A nurse is caring for a client who has HIV.
Which of the following laboratory values is the nurse's priority?
WBC 5,000/mm³.
Platelets 150,000/mm³.
O Positive Western blot test.
CD4-T-cell count 180 cells/mm.
The Correct Answer is D
Choice A rationale:
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
Choice B rationale:
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
Choice C rationale:
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
Choice D rationale:
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C: "I will make a list of my favorite beverages."
Choice A rationale: Stating that they will put beverages in large containers to give the appearance of drinking a lot demonstrates a lack of understanding of fluid restriction guidelines. It focuses on the appearance rather than the actual fluid intake limitation. This statement does not reflect an understanding of the need to limit fluids in acute kidney disease.
Choice B rationale: Consuming most fluids during the evening is not recommended for clients with acute kidney disease as it may lead to discomfort, nighttime urination, and fluid overload. This statement does not demonstrate an understanding of the importance of spreading fluid intake throughout the day.
Choice C rationale: Making a list of favorite beverages indicates the client's understanding of fluid restrictions. This approach can help the client prioritize their preferred beverages while staying within their prescribed fluid allowance. It shows that the client is aware of the need to be selective in their fluid intake.
Choice D rationale: Although avoiding ice cream is an appropriate action due to its contribution to fluid intake, this statement alone does not necessarily indicate a comprehensive understanding of fluid restrictions. The client must also be aware of the importance of monitoring all sources of fluid intake, including other foods and beverages.
Correct Answer is B
Explanation
The correct answer is choice B: Shivering.
Choice A rationale: Dehydration is a risk associated with high fever and infections like meningitis, but it is not a direct complication of using a hypothermia blanket.
Choice B rationale: Shivering is a complication of using a hypothermia blanket, as the body may react to the induced cooling by shivering, which can raise body temperature and counteract the blanket's cooling effect.
Choice C rationale: Seizures can occur in meningitis cases, but they are not specifically a complication of using a hypothermia blanket.
Choice D rationale: Burns are not a typical complication of using a hypothermia blanket when it is used as directed and monitored appropriately. However, skin irritation may occur in some cases.
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