The nurse is caring for clients on the medical-surgical unit.
What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?

Choice A rationale

A positive Western blot is a confirmatory diagnostic test for HIV infection, establishing the presence of antibodies. While important, it is not an acute parameter reflecting the current status of immune function or risk of opportunistic infection.

Choice B rationale

A platelet count of 150,000/mm is at the lower limit of the normal range (150,000 to 450,000/mm). This value does not indicate a critical clotting abnormality or an immediate life-threatening bleeding risk.

Choice C rationale

A white blood cell (WBC) count of 5,000/mm is within the normal range (4,500 to 11,000/mm). This value does not suggest an acute, uncontrolled infection or severe neutropenia requiring urgent intervention.

Choice D rationale

A CD4-T-cell count of 180 cells/mm is critically low, falling below the diagnostic threshold of 200 cells/mm for an AIDS diagnosis. This severe immunosuppression places the client at highest immediate risk for developing life-threatening opportunistic infections and malignancies.

Choice A rationale

Although accidental puncture wounds (e.g., needlestick injuries in healthcare settings) can transmit HIV, this is considered a risk for occupational exposure and not the primary or most common route of transmission in the general population. The main routes involve direct exposure to significant volumes of virus-containing bodily fluids during specific high-risk activities.

Choice B rationale

HIV is not transmitted through casual contact like hugging, shaking hands, sharing eating utensils, or using the same toilet seat. The virus cannot survive for long outside the human body and is only transmitted when certain infected bodily fluids enter the bloodstream of another person, directly excluding everyday social contact.

Choice C rationale

Extensive scientific research has definitively shown that HIV is not transmitted by insects or mosquitoes. The virus does not replicate or survive within the insect's body, and the amount of blood transferred during a bite is insufficient for transmission, distinguishing it from arboviruses.

Choice D rationale

HIV is primarily transmitted through direct contact with specific infected body fluids: blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, and breast milk. This typically occurs through unprotected sexual contact (anal or vaginal), sharing needles for drug injection, or from mother to child during pregnancy, birth, or breastfeeding.