplet Precautions are used for patients with infections that can be spread through large respiratory droplets, such as influenza, pertussis, or meningococcal meningitis. These precautions involve the use of masks and eye protection.
While the patient's symptoms of fever, night sweats, and severe cough could be consistent with a droplet-spread infection, there's no definitive evidence to support this at the present time. Initiating Droplet Precautions without a clear indication could also lead to unnecessary resource use and potential anxiety for the patient.
Rationale for Choice D:
Standard Precautions are the foundation of infection control and should be used for all patients, regardless of their known or suspected infection status. These precautions include hand hygiene, use of personal protective equipment (PPE) when indicated, and safe handling of sharps and bodily fluids.
By implementing Standard Precautions, the nurse can effectively minimize the risk of transmission of pathogens, protecting both the patient and other individuals in the healthcare setting. This is the most appropriate first action to ensure a safe and appropriate level of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale for Choice A:
Documentation is essential for communication and continuity of care, but it is not the most immediate priority in this situation.
The nurse should document the episode of vomiting, including the time, amount, and characteristics of the vomitus, as well as any associated symptoms or interventions.
However, auscultating lung sounds should be done first to assess for potential aspiration, which is a more urgent concern.
Rationale for Choice B:
Offering dry toast may be appropriate after the nurse has assessed for aspiration and determined that it is safe for the client to resume oral intake.
However, it is not the most important action at this time.
The nurse should first assess the client's respiratory status and address any potential complications.
Rationale for Choice C:
Rest is important for healing and recovery, but it is not the most immediate priority in this situation. The nurse should first assess the client's respiratory status and address any potential complications. Once the client is stable, the nurse can then encourage rest.
Rationale for Choice D:
Auscultating lung sounds is the most important action for the nurse to take after a client vomits.
This is because aspiration of vomitus is a serious complication that can lead to pneumonia, respiratory distress, and even death.
By auscultating lung sounds, the nurse can assess for signs of aspiration, such as crackles, wheezing, or diminished breath sounds.
If aspiration is suspected, the nurse can initiate appropriate interventions, such as suctioning, oxygen therapy, and positioning the client to facilitate drainage of secretions.
Correct Answer is B
Explanation
Choice A rationale:
While promptly removing urinary catheters can reduce the risk of catheter-associated urinary tract infections (CAUTIs), it addresses only one specific type of infection. It doesn't comprehensively address other common healthcare-associated infections (HAIs) like central line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections (CDI).
Education about infection control methods, however, encompasses a broader range of preventive measures that can be applied to various HAIs, making it a more effective strategy for overall infection prevention.
Choice C rationale:
Placing patients in appropriate isolation can prevent the spread of infections, but it's a reactive measure that's implemented after an infection has already occurred. It doesn't address the root causes of infections or prevent their occurrence in the first place.
Education about infection control methods, on the other hand, is a proactive approach that aims to prevent infections from happening in the first place by teaching staff about proper hygiene practices, aseptic techniques, and other infection prevention strategies.
Choice D rationale:
Monitoring hand hygiene practices is crucial for infection prevention, but it's only one aspect of a comprehensive infection control program. Education about infection control methods goes beyond hand hygiene and covers various other preventive measures, such as:
Proper use of personal protective equipment (PPE) Aseptic technique during invasive procedures
Proper cleaning and disinfection of equipment and surfaces Proper handling of patient waste
Recognition of signs and symptoms of infection Prompt reporting of potential outbreaks
Therefore, educating staff members about infection control methods is the most effective action the nursing manager can take to prevent infections in the hospital unit because it provides a comprehensive approach to infection prevention, addressing various aspects of HAI prevention and promoting a culture of safety among healthcare staff.
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