A nurse is caring for a client with HIV/AIDS who has a CD4+ T-cell count of 180 cells/mm³. Which nursing intervention should be the highest priority to ensure client safety?
1Encourage the client to maintain social activities to prevent depression
2Provide a high-protein diet to improve nutritional status
3Implement strict infection control precautions and protective isolation measures✓ 정답
4Administer prescribed antiretroviral medications on schedule
해설
With a CD4+ T-cell count of 180 cells/mm³, the client is severely immunocompromised, making strict infection control and protective isolation the highest priority to prevent life-threatening opportunistic infections. Other interventions are important but do not address the immediate safety risk.
Understanding the Clinical Priority
The client's CD4+ T-cell count is 180 cells/mm³. This value is critically below the threshold of 200 cells/mm³, which defines the transition from HIV infection to AIDS (Acquired Immunodeficiency Syndrome). At this level of severe immunosuppression, the body's cell-mediated immunity is profoundly compromised, rendering the client extremely vulnerable to opportunistic infections. The immediate physiological threat is not nutritional deficit or social isolation, but the high risk of acquiring a life-threatening infection from common environmental or nosocomial pathogens. Therefore, the highest priority intervention must directly address this imminent safety risk.
Why Infection Control is the Highest Priority
Implementing strict infection control precautions and protective isolation measures directly mitigates the most immediate threat to a client with a CD4+ count of 180 cells/mm³. The provided evidence underscores that immunocompromised patients are a uniquely vulnerable population during infectious outbreaks, facing amplified morbidity and mortality [1]. For a client with AIDS, a common hospital-acquired infection like influenza is not a minor illness; it can be catastrophic. The concept of protective isolation involves creating a safer environment by rigorously applying practices such as strict hand hygiene, ensuring the client's immediate surroundings are free from pathogens like Aspergillus (often requiring a HEPA-filtered room), and screening visitors and staff for active infections. This intervention is a foundational safety measure that prevents exposure to pathogens the client's body can no longer fight, making it the priority over other important but less immediately protective actions.
Analysis of Other Options
While the other interventions are valuable components of holistic care, they do not address the most acute safety risk.
- Option 1 (Social activities): While preventing depression is important for quality of life, a social setting introduces a high risk of exposure to community-acquired pathogens. At this CD4+ level, the risk of infection outweighs the psychological benefit of group activities.
- Option 2 (High-protein diet): Nutritional support is crucial for maintaining immune function and muscle mass in HIV/AIDS, but it is a long-term, supportive intervention. It does not provide immediate protection against the acute risk of acquiring a fatal infection today.
- Option 4 (Administering antiretrovirals): Adherence to antiretroviral therapy (ART) is the cornerstone of treatment to suppress the viral load and allow immune reconstitution. However, this is a pharmacological intervention that takes weeks to months to raise the CD4+ count. It does not shield the client from an infection they might encounter in the next hour. The immediate safety need is a physical barrier and process-based protection, which is provided by infection control precautions.
Clinical Application of the Evidence
The narrative review highlights that the COVID-19 era has reinforced the critical importance of stringent infection control norms, such as appropriate mask use and ventilation improvements, especially for immunocompromised inpatients [1]. Applying this to the NCLEX-RN context, the nurse must translate these system-level practices into individual client care. For a client with a CD4+ count of 180 cells/mm³, this means the nurse must actively implement protective isolation. This includes placing the client in a private room, ensuring anyone entering wears a standard surgical mask if the client is not on airborne precautions for a specific condition, rigorously disinfecting equipment like stethoscopes before use, and strictly excluding any staff member or visitor with even mild respiratory symptoms. The principle of prioritizing physiological safety, specifically protection from infection in an immunocompromised host, is the driving force behind this nursing action.
References (research sources)
[1]
Hospital Influenza Outbreak Management in the Post-COVID Era: A Narrative Review of Evolving Practices and Feasibility Considerations.Research articleHuang WH, Ho YF, Yeh JY, Liu PY, Huang PH. (2025) · DOI: 10.3390/healthcare14010050
Clinical Safety Guide: Caring for a Client with Severe Immunosuppression (CD4 < 200)
Immediate Priority: Infection Prevention
For a client with a CD4 count of 180 cells/mm³, the highest priority is strict infection control. The immune system is profoundly compromised, making common environmental microbes a life-threatening risk.
Protective Environment: Place the client in a private room with HEPA filtration to minimize exposure to airborne fungi like Aspergillus. Keep the door closed.
Rigorous Hand Hygiene: Perform hand hygiene with antimicrobial soap or alcohol-based rub before and after all patient contact, even when using gloves.
Standard & Transmission-Based Precautions: Strictly adhere to all standard precautions. Use appropriate personal protective equipment (PPE) based on anticipated exposure to bodily fluids.
Restrict Exposure: Screen visitors and staff for active infections. Do not allow fresh flowers or live plants in the room, as they can harbor bacteria and fungi.
Key Monitoring & Interventions
Vigilant Assessment: Monitor vital signs and assess for subtle signs of infection every 4 hours. A low-grade fever in this client is a critical finding requiring immediate reporting.
Skin Integrity: Inspect skin and mucous membranes daily for any breaks, redness, or lesions, as these are portals of entry for pathogens.
Nutritional Support: Collaborate with a dietitian to provide a high-protein, high-calorie diet to support immune function, but ensure all food is well-cooked and avoids raw items.
Medication Safety: Administer antiretroviral therapy on a strict schedule to maintain therapeutic drug levels, but never at the expense of immediate infection control breaches.
CD4+ T-cell count — A laboratory marker of immune function; a count below 200 cells/mm³ indicates severe immunosuppression and defines a diagnosis of AIDS.
AIDS (Acquired Immunodeficiency Syndrome) — The most advanced stage of HIV infection, characterized by a CD4 count below 200 cells/mm³ or the presence of an AIDS-defining opportunistic infection.
Protective Isolation — A set of infection control practices designed to protect a severely immunocompromised patient from environmental and nosocomial pathogens.
Opportunistic Infection — An infection caused by a pathogen that rarely causes disease in a person with a healthy immune system but can be life-threatening in an immunocompromised host.
Nursing Priority — The clinical decision-making process of ranking patient needs by immediate threat to life and safety, often guided by frameworks like Maslow's hierarchy or the ABCs.