A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has a CD4+ T-cell count of 220 cells/mm³. Which nursing intervention should be the highest priority to ensure client safety?

1 Implement strict hand hygiene protocols and use personal protective equipment for all client interactions ✓ 정답
2 Administer prescribed antiretroviral medications at scheduled times
3 Encourage increased fluid intake to prevent dehydration
4 Provide emotional support and counseling resources

해설

With a CD4+ count of 220 cells/mm³, the client is immunocompromised, making infection prevention through strict hand hygiene and PPE the highest priority for safety. Other interventions are important but do not address the immediate risk of infections.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the ability to prioritize nursing interventions for a patient with Acquired Immunodeficiency Syndrome (AIDS) based on their level of immunosuppression. The key data point is the CD4+ T-cell count of 220 cells/mm³. CD4+ cells are a type of white blood cell (lymphocyte) that orchestrates the immune response. A normal count is typically 500–1,500 cells/mm³. A count below 200 cells/mm³ defines the progression from HIV infection to AIDS, but any count significantly below normal indicates severe immunosuppression. The primary risk for an immunocompromised patient is Key Point! opportunistic infections, which are the leading cause of morbidity and mortality. Therefore, the highest priority nursing action is always Key Point! infection prevention.

Answer Rationale: Option ①, "Implement strict hand hygiene protocols and use personal protective equipment for all client interactions," is correct because it directly addresses the greatest safety threat to this client. Hand hygiene is the single most effective measure to prevent the transmission of pathogens. Using PPE (e.g., gloves, gowns, masks as indicated) protects the client from microorganisms that healthcare workers might carry. For a client with a CD4+ count of 220, even common bacteria or viruses can cause severe, life-threatening illness. This intervention aligns with the nursing principle of safety first and the concept of standard precautions, which are applied to all patients but are critically intensified for the immunocompromised.

Distractor Analysis:
Watch out for confusion! Option ②, "Administer prescribed antiretroviral medications at scheduled times," is a very important intervention for long-term management of HIV/AIDS. Adherence to antiretroviral therapy (ART) is crucial for suppressing the viral load and potentially allowing the CD4+ count to rise. However, in the context of immediate client safety during nursing care, preventing a new infection takes precedence over the scheduled administration of a medication that works over the long term. Missing a dose is a concern, but it does not pose the same acute, direct threat as introducing an infection.
Watch out for confusion! Option ③, "Encourage increased fluid intake to prevent dehydration," is a supportive measure. Patients with AIDS may be at risk for dehydration due to fever, diarrhea, or poor oral intake. While hydration is important for overall health, it is not the highest priority for ensuring safety against the primary complication of immunosuppression.
Watch out for confusion! Option ④, "Provide emotional support and counseling resources," addresses the psychosocial and holistic needs of the client, which are vitally important in chronic and stigmatized illnesses like HIV/AIDS. However, according to Maslow's Hierarchy of Needs and nursing prioritization frameworks (e.g., ABCs, safety risks), physiological safety (preventing infection) must be secured before addressing higher-level psychological needs.

Related Concepts: This question integrates knowledge of HIV pathophysiology, infection control principles, and nursing prioritization. Remember that for immunocompromised patients, the nurse's role as a protector against infection is paramount. Other safety considerations for hospitalized AIDS patients include protecting them from injury (due to potential neurologic complications), ensuring nutritional support, and monitoring for signs of opportunistic infections (e.g., fever, cough, dyspnea, diarrhea, skin lesions).

