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: Ensuring the client is warm
While maintaining client warmth is important for comfort and to prevent hypothermia, it is not the immediate priority upon arrival in the postoperative unit. Thermoregulation can be addressed after more urgent assessments have been completed.
Rationale for Choice B: Participating in hand-off report
A thorough hand-off report is essential for continuity of care, but it does not take precedence over assessing the client's immediate physiological status. The nurse can gather information from the report while simultaneously performing essential assessments.
Rationale for Choice C: Checking the surgical dressings
Monitoring surgical dressings is a crucial aspect of postoperative care, but it does not take priority over assessing fluid and blood output. Excessive bleeding or fluid shifts can rapidly compromise the client's hemodynamic stability and require prompt intervention.
Rationale for Choice D: Assessing fluid and blood output
This is the priority action for several reasons:
Monitoring for Hemorrhage: Early detection of excessive bleeding is crucial to prevent hypovolemic shock, a life-threatening complication. Postoperative bleeding can occur internally or externally, and prompt assessment of fluid and blood output allows for timely interventions to control bleeding and maintain hemodynamic stability.
Assessing Fluid Balance: Maintaining fluid balance is essential for optimal organ function and electrolyte balance. Postoperative clients are at risk for fluid imbalances due to blood loss, fluid shifts, and the use of diuretics or IV fluids. Assessing fluid intake and output helps to identify and address fluid imbalances early.
Evaluating Renal Function: Urine output is a key indicator of renal function. Postoperative clients are at risk for acute kidney injury due to factors such as hypotension, blood loss, and nephrotoxic medications. Assessing urine output helps to detect early signs of kidney dysfunction and initiate appropriate interventions.
Guiding Fluid and Blood Product Replacement: The assessment of fluid and blood output provides essential information to guide the administration of fluids and blood products as needed. This ensures that the client's fluid status and oxygen-carrying capacity are maintained within safe parameters.
Therefore, assessing fluid and blood output takes priority as it allows the nurse to identify and address potential life- threatening complications promptly, as well as guide interventions to maintain fluid balance and organ function.
Correct Answer is D
Explanation
Choice A rationale:
Utilizing a respirator when handling urine output is not the most appropriate action for a nurse caring for a patient with MRSA.
MRSA is not typically transmitted through the air, but rather through direct contact with infected wounds or contaminated surfaces.
While a respirator may offer some protection against airborne particles, it is not necessary for routine care of a patient with MRSA.
It is more important to focus on hand hygiene and other infection control measures.
Choice B rationale:
Restricting visitors strictly to immediate family members only is not necessary for a patient with MRSA.
While it is important to limit the number of visitors to reduce the risk of spreading infection, there is no need to restrict visitors to immediate family members only.
Visitors should be instructed on proper hand hygiene and other infection control measures, and they should avoid contact with the patient's wounds or dressings.
Choice C rationale:
Washing hands only after removing gloves post-care is not sufficient for preventing the spread of MRSA. It is important to wash hands before and after any contact with the patient, even when wearing gloves.
This is because gloves can become contaminated with bacteria, and hand washing helps to remove any bacteria that may have gotten on the hands.
Choice D rationale:
Preparing to administer vancomycin is the most appropriate action for a nurse caring for a patient with MRSA. Vancomycin is an antibiotic that is effective against MRSA.
It is often used to treat MRSA infections, and it can help to prevent the infection from spreading.
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