A client has acquired immunodeficiency syndrome (AIDS). Which of these assessment findings indicate possible infection? (Select all that apply.)
Temperature: 101.3 degrees Fahrenheit
Oxygen saturation: 97% on room air
Respirations: 22 breaths per minute
Purulent drainage
Client ambulates 20 feet
Correct Answer : A,D
Choice A reason: A temperature of 101.3 degrees Fahrenheit is a sign of fever, which is a common symptom of infection. Clients with AIDS have a weakened immune system and are more susceptible to opportunistic infections. Fever indicates that the body is trying to fight off an infection.
Choice B reason: An oxygen saturation of 97% on room air is within the normal range and does not indicate infection. Oxygen saturation measures the percentage of hemoglobin that is bound to oxygen in the blood. A low oxygen saturation may indicate respiratory problems, such as pneumonia, which is a common infection in clients with AIDS.
Choice C reason: A respiratory rate of 22 breaths per minute is slightly above the normal range of 12 to 20 breaths per minute, but it does not necessarily indicate infection. Respiratory rate may vary depending on factors such as activity level, stress, pain, or anxiety. A high respiratory rate may indicate respiratory distress, which could be caused by infection or other conditions.
Choice D reason: Purulent drainage is a thick, yellowgreen, or brown pus that indicates infection. It may come from a wound, an abscess, or a body cavity. Purulent drainage is a sign of inflammation and infection and should be reported to the health care provider.
Choice E reason: A client's ability to ambulate 20 feet is not related to infection. Ambulation is a measure of mobility and function and may be affected by factors such as pain, fatigue, or muscle weakness. Ambulation does not reflect the presence or absence of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administering topical hydrocortisone is the appropriate nursing intervention, because it can help reduce the inflammation and itching of the skin lesions that are common in SLE. SLE is a chronic autoimmune disease that causes the immune system to attack various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Hydrocortisone is a type of corticosteroid that can suppress the immune response and relieve the symptoms of SLE.
Choice B reason: Applying cold therapy to the extremities is not the appropriate nursing intervention, because it can worsen the circulation and sensation of the fingers and toes that are affected by Raynaud's phenomenon, which is a complication of SLE. Raynaud's phenomenon is a condition that causes the blood vessels in the extremities to narrow and spasm in response to cold or stress, resulting in numbness, pain, and color changes. Cold therapy can trigger or aggravate Raynaud's phenomenon.
Choice C reason: Administering antibiotics is not the appropriate nursing intervention, because it is not indicated for SLE, unless there is a secondary infection. SLE is not caused by bacteria, but by the abnormal activity of the immune system. Antibiotics are drugs that can kill or inhibit the growth of bacteria, but they have no effect on the underlying cause of SLE. Antibiotics can also have side effects, such as allergic reactions, gastrointestinal disturbances, or resistance.
Choice D reason: Encouraging ultraviolet (UV) light exposure is not the appropriate nursing intervention, because it can trigger or worsen the skin lesions and the disease activity of SLE. UV light is a type of radiation that can damage the DNA and the cells of the skin, causing inflammation, redness, and blistering. UV light can also stimulate the production of antibodies and cytokines that can attack the organs and tissues of the body.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Polyuria is the production of abnormally large amounts of urine, which can be caused by various factors, such as diabetes, kidney disease, or diuretics. Polyuria is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not affect the urinary system directly, unless the inflammation is located in the kidneys or bladder.
Choice B reason: Edema is the swelling of tissues due to excess fluid accumulation, which can be caused by various factors, such as heart failure, liver disease, or venous insufficiency. Edema is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not cause fluid retention, but rather fluid leakage from the blood vessels into the interstitial spaces.
Choice C reason: Heat is an expected finding in a client with inflammation, which is the body's response to injury or infection. Heat is caused by the increased blood flow to the inflamed area, which brings more oxygen and nutrients to the damaged tissues. Heat also helps to kill or inhibit the growth of microorganisms that may cause infection.
Choice D reason: Erythema is an expected finding in a client with inflammation, which is the body's response to injury or infection. Erythema is the redness of the skin due to the dilation of the blood vessels in the inflamed area, which increases the blood flow and the delivery of oxygen and nutrients to the damaged tissues. Erythema also helps to signal the presence of inflammation and attract immune cells to the site.
Choice E reason: Pain is an expected finding in a client with inflammation, which is the body's response to injury or infection. Pain is caused by the stimulation of the nerve endings by chemical mediators, such as histamine, prostaglandins, and bradykinin, that are released by the inflamed tissues. Pain also helps to alert the client of the injury or infection and to limit the movement or use of the affected area.
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