A nurse is assisting with the plan of care for10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
Administer granulocyte colony stimulating factor.
Monitor the infant's lymphocyte count.
Initiate droplet precautions.
Educate the infant's guardians about exchange transfusions.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Staff members used a class A fire extinguisher during an electrical fire.
This response indicates that the safety plan is effective because it shows that the staff used the correct type of fire extinguisher for the fire they encountered. Class A fire extinguishers are designed for ordinary combustibles (e.g., wood, paper, cloth), but using a fire extinguisher that is correctly suited to the fire type demonstrates that the staff are trained and prepared to respond appropriately in an emergency. For electrical fires, however, a Class C fire extinguisher should be used. This suggests a review of fire safety plan training might be necessary to align fire extinguisher types with fire classes.
B) Staff members review the locations of fire extinguishers every 2 to 3 years.
Reviewing the locations of fire extinguishers every 2 to 3 years is not an adequate frequency. Fire safety protocols should be reviewed more frequently to ensure that staff are consistently aware of fire extinguisher locations. Routine and more frequent checks (e.g., annually) are required to ensure proper preparedness in an emergency.
C) An evacuation was ordered during a fire when fire extinguishers were not effective.
While evacuations are necessary in certain situations, an evacuation being ordered because fire extinguishers were ineffective could indicate that the safety plan was not properly executed or that there was an issue with fire extinguisher maintenance or staff training. The effectiveness of fire safety plans should reduce the need for evacuations due to inadequate response efforts.
D) Fire alarms in the facility have the same sound as other alarms.
Fire alarms should have a distinct sound that differentiates them from other types of alarms (e.g., medical or security alarms). If fire alarms have the same sound as other alarms, it could create confusion in an emergency, undermining the effectiveness of the safety plan. The alarm system should be unique and easily identifiable.
Correct Answer is D
Explanation
A) I have occasional vaginal spotting: Vaginal spotting can occur as a side effect of medroxyprogesterone, especially in the first few months of use. While this should be monitored, it is not an immediate concern that requires urgent reporting unless the spotting becomes heavy or persistent, which could indicate other issues.
B) I have developed brown patches on my face: The development of brown patches on the face (known as melasma) is a known side effect of hormonal contraceptives, including medroxyprogesterone. Although this is an undesirable cosmetic effect, it is not an urgent medical concern that requires immediate attention.
C) I have breast tenderness: Breast tenderness is a common side effect of medroxyprogesterone and other hormonal medications. It is usually mild and resolves over time. While the client should continue to monitor the tenderness, it does not present an immediate risk or require urgent intervention.
D) I have intermittent calf pain: Intermittent calf pain could be a sign of a more serious complication, such as a deep vein thrombosis (DVT), especially since medroxyprogesterone can increase the risk of blood clots. This symptom should be reported immediately to the healthcare provider, as a DVT could potentially lead to a pulmonary embolism if left untreated, which is a life-threatening condition. Therefore, this is the priority finding to report.
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