A nurse is providing care to a client who is immunocompromised.

Which of the following should the nurse identify as a possible source of infection?

Explanation

A. Increased erythrocyte sedimentation rate

A. Increased erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation in the body. In the presence of an infection, the ESR tends to rise due to increased levels of acute-phase reactants, such as fibrinogen and globulins. However, it is important to note that an increased ESR alone does not diagnose a specific infection but rather indicates the presence of inflammation or infection.

Decreased platelets in (option B) should not be included because they are not typically associated with infection. Low platelet levels (thrombocytopenia) may occur due to various reasons, such as certain medications, immune disorders, or bone marrow problems, but they are not directly linked to infections.

Increased iron level in (option C) should not be included because it is not a typical finding in an active infection. In fact, during an infection, iron levels tend to decrease in response to the body's efforts to withhold iron from pathogens, as most microorganisms require iron for their growth and survival.

Decreased haemoglobin in (option D) should not be included because it is not directly indicative of an infection. A decrease in hemoglobin levels may be associated with conditions such as anaemia, blood loss, or certain chronic diseases, but it is not a specific marker for infection.

Based on the given information, the nurse should take the following actions in preparation for surgery:

• Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
• Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
• Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to Rh-positive blood.
• Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
• Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.

The following actions are not indicated based on the given information:

• Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
• Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.