# A nurse is caring for a client with severe combined immunodeficiency (SCID) who has been admitted to the hospital. Which nursing intervention is the highest priority to prevent life-threatening complications? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540843 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with severe combined immunodeficiency (SCID) who has been admitted to the hospital. Which nursing intervention is the highest priority to prevent life-threatening complications? ## 보기 1. Administer prophylactic antibiotics as prescribed 2. Monitor vital signs every 4 hours 3. Encourage increased fluid intake 4. Implement strict reverse isolation precautions **✔ 정답** **정답: 4** ## 해설 Strict reverse isolation is the highest priority for SCID patients to prevent exposure to fatal infections due to their severely compromised immune system. Other interventions like antibiotics and monitoring are secondary as they do not prevent initial exposure. ## 심화 해설 Understanding the Priority for a Client with SCID The correct answer is Implement strict reverse isolation precautions. For a client with severe combined immunodeficiency (SCID), the highest priority nursing intervention is to protect them from acquiring any infection, as their immune system is profoundly deficient in both B-cell and T-cell function. This makes them susceptible to life-threatening infections from even common or typically harmless environmental microbes. Why Infection Prevention is the Highest Priority Using Maslow’s hierarchy of needs and the ABC (Airway, Breathing, Circulation) framework, physiological safety is paramount. For an immunocompromised client, the most immediate physiological threat is an overwhelming infection, which can rapidly lead to sepsis, respiratory failure, and death. Strict reverse isolation, also known as protective environment precautions, is a fundamental safety intervention that creates a physical barrier between the client and potential pathogens. This directly addresses the root cause of their risk. Clinical Rationale from the Case Report Evidence The provided case report on a patient with severe aplastic anemia and mucormycosis undergoing hematopoietic stem cell transplantation (HSCT) illustrates the extreme vulnerability of severely immunocompromised patients and the critical nature of protective nursing care [1]. Although the primary diagnosis differs from SCID, the nursing care model for a patient with a non-functional immune system is directly transferable. The report emphasizes that a nurse-led multidisciplinary team implemented a structured care model to manage a patient at profound risk for infection. The core of this model relies on creating and maintaining a strict protective environment to prevent the introduction of new pathogens, which is the essence of reverse isolation. This clinical evidence supports that environmental control is a foundational, non-negotiable element of care before other interventions can be effective. Analysis of Other Options While the other options are important aspects of care, they do not constitute the highest priority intervention: - Administer prophylactic antibiotics as prescribed: This is a dependent nursing intervention that requires a provider's order and addresses bacterial infections specifically. It does not protect against viral or fungal pathogens, which are equally deadly to a client with SCID. Furthermore, the physical implementation of isolation must be established first to provide a safe baseline. - Monitor vital signs every 4 hours: This is an assessment and monitoring intervention. It helps detect early signs of infection but does not prevent it. The priority is to implement a preventative measure to avoid the complication altogether. A frequency of every 4 hours may also be insufficient for a client at such high risk; more frequent monitoring would be initiated after the protective environment is secured. - Encourage increased fluid intake: Maintaining hydration is a supportive care measure. While important for overall health, it does not directly address the imminent, life-threatening risk of acquiring a fatal infection. This intervention is lower on the hierarchy of priorities compared to a safety measure that prevents immediate harm. The case report’s focus on a structured care model for an immunocompromised patient reinforces that meticulous environmental control, the core of reverse isolation, is the first and most critical step in preventing life-threatening complications like the invasive mucormycosis described [1].References (research sources) - [1]Salvage allogeneic hematopoietic stem cell transplantation in a patient with preexisting refractory maxillofacial mucormycosis and severe aplastic anemia: a case report and nursing care model.Case reportCao W, Wu Q. (2026) · DOI: 10.3389/fmed.2026.1784004 ## 임상 시나리오 Protective Environment for the Immunocompromised PatientImplementing Strict Reverse Isolation for SCID The highest priority for a patient with Severe Combined Immunodeficiency (SCID) is preventing infection through a protective environment, commonly called reverse isolation. This creates a physical barrier against environmental pathogens. Key components include a private room with HEPA filtration, strict hand hygiene, and ensuring all staff and visitors wear appropriate personal protective equipment (PPE) like gowns, gloves, and masks. No fresh flowers or live plants are allowed. CautionA simple surgical mask on the patient is insufficient. The patient's room must be under positive pressure relative to the corridor to keep unfiltered air from entering. Monitor for any breach in protocol immediately. ## 핵심 개념 - **Severe Combined Immunodeficiency (SCID)** — A primary immunodeficiency disorder characterized by a profound deficiency of both B-cell and T-cell function, leading to extreme vulnerability to infections. - **Reverse Isolation** — A protective environment precaution designed to protect a highly immunocompromised patient from external pathogens, using barriers like HEPA filtration and strict hygiene. - **Prophylactic Antibiotics** — Antimicrobial drugs administered to prevent, rather than treat, an infection in a high-risk patient. - **Opportunistic Infection** — An infection caused by pathogens that usually do not cause disease in a host with a healthy immune system. ## 같은 주제 문제 - [A nurse is caring for an adult client with severe combined immunodeficiency (SCID) who has…](https://mymerci.kr/pages/nclex_q.php?qn_id=540844) - [A nurse is caring for a client with severe combined immunodeficiency (SCID) who has been a…](https://mymerci.kr/pages/nclex_q.php?qn_id=540845) - [A nurse is caring for a client with severe combined immunodeficiency (SCID) who has been a…](https://mymerci.kr/pages/nclex_q.php?qn_id=540846) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._