A nurse is assisting with the care of client.

Drag 1 condition and 1 finding to fill in each blank in the following sentences

The client likely suffered from

____

as evidenced by

____

.

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.

A) "Tape the tube to the child's cheek."
Taping the tube to the child's cheek is not appropriate for securing a gastrostomy enteral tube. The tube should be securely anchored to the child's abdomen to prevent dislodgment or irritation. Taping to the cheek can lead to unnecessary friction or skin breakdown.

B) "Secure the tubing to the child's abdomen."
The proper method to secure a gastrostomy tube is to anchor the tubing to the child’s abdomen with a specialized securing device or adhesive bandage. This ensures the tube remains in place, minimizing movement and preventing irritation or accidental removal. Proper securing also promotes comfort and safety for the child.

C) "Apply water-soluble lubricant to the site."
Water-soluble lubricant should not be applied directly to the gastrostomy site. This can cause irritation or create a barrier that inhibits proper healing. Instead, the site should be kept clean and dry, with appropriate care to prevent infection or breakdown.

D) "Attach an extension tube to the site's opening prior to use."
While attaching an extension tube may be necessary for feeding or drainage, this action is not related to site care. The focus of site care is to ensure the gastrostomy tube remains securely in place, and the skin around the site is maintained without infection or irritation. Extension tubes are used for feeding or medication administration, not for routine site care.