# A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has a CD4+ T cell count of 150 cells/mm³. Which nursing intervention should be the highest priority to ensure client safety? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540867 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has a CD4+ T cell count of 150 cells/mm³. Which nursing intervention should be the highest priority to ensure client safety? ## 보기 1. Administering prescribed antiretroviral therapy on schedule 2. Implementing strict infection control precautions and protective isolation measures **✔ 정답** 3. Providing nutritional counseling to prevent weight loss 4. Monitoring vital signs every 4 hours for signs of opportunistic infections **정답: 2** ## 해설 Strict infection control is the highest priority for a severely immunocompromised AIDS patient (CD4+ 150 cells/mm³) to prevent life-threatening opportunistic infections. Other interventions (ART, nutrition, monitoring) are important but less urgent for immediate safety. ## 심화 해설 Priority Setting Using Maslow's Hierarchy and Safety Principles When a client with AIDS has a CD4+ T cell count of 150 cells/mm³, the immune system is severely compromised. A count below 200 cells/mm³ defines the transition from HIV to AIDS and indicates a high risk for opportunistic infections. In NCLEX-RN priority questions, physiological safety and infection prevention take precedence based on Maslow's hierarchy of needs. The systematic review by Tchouaket et al. highlights that vulnerable populations in care settings face heightened risks of contracting healthcare-associated infections (HCAIs), and that these infections are largely preventable through strict infection prevention and control (IPC) clinical best practices [1]. Therefore, the nurse's immediate priority is to protect the client from environmental pathogens. Rationale for Correct Answer Implementing strict infection control precautions and protective isolation measures (Option 2) directly addresses the most immediate threat to life: acquiring a new infection that the client's immune system cannot fight. The evidence underscores that environments with close living conditions and frequent staff-resident interactions are high-risk for HCAIs, and that IPC measures are critical for ensuring safety and improving health outcomes [1]. For a client with a CD4 count of 150 cells/mm³, protective isolation (reverse isolation) creates a barrier against exogenous pathogens, which is the most direct safety intervention. Analysis of Incorrect Options While administering antiretroviral therapy (Option 1) is essential for long-term immune reconstitution, it does not provide immediate protection against environmental pathogens. Medication timing, though important, is a lower priority than establishing a safe physical environment. Providing nutritional counseling (Option 3) addresses a psychosocial and long-term physiological need, which ranks lower on the hierarchy than immediate safety. Monitoring vital signs (Option 4) is a form of assessment and secondary prevention; it helps detect infection early but does not prevent it. In the NCLEX-RN framework, an intervention that actively prevents a life-threatening event takes priority over monitoring or health promotion activities. References (research sources) - [1]Impact of infection prevention and control on costs, quality, safety and health in long-term care facilities: a systematic review protocol.Meta-analysis/systematic reviewTchouaket E, El-Mousawi F, Robins S, Ménard A, Bernard L, Preema D'Souza J, Gull S. (2026) · DOI: 10.3389/fpubh.2026.1784637 ## 임상 시나리오 Protective Isolation for Severe ImmunosuppressionManaging a Client with a CD4 Count Below 200 cells/mm³ A CD4+ T cell count below 200 cells/mm³ marks the transition to AIDS and signals a critical failure of the immune system. The immediate priority is creating a safe environment to prevent exposure to opportunistic infections. Implement protective isolation (reverse isolation) in a private room with the door kept closed. Use HEPA filtration for air entering the room. All staff and visitors must perform meticulous hand hygiene and wear appropriate personal protective equipment (PPE), including a mask, before entering. CautionStrictly exclude any staff or visitors with even minor signs of illness. Do not bring fresh flowers or live plants into the room, as they can harbor fungal spores like Aspergillus. A simple mask on the client is insufficient; the focus is on controlling the environment. ## 핵심 개념 - **Protective Isolation** — Also called reverse isolation; infection control practices designed to protect a severely immunocompromised patient from environmental pathogens. - **CD4+ T cell count** — A laboratory marker of immune function; a count below 200 cells/mm³ indicates a diagnosis of AIDS and severe immunosuppression. ## 같은 주제 문제 - [A nurse is assessing a 28-year-old patient who has been experiencing recurrent infections …](https://mymerci.kr/pages/nclex_q.php?qn_id=540860) - [A nurse is assessing a 35-year-old patient who has been experiencing recurrent infections …](https://mymerci.kr/pages/nclex_q.php?qn_id=540861) - [A nurse is assessing a 28-year-old patient with suspected primary immunodeficiency syndrom…](https://mymerci.kr/pages/nclex_q.php?qn_id=540862) - [A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has deve…](https://mymerci.kr/pages/nclex_q.php?qn_id=540863) - [A nurse is caring for a 38-year-old female client with acquired immunodeficiency syndrome …](https://mymerci.kr/pages/nclex_q.php?qn_id=540864) - [A nurse is caring for a 45-year-old male client with acquired immunodeficiency syndrome (A…](https://mymerci.kr/pages/nclex_q.php?qn_id=540865) - [A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has a CD…](https://mymerci.kr/pages/nclex_q.php?qn_id=540866) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._