Concept Summary

Concept	Key Takeaway
CD4+ T-cell Count	Marker of immune function. Normal: 500-1,500 cells/mm³. AIDS-defining: 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are assigned to care for Mr. Johnson, a 45-year-old man with AIDS, admitted for weakness and weight loss. His latest lab shows a CD4+ count of 220 cells/mm³. As you enter his room, you notice he has a persistent, dry cough. Nursing Intervention Strategy: Assessment: Immediately perform a focused respiratory assessment (lung sounds, respiratory rate, oxygen saturation). Note any fever, sputum production, or chest pain. This baseline is critical for detecting early Pneumocystis pneumonia (PCP), a common opportunistic infection. Safety & Infection Prevention (Priority Action): Before touching Mr. Johnson or any surface in his room, perform hand hygiene with alcohol-based rub or soap and water. For this interaction, don gloves. If his cough becomes productive or a procedure is planned that might generate splashes, add a gown and mask/eye protection as per Standard Precautions. Environment: Ensure his room is clean. If possible, assign him a private room to minimize exposure to other patients' pathogens. Educate visitors on the importance of hand hygiene and asking them not to visit if they are ill. Medication Administration: Administer his ART on schedule. Use this time to assess adherence barriers and provide education on the importance of never missing a dose to prevent resistance. Evaluation: Continuously monitor for any change in condition, especially signs of infection. Report new fever, worsening cough, or dyspnea to the provider immediately. Patient Safety and Precautions: Protect the Patient: You are his primary defense against healthcare-associated infections (HAIs). Meticulous aseptic technique is non-negotiable for all procedures (IV care, wound care, catheter care). Medication Cautions: Many ART drugs have significant side effects and drug interactions. Monitor for nausea, liver toxicity, lipodystrophy, and bone marrow suppression. Administer some drugs with food to improve tolerance. Psychosocial Sensitivity: Provide emotional support in a non-judgmental manner. The stigma of HIV/AIDS is real. Connect the patient with social work or support groups as needed, but remember, physiological safety comes first. Nursing Procedure & Medication Flow Hand Hygiene Procedure (The Priority Intervention): 1. Remove jewelry. 2. Wet hands with warm water. 3. Apply soap. 4. Rub all surfaces (palms, backs, between fingers, under nails) for at least 20 seconds. 5. Rinse thoroughly. 6. Dry with a clean towel/air dryer. 7. Use the towel to turn off the faucet. Alternative: Use enough alcohol-based rub to cover all hand surfaces; rub until dry. ART Administration: Adherence is key. Use pill organizers, set alarms, and link doses to daily routines. Educate on the consequence of non-adherence: viral rebound, drop in CD4+, and development of drug-resistant HIV. A Word from Your Senior Nurse "Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, recognizing subtle changes in a patient's vital signs early can prevent deterioration. When studying for your boards, don't just memorize — connect everything to a real patient situation and always ask 'why?' That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse! For Mr. Johnson, your clean hands are more important than any medication you'll give him during that shift. You are his immune system's backup. Never underestimate the power of this simple, fundamental act." 핵심 개념 CD4+ T-cell Count — A measure of the number of helper T lymphocytes in the blood. It is the primary indicator of immune function in HIV infection. A count below 200 cells/mm³ is diagnostic for AIDS. Opportunistic Infection — An infection caused by pathogens that take advantage of a host's weakened immune system (e.g., in AIDS). Examples include Pneumocystis pneumonia (PCP), candidiasis, and tuberculosis. Standard Precautions — A set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin, and mucous membranes. They are the foundation for protecting all patients, especially the immunocompromised. Antiretroviral Therapy — The combination of several antiretroviral medicines used to slow the replication of the Human Immunodeficiency Virus (HIV). The goal is to achieve and maintain an undetectable viral load. Hand Hygiene — The most important single measure to reduce the risks of transmitting pathogens to patients and healthcare workers. It includes washing hands with soap and water or using an alcohol-based hand rub. 마이메르시로 국가고시 완벽 대비 기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요. 무료로 시작하기 App Store Google Play 학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요. 같은 주제 문제 A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has a CD… A nurse is caring for a 45-year-old male client with acquired immunodeficiency syndrome (A… A nurse is caring for a 38-year-old female client with acquired immunodeficiency syndrome … A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has deve… A nurse is assessing a 28-year-old patient with suspected primary immunodeficiency syndrom… A nurse is assessing a 35-year-old patient who has been experiencing recurrent infections … A nurse is assessing a 28-year-old patient who has been experiencing recurrent infections …

Concept

Key Takeaway

CD4+ T-cell Count

Marker of immune function. Normal: 500-1,500 cells/mm³. AIDS-defining:

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are assigned to care for Mr. Johnson, a 45-year-old man with AIDS, admitted for weakness and weight loss. His latest lab shows a CD4+ count of 220 cells/mm³. As you enter his room, you notice he has a persistent, dry cough.

