A client with a diagnosis of Human Immunodeficiency Virus develops pneumonia. What type of infection is this?

Correct Answer: A

Rationale: The correct answer is A: An opportunistic infection. In patients with Human Immunodeficiency Virus (HIV), infections like pneumonia are considered opportunistic because they take advantage of a weakened immune system. Option B, root cause infection, is incorrect as it does not describe the nature of the infection in relation to the patient's condition. Option C, pathogenic infection, is incorrect because while pneumonia is caused by pathogens, in the context of HIV, it is specifically termed as an opportunistic infection. Option D, nosocomial infection, is also incorrect as it refers to infections acquired in a healthcare setting, not related to the patient's HIV status.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Blood pressure of 175/90 mm Hg. Rationale: Post-surgery, pain can cause an increase in blood pressure due to the body's stress response. Elevated blood pressure is a common physiological response to pain as the body releases stress hormones that can lead to vasoconstriction, increasing blood pressure. Option B) Respirations of 10 breaths per minute is less likely related to pain as low respiratory rate is not a typical indicator of pain. Option C) Heart rate of 60 beats/minute is also less likely as pain usually causes an increase in heart rate due to sympathetic nervous system activation. Option D) Oxygen saturation of 97% is not directly related to pain assessment but is more indicative of oxygenation status. Educational Context: Understanding the physiological responses to pain is crucial for healthcare professionals to assess and manage post-operative care effectively. Recognizing the relationship between pain and vital signs helps in providing appropriate interventions to alleviate discomfort and ensure optimal recovery for the patient.

Correct Answer: B

Rationale: In the context of a client with an open fracture, preventing osteomyelitis is crucial for their recovery. The best way for a nurse to prevent osteomyelitis in this situation is by choosing option B, which is to use proper hand hygiene and strict infection control measures. By maintaining good hand hygiene practices and implementing infection control protocols, the nurse can significantly reduce the risk of introducing harmful pathogens to the open fracture site, thereby lowering the chances of osteomyelitis development. Option A, administering pain medication, is important for managing the client's discomfort but does not directly address the prevention of osteomyelitis. Option C, delegating all client personal care to specific unlicensed assistive personnel, may compromise infection control practices and increase the risk of introducing pathogens to the open wound. Option D, placing the client in contact precautions, is not necessary unless there is a known infectious agent that requires such measures. From an educational perspective, it is essential to emphasize the significance of infection prevention in clients with open fractures. Nurses must be diligent in following proper hand hygiene techniques and infection control protocols to provide optimal care and reduce the risk of complications like osteomyelitis. This scenario highlights the critical role of nursing interventions in promoting positive client outcomes and underscores the importance of evidence-based practices in clinical settings.

Correct Answer: C

Rationale: In the context of wound assessment, the correct answer is C) Heat. When documenting exudate from a wound, it is important to include details about the amount, consistency, and odor as they provide valuable information about the wound healing process and potential signs of infection. The option C) Heat is incorrect because heat is not typically associated with wound exudate. Heat is more indicative of inflammation or infection in the surrounding tissue rather than the characteristics of exudate itself. Educationally, understanding the components of wound assessment, including exudate characteristics, is crucial for nurses and healthcare professionals to monitor wound healing progress, detect early signs of complications, and provide appropriate interventions. By accurately documenting exudate features, healthcare providers can track changes in the wound over time and make informed decisions regarding wound care management.