Nursing Intervention Strategy:

Assessment: Immediately perform a focused respiratory assessment (lung sounds, respiratory rate, oxygen saturation). Note any fever, sputum production, or chest pain. This baseline is critical for detecting early Pneumocystis pneumonia (PCP), a common opportunistic infection.
Safety & Infection Prevention (Priority Action): Before touching Mr. Johnson or any surface in his room, perform hand hygiene with alcohol-based rub or soap and water. For this interaction, don gloves. If his cough becomes productive or a procedure is planned that might generate splashes, add a gown and mask/eye protection as per Standard Precautions.
Environment: Ensure his room is clean. If possible, assign him a private room to minimize exposure to other patients' pathogens. Educate visitors on the importance of hand hygiene and asking them not to visit if they are ill.
Medication Administration: Administer his ART on schedule. Use this time to assess adherence barriers and provide education on the importance of never missing a dose to prevent resistance.
Evaluation: Continuously monitor for any change in condition, especially signs of infection. Report new fever, worsening cough, or dyspnea to the provider immediately.

Patient Safety and Precautions:

Protect the Patient: You are his primary defense against healthcare-associated infections (HAIs). Meticulous aseptic technique is non-negotiable for all procedures (IV care, wound care, catheter care).
Medication Cautions: Many ART drugs have significant side effects and drug interactions. Monitor for nausea, liver toxicity, lipodystrophy, and bone marrow suppression. Administer some drugs with food to improve tolerance.
Psychosocial Sensitivity: Provide emotional support in a non-judgmental manner. The stigma of HIV/AIDS is real. Connect the patient with social work or support groups as needed, but remember, physiological safety comes first.

Nursing Procedure & Medication Flow Hand Hygiene Procedure (The Priority Intervention): 1. Remove jewelry. 2. Wet hands with warm water. 3. Apply soap. 4. Rub all surfaces (palms, backs, between fingers, under nails) for at least 20 seconds. 5. Rinse thoroughly. 6. Dry with a clean towel/air dryer. 7. Use the towel to turn off the faucet. Alternative: Use enough alcohol-based rub to cover all hand surfaces; rub until dry.
ART Administration: Adherence is key. Use pill organizers, set alarms, and link doses to daily routines. Educate on the consequence of non-adherence: viral rebound, drop in CD4+, and development of drug-resistant HIV.

A Word from Your Senior Nurse "Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, recognizing subtle changes in a patient's vital signs early can prevent deterioration. When studying for your boards, don't just memorize — connect everything to a real patient situation and always ask 'why?' That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse! For Mr. Johnson, your clean hands are more important than any medication you'll give him during that shift. You are his immune system's backup. Never underestimate the power of this simple, fundamental act."

핵심 개념

CD4+ T-cell Count — A measure of the number of helper T lymphocytes in the blood. It is the primary indicator of immune function in HIV infection. A count below 200 cells/mm³ is diagnostic for AIDS.
Opportunistic Infection — An infection caused by pathogens that take advantage of a host's weakened immune system (e.g., in AIDS). Examples include Pneumocystis pneumonia (PCP), candidiasis, and tuberculosis.
Standard Precautions — A set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin, and mucous membranes. They are the foundation for protecting all patients, especially the immunocompromised.
Antiretroviral Therapy — The combination of several antiretroviral medicines used to slow the replication of the Human Immunodeficiency Virus (HIV). The goal is to achieve and maintain an undetectable viral load.
Hand Hygiene — The most important single measure to reduce the risks of transmitting pathogens to patients and healthcare workers. It includes washing hands with soap and water or using an alcohol-based hand rub.

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성장을 멈추지 마세요

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has a CD4+ T-cell count of 220 cells/mm³. Which nursing intervention should be the highest priority to ensure client safety?

심화 해설

임상 시나리오

핵심 개념

마이메르시로 국가고시 완벽 